Background:Patients with out-of-hospital cardiac arrest (OHCA) undergoing extracorporeal cardiopulmonary resuscitation with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) are at high risk of nosocomial infections, and prophylactic antibiotics may reduce the infections, but there is limited evidence. This study evaluated the effectiveness of prophylactic antibiotic administration on survival and neurological outcomes in patients with OHCA receiving VA-ECMO. Methods:As a prespecified research question within the Survey of Survivors after Cardiac Arrest in the Kanto Area in 2017 (SOS-KANTO 2017) study, we conducted a multicenter observational study analyzing 153 patients with OHCA who underwent VA-ECMO between September 2019 and March 2021. Patients were categorized into the prophylactic antibiotic group (n = 106) or control group (n = 47). The primary endpoint was 30-day survival, and the secondary endpoints were ECMO-free days and a 30-day cerebral performance category of 1 or 2. Results:After Inverse Probability of Treatment Weighting (IPTW), the 30-day survival was significantly higher in the antibiotic group than in the control group (42.8% vs. 20.3%; p < 0.001) and also ECMO-free days were higher in the antibiotic group (7.1 days vs. 1.4 days; p < 0.001). However, there was no significant difference in neurological outcomes (13.2% vs. 11.1%; p = 0.584). Conclusions:Prophylactic antibiotic administration during VA-ECMO was associated with improved 30-day survival in patients with OHCA. Although these findings suggest a potential benefit, further randomized controlled trials are required to establish clinical recommendations.
Introduction:Group A Streptococcus (GAS), particularly the M1UK lineage, has re-emerged as a major global public health concern following the COVID-19 pandemic, with a rise in invasive GAS (iGAS) and streptococcal toxic shock syndrome (STSS). Although STSS is under national surveillance in Japan, comprehensive molecular monitoring of iGAS infections remains limited, and the clinical characteristics of M1UK-associated iGAS have not been fully elucidated. Methods:We retrospectively reviewed four consecutive iGAS cases requiring intensive care between March and May 2024. Detailed clinical, microbiological, and genomic investigations were performed to characterize the causative strains and their associated virulence profiles. Results:All patients required respiratory and/or circulatory support with surgical debridement. Three cases involved necrotizing fasciitis, and one involved intra-abdominal infection secondary to ovarian tumor rupture. All four patients received penicillin G and clindamycin as definitive antimicrobial therapy, with two developing severe drug-related adverse events. Genotypic analysis identified three isolates as emm1 strains, including two M1UK lineage strains. The two M1UK isolates commonly harbored multiple superantigen genes. All isolates remained susceptible to β-lactam, clindamycin, and macrolide antibiotics. Conclusion:This case series documents the identification of the M1UK lineage among critically ill patients with iGAS infections in Japan. Our findings support the need for continued molecular surveillance while reinforcing the importance of prompt surgical source control and appropriate antimicrobial therapy in the management of severe iGAS.
Aim:DataVerse Japan is a multi-institutional clinical data platform that retains all exportable clinical information from each participating center's information systems and generates analysis-ready datasets for each research question. This study aimed to describe its design, participating centers, data composition, and patient profile, and to characterize its data quality. Methods:The platform captures clinical information from each center's information systems, currently the electronic health record (EHR), which incorporates patient data management system (PDMS) data and claims data; reshapes the records into a common five-column long-format (Code, Day, Time, Variable, Value); and stores them as relationally linked. rds objects. We summarized admissions to the participating centers between January 2016 and December 2025. Results:Four emergency and critical care centers contributed 41,173 admissions from 38,287 individuals and 644,838 patient-days. The platform contains approximately 45 million vital sign records, 30 million laboratory records, and 32 million claims records. Median patient age was 70 years (IQR 49-81), and in-hospital mortality was 16.3%. Admission-level presence coverage, defined as the proportion of admissions with at least one record in a category, varied substantially by category, center, and year and improved after EHR and PDMS upgrades. Conclusion:DataVerse Japan provides a continuously updated multi-institutional clinical data platform that expands its participating centers over time. The coverage and validation metrics reported here allow investigators to judge whether the platform is suitable for a specific research question in emergency and critical care medicine in Japan.
