Retroperitoneal abscess associated with closed pelvic ring fracture diagnosed by fine free air on initial trauma pan computed tomography scan.

The patient was a 49-year-old male. He had a closed fracture of the pelvic ring that was treated successfully by avoiding anterior pelvic ring stabilization because of the presence of microscopic free air in the retroperitoneal space behind the pubic bone on initial whole-body trauma computed tomography scan. For his pelvic ring injury, transiliac rod and screw fixation was performed without the need for a pubic symphysis plate by developing the retroperitoneal space. His retroperitoneal abscess was treated by minimally invasive treatment of retroperitoneal abscess with computed tomography-guided percutaneous drainage. At 2 years postoperatively, there was no fever or elevated inflammatory response suspicious of retroperitoneal abscess recurrence. In this case, the presence of microscopic free air influenced the choice of treatment. Even in closed pelvic ring fractures, the presence of free air should be carefully considered when reading images.

Survey of sensory impairment in critically ill patients after intensive care unit discharge: An ambidirectional cohort study.

BACKGROUND: Sensory impairment affects the quality of life after intensive care. However, no studies have comprehensively examined sensory impairment after intensive care. OBJECTIVES: This study aimed to investigate sensory impairment in critically ill patients. METHODS: This ambidirectional cohort study was conducted in the intensive care unit (ICU) of a university hospital between April 2017 and January 2020. Patients who survived despite invasive mechanical ventilation for >48 h, with a discharge period of >6 months, participated in the study. A questionnaire was sent to consenting patients to investigate the presence or absence of sensory impairment at that time, and treatment-related data were collected from their medical records. RESULTS: Of 75 eligible patients, 62 responded to our survey. Twenty-seven (43.6%) patients had some sensory impairment. Nine (14.5%) patients had chronic pain after ICU discharge, 4 (6.5%) had chronic pain and visual impairment, 3 (4.8%) had visual impairment only, and 3 (4.8%) had chronic pain and taste impairment. The most common overlapping symptom was a combination of chronic pain. CONCLUSIONS: Critically ill patients who survived and were discharged from the ICU accounted for 43.6% of patients with complaints of sensory impairment in the chronic phase. The results of this study suggest the need for follow-up and treatment of possible sensory impairment following ICU discharge.

Characteristics of patients resuscitated after burn related out-of-hospital cardiac arrest.

AIM: This study's objective was to describe the characteristics of burn injury patients who were resuscitated after burn related out-of-hospital cardiac arrest (OHCA). METHOD: We conducted a retrospective cohort study and examined characteristics of burn related OHCA using data from a Japanese nationwide burn registry that was collected between April 1, 2011 and March 31, 2020. First, we compared the characteristics of burn patients with and without OHCA. Second, among burn patients with OHCA, we compared the characteristics of survivors with non-survivors. RESULTS: In the database, there were 16,995 hospitalised burn patients and 256 burn related OHCA. Thirty-two of the 256 burn patients (13%) survived after admission. Among patients with burns who also had OHCA, flames were the most common injury mechanism (74%); in comparison to all other injury mechanisms, the rate of flame burn was significantly higher in burn patients with OHCA than in burn patients without OHCA. The most common cause of death for burn related OHCA is carbon-monoxide poisoning (46%). Compared with survivors, non-survivors had a larger burn area, greater age and more complications. such as inhalation injuries and perineal burn injuries. Compared to other mechanisms of burn injury, electrical burn injuries were more common among survivors. In twelve patients with electrical burns, eight patients survived (67%) OHCA; of those eight patients, six (50%) could be discharged home. CONCLUSION: Patients with burn related OHCA have a poor prognosis; however, patients who sustain electrical shock injuries may do better.

Association of early-onset constipation and diarrhoea with patient outcomes in critically ill ventilated patients: A retrospective observational cohort study.

