中田 孝明

While the development of prehospital diagnosis scales has been reported in various regions, we have also developed a scale to predict stroke type using machine learning. In the present study, we aimed to assess for the first time a scale that predicts the need for surgical intervention across stroke types, including subarachnoid haemorrhage and intracerebral haemorrhage. A multicentre retrospective study was conducted within a secondary medical care area. Twenty-three items, including vitals and neurological symptoms, were analysed in adult patients suspected of having a stroke by paramedics. The primary outcome was a binary classification model for predicting surgical intervention based on eXtreme Gradient Boosting (XGBoost). Of the 1143 patients enrolled, 765 (70%) were used as the training cohort, and 378 (30%) were used as the test cohort. The XGBoost model predicted stroke requiring surgical intervention with high accuracy in the test cohort, with an area under the receiver operating characteristic curve of 0.802 (sensitivity 0.748, specificity 0.853). We found that simple survey items, such as the level of consciousness, vital signs, sudden headache, and speech abnormalities were the most significant variables for accurate prediction. This algorithm can be useful for prehospital stroke management, which is crucial for better patient outcomes.

【目的】臨床症状と血液検査,画像診断を用いた救急外来を受診する患者における新型コロナウイルス感染症(COVID-19)の診断予測精度を明らかにする。【方法】対象は2021年2月～2022年5月の期間に千葉大学医学部附属病院の救急外来を受診し,SARS-CoV-2抗原定量検査とRT-qPCRを施行した患者とした。Receiver operating characteristic(ROC)曲線の曲線下面積(area under the curve;AUC)を算出して臨床症状と検査所見を用いたCOVID-19の診断予測精度を前方視的に検討した。【結果】解析対象患者213名のうちCOVID-19陽性患者は8名であり,全例でSARS-CoV-2抗原定量検査が陽性であった。COVID-19に特徴的な臨床症状数によるAUCは0.679(95%信頼区間0.470-0.887)であった一方,C-reactive proteinとCOVID-19に特徴的な胸部コンピュータ断層撮影(CT)画像所見数を基にしたAUCはそれぞれ0.839(95%信頼区間0.666-1.000),0.877(95%信頼区間0.721-1.000)であった。【結語】救急外来を受診する患者では,臨床症状よりも血液検査や画像所見を用いたCOVID-19の診断予測精度のほうが高かった。(著者抄録)

INTRODUCTION: Capillary refill time (CRT) is an indicator of peripheral circulation and is recommended in the 2021 guidelines for treating and managing sepsis. STUDY OBJECTIVE: This study developed a portable device to realize objective CRT measurement. Assuming that peripheral blood flow obstruction by the artery occlusion test (AOT) or venous occlusion test (VOT) increases the CRT, the cut-off value for peripheral circulatory failure was studied by performing a comparative analysis with CRT with no occlusion test (No OT). METHODS: Fourteen (14) healthy adults (age: 20-26 years) participated in the study. For the vascular occlusion test, a sphygmomanometer was placed on the left upper arm of the participant in the supine position, and a pressure of 30mmHg higher than the systolic pressure was applied for AOT, a pressure of 60mmHg was applied for VOT, respectively, and no pressure was applied for No OT. The CRT was measured from the index finger of the participant's left hand. RESULTS: Experimental results revealed that CRT was significantly longer in the AOT and did not differ significantly in the VOT. The cut-off value for peripheral circulatory failure was found to be 2.88 seconds based on Youden's index by using receiver operating characteristic (ROC) analysis with AOT as positive and No OT as negative. CONCLUSION: Significant results were obtained in a previous study on the evaluation of septic shock patients when CRT > three seconds was considered abnormal, and the cut-off value for peripheral circulatory failure in the current study validated this.

BACKGROUND: Patients with severe acute kidney injury (AKI) who require continuous venovenous hemodiafiltration (CVVHDF) in intensive care unit (ICU) are at high mortality risk. Little is known about clinical biomarkers for risk prediction, optimal initiation, and optimal discontinuation of CVVHDF. METHODS: This prospective observational study was conducted in seven university-affiliated ICUs. For urinary neutrophil gelatinase-associated lipocalin (NGAL) and plasma IL-6 measurements, samples were collected at initiation, 24 h, 48 h after, and CVVHDF discontinuation in adult patients with severe AKI. The outcomes were deaths during CVVHDF and CVVHDF dependence. RESULTS: A total number of 133 patients were included. Twenty-eight patients died without CVVHDF discontinuation (CVVHDF nonsurvivors). Urinary NGAL and plasma IL-6 at the CVVHDF initiation were significantly higher in CVVHDF nonsurvivors than in survivors. Among 105 CVVHDF survivors, 70 patients were free from renal replacement therapy (RRT) or death in the next 7 days after discontinuation (success group), whereas 35 patients died or needed RRT again (failure group). Urinary NGAL at CVVHDF discontinuation was significantly lower in the success group (93.8 ng/ml vs. 999 ng/ml, p < 0.01), whereas no significant difference was observed in plasma IL-6 between the groups. Temporal elevations of urinary NGAL levels during the first 48 h since CVVHDF initiation were observed in CVVHDF nonsurvivors and those who failed in CVVHDF discontinuation. CONCLUSIONS: Urinary NGAL at CVVHDF initiation and discontinuation was associated with mortality and RRT dependence, respectively. The serial changes of urinary NGAL might also help predict the prognosis of patients with AKI on CVVHDF.