Aim:To assess the current status of initial fluid administration in patients with cardiogenic shock. Methods:Patients with cardiogenic shock registered in the Japanese Circulation Society Cardiovascular Shock Registry were analyzed to investigate real-world fluid resuscitation status upon hospital arrival. From this registry, patients with and without pulmonary congestion were investigated to identify differences in fluid administration. Additionally, the 30-day mortality rate between the groups was examined on the basis of the initial fluid volume administered. Results:A total of 586 patients with cardiogenic shock were included. Initial fluid resuscitation within 30 min after hospital arrival was administered to 568 (96.9%) patients. In multivariate logistic regression for 30-day mortality, older age, lower systolic blood pressure, and a fluid volume of 1001-2000 mL within 30 min after hospital arrival were significant predictors. The 30-day mortality rate in patients with pulmonary congestion (442 patients) was higher than that in patients without pulmonary congestion (144 patients). However, there was no difference in the 30-day mortality rate between the groups based on the initial fluid volume administered. Conclusion:Initial fluid administration in patients with cardiogenic shock is common practice. Although patients with pulmonary congestion had higher overall 30-day mortality, the volume of initial fluid administered after hospital arrival was not associated with worse 30-day mortality.
Background:We report a case of severe drug reaction with eosinophilia and systemic symptoms (DRESS) associated with early coagulation abnormalities following lamotrigine administration, in which aggressive treatment, including steroid pulse therapy and plasma exchange, resulted in a favorable outcome. Case Presentation:A 20-year-old woman with a history of epilepsy presented with fever, rash, anorexia, and cervical lymphadenopathy after initiating lamotrigine and valproate sodium treatment for seizures. Laboratory results showed thrombocytopenia, an elevated prothrombin time/international normalized ratio, and low fibrinogen, high fibrinogen degradation product, and elevated liver enzyme levels, raising suspicion of DRESS. Lamotrigine was discontinued, and fresh-frozen plasma was administered without improvement. Steroid pulse therapy and plasma exchange were initiated. The patient was diagnosed with DRESS based on a RegiSCAR (Registry of Severe Cutaneous Adverse Reaction) score of 6, indicating a definite case. Valproate sodium was reintroduced without recurrence of the DRESS. The patient's condition improved, and she was discharged after 32 days. Conclusion:Lamotrigine-induced DRESS may present with severe coagulation abnormalities early in the course of the disease. In severe cases of coagulopathy, steroid pulse therapy and plasma exchange may be considered viable treatment options.
Background:It remains controversial whether the lateral or the anterior approach is optimal for chest tube insertion in patients with traumatic pneumothorax (PTH). Objectives:This study aimed to evaluate the incidence of functional malpositioning of chest tubes inserted via the lateral versus anterior approach in patients with traumatic pneumothorax (PTH) and/or hemopneumothorax (HPTH), with or without a preceding CT examination. Methods:We conducted a two-center, retrospective, observational study of consecutive patients treated with a chest tube for traumatic PTH/HPTH between August 2012 and September 2021. Patients were divided into two groups according to the presence or absence of CT examination before chest tube insertion: CT(+) or CT(-) group. In each group, the risk of functional malpositioning was compared between the lateral and anterior approaches. Results:Among 388 patients, 271 patients were analyzed. The CT(+) group comprised 200 (74%) patients, while the CT(-) group comprised 71 (26%) patients. The adjusted odds ratio of functional malpositioning with the lateral approach was 1.38 (95% confidence interval 0.64-2.98, p = 0.41) in the CT(+) group and 9.24 (95% confidence interval 1.49-57.50, p < 0.01) in the CT(-) group. There was a trend suggesting that the risk of functional malposition of chest tubes associated with the lateral approach, compared with the anterior approach, was modified by the presence or absence of a preceding CT examination (p interaction = 0.01). Conclusions:The occurrence of functional malpositioning of the chest tube in patients with traumatic PTH/HPTH was higher with the lateral approach in patients without a preceding CT examination.
