Background Few prediction models for individuals with early‐stage out‐of‐hospital cardiac arrest (OHCA) have undergone external validation. This study aimed to externally validate updated prediction models for OHCA outcomes using a large nationwide dataset. Methods and Results We performed a secondary analysis of the JAAM‐OHCA (Comprehensive Registry of In‐Hospital Intensive Care for Out‐of‐Hospital Cardiac Arrest Survival and the Japanese Association for Acute Medicine Out‐of‐Hospital Cardiac Arrest) registry. Previously developed prediction models for patients with cardiac arrest who achieved the return of spontaneous circulation were updated. External validation was conducted using data from 56 institutions from the JAAM–OHCA registry. The primary outcome was a dichotomized 90‐day cerebral performance category score. Two models were updated using the derivation set (n=3337). Model 1 included patient demographics, prehospital information, and the initial rhythm upon hospital admission; Model 2 included information obtained in the hospital immediately after the return of spontaneous circulation. In the validation set (n=4250), Models 1 and 2 exhibited a C‐statistic of 0.945 (95% CI, 0.935–0.955) and 0.958 (95% CI, 0.951–0.960), respectively. Both models were well‐calibrated to the observed outcomes. The decision curve analysis showed that Model 2 demonstrated higher net benefits at all risk thresholds than Model 1. A web‐based calculator was developed to estimate the probability of poor outcomes ( https://pcas‐prediction.shinyapps.io/90d_lasso/ ). Conclusions The updated models offer valuable information to medical professionals in the prediction of long‐term neurological outcomes for patients with OHCA, potentially playing a vital role in clinical decision‐making processes.

While nonocclusive mesenteric ischemia (NOMI) has been reported in a significant percentage of adults who were resuscitated after cardiac arrest, it is rare in children. This report presents the first known Japanese case of pediatric NOMI after return of spontaneous circulation following cardiac arrest. A 16-month-old boy experienced cardiac arrest due to asphyxiation from foreign bodies in the airway. After receiving 10 doses of adrenaline, with a maximum arrest time of 95 minutes, the patient achieved return of spontaneous circulation. However, 40 hours after onset, the patient developed NOMI, resulting in refractory hypotensive shock with decreased blood pressure, distended abdomen, and increased intravesical pressure. The patient was successfully rescued with two laparotomies and was discharged. Although NOMI is uncommon in children, appropriate treatment can be lifesaving.

Aim: Life-threatening electrocardiographic (ECG) findings aid in the diagnosis of acute coronary syndrome (ACS), which has not been well -evaluated in patients with out-of-hospital cardiac arrest (OHCA). This study aimed to evaluate the diagnostic test accuracy (DTA) of ST-elevation myocardial infarction (STEMI) equivalents following the return of spontaneous circulation (ROSC) in patients with OHCA to identify patients with ACS.Methods: Using the database of the Comprehensive Registry of In-Hospital Intensive Care for OHCA Survival study from 2012 to 2017, patients aged >= 18 years with non-traumatic OHCA and ventricular fibrillation or pulseless ventricular tachycardia on the arrival of emergency medical service personnel or arrival at the emergency department, who achieved ROSC, were included. Patients without ST-segment elevation or complete left bun-dle branch block on ECG and those who did not undergo ECG or coronary angiography, were excluded from the study. We evaluated the DTA of STEMI equivalents for the diagnosis of ACS: isolated T-wave inversion, ST-segment depression, Wellens' signs, and ST-segment elevation in lead aVR.Results: Isolated T-wave inversion and Wellens' signs had high specificity for ACS with 0.95 (95% confidence interval [CI], 0.87-0.99) and 0.92 (95% CI, 0.82-0.97), respectively, but their positive likelihood ratios were low, with a wide range of 95% CI: 1.89 (95% CI, 0.51-7.02) and 0.81 (95% CI, 0.25-2.68), respectively.Conclusion: The DTA of STEMI equivalents for the diagnosis of ACS was low among patients with OHCA. Further investigation considering the measurement timing of the ECG after ROSC is required.

