Adherence rate of quality-of-care indicators for Staphylococcus aureus bacteremia is extremely low in Japanese emergency and critical care departments: a multicenter retrospective observational study.

Aim: Staphylococcus aureus bacteremia causes significant morbidity and mortality and requires specific management to prevent complications. Most studies evaluating quality of care have been carried out in Europe and North America, and accurate epidemiological data are lacking in Asia. We aimed to describe the epidemiology and evaluate the quality of care for S. aureus bacteremia in Japan. Methods: From February 2011 to January 2014, we undertook a multicenter retrospective observational study in 10 departments of emergency and critical care in Japan. We included 118 hospitalized adult patients with S. aureus bacteremia and evaluated three quality-of-care indicators: follow-up blood culture, treatment duration, and echocardiography. Results: The mean age of the patients was 63.5 ± 17.0 years. The major source of bacteremia was pneumonia (n = 22, 19%), followed by skin and soft tissue infection (n = 18, 15%). Thirty patients (25%) died in the hospital. Follow-up blood culture was performed in 21/112 patients (19%). The duration of antimicrobial treatment was sufficient in 49/87 patients (56%). Echocardiography for patients with clinical indication was undertaken in 39/59 patients (66%). Any of the three indicators were inadequate in 101/118 (86%). Conclusion: The rate of adequate care for S. aureus bacteremia is low in Japan. The low adherence rate for follow-up blood culture was particularly notable. Staphylococcus aureus bacteremia can be an important target of quality improvement interventions.

Continuous improvements in "chain of survival" increased survival after out-of-hospital cardiac arrests: a large-scale population-based study.

BACKGROUND: The impact of ongoing efforts to improve the "chain of survival" for out-of-hospital cardiac arrest (OHCA) is unclear. The objective of this study was to evaluate the incremental effect of changes in prehospital emergency care on survival after OHCA. METHODS AND RESULTS: This prospective, population-based observational study involved consecutive patients with OHCA from May 1998 through December 2006. The primary outcome measure was 1-month survival with favorable neurological outcome. Multiple logistic regression analysis was used to assess factors that were potentially associated with better neurological outcome. Among 42,873 resuscitation-attempted adult OHCAs, 8782 bystander-witnessed arrests of presumed cardiac origin were analyzed. The median time interval from collapse to call for medical help, first cardiopulmonary resuscitation, and first shock shortened from 4 (interquartile range [IQR] 2 to 11) to 2 (IQR 1 to 5) minutes, from 9 (IQR 5 to 13) to 7 (IQR 3 to 11) minutes, and from 19 (IQR 13 to 22) to 9 (IQR 7 to 12) minutes, respectively. Neurologically intact 1-month survival after witnessed ventricular fibrillation increased from 6% (6/96) to 16% (49/297; P<0.001). Among all witnessed OHCAs, earlier cardiopulmonary resuscitation (odds ratio per minute 0.89, 95% confidence interval 0.85 to 0.93) and earlier intubation (odds ratio per minute 0.96, 95% confidence interval 0.94 to 0.99) were associated with better neurological outcome. For ventricular fibrillation, only earlier shock was associated with better outcome (odds ratio 0.84, 95% confidence interval 0.80 to 0.88). CONCLUSIONS: Data from a large, population-based cohort demonstrate a continuous increase in OHCA survival with improvement in the chain of survival. The incremental benefit of early advanced care on OHCA survival is also suggested.

Usefulness of procalcitonin serum level for the discrimination of severe sepsis from sepsis: a multicenter prospective study.

Procalcitonin serum level has been recommended as a new marker of bacterial infectious diseases. The aim of this prospective, multicenter study was to determine the clinical usefulness of procalcitonin in differentiating patients with sepsis from those with severe sepsis. Eighty-two patients were enrolled: 20 without systemic inflammatory response syndrome (SIRS), 9 with SIRS, 34 with sepsis, and 19 with severe sepsis. The patients with severe sepsis had significantly higher procalcitonin levels (median, 36.1 ng/ml) than those with sepsis (median, 0.6 ng/ml). With a procalcitonin cutoff value of 2.0 ng/ml, sensitivity for the detection of severe sepsis and specificity for the detection of sepsis were 94.7% and 78.1%, respectively. A good correlation was found between the serum procalcitonin level and the Sepsis-Related Organ Failure Assessment (SOFA) score (r = 0.680), although no correlation was found between the C-reactive protein (CRP) level and the SOFA score. In conclusion, the procalcitonin serum level may be useful not only for aiding the diagnosis of sepsis but also for discriminating between sepsis and severe sepsis.