BACKGROUND: Constipation and diarrhoea are closely related, but few studies have examined them simultaneously. OBJECTIVES: The purpose of this study was to describe patient defecation status after intensive care unit (ICU) admission and determine the association between early-onset constipation and diarrhoea following ICU admission with outcomes for critically ill ventilated patients. METHODS: Patients ventilated for ≥48 h in an ICU were retrospectively investigated, and their defecation status was assessed during the first week after admission. Early-onset constipation and diarrhoea were defined as onset during the first week of ICU admission. The patients were divided into three groups-normal defecation, constipation, and diarrhoea-and multiple comparisons were performed using the Kruskal-Wallis test and the Mann-Whitney U test with Bonferroni adjustment. Additionally, multivariable analysis was performed for mortality and length of stay using the linear and logistic regression models. RESULTS: Of the 85 critically ill ventilated patients, 47 (55%) experienced early-onset constipation and 12 (14%) experienced early-onset diarrhoea. Patients with normal defecation and diarrhoea increased from the 4th and 5th day of ICU admission. Early-onset diarrhoea was significantly associated with the length of ICU stay (B = 7.534, 95% confidence interval: 0.116-14.951). CONCLUSIONS: Early-onset constipation and diarrhoea were common in critically ill ventilated patients, and early-onset diarrhoea was associated with the length of ICU stay.

Adequacy of compression positioning using the feedback device during chest compressions by medical staff in a simulation study.

BACKGROUND: The 2020 American Heart Association guidelines recommend the use of a feedback device during chest compressions (CCs). However, these devices are only placed visually by medical personnel on the lower half of the sternum and do not provide feedback on the adequacy of the pressure-delivery position. In this study, we investigated whether medical staff could deliver CCs at the adequate compression position using a feedback device and identified where the inadequate position was compressed. METHODS: This simulation-based, prospective single-centre study enrolled 44 medical personnel who were assigned to four different groups based on the standing position and the hand in contact with the feedback device as follows: right-left (R-l), right-right (R-r), left-right (L-r), and left-left (L-l), respectively. The sensor position where the maximal average pressure was applied during CCs using the feedback device were ascertained with a flexible capacitive pressure sensor. We determined if this position is the adequate compression position or not. The intergroup differences in the frequency of the adequate compression position, the maximal average pressure, compression rate, depth and recoil were determined. RESULTS: The frequencies of adequate compression positioning were 55, 50, 58, and 60% in the R-l, R-r, L-r, and L-l groups, respectively, with no significant intergroup difference (p = 0.917). Inadequate position occurred in the front, back, hypothenar and thenar sides. The maximal average pressure did not significantly differ among the groups (p = 0.0781). The average compression rate was 100-110 compressions/min in each group, the average depth was 5-6 cm, and the average recoil was 0.1 cm, with no significant intergroup differences (p = 0.0882, 0.9653, and 0.2757, respectively). CONCLUSIONS: We found that only approximately half of the medical staff could deliver CCs using the feedback device at an adequate compression position and the inadequate position occurred in all sides. Resuscitation courses should be designed to educate trainees about the proper placement during CCs using a feedback device while also evaluating the correct compression position.

Association Between Perineal Burns Injury and In-hospital Mortality: A Retrospective Observational Study from the Nation-Wide Burn Registry in Japan.

Although perineal burn injury is included in the burn center referral criteria for Advanced Burn Life Support, clinical evidence that perineal burn injury increases mortality risk is limited, especially from Asian countries. The objective of this study was to investigate whether perineal burns affect in-hospital mortality. Using data from the nation-wide burn registry collected from April 1, 2011 to March 31, 2019, we retrospectively identified 10,179 hospitalized burn patients over 16 years of age. The in-hospital mortality rate between the patients with perineal burn and those with other burns was compared, and the adjusted odds ratio for in-hospital mortality was determined with multivariable logistic regression analysis controlling for age, gender, mechanism of burn injury, year of admission, total burn surface area, inhalation injury, hand injury, and transfers from another hospital. One thousand one hundred forty-nine patients with perineal burn were enrolled, and the in-hospital mortality of this group was higher than that of the group of patients with other types of burns (46 vs 5.2%, P < 0.001). Multivariable analysis found that the presence of perineal burns is associated with in-hospital mortality (odds ratio 2.11 [95% confidence intervals (CI) 1.64-2.71]; P < 0.001). Our data, as evidence, certified the referral criteria that perineal burn injury is associated with higher in-hospital mortality in Japan.