Background The efficacies of fresh frozen plasma and coagulation factor transfusion have been widely evaluated in trauma-induced coagulopathy management during the acute post-injury phase. However, the efficacy of red blood cell transfusion has not been adequately investigated in patients with severe trauma, and the optimal hemoglobin target level during the acute post-injury and resuscitation phases remains unclear. Therefore, this study aimed to examine whether a restrictive transfusion strategy was clinically non-inferior to a liberal transfusion strategy during the acute post-injury phase. Methods This cluster-randomized, crossover, non-inferiority multicenter trial was conducted at 22 tertiary emergency medical institutions in Japan and included adult patients with severe trauma at risk of major bleeding. The institutions were allocated a restrictive or liberal transfusion strategy (target hemoglobin levels: 7–9 or 10–12 g/dL, respectively). The strategies were applied to patients immediately after arrival at the emergency department. The primary outcome was 28-day survival after arrival at the emergency department. Secondary outcomes included transfusion volume, complication rates, and event-free days. The non-inferiority margin was set at 3%. Results The 28-day survival rates of patients in the restrictive ( n = 216) and liberal ( n = 195) strategy groups were 92.1% and 91.3%, respectively. The adjusted odds ratio for 28-day survival in the restrictive versus liberal strategy group was 1.02 (95% confidence interval: 0.49–2.13). Significant non-inferiority was not observed. Transfusion volumes and hemoglobin levels were lower in the restrictive strategy group than in the liberal strategy group. No between-group differences were noted in complication rates or event-free days. Conclusions Although non-inferiority of the restrictive versus liberal transfusion strategy for 28-day survival was not statistically significant, the mortality and complication rates were similar between the groups. The restrictive transfusion strategy results in a lower transfusion volume. Trial registration number: umin.ac.jp/ctr : UMIN000034405, registration date: 8 October 2018.

Background: We aimed to investigate the association between blood urea nitrogen to creatinine ratio (BCR) and survival with favourable neurological outcomes in patients with out-of-hospital cardiac arrest (OHCA). Methods: This prospective, multicentre, observational study conducted in Osaka, Japan enrolled consecutive OHCA patients transported to 16 participating institutions from 2012 through 2019. We included adult patients with non-traumatic OHCA who achieved a return of spontaneous circulation and whose blood urea nitrogen and creatinine levels on hospital arrival were available. Based on BCR values, they were divided into: 'low BCR' (BCR <10), 'normal BCR' (10 <= BCR < 20), 'high BCR' (20 <= BCR < 30), and 'very high BCR' (BCR >= 30). We evaluated the association between BCR values and neurologically favourable outcomes, defined as cerebral performance cate-gory score of 1 or 2 at one month after OHCA. Results: Among 4415 eligible patients, the 'normal BCR' group had the highest favourable neurological outcome [19.4 % (461/2372)], followed by 'high BCR' [12.5 % (141/1127)], 'low BCR' [11.2 % (50/445)], and 'very high BCR' groups [6.6% (31/471)]. In the multivariable analysis, adjusted odds ratios for 'low BCR', 'high BCR', and 'very high BCR' compared with 'normal BCR' for favourable neurological outcomes were 0.58 [95 % confidence interval (CI 0.37-0.91)], 0.70 (95 % CI 0.49-0.99), and 0.40 (95 % CI 0.21-0.76), respectively. Cubic spline analysis indicated that the association between BCR and favourable neurological outcomes was non-linear (p for non-linearity = 0.003). In subgroup analysis, there was an interaction between the aetiology of arrest and BCR in neurological outcome (p for interaction <0.001); favourable neurological outcome of cardiogenic OHCA patients was lower when the BCR was higher or lower, but not in non-cardiogenic OHCA patients. Conclusions: Both higher and lower BCR were associated with poor neurological outcomes compared to normal BCR, especially in cardiogenic OHCA patients. (c) 2023 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

Background: The effectiveness of IABP for shockable out-of-hospital cardiac arrest (OHCA) has not been extensively investigated. This study aimed to investigate whether the use of an intra-aortic balloon pump (IABP) for non-traumatic shockable OHCA patients was associated with favorable neurological outcomes. Methods: From the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest registry, a nationwide multicenter prospective registry, we enrolled adult patients with non-traumatic and shockable OHCA for whom resuscitation was attempted, and who were transported to participating hospitals between 2014 and 2019. The primary outcome was 1-month survival with favorable neurological outcomes after OHCA. After adopting the propensity score (PS) inverse probability of weighting (IPW), we evaluated the association between IABP and favorable neurological outcomes. Results: Of 57,754 patients in the database, we included a total of 2738 adult non-traumatic shockable patients. In the original cohort, the primary outcome was lower in the IABP group (OR with 95% confidence intervals (CIs)), 0.57 (0.48–0.68), whereas, in the IPW cohort, it was not different between patients with and without IABP (OR, 1.18; 95% CI, 0.91–1.53). Conclusion: In adult patients with non-traumatic shockable OHCA, IABP use was not associated with 1-month survival with favorable neurological outcomes.