Background:Although minor (mild-to-moderate) trauma generally leads to favorable outcomes, some patients experience in-hospital mortality. Traditional trauma severity scores alone may not sufficiently reflect the prognostic variability in aging populations with comorbidities. This study examined the associations between patient characteristics and in-hospital mortality among patients with minor trauma. Methods:This retrospective cohort study used data from adult patients with minor trauma, defined by an Injury Severity Score (ISS) < 16 from the Japan Trauma Data Bank. A logistic regression analysis was performed to evaluate associations between mortality and patient characteristics, including age, sex, ISS, and the Charlson Comorbidity Index (CCI) score. Subgroup analyses were conducted among patients with moderate trauma (ISS 9-15) to examine the associations between the Abbreviated Injury Scale (AIS) scores of injuries at three specific anatomical regions and in-hospital mortality. Results:After applying the exclusion criteria, of the 56,821 patients with ISS < 16 identified in the Japan Trauma Data Bank, 50,087 were included in the final analysis. The logistic regression analysis identified older age, male sex, ISS ≥ 9, and higher CCI scores as independent predictors of in-hospital mortality. In patients with moderate trauma, the AIS scores of injuries involving the three regions (head/neck, abdomen, and external/other trauma injury regions) were significantly associated with increased mortality. Conclusion:Among patients with minor trauma, advanced age, male sex, comorbidities, and specific injury regions were associated with increased in-hospital mortality. These findings highlight the importance of early risk recognition and tailored clinical management in this population.
Objective:Persistent inflammation, immunosuppression, and catabolism syndrome (PIICS) is a pathophysiological condition that may underlie poor long-term outcomes after critical illness. We investigated whether the early combined initiation of oral/enteral feeding and rehabilitation is associated with the development of PIICS. Methods:We Retrospectively Analyzed Patients Admitted to the Emergency ICU of Osaka University Hospital During 2016-2024. PIICS Was Diagnosed on Hospital Day 14 (±3 Days) Based on CRP > 2.0 mg/dL, Lymphocytes < 800/μL, and Albumin < 3.0 g/dL, With ≥ 2 of 3 Criteria Required for Diagnosis. Early Combined Intervention Was Defined as Oral/Enteral Feeding Initiation Within 3 Days and Rehabilitation Within 7 Days of ICU Admission. Missing SOFA Scores (45.3%) Were Multiply Imputed by Predictive Mean Matching (m = 50). Propensity Score Matching Was Performed Within Each Imputed Dataset Using a Within-Imputation Approach, With Estimates Pooled Using Rubin's Rules. Results:Among 5709 ICU Patients, 2860 Were Eligible for the Primary Analysis. Early Combined Intervention Was Initiated in 348 (12.2%). Propensity Score Matching Generated an Average of 347 Pairs Per Imputed Dataset (Range: 333-348). Early Combined Intervention Was Associated With Lower PIICS Incidence (OR = 0.481, 95% CI 0.337-0.686, p < 0.001). Significance Was Retained in the Sensitivity Analysis Restricted to Patients With Observed SOFA Scores (Complete-Case Analysis, n = 1512; OR = 0.533, 95% CI 0.340-0.836, p < 0.001). Conclusion:Early combined initiation of oral/enteral feeding and rehabilitation was associated with lower PIICS incidence in critically ill patients, suggesting the value of integrated multimodal supportive care for PIICS prevention and providing a rationale for prospective multicenter studies to establish causality.
Aim:Mamushi (Gloydius blomhoffii) bite is the most common type of snakebite in Japan. However, clinical information on pediatric patients remains limited. This study aimed to clarify the clinical characteristics of pediatric cases of mamushi envenomation by making comparisons with adult cases. Methods:This secondary analysis used data from the OROCHI study, a multicenter prospective observational study conducted at 24 hospitals in Japan, of patients hospitalized for confirmed or suspected mamushi envenomation. The primary outcome was hospital stay. Secondary outcomes included adverse events, pain scores, and the grade of swelling. Patients were classified into pediatric (< 18 years) and adult (≥ 18 years) groups. Results:Of the 106 patients enrolled in the OROCHI study, 99 met the inclusion criteria for this analysis (7 pediatric cases; 92 adult cases). There was no significant difference in median (interquartile range) hospital stay between the pediatric and adult groups (4 days; p = 0.375). Among patients who received antivenom, no adverse reactions were observed in the pediatric group, whereas four adults experienced adverse reactions, including one case of anaphylaxis. The pain scores at antivenom administration were higher in pediatric patients (median 10 vs. 5), but no significant differences were observed after 6 h. The grade of swelling did not differ significantly between the groups at any time point. Conclusion:The clinical course and outcomes of pediatric patients with mamushi envenomation appear similar to those of adult patients. Further accumulation of pediatric cases is warranted to strengthen these findings.