Survival rate and factors associated with 1-month survival of witnessed out-of-hospital cardiac arrest of cardiac origin with ventricular fibrillation and pulseless ventricular tachycardia: the Utstein Osaka project.

OBJECTIVE: We reassessed 1-month survival of patients with witnessed out-of-hospital cardiac arrest (OHCA) of cardiac origin with ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) in Osaka, Japan, and identified factors associated with 1-month survival using updated data from 1998 to 2004 collected based on the Utstein Style. METHODS: Using the Utstein Osaka Project database, we analyzed 1028 cases which met the following criteria: (1) patient age 18 years or older; (2) presumed cardiac origin based on the definition of the Utstein Style; (3) witnessed by citizens; (4) VF or pulseless VT at the time of arrival of the ambulance. The main outcome measure was survival at 1 month after collapse. Variables to develop a predictive model for 1-month survival were selected by stepwise logistic regression. RESULTS: Survival at 1 month was 19.6%. Factors retained in the final logistic regression were age, sex, type of witness, and time interval from (a) ambulance call receipt to cardiopulmonary resuscitation (CPR) by the ambulance crew; (b) ambulance call to defibrillation; (c) CPR by the ambulance crew to hospital arrival. Area under the receiver-operating characteristic curve for the model developed with the six variables was 0.738 and Hosmer-Lemshow goodness-of-fit p-value was 0.94. CONCLUSION: We successfully developed a model to estimate the probability of 1-month survival using variables easy to collect in the early phase of resuscitation, and this model would help physicians and family members predict the likelihood of 1-month survival of OHCA patients on admission.

Effectiveness of bystander-initiated cardiac-only resuscitation for patients with out-of-hospital cardiac arrest.

BACKGROUND: Previous animal and clinical studies suggest that bystander-initiated cardiac-only resuscitation may be superior to conventional cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrests. Our hypothesis was that both cardiac-only bystander resuscitation and conventional bystander CPR would improve outcomes from out-of-hospital cardiac arrests of < or = 15 minutes' duration, whereas the addition of rescue breathing would improve outcomes for cardiac arrests lasting > 15 minutes. METHODS AND RESULTS: We carried out a prospective, population-based, observational study involving consecutive patients with emergency responder resuscitation attempts from May 1, 1998, through April 30, 2003. The primary outcome measure was 1-year survival with favorable neurological outcome. Multivariable logistic regression analysis was performed to evaluate the relationship between type of CPR and outcomes. Among the 4902 witnessed cardiac arrests, 783 received conventional CPR, and 544 received cardiac-only resuscitation. Excluding very-long-duration cardiac arrests (> 15 minutes), the cardiac-only resuscitation yielded a higher rate of 1-year survival with favorable neurological outcome than no bystander CPR (4.3% versus 2.5%; odds ratio, 1.72; 95% CI, 1.01 to 2.95), and conventional CPR showed similar effectiveness (4.1%; odds ratio, 1.57; 95% CI, 0.95 to 2.60). For the very-long-duration arrests, neurologically favorable 1-year survival was greater in the conventional CPR group, but there were few survivors regardless of the type of bystander CPR (0.3% [2 of 624], 0% [0 of 92], and 2.2% [3 of 139] in the no bystander CPR, cardiac-only CPR, and conventional CPR groups, respectively; P<0.05). CONCLUSIONS: Bystander-initiated cardiac-only resuscitation and conventional CPR are similarly effective for most adult out-of-hospital cardiac arrests. For very prolonged cardiac arrests, the addition of rescue breathing may be of some help.

Neutrophil elastase as a predicting factor for development of acute lung injury.

OBJECTIVE: To determine whether the development of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) associated with systemic inflammatory response syndrome (SIRS) can be predicted by the plasma neutrophil elastase level. PATIENTS AND METHODS: Patients were sequentially enrolled after obtaining informed consent. Twenty-three adult patients with SIRS were classified into the following groups; SIRS alone (5 patients), Group A of ALI/ARDS with SIRS (9 patients) that did not require mechanical ventilation, and Group B of ALI/ARDS with SIRS (9 patients) that required mechanical ventilation. Blood samples were obtained after the diagnosis of SIRS, and the sequential sampling was performed. RESULTS: The plasma neutrophil elastase level was significantly elevated in all patient groups as compared with healthy controls (43.7+/-5.4 ng/ml). The elastase levels in SIRS alone, Group A of ALI/ARDS, and Group B of ALI/ARDS were 126.9+/-11.0 ng/ml, 316.2+/-68.9 ng/ml, and 458.4+/-132.8 ng/ml, respectively. The elastase level in ALI/ARDS with SIRS was significantly greater than that in SIRS alone. The maximal level in 13 of 18 patients with ALI/ARDS with SIRS was more than 220 ng/ml. The level in all patients with SIRS alone was consistently less than 220 ng/ml over the study period. The serum levels of inflammatory cytokines were elevated in these patients, but no statistical significance was detected among the groups. CONCLUSION: The critical level of plasma neutrophil elastase is 220 ng/ml, and the SIRS patients with more than 220 ng/ml neutrophil elastase are highly likely to develop ALI/ARDS.