Background: Extracorporeal cardiopulmonary resuscitation (ECPR) has been focused as a rescue therapy for the refractory cardiac arrest patients; however, little is known about the effect of ECPR on survival. The aim of this study is to evaluate the association between ECPR and the survival among the out-of-hospital cardiac arrest patients. Method: This was the secondary analysis of JAAM-OHCA registry which is a nationwide multicenter prospective study collecting the data of out-of-hospital cardiac arrest patients from July 2012 to December 2019. The study participant were adult (≥18 years) cardiac arrest patients due to internal medical cause. Initial cardiac rhythm was stratified as initial shockable and non-shockable rhythm. Patients received ECPR were sequentially matched with the patients who had not yet received within the same minutes (control) based on the time-dependent propensity scores calculated from the patient characteristics to eliminate the resuscitation time bias. Odds ratio with 95% confidence interval (CI) of ECPR for the 30-day survival were calculated by conditional logistic model. Results: Of 57,754 patients in the JAAM-OHCA registry, 1,826 matched cohort with initial shockable rhythm (913 treated with ECPR and 913 control) and 740 matched cohort with initial non-shockable rhythm (370 treated with ECPR and 370 control) were eligible for analysis. Their characteristics between with ECPR and control were well balanced. In the matched cohort with initial shockable rhythm, 30-day survival was 24.6% (225/913) in the patients with ECPR and 16.3% (149/913) in the control. In the matched cohort with initial non-shockable rhythm, 30-day survival was 11.9% (44/370) in the patients with ECPR and 2.4% (9/370) in the control. Odds ratio of with ECPR for 30-day survival was 1.76 [95%CI: 1.38-2.25] in shockable rhythm and 5.37 [95%CI: 2.53- 11.43] in non-shockable rhythm, referred to the control. Conclusion: This time-dependent propensity score sequential matching analysis suggested that ECPR was associated with the 30-day survival outcomes among the out-of-hospital cardiac arrest patients with both initial shockable and non-shockable rhythms.

Vascular Ehlers-Danlos syndrome is a fatal disease caused by a type III collagen mutation that can result in the rupture of blood vessels, the intestinal tract, and/or the uterus. Despite being the most severe form of Ehlers-Danlos syndrome, it is not well known in the pediatric context because it rarely presents serious complications in childhood. In this case, the patient experienced a subclavian artery rupture triggered by sneezing, which was initially managed with an endovascular stent. However, the descending aorta subsequently ruptured, and the patient died. Traditionally, surgical or endovascular treatments have been avoided due to the inherent fragility of blood vessels. Nevertheless, favorable outcomes have been documented with a wait -and -see surgical approach or endovascular treatment, especially when the diagnosis precedes the onset of vascular complications. Notably, celiprolol, a partial I32-agonist and I31-blocker, has demonstrated efficacy in preventing vascular complications. Therefore, early diagnosis plays a pivotal role. Raising awareness about this syndrome, along with its management and prophylaxis, holds the potential to enhance the survival rate.

While prehospital medical interventions are evolving and improving survival rates, the evidence for adequate early prognostic assessment is often insufficient. A 12-year-old Japanese child was found hanging on the roof of his home. After being rescued by his mother, he was transported by an ambulance and a rapid response car (RRC) with doctors, nurses, and paramedics on board, and admitted to our hospital. His initial Glasgow Coma Scale score in the RRC was 4. Although he did not undergo intubation and targeted temperature management (TTM), he had no neurological sequelae upon discharge. To the best of our knowledge, this report is the first to describe the case of a child with a decreased level of consciousness after near-hanging, who was treated without intubation and TTM.