Reflection analysis of absorbing film with diffractive structures for incoherent light by rigorous coupled-wave analysis.

Reflectivity is useful for evaluating the extinction coefficient; however, it is highly sensitive to the refractive index structure. In this study, we propose a novel, to the best of our knowledge, method for evaluating the influence of the structure on reflectivity using rigorous coupled-wave analysis (RCWA), and apply it to analyze the reflectivity of the dye rhodamine B. The reflection-absorption spectrum of the film was significantly affected by its surface and internal structure. We found that simulating the reflectivity of a film with an unknown internal structure, using the coherency parameter is convenient. The RCWA facilitated simultaneous treatment of the coherent diffraction by the surface structure and incoherent reflection in the film.

Impact of adverse events on patient outcomes in a Japanese intensive care unit: a retrospective observational study.

AIM: We investigated adverse events (AEs) in a Japanese intensive care unit (ICU) and evaluated the impact of cause-specific AEs on mortality and length of stay. DESIGN: A retrospective observational study in the ICU of an academic hospital. METHODS: We reviewed medical records with the Global Trigger Tool. RESULTS: Of the 246 patients, 126 (51%) experienced one or more AEs with an incidence of 201 per 1000 patient-days and 115 per 100 admissions. A total of 294 AEs were detected with 119 (42%) adverse drug events, 67 (24%) procedural complications, 63 (22%) surgical complications, 26 (9%) nosocomial infections, 5 (2%) therapeutic errors and 4 (1%) diagnostic errors. Adverse event (AE) presence was associated with length of ICU stay (ß = 2.85, 95% confidence interval [CI]: 1.09-4.61). Adverse drug events, procedural complications and nosocomial infections were strongly associated with length of ICU stay (ß = 2.38, 95% CI: 0.77-3.98; ß = 3.75, 95% CI: 2.03-5.48; ß = 6.52, 95% CI: 4.07-8.97 respectively).

Development of the Japanese version of the Intensive Care Unit Trigger Tool to detect adverse events in critically ill patients.

AIM: The Intensive Care Unit Trigger Tool (ICUTT) was developed to detect adverse events (AEs) in intensive care unit (ICU) patients. The purpose of this study was to determine the validity and reliability of the Japanese version of the ICUTT (ICUTT-J). METHODS: The translation of ICUTT was carried out based on the guideline for translation of instruments. Subsequently, two review teams independently reviewed 50 patients' medical records using the ICUTT-J, and agreement regarding the presence and number of AEs was evaluated to ensure reliability. RESULTS: The ICUTT-J was submitted to the authors of the original ICUTT, who confirmed it as being equivalent to the original version. The item-content validity index and scale-content validity index were 1.00 and 1.00, respectively. Interrater reliability showed moderate agreement of κ = 0.52 in terms of the presence of AEs and linear weighting of κ = 0.49 (95% confidence interval, 0.28, 0.71) in terms of the number of AEs. CONCLUSION: This study's findings suggest that the ICUTT-J is valid and moderately reliable for use in ICUs.

Adequacy of hand positioning by medical personnel during chest compression in a simulation study.

AIM: During chest compressions (CCs), the hand position at the lower half of the sternum is not strictly maintained, unlike depth or rate. This study was conducted to determine whether medical staff could adequately push at a marked location on the lower half of the sternum, identify where the inappropriate hand position was shifted to, and correct the inappropriate hand position. METHODS: This simulation-based, prospective single-center study enrolled 44 medical personnel. Pressure and hand position during CC were ascertained using a flexible pressure sensor. The participants were divided into four groups by standing position and the hand in contact with the sternum: right-left (R-l), right-right (R-r), left-right (L-r), and left-left (L-l). We compared the groups and the methods: the manual method (MM), the thenar method, and the hypothenar method (HM). RESULTS: Among participants using the MM, 80% did not push adequately at the marked location on the lower half of the sternum; 60%-90% of the inadequate positions were shifted to the hypothenar side. CCs with the HM facilitated stronger pressure, and the position was minimally shifted to the hypothenar side. CONCLUSION: Medical staff could not push at an appropriate position during CCs. Resuscitation courses should be designed to educate personnel on the appropriate position for application of maximal pressure while also evaluating the position during CCs.