Data collection on adverse reactions in recipients after vaccination is vital to evaluate potential health issues, but health observation diaries are onerous for participants. Here, we present a protocol to collect time series information using a smartphone or web-based platform, thus eliminating the need for paperwork and data submission. We describe steps for setting up the platform using the Model-View-Controller web framework, uploading lists of recipients, sending notifications, and managing respondent data. For complete details on the use and execution of this protocol, please refer to Ikeda et al. (2022).1.

OBJECTIVES: The pharmacokinetics of vancomycin and meropenem in patients treated with continuous online hemodiafiltration (OL-HDF) are not well understood. CASE: We evaluated dialytic clearance and serum concentrations of vancomycin and meropenem by OL-HDF in a critically ill patient with soft tissue infection. The mean clearance of OL-HDF and mean serum concentrations during continuous OL-HDF were 155.2 mL/min and 23.1 μg/mL for vancomycin and 145.6 mL/min and 22.7 μg/mL for meropenem. CONCLUSION: Vancomycin and meropenem showed high clearance rates during continuous OL-HDF. However, continuous infusion of these agents at high doses maintained therapeutic serum concentrations.

BACKGROUND: A substantial number of sepsis patients require specialized care, including multidisciplinary care, close monitoring, and artificial organ support in the intensive care unit (ICU). However, the efficacy of ICU management on clinical outcomes remains insufficiently researched. Therefore, we tested the hypothesis that ICU admission would increase the survival rate among sepsis patients. METHODS: We conducted a retrospective study using the nationwide medical claims database of sepsis patients in Japan from 2010 to 2017 with propensity score matching to adjust for baseline imbalances. Patients aged over 20 years, with a combined diagnosis of presumed serious infection and organ failure, were included in this study. The primary outcome studied was the in-hospital mortality among non-ICU and ICU patients. In addition to propensity score matching, we performed a multivariable logistic regression analysis for the primary outcome. As the treatment policy was not extracted from the database, we performed sensitivity analyses to determine mortality differences in adults (20 ≤ age ≤ 64), independent patients, patients without malignant tumors, based on the assumption that treatment intensity is likely to increase in those population. RESULTS: Among 1,167,901 sepsis patients (974,289 in non-ICU and 193,612 in ICU settings), the unadjusted in-hospital mortality was 22.5% among non-ICU patients and 26.2% among ICU patients (3.7% [95% CI 3.5-3.9]). After propensity score matching, the in-hospital mortality was 29.2% among non-ICU patients and 25.8% among ICU patients ([Formula: see text] 3.4% [95% CI [Formula: see text] 3.7 to [Formula: see text] 3.1]). In-hospital mortality with a multivariable regression analysis ([Formula: see text] 5.0% [95% CI [Formula: see text] 5.2 to [Formula: see text] 4.8]) was comparable with the results of the propensity score matching analysis. In the sensitivity analyses, the mortality differences between non-ICU and ICU in adults, independent patients, and patients without malignant tumors were [Formula: see text] 2.7% [95% CI [Formula: see text] 3.3 to [Formula: see text] 2.2], [Formula: see text] 5.8% [95% CI [Formula: see text] 6.4 to [Formula: see text] 5.2], and [Formula: see text] 1.3% [95% CI [Formula: see text] 1.7 to [Formula: see text] 1.0], respectively. CONCLUSIONS: Herein, using the nationwide medical claims database, we demonstrated that ICU admission was potentially associated with decreasing in-hospital mortality among sepsis patients. Further investigations are warranted to validate these results and elucidate the mechanisms favoring ICU management on clinical outcomes.