Outcome and characteristics of out-of-hospital cardiac arrest according to location of arrest: A report from a large-scale, population-based study in Osaka, Japan.

OBJECTIVE: To evaluate the outcome and the factors concerned with of out-of-hospital cardiac arrest patients according to the location of the collapse. METHODS: From May 1st, 1998 to April 30th, 2001, 15,211 consecutive out-of-hospital cardiac arrest cases considered for resuscitation were recorded. Of these cases 7540 arrests in subjects aged 18 years or older with cardiac aetiology were analyzed. The outcome and the related-factors, particularly incidence of ventricular fibrillation, were evaluated according to the location of the cardiac arrest. To analyze the factors that affect the incidence of ventricular fibrillation, a logistic regression model was used. RESULTS: About three-quarters of out-of-hospital cardiac arrests occurred at private residences. The outcome and characteristics were significantly different according to the location of the arrest. Arrest patients in public or in the work place had a higher chance of being found in ventricular fibrillation and survival than those at a private residence. The multivariate adjusted odds ratios for ventricular fibrillation in a public or work place were significantly higher than that in private residences, after adjusting for covariates affecting initial rhythm, such as age, sex, witnessed status, bystander cardiopulmonary resuscitation, and response interval. CONCLUSION: Although the majority of out-of-hospital cardiac arrests occur at private residences, arrests in public or in the work place had a higher chance of being found in ventricular fibrillation and survival than those at private residences. In order to establish a system to improve the outcome of out-of-hospital cardiac arrest, a well-considered strategy considering the location of arrest is necessary.

Multicenter prospective study of procalcitonin as an indicator of sepsis.

The clinical significance of serum procalcitonin (PCT) for discriminating between bacterial infectious disease and nonbacterial infectious disease (such as systemic inflammatory response syndrome (SIRS)), was compared with the significance of endotoxin, beta-D: -glucan, interleukin (IL)-6, and C-reactive protein (CRP) in a multicenter prospective study. The concentrations of PCT in patients with systemic bacterial infection and those with localized bacterial infection were significantly higher than the concentrations in patients with nonbacterial infection or noninfectious diseases. In addition, PCT, endotoxin, IL-6, and CRP concentrations were significantly higher in patients with bacterial infectious disease than in those with nonbacterial infectious disease (P<0.001, P<0.005, P<0.001, and P<0.001, respectively). The cutoff value of PCT for the discrimination of bacterial and nonbacterial infectious diseases was determined to be 0.5 ng/ml, which was associated with a sensitivity of 64.4% and specificity of 86.0%. Areas under the receiver operating characteristic curves (POCs) were 0.84 for PCT, 0.60 for endotoxin, 0.77 for IL-6, and 0.78 for CRP in the combined group of patients with bacterial infectious disease and those with nonbacterial infectious disease, and the area under the ROC for PCT was significantly higher than that for endotoxin (P<0.001). In patients diagnosed with bacteremia based on clinical findings, the positive rate of diagnosis with PCT was 70.2%, while that of blood culture was 42.6%. PCT is thus essential for discriminating bacterial infection from SIRS, and is superior in this respect to conventional serum markers and blood culture.

[Infection and plasma procalcitonin].

Procalcitonin, a propeptide of calcitonin, is normally produced in the C-cells of the thyroid gland, but it's plasma level markedly increases, mostly due to extra-thyroidal production in cases of severe infections (bacterial, parasitic and fungal) with systemic manifestations, especially in the presence of septic shock. Since noninfectious inflammatory reaction, viral infection and localized bacterial infections manifest only small to modest increases of procalcitonin in plasma, procalcitonin levels may be useful in differentiating between these diseases and sepsis. In addition, it has been suggested that procalcitonin is an early and good marker of elevated cytokines in patients with sepsis, and that it's plasma level is correlated with Sepsis-related Organ Failure Assessment (SOFA) score. Since plasma procalcitonin is measured easily, quickly and accurately by immunoluminometric assay, it is useful for early diagnosis of sepsis in patients with severe systemic inflammatory response syndrome and as an indicator of severity of sepsis in such patients.