High accuracy cross-sectional shape analysis by coherent soft x-ray diffraction.

When the scatterer size is less than 100 wavelengths, the effect of diffraction is large. The analysis of diffraction is important for 3D shape measurement. However, in soft x rays, shapes suitable for rigorous diffraction analysis have been limited to ellipses and periodic structures. We have developed a method to expand this to any shape (isolated triangle, rectangle, etc.). Experimentally, we measured the respective widths of the cross section of a column consisting of two layers and showed that the resolution was at least a few wavelengths. For this purpose, we have also developed a fast simulation method with a small memory size.

Fatal acute hypernatremia resulting from a massive intake of seasoning soy sauce.

BACKGROUND: Hypernatremia due to salt poisoning is clinically rare and standard care procedures have not been established. We report a case of salt poisoning due to massive intake of seasoning soy sauce. CASE PRESENTATION: A 40-year-old woman presented to the emergency department with seizures and remarkable hypernatremia with a serum sodium concentration of 183 mEq/L. The initial brain computed tomography scan showed brain shrinkage, which could occur during the acute phase of hypernatremia. We reduced her serum sodium level rapidly, rather than at the recommended slow rate. On day 3, the patient's brain computed tomography scan showed widespread low-density areas and edema. The patient died 8 days after admission. CONCLUSION: After reviewing instances of resuscitation following salt intoxication, aggressive rapid correction of serum sodium concentration should only be considered in acute phases of hypernatremia within a few hours from ingestion, and 2-3 h could be one of the criteria.

Delayed union of a surgically treated fragility fracture of the pelvis: A case report.

INTRODUCTION: There are no universally accepted treatment strategies for fragility fractures of the pelvis (FFPs). The incidence of delayed union or non-union of Type IIIa FFP is still unknown. PRESENTATION OF CASE: We describe a case of delayed union of a Type IIIa FFP. A 96-year-old female patient who lives independently accidentally fell when exiting a car. The diagnosis of Type IIIa FFP with displaced left ilium and left pubic rami fracture. Surgical repair was performed using an anterior intrapelvic approach with constructs made using two reconstruction contoured plates to bridge the medial edge and middle part of the fracture. This case was revealed delayed union. The periodic CT examinations were performed to determine the progress of bone union. The patient returned to most social activities including living independently and the Modified Majeed score was 94 at 12 months post-operation. DISCUSSION: For the case of TypeⅢa FFP, soft tissue is spread over a wide area. When the fracture site of ilium was exposed, the cortical bone was found to be thin with poor blood flow. There is a possibility that the blood flow was hindered by subperiosteal elevation of the iliacus muscle from the internal iliac fossa in this case. CONCLUSION: Non-union of the iliac wings is relatively rare following high-energy pelvic ring fractures. The incidence of delayed union or non-union of Type IIIa FFP remains unknown; therefore, careful follow-up of patients who undergo treatment is necessary to reduce the risk of delayed union.

Association between fluid overload and delirium/coma in mechanically ventilated patients.

AIM: Several studies have shown an association between fluid overload (FO) and mortality or duration of mechanical ventilation in critically ill patients. However, the association between FO and delirium duration remains unclear. METHODS: This retrospective observational cohort study was undertaken at University of Tsukuba Hospital (Tsukuba, Japan) from April 2015 to March 2017. Mechanically ventilated patients who stayed in the intensive care unit for more than 7 days were eligible for inclusion. Univariate analysis was carried out with the Mann-Whitney U-test for continuous variables and Fisher's exact test for categorical variables. A multivariate proportional odds logistic regression model was used to evaluate the association between FO and delirium/coma days (DCDs) during the 7-day study period. RESULTS: A total of 118 patients were included and divided into FO and non-FO groups. Fluid overload occurred in 40% of patients. The FO group had a higher APACHE II score than the non-FO group (19 [16-26] versus 23 [20-29], P = 0.017). Cumulative fluid balance at day 3 was higher in the FO group (3,238 [281-6,530] versus 7,886 [4,106-10,631], P < 0.001). Delirium days within 7 days was longer in the FO group (1 [0-3] versus 2 [1-3], P = 0.048) and DCDs was longer in the FO group (4 [1-5] versus 6 [3-7], P = 0.002). After adjusting for covariates, there were significant associations between FO and DCDs (odds ratio, 2.16; 95% confidence interval, 1.05-4.47). CONCLUSIONS: Our findings suggest that FO is associated with increased DCDs in mechanically ventilated patients.