Background: Out-of-hospital cardiac arrest (OHCA) patients with acute coronary syndrome (ACS) needs emergent coronary angiography and subsequent percutaneous coronary intervention to improve their outcomes. ‘STEMI equivalents’ in electrocardiogram (ECG) are known to help the diagnosis of ACS. However, these findings have not been sufficiently evaluated among OHCA patients. This study aimed to evaluate the diagnostic test accuracy (DTA) of ‘STEMI equivalents’ to identify ACS among OHCA patients without ST-segment elevation. Methods/Results: Nine emergency medical departments among the Comprehensive Registry of In-Hospital Intensive Care for OHCA Survival (CRITICAL) study in Osaka, Japan collected the patients' first 12 leads ECGs after return of spontaneous circulation (ROSC) from 2012 to 2017. Patients with non-traumatic OHCA aged >=18 years old with ventricular fibrillation / pulseless ventricular tachycardia as first documented rhythm or rhythm at hospital arrival were included. Of them, patients without ST-segment elevation nor complete left bundle branch block were extracted. The DTAs; sensitivity, specificity, positive likelihood ratio (LR+), and negative and likelihood ratio (LR-) of STEMI equivalents (i.e., Isolated T-wave inversion, Wellens signs) for the diagnosis of the ACS were evaluated. ACS was diagnosed by the physicians in each hospital based on the coronary angiography. Results: A total of 143 cases were included in the analysis and 79 patients were diagnosed as ACS. Isolated T-wave inversion was found in 7 (3.2%) patients in the ACS group and 3 (8.8%) in the non-ACS group. The Wellens signs was present in 5 (6.3%) and 5 (7.8%) patients, respectively. The isolated T-wave inversion and the Wellens signs had high specificity with 0.95 (95% CI: 0.87-0.99) and 0.92 (95% CI: 0.82-0.97), whereas these findings had low LR+ with wide range of 95% CI with 1.89 (95% CI: 0.51-7.02), and 0.81 (95% CI: 0.25-2.68), respectively. Conclusion: In this study, the DTA of STEMI equivalents of single 12 leads ECG alone were not sufficient for the diagnosis of ACS after ROSC among OHCA patients without ST-segment elevation. Further investigation of the DTA evaluation considering the measurement timing and the change of the ECG is needed.

Aim: Extracorporeal cardiopulmonary resuscitation (ECPR) is performed in refractory out-of-hospital cardiac arrest (OHCA) patients, and the eligibility has been conventionally determined based on three criteria (initial cardiac rhythm, time to hospital arrival within 45 minutes, and age <75 years) in Japan. Owing to limited information, this study descriptively determined neurological outcomes after applying the three criteria among OHCA patients who underwent ECPR. Methods: This study conducted a post-hoc analysis of data from the Comprehensive Registry of Intensive Care for OHCA Survival (CRITICAL) study. This was a multi-institutional prospective observational study of OHCA patients in Osaka Prefecture, Japan. All adult (aged >= 18 years) OHCA patients with internal medical causes treated with ECPR between 1 July 2012 and 31 December 2019 were evaluated. We described one-month neurological favourable outcomes based on the three criteria (initial shockable, time to hospital arrival within 45 minutes, and age <75 years), and we compared them using the chi-square test. Results: Among 18,379 patients screened from the CRITICAL study database, we included 517 OHCA patients treated by ECPR; 311 (60.2%) patients met all three criteria. Favourable neurological outcomes were as follows: patients meeting no or one criterion: 2.3% (1/43), those meeting two criteria: 8% (13/163), and those meeting all criteria: 16.1% (50/311) (P-value = 0.004). Conclusions: In this study, approximately 60% of patients treated by ECPR met the three criteria (initial shockable, time to hospital arrival within 45 minutes, and age <75 years), and the greater the number of criteria met, the better were the neurological outcomes achieved.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Carbapenem-resistant Enterobacteriaceae (CRE) are resistant to almost all β-lactam antibiotics. Colistin,the production of which had been halted in Japan because of its serious side effects and the availability of safer alternatives, was re-evaluated as an antibiotic against CRE and re-approved in March 2015. However,the pediatric use of colistin has been reported in only few studies. A 4-year-old girl with juvenile myelomonocytic leukemia underwent stem cell transplantation (SCT) from her mother after the rejection of umbilical cord blood transplantation. Two months after engraftment, her neutrophil count gradually decreased. She developed sepsis caused by carbapenem-resistant Escherichia coli with severe neutropenia. Although multidrug therapy was initiated, E. coli continued to be detected in her blood cultures. We initiated colistin as an emergency measure and infused it into the patient at a dose of 5mg/kg/day. Despite clinical and microbiological responses and an immediate negativity of blood cultures, she redeveloped a high fever, and E. coli was again detected in her blood cultures. The colistin dose was increased to 7mg/kg/day. Neutrophils from her father were transfused after the patient had the central venous catheter was removed. Eventually,her temperature normalized, and her blood cultures became negative again. Colistin was administered for 14 days. No side effects related to colistin were detected. It is suggested that colistin in multidrug therapy can be safely and effectively used for children with severe CRE infections.