Three year longitudinal study for out-of-hospital cardiac arrest in Osaka Prefecture.

OBJECTIVE: To analyze the longitudinal changes in the treatment of out-of-hospital cardiac arrests. These analyses have focused on the time interval from the receipt of call until defibrillation of patients with ventricular fibrillation. DESIGN: Population-based, prospective longitudinal study according to the Utstein style. SETTING: Osaka Prefecture (population 8, 800, 000), served by 36 municipal fire and emergency departments. PATIENTS: Consecutive, out-of-hospital cardiac arrests occurring between May 1998 and April 2001. MAIN OUTCOME MEASURES: Change in the interval to defibrillation, and one-year survival from cardiac arrest. RESULTS: Of the 15,211 cases of confirmed cardiac arrests during the three years, resuscitation was attempted in 14,609 subjects. Of the 2957 cases of cardiac origin and witnessed by bystanders, 90 cases (3.0%) were alive 1 year following the episode. In 383 cases of defibrillation, the interval from receipt of call to defibrillation was evaluated annually. This interval decreased significantly during the three year course (14.5, 13.0, and 11.5 min expressed by the median), suggesting that this project to report the data of out-of-hospital arrests was an effective campaign for EMT. However, the outcome did not improve significantly during this period (3.0%, 2.6%, and 3.6% alive 1 year in witnessed arrests with cardiac etiology). This may be because the third year median duration of 11.5 min, is still insufficient to indicate a significant improvement in the outcome. CONCLUSIONS: This project to report the data of out-of-hospital cardiac arrest might have contributed to the reduction of the interval for defibrillation, as a campaign for the EMTs; although the decrease in this interval was still insufficient to result in a significant increase in the number of cases who are alive one year later.

Effect of enteral nutrition of monoacetoacetin on bacterial translocation in burned rats.

BACKGROUND: Bacterial translocation (BT) occurs under stress, and enteral nutrition is said to be effective in counteracting this effect. The usefulness of i.v. nutrition of monoacetoacetine (MA) under stress has been reported previously, and we studied the effect of enteral nutrition of MA as it is related to BT. METHODS: Rats were given 13.6% MA or 15% glucose (Glu) via gastrostomy, and after 4 days a 30% full-thickness burn was made. Before and after administration of the burn, we measured serum cytokines; amounts of bacteria in the mesenteric lymph node (MLN), liver, and spleen (estimation of BT); mucosal thickness of the terminal ileum; and body weight changes. To confirm the effectiveness of MA in the small intestine, we estimated succinyl-CoA:3-oxoacid CoA-transferase (SCOT) expression in the terminal ileum by immunohistochemical staining and Western blot analysis. RESULTS: At 6 hours after burn, all cytokines were lower, and BT in the MLN was inhibited significantly in the MA group. Ileal mucosal thickness was not significantly different, but mucosa was more edematous in the Glu group. At 3 days after burn injury, BT was significantly inhibited in the MLN and liver, and the ileal mucosa was significantly thicker in the MA group. Body weight loss after burn injury was significantly smaller in the MA group. SCOT expression was the strongest at 6 hours after burn injury by Western blot analysis but not by immunohistochemical staining. CONCLUSIONS: Enteral nutrition of MA may be useful for the inhibition of intestinal mucosal atrophy and the prevention of multiple organ dysfunction syndrome caused by the inhibition of BT and subsequent overproduction of cytokines.

Incidence and survival rate of bystander-witnessed out-of-hospital cardiac arrest with cardiac etiology in Osaka, Japan: a population-based study according to the Utstein style.

PURPOSE: To clarify the incidence and survival rate of bystander-witnessed out-of-hospital cardiac arrests (OHCA) with cardiac etiology in Osaka Prefecture, Japan, with a population of nearly 9 million according to the Utstein style. SUBJECTS AND METHODS: 5047 consecutive OHCA cases were treated by ambulance personnel during the 12-month period starting since 1 May 1998. 974 cases were considered to be bystander-witnessed OHCA with cardiac etiology and analyzed using the Utstein style. RESULTS: Of the 974 cases (100%), 50 cases (5.1%) survived after 1 month and 28 (2.9%) of them after 1 year. The Ventricular fibrillation (VF)/ventricular tachycardia (VT) group comprised 164 (16.8%) cases and there were statistically differences between the two groups as below (the VF/VT group vs. the non-VF/VT group): gender (male: 76.8 vs. 60.7%), age (61.7+/-14.7 vs. 68.7+/-17.1), history of ischemic heart disease (IHD) (30.5 vs. 15.3%), performance rate of bystander cardiopulmonary resuscitation (CPR) (34.1 vs. 21.4%) and time interval between receipt of an emergency call and arrival at the scene (5.5+/-2.9 vs. 6.0+/-2.9 min). CONCLUSION: The incidence of bystander-witnessed (OHCA) with cardiac etiology and VF or VT were remarkably low compared with those reported by other studies conducted in some areas of Europe or the USA.