Introduction:Supine chest radiography is routinely used in trauma care; however, its sensitivity is limited in pneumothorax detection. Although artificial intelligence (AI) has recently been introduced as a diagnostic support tool for chest radiograph interpretation, its use in trauma radiographs and its interaction with physician experience remain unclear. We aimed to evaluate the diagnostic performance of AI-assisted image interpretation in traumatic pneumothorax detection among emergency medicine specialists and non-specialists. Methods:In this retrospective single-center study, 34 supine chest radiographs (17 pneumothorax and 17 non-pneumothorax cases confirmed with computed tomography) were interpreted by 20 emergency medicine physicians (10 specialists and 10 non-specialists). Each participant reviewed all radiographs twice: first without AI assistance and then with AI assistance after a 2-week washout period. Sensitivity, specificity, accuracy, and precision were calculated. To account for clustering of observations within readers and cases, mixed-effects logistic regression analysis was performed. Results:AI assistance significantly improved sensitivity and diagnostic accuracy across participants, whereas specificity and precision were not significantly affected. Specialists demonstrated higher baseline sensitivity and accuracy than non-specialists. In the mixed-effects logistic regression analysis, AI assistance was independently associated with improved diagnostic accuracy (odds ratio 2.37, p < 0.001). Additionally, the interaction between AI assistance and physician specialist status was significant (p = 0.010). Conclusion:AI-assisted interpretation of supine chest radiographs is a potentially useful decision-support tool for detecting traumatic pneumothorax in emergency settings.
Aim:We aimed to compare the effectiveness and safety of 50% and 20% glucose solutions administered to patients with hypoglycemia in prehospital settings. Methods:This retrospective cohort study analyzed cases of hypoglycemia treated by paramedics with either 50% or 20% glucose solution (40 mL) between 2016 and 2023 in the Shida-Haibara district of Shizuoka Prefecture, Japan. The primary outcome was the degree of improvement in the Japan Coma Scale (JCS). Secondary outcomes were the blood glucose level at hospital arrival and the proportion of patients exhibiting JCS improvement, rebound hypoglycemia, need for in-hospital glucose administration, and adverse events. Results:A total of 242 patients met the inclusion criteria (131 and 111 in the 50% and 20% groups, respectively). The median initial blood glucose levels were similar (31 vs. 30 mg/dL), but they were significantly higher in the 50% group upon hospital arrival (151 vs. 81 mg/dL). The degree of JCS improvement did not differ significantly (4 vs. 3 grades). However, the proportion of patients with JCS improvement was higher in the 50% group (92% vs. 82%). Rebound hypoglycemia occurred in 15% and 9.0% of the patients, respectively (not statistically significant). In-hospital glucose administration was less frequent in the 50% group (42% vs. 75%). No soft tissue injuries were observed. Conclusion:The degree of JCS improvement did not differ significantly between the two groups; however, the 50% glucose solution was superior in some secondary outcomes.
Background "Human skin gas," the trace amounts of bio-volatile gases emitted from the surface of human skin, contains a variety of biological information and can be used in diagnosing several diseases. Herein, we described a case of the identification of the causative agent in a patient with acute poisoning using human skin gas. Case Presentation A 52-year-old man cut his wrists and neck and crashed his car into a tunnel wall. The patient informed the paramedics that he had taken paraquat dimethyl sulfate and was transported to our emergency medical center. Since paraquat was not found in the home, the skin gas was measured, and ortho-dichlorobenzene was detected. An insecticide containing ortho-dichlorobenzene was found in the home, and he was strongly suggested with ortho-dichlorobenzene poisoning. Conclusion The human skin gas assay was used to identify intoxicants and is useful for the diagnosis of poisoning.
Aim:Out-of-hospital cardiac arrest (OHCA) carries a poor prognosis despite advances in cardiopulmonary resuscitation (CPR). Traditional prognostic factors have limited accuracy, and "signs of life," including gasping, pupillary light reflex (PLR), and CPR-induced consciousness (CPRIC), have been proposed as prognostic markers. We conducted a systematic review and meta-analysis to evaluate the association between signs of life and outcomes in OHCA. Methods:PubMed, MEDLINE, and Web of Science were systematically searched. Eligible studies included adult patients with OHCA of presumed medical origin reporting survival or neurological outcomes in relation to signs of life. Study quality was assessed using the Newcastle-Ottawa Scale. Pooled odds ratios with 95% confidence intervals were calculated using a random-effects model. Results:Eight cohort studies, including 4,862 patients, were analyzed. All studies were of good methodological quality. The presence of signs of life was associated with higher survival and favorable neurological outcomes within 30 days after cardiac arrest (CA). Similar associations were observed for longer-term survival, although evidence for longer-term neurological outcomes was limited. Conclusion:Signs of life during CA or CPR were consistently associated with improved survival and favorable neurological outcomes in patients with OHCA, both within 30 days and beyond 90 days. These findings suggest that signs of life may have prognostic value; however, their applicability may vary depending on clinical context. Systematic documentation of signs of life may be considered in standardized reporting frameworks.