The Validity and Reliability of the Japanese Version of the Cornell Assessment of Pediatric Delirium.

OBJECTIVES: To examine validity and reliability of the Japanese version of the Cornell Assessment of Pediatric Delirium. DESIGN: Prospective double-blinded observational cohort study. SETTING: Eight-bed mixed PICU (post-surgical and internal medicine) from May 2017 to June 2018. PATIENTS: All children between the ages of 0-13 years who were admitted to the PICU for at least 24 hours were eligible for inclusion, as long as the child was arousable to verbal stimulation. INTERVENTIONS: Two nurses simultaneously and independently assessed each patient for pediatric delirium with the Japanese version of the Cornell Assessment of Pediatric Delirium; this was compared to the gold standard of psychiatric diagnosis based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition standards. MEASUREMENTS AND MAIN RESULTS: Forty-one children were enrolled and 92 assessments (ranging from one to four per subject) were completed. Congenital heart disease patients accounted for 73 enrollees (79%). Forty-three percent of observations were performed in children on invasive mechanical ventilation. Pediatric delirium prevalence (as determined by psychiatric diagnosis) was 53%. The Japanese version of the Cornell Assessment of Pediatric Delirium demonstrated an optimal scoring cutpoint of 9. Overall, area under the curve was 92%, sensitivity 90% (95% CI, 79-97%), specificity 88% (95% CI, 75-96%), positive predictive value of 90% (95% CI, 79-97%), negative predictive value of 91% (95% CI, 80-97%), and a Cohen's κ of 0.89 (95% CI, 0.8-0.98). In children on invasive mechanical ventilation, the Japanese version of the Cornell Assessment of Pediatric Delirium maintained an area under the curve 87%, sensitivity 97%, and specificity 64%. CONCLUSIONS: The Japanese version of the Cornell Assessment of Pediatric Delirium is a valid and reliable tool for use in Japanese PICUs. This will allow for detection of delirium in real-time and may lead to better identification of the population and risk factors for appropriate management and therapeutic and preventative interventions.

Risk factors for prolonged intensive care unit and hospital stay among patients with acute drug overdose in Japan.

AIM: Hospital selection for patients with drug overdose (DOD) is a critical issue. In Tokyo, the 50-tablet rule has been widely utilized by paramedics for triaging patients with DOD given that it shortens the triage time. However, studies have not investigated the utility of such a rule in local cities. The present study aimed to identify prognostic pre- and in-hospital factors among patients with DOD and determine whether the 50-tablet rule benefits local cities. METHODS: Clinical records of patients with DOD admitted at the University of Tsukuba Hospital (Tsukuba, Japan) between 2013 and 2017 were retrospectively reviewed. RESULTS: A total of 93 patients with DOD were enrolled in this study. Multivariate analysis showed that creatine kinase and C-reactive protein values and the total number of ingested pills were in-hospital risk factors that significantly prolonged intensive care unit (ICU) and hospital stay. Moreover, Glasgow Coma Scale score on admission and the total number of ingested pills were identified as significant pre-hospital risk factors for prolonged ICU and hospital stay. Setting the total number of ingested pills to 50 tablets did not significantly influence ICU and hospital stay. CONCLUSION: The total number of ingested pills and creatine kinase and C-reactive protein values were identified as predictive factors for prolonged ICU and hospital stay in patients with DOD after admission. Moreover, pre-hospital risk factors included Glasgow Coma Scale score and the total number of ingested pills. However, the 50-tablet rule was determined to be a poor cut-off value for patients with DOD. We presented a subset of our findings at the 46th annual meeting of the Japanese Society for Acute Medicine (Yokohama, Japan) on 20 November 2018.