Age and sex analyses of out-of-hospital cardiac arrest in Osaka, Japan.

OBJECTIVE: To determine effective interventional targets for out-of-hospital cardiac arrests by analyzing the distribution characteristics of arrest patients according to age and sex with special emphasis on ventricular fibrillation (VF). METHODS: All patients who suffered out-of-hospital cardiac arrest in Osaka Prefecture, Japan during 2 years, were prospectively recorded based on the Utstein style. The number and the incidence rate of cases of arrest, witnessed arrest, and witnessed VF were evaluated according to age and sex. The percentage of resuscitation attempts in arrest cases was also calculated. RESULTS: We recorded 10139 consecutive out-of-hospital cardiac arrest cases. Resuscitation was attempted in 97.0% of 10139 and showed no significant differences by age and sex. The incidence rate of cardiac arrests increased exponentially with age. Men showed a significantly higher incidence rate of out-of-hospital arrests than women in every age group. Most of the witnessed VF cases showed cardiac a aetiology and were predominantly observed in men in their 50s, 60s and 70s. The incidence rates of witnessed VF were also greater in them. CONCLUSION: Our study provides evidence that there are significant age and sex related epidemiological differences in cardiac arrests and we need to understand them better. Strategies that focus on high yielded patients, those in witnessed VF, should be pursued. These efforts should be expected to yield sex and age related differences in survivors.

Death following spontaneous recovery from cardiopulmonary arrest in a hospital mortuary: 'Lazarus phenomenon' in a case of alleged medical negligence.

We report a possibly first forensic autopsy case of death following a spontaneous recovery from cardiopulmonary arrest (CPA) after clinical declaration of death: 'Lazarus phenomenon'. A 65-year-old male with congenital deafness and dumbness was found unconscious in his room at a public home. During pre-hospital and clinical resuscitation including defibrillation and medications for about 35 min, CPA persisted under electrocardiographic (ECG) monitoring and therefore, his death was pronounced. However, about 20 min later, a police officer who had been called for the postmortem investigation found the patient moving in the mortuary. The patient subsequently showed typical ECG signs and laboratory findings of early inferior wall myocardial infarction and died 4 days later. The forensic autopsy, due to alleged medical negligence, revealed myocardial infarction with thrombotic occlusion of the right coronary artery and secondary hypoxic brain damage. The present case and the related clinical literature suggest that, especially in cases of acute myocardial infarction in elderly patients, a careful observation to confirm death after discontinuation of resuscitation is recommended to provide appropriate medical care, irrespective of the quality or duration of advanced life supporting efforts.

Lumbar epidural buprenorphine for postoperative pain relief following hepatectomy.

The induction of postoperative pain relief with lumbar epidural or intramuscular buprenorphine was studied in 30 patients undergoing hepatectomy. When patients first complained of pain after surgery, 0.06 mg or 0.12 mg of buprenorphine in 10 ml or 20 ml of saline was administered through an epidural catheter inserted at the L3-4 interspace, or 0.12 mg was administered intramuscularly. Two of seven patients receiving epidural buprenorphine 0.12 mg in 10 ml saline were completely pain-free, and the other five patients in this group had only slight pain. Four of eight patients receiving epidural buprenorphine 0.12 mg in 20 ml saline were completely pain-free, and the other four patients in this group had only slight pain. Epidural buprenorphine 0.06 mg in 20 ml saline and intramuscular buprenorphine 0.12 mg each yielded only incomplete analgesia. The duration of analgesia of epidural buprenorphine 0.12 mg administered at the lumbar level was about 8 h. There were no significant changes over time in circulatory or respiratory variables induced by buprenorphine. No patient had serious adverse effects. Lumbar epidural administration of buprenorphine 0.12 mg diluted to 10 or 20 ml (20 ml might be preferable) with saline is recommended for induction of postoperative analgesia following hepatectomy.