Sepsis is the leading cause of death worldwide. Considering regional variations in the characteristics of patients with sepsis, a better understanding of the epidemiology in Japan will lead to further development of strategies for the prevention and treatment of sepsis. To investigate the epidemiology of sepsis, we conducted a systematic literature review of PubMed between 2003 and January 2023. Among the 78 studies using a Japanese administrative database, we included 20 that defined patients with sepsis as those with an infection and organ dysfunction. The mortality rate in patients with sepsis has decreased since 2010, reaching 18% in 2017. However, the proportion of inpatients with sepsis is increasing. A study comparing short-course (≤7 days) and long-course (≥8 days) antibiotic administration showed lower 28-day mortality in the short-course group. Six studies on the treatment of patients with septic shock reported that low-dose corticosteroids or polymyxin B hemoperfusion reduced mortality, whereas intravenous immunoglobulins had no such effect. Four studies investigating the effects of treatment in patients with sepsis-associated disseminated intravascular coagulation demonstrated that antithrombin may reduce mortality, whereas recombinant human soluble thrombomodulin does not. A descriptive study of medical costs for patients with sepsis showed that the effective cost per survivor decreased over an 8-year period from 2010 to 2017. Sepsis has a significant impact on public health, and is attracting attention as an ongoing issue. Further research to determine more appropriate prevention methods and treatment for sepsis should be a matter of priority.

目的:Advanced Surgical Skills for Exposure in Trauma(ASSET)コースは米国外科学会が開発したご遺体を用いた外傷トレーニングコースの1つである。世界各国で開催されており,わが国では2016年に初開催された。本コースでは,外傷症例のディスカッションを行い,手術手技を1日で学ぶ。わが国における本コースの有用性が明らかでないため,アンケート調査結果を分析した。方法:過去9回,76名の受講者に対してアンケートを行い,以下の各項目(全体評価,プログラムのトピックスと内容,必要性との合致性,教育の形式,実際の臨床への有用性,新しい知識/技術の習得,満足度など)を分析した。さらに解剖学的に役立った部位も調査した。結果:5段階評価にて平均4.3～4.8と高評価であった。役立った部位は,頸部や上肢を選ぶ受講生が多かった。結論:ASSTコースにも長所,短所があるものの,アンケート調査結果は高評価であり,今後も継続的な普及が望まれる。(著者抄録)

目的:Advanced Surgical Skills for Exposure in Trauma(ASSET)コースは米国外科学会が開発したご遺体を用いた外傷トレーニングコースの1つである。世界各国で開催されており,わが国では2016年に初開催された。本コースでは,外傷症例のディスカッションを行い,手術手技を1日で学ぶ。わが国における本コースの有用性が明らかでないため,アンケート調査結果を分析した。方法:過去9回,76名の受講者に対してアンケートを行い,以下の各項目(全体評価,プログラムのトピックスと内容,必要性との合致性,教育の形式,実際の臨床への有用性,新しい知識/技術の習得,満足度など)を分析した。さらに解剖学的に役立った部位も調査した。結果:5段階評価にて平均4.3～4.8と高評価であった。役立った部位は,頸部や上肢を選ぶ受講生が多かった。結論:ASSTコースにも長所,短所があるものの,アンケート調査結果は高評価であり,今後も継続的な普及が望まれる。(著者抄録)

OBJECTIVES: The aim of this study was to reveal the neurological outcomes of choking-induced out-of-hospital cardiac arrest (OHCA) and evaluate the presence of witnesses, cardiopulmonary resuscitation (CPR) performed by a witness (bystander-witnessed CPR), and the proportion of patients with favourable neurological outcomes by the time from CPR by emergency medical services (EMS) to the return of spontaneous circulation (ROSC) (CPR-ROSC time). METHODS: We retrospectively analysed the SOS-KANTO 2012 database, which included data of 16,452 OHCAs in Japan. We selected choking-induced OHCA patients aged ≥ 20 years. We evaluated the neurological outcomes at 1 month with the Cerebral Performance Category (CPC). We defined favourable neurological outcomes (CPCs: 1-2) and present the outcomes with descriptive statistics. RESULTS: Of 1,045 choking-induced OHCA patients, 18 (1.7%) had a favourable neurological outcome. Of 1,045 OHCAs, 757 (72.6%) were witnessed, and 375 (36.0%) underwent bystander-witnessed CPR. Of the 18 OHCAs with favourable outcomes, 17 (94.4%) were witnessed, and 11 (61.1%) underwent bystander-witnessed CPR. With a CPR-ROSC time of 0-5 minutes, the proportion of patients with favourable neurological outcomes was 29.7%, ranging from 0% to 6% in the following time groups. CONCLUSIONS: The neurological outcome of choking-induced OHCA was poor. The neurological outcomes deteriorated rapidly from 5 minutes after the initiation of CPR by EMS. The presence of witnesses and bystander-witnessed CPR may be factors that contribute to improved outcomes, but the effects were not remarkable. As another approach to reduce deaths due to choking, citizen education for the prevention of choking may be effective.