Method for Prediction of Efficacy of Sugammadex Administered to Recover from Rocuronium-Induced Neuromuscular Blockade in Gynecological Laparoscopic Surgery Cases.

Sugammadex (SDX), a neuromuscular blocking-reversal agent, quickly reverses neuromuscular blockade induced by rocuronium (RCR). SDX dosage is set according to the state of neuromuscular blockade determined with a neuromuscular monitoring device. However, in clinical situations, such a devise is not frequently used. Here, we report construction of a method for theoretically setting SDX dose by which the optimum reverse time (RT) can be obtained for individual patients even when the device is not available. The subjects were 42 adult female patients who underwent laparoscopic surgery from 1 August 2015 to 31 March 2016, during which RCR and SDX were administered. We formulated an equation for theoretically calculating the RCR residual ratio (RR) in blood after SDX administration. Furthermore, we examined the relationship between RR and RT. Based on the results obtained, we developed a method for predicting RT using RR. We excluded 1 subject as the RT value was detected as an outlier in our analysis. Multiple regression analysis was performed using standard body weight, serum creatinine, total bilirubin, and RR as explanatory variables. The number of subjects with a prediction error of RT within ±1 min was 36 (87.8%) of 41 in multiple regression analysis. We could predict RT following SDX administration by using the RT prediction expression with RR obtained for subjects administered RCR during the surgery. Furthermore, our results suggest that the SDX dose able to achieve optimum RT may be set prior to surgery on the basis of the present methodology.

Verifying the validity and reliability of the Japanese version of the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale.

BACKGROUND: Pediatric patients, especially in the preverbal stage, cannot self-report intensity of pain therefore several validated observational tools, including the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale, have been used as a benchmark to evaluate pediatric pain. Unfortunately, this scale is currently unavailable in Japanese, precluding its widespread use in Japanese hospitals. OBJECTIVES: To translate and verify the validity and reliability of the Japanese version of the FLACC Behavioral Scale. METHOD: Back-translation was first conducted by eight medical researchers, then an available sample of patients at the University of Tsukuba Pediatric Intensive Care Unit (from May 2017 to August 2017) was enrolled in a clinical study. Two researchers evaluated the validity of the translated FLACC Behavioral Scale by weighted kappa coefficient and intraclass correlation coefficients (ICC). Observational pain was simultaneously measured by the visual analog scale (VAS obs) and reliability was evaluated by correlation analysis. RESULT: The original author approved the translation. For the clinical study, a total of 121 observations were obtained from 24 pediatric patients. Agreement between observers was highly correlated for each of the FLACC categories (Face: κ = 0.85, Leg: κ = 0.74, Activity: κ = 0.89, Cry: κ = 0.93, Consolability: κ = 0.93) as well as the total score (Total: κ = 0.95,). Correlation analysis demonstrated a good criterion validation between the FLACC scale and the VAS obs. (r = 0.96). CONCLUSION: Our Japanese version of the FLACC Behavioral Scale shows high validity and reliability.

A case of disseminated cryptococcosis with necrotizing fasciitis in a non-HIV patient.

Case: Disseminated cryptococcosis is a well-recognized condition among HIV patients, but it also occurs in non-HIV patients. Necrotizing fasciitis caused by cryptococcus is rare. An 81-year-old man who had received steroid therapy presented with erythema and pain in his right thigh. After the rapid progression of symptoms and a failure to respond to antibiotic therapy, a clinical diagnosis of necrotizing fasciitis was made. We performed debridement, and yeasts were detected using a Gram stain of the fascia. We treated the patient with liposomal amphotericin B. On day 3, he developed meningitis. Cryptococcus neoformans was detected in the blood, fascia, and cerebrospinal fluid. Flucytosine was added to liposomal amphotericin B. Outcome: Despite the antifungal treatment, new regions of dissemination to the skin developed, and the patient died of multiple organ failure. Conclusion: A diagnosis of disseminated cryptococcosis should be considered in a differential diagnosis of necrotizing fasciitis among immunocompromised patients, regardless of their HIV status.