Case:An 85-year-old man was admitted to the hospital, underwent laparotomy, and was diagnosed with diffuse peritonitis due to perforation of gastric ulcer. Omental patch repair was carried out. After surgery, he suddenly vomited blood and manifested hypovolemic shock. An emergency upper gastrointestinal endoscopy was carried out immediately. However, the bleeding source was not visible. Dynamic-enhanced abdominal computed tomography showed a pseudoaneurysm of the gastroduodenal artery-communicating duodenal lumen with extravasation. Next, the patient underwent angiography for embolization. However, selective arterial embolization was not successful.Outcome:Finally, duodenotomy was carried out. The fistula between the pseudoaneurysm and duodenal lumen was directly ligated. An aneurysm could be clearly identified by previous findings.Conclusions:Gastroduodenal artery aneurysms are very uncommon but possibly lethal if they rupture. This life-threatening condition requires rapid diagnosis and treatment. Minimally invasive treatment is the preferred therapy for gastroduodenal artery aneurysm; however, acute care surgery should be considered without hesitation when conditions are critical.

【目的】重症救急患者を対象に，蛋白含有量の異なる2種類の濃厚流動食の効果を検討した。【方法】非蛋白カロリー/窒素比（non-protein calorie/nitrogen ratio, NPC/N）76のA群13例とNPC/N 132のS群15例について，前向き無作為比較試験を行った。【結果】患者背景に差はなく，蛋白投与量はA群で有意に多かった（P＝0.02）。血清アルブミン，プレアルブミン値の推移はA群で高い傾向を示した（P＝0.13，P＝0.10）。Ventilator-free daysは中央値（四分位範囲）でA群17（15～20）日，S群9（2～15）日とA群で長い傾向にあった（P＝0.10）が，SOFA scoreの推移や28日死亡率は両群間に有意差を認めなかった。【結論】蛋白含有量の多い濃厚流動食により，人工呼吸管理期間の短縮と中期的な栄養状態の改善が期待できる。

【目的】小児集中治療室（PICU）における人工呼吸器関連肺炎（ventilator-associated pneumonia, VAP）の現状と人工呼吸器関連事象（ventilator-associated events, VAE）サーベイランスの評価を行う。【方法】侵襲的人工呼吸管理を48時間以上施行した患者を対象とした，前方視VAPサーベイランスおよび同時期の後方視VAEサーベイランスを行った。【結果】対象患者200名のうち，VAPは12件, 7.1件/1,000呼吸器管理日数，VAEは16件, 9.4件/1,000呼吸器管理日数であった。人工呼吸器装着期間・ICU入室日数に関してVAPとVAEサーベイランスともに陽性群と陰性群で差が見られたが，ICU死亡率は両サーベイランスともに差が見られなかった。VAP 12例のうちVAE基準を満たしたものは3例のみであった。【結論】成人の基準を用いたVAEサーベイランスは，小児においてもVAPに代わり人工呼吸器使用管理の指標となる可能性がある。

Appropriate patient selection is very important when initiating mild therapeutic hypothermia (MTH) for patients following out-of-hospital cardiac arrest, and the extent of unconsciousness at implementation must be defined in such cases. However, there are no clear standards regarding the level of unconsciousness at which MTH would be beneficial. The effects of MTH in patients with different degrees of unconsciousness according to the motor response score of the Glasgow Coma Scale (GCS) were investigated.