Aim:This study aimed to evaluate whether early enteral nutrition can be administered without increasing gastrointestinal complications in patients receiving mechanical circulatory support. Methods:This retrospective observational study was conducted at a tertiary hospital in Japan. We consecutively included adult patients supported with intra-aortic balloon pumping alone or with both intra-aortic balloon pumping and veno-arterial extracorporeal membrane oxygenation who remained in the intensive care unit for > 1 week between January 2010 and December 2019. Patients were divided into an early group (enteral nutrition initiated within 48 h of admission) and a late group (enteral nutrition initiated after 48 h). The study endpoints were the amount of energy administered in each group and the frequency of gastrointestinal complications. Results:Fifty-five patients were eligible, including 16 in the early group and 39 in the late group. Time from admission to enteral nutrition initiation was 1.5 (1-2) days in the early group and 4.5 (3-6.5) days in 24 late-group patients who received enteral nutrition. Energy administered per ideal body weight increased earlier in the early group and differed significantly from Day 2 to Day 5, whereas no significant difference was observed after Day 6. No significant differences were found in gastrointestinal complications or mortality between groups; mortality was 7 patients (35%) in the early group and 17 patients (44%) in the late group. Conclusion:These findings suggest that early enteral nutrition may be a feasible option in carefully selected patients receiving mechanical circulatory support during intensive care.
Background: Traumatic arterioportal (AP) shunts are rare vascular complications of hepatic trauma. In patients with severe liver injury, portal hypertension and hepatic dysfunction may develop during the postoperative course, and delayed AP shunts can be difficult to detect on computed tomography. Case Presentation: We report the case of a 19-year-old male who sustained a severe blunt liver injury in a motorcycle accident and presented with hemorrhagic shock. After initial surgical and endovascular hemostatic management, he developed progressive portal hypertension, worsening hepatic dysfunction, and persistent large-volume abdominal fluid. A multiphasic computed tomography scan performed on hospital day 32 showed no definite arterioportal shunt, although splenomegaly and gastrointestinal wall edema were present. On hospital day 39, angiography revealed an AP shunt between the right hepatic artery and the posterior branch of the portal vein. The shunt was treated with transcatheter arterial embolization, after which the patient showed gradual clinical improvement, including reduction of ascitic drainage and recovery of portal venous flow direction on follow-up ultrasonography. Conclusion: This case highlights that traumatic AP shunts may be identified during the course of severe liver injury with portal hypertension and hepatic dysfunction, even when computed tomography is initially negative. Angiography should be considered when delayed vascular complications are suspected, and timely embolization may contribute to clinical improvement.
Aim:Femoral artery sheath insertion is a common resuscitation procedure; however, most research on complications focuses on cardiovascular medicine. No studies have examined sheath insertion complications in emergency or intensive care settings where fluoroscopy is unavailable. This study investigated complications associated with femoral artery sheath insertion in non-fluoroscopic resuscitation. Methods:This retrospective, single-center observational study included patients who underwent femoral artery sheath insertion for resuscitation under non-fluoroscopic conditions between April 2014 and August 2024 and subsequently underwent computed tomography. Patients were categorized into the non-complication and complication groups. Vascular and skin insertion positions were measured using computed tomography, and patient backgrounds were compared between groups. Results:The study included 151 patients in the non-complication group and 16 in the complication group, yielding a complication rate of 9.6%. A significant difference was observed in sheath insertion position (p < 0.001). The proportion of sheath insertions at the level of the femoral head was higher in the non-complication group, whereas insertions below the femoral head were more frequent in the complication group. Conclusion:Femoral artery sheath insertion without fluoroscopy during resuscitation was associated with a 9.6% complication rate, with the complication group having a higher rate of vascular puncture below the femoral head than the non-complication group.
