Characteristics and outcomes of out-of-hospital cardiac arrest in a hilly area: Utstein Registry data from the Nagasaki Medical Region, Japan.

Aim: To analyze characteristics and investigate prognostic indicators of out-of-hospital cardiac arrest (OHCA) in a hilly area in Japan. Methods: A retrospective population-based study was conducted using the Utstein Registry for 4280 OHCA patients in the Nagasaki Medical Region (NMR) registered over the 10-year period from 2011 to 2020. The main outcome measure was a favorable cerebral performance category (CPC 1-2). Sites at which OHCA occurred were classified into "sloped places (SPs)" (not easily accessible by emergency medical services [EMS] personnel due to slopes) and "accessible places (APs)" (EMS personnel could park an ambulance close to the site). The characteristics and prognosis based on CPC were compared between SPs and APs, and multivariable analysis was performed. Results: No significant improvement in prognosis occurred in the NMR from 2011 to 2020. Prognosis in SPs was significantly worse than that in APs. However, multivariable analysis did not identify SP as a prognostic indicator. The following factors were associated with survival and CPC 1-2: age group, witness status, first documented rhythm, bystander-initiated cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use, use of mechanical CPR (m-CPR) device or esophageal obturator airway (EOA), and year. Both m-CPR and EOA use were associated with a poor prognosis. Conclusion: In a hilly area, OHCA patients in SPs had a worse prognosis than those in APs, but SPs was not significantly associated with prognosis by multivariable analysis. Interventions to increase bystander-initiated CPR and AED use could potentially improve outcomes of OHCA in the NMR.

Balance of the prooxidant and antioxidant system is associated with mortality in critically ill patients.

It is well known that oxidative stress causes certain diseases and organ damage. However, roles of oxidative stress in the acute phase of critical patients remain to be elucidated. This study aimed to investigate the balance of oxidative and antioxidative system and to clarify the association between oxidative stress and mortality in critically ill patients. This cohort study enrolled 247 patients transported to our emergency department by ambulance. Blood was drawn on hospital arrival, and serum derivatives of reactive oxidant metabolites (dROMs, oxidative index) and biological antioxidant potential (BAP, antioxidative index) were measured. Modified ratio (MR) is also calculated as BAP/dROMs/7.51. There were 197 survivors and 50 non-survivors. In the non-survivors, dROMs were significantly lower (274 vs 311, p<0.01), BAP was significantly higher (2,853 vs 2,138, p<0.01), and MR was significantly higher (1.51 vs 0.92, p<0.01) compared to those in the survivors. The AUC of MR was similar to that for the APACHE II score. Contrary to our expectations, higher BAP and lower dROMs were observed on admission in non-survivors. This may suggest that the antioxidative system is more dominant in the acute phase of severe insults and that the balance toward a higher antioxidative system is associated with mortality.

How to Safely Prevent Venous Thromboembolism in Severe Trauma Patients.

Venous thromboembolism (VTE) is a life-threatening complication after trauma. Several studies have reported VTE prophylaxis using low-molecular-weight heparin; however, there is no consensus for prophylaxis after trauma. This study aimed to assess the efficacy and safety of our new anticoagulation therapy protocol using unfractionated heparin (UFH) plus intermittent pneumatic compression (IPC) to prevent post-traumatic VTE in high-risk trauma patients.This study enrolled 70 trauma patients who were admitted to the emergency medical center of Nagasaki University Hospital and had Risk Assessment Profile (RAP) scores ≥ 5. After stopping bleeding at the trauma site, all patients received intravenous UFH (10,000 U/day) plus IPC, which was continued for 14 days or until the patients could walk. On days 7 and 14, all patients underwent lower extremity sonography for deep-vein thrombosis screening. VTE incidences between patients with the above intervention and historical controls with IPC alone were compared.No significant differences in age, sex, and the RAP score were observed between the 105 controls and intervention patients. VTE occurrence was fewer in patients with the intervention (14.3%) than in the controls (28.6%; P = 0.029). No hemorrhagic complications occurred after UFH administration. Multivariable logistic analysis revealed a significant association between the intervention and low incidence of VTE (odds ratio: 0.390; 95% confidence interval: 0.163-0.913; P = 0.030).Routine UFH administration with IPC may prevent post-traumatic VTE without adverse events.

Effects of a trauma center on early mortality after trauma in a regional city in Japan: a population-based study.

BACKGROUND: Although the effects of the trauma center(TC) were researched in several studies, there have been few studies on changes in the regional mortality due to the implementation of a TC. An emergency medical center (EMC) and TC were implemented at Nagasaki University Hospital (NUH) for the first time in the Nagasaki medical region of Japan in April 2010 and October 2011, respectively, and they have cooperated with each other in treating trauma patients. The purpose of this study was to investigate the effects on the early mortality at population level of a TC working in cooperation with an EMC. METHODS: This is a retrospective study using standardized regional data (ambulance service record) in Nagasaki medical region from April 2007 through March 2017. We included 19,045 trauma patients directly transported from the scene. The outcome measures were prognosis for one week. To examine the association between the implementation of the EMC and TC and mortality at a region, we fit adjusted logistic regression models. RESULTS: The number of patients of each fiscal year increased from 1492 in 2007 to 2101 in 2016. The number of all patients transported to NUH decreased until 2009 to 70, but increased after implementation of the EMC and TC. Overall mortality of all patients in the region improved from 2.3% in 2007 to 1.0% in 2016. In multivariate logistic regression model, odds ratio of death was significantly smaller at 2013 and thereafter if the data from 2007 to 2011 was taken as reference. CONCLUSIONS: Implementation of the EMC and TC was associated with early mortality in trauma patients directly transported from the scene by ambulance. Our analysis suggested that the implementation of EMC and TC contributed to the improvement of the early mortality at a regional city with 500000 populations. LEVEL OF EVIDENCE: Level III.

Novel screening criteria for post-traumatic venous thromboembolism by using D-dimer.

AIM: Because severe trauma patients frequently manifest coagulopathy, it is extremely important to detect venous thromboembolism (VTE) in the acute phase. However, no reference value for D-dimer in post-traumatic VTE has been reported given the substantial increase in its levels after injury. Therefore, this study evaluates the ability of our screening criteria using D-dimer to detect VTE in severe trauma patients. METHODS: Trauma patients (n = 455) who were admitted to our emergency medical center during October 2011-June 2015 were included in this study. To prevent VTE, intermittent pneumatic compression was carried out in most patients. Our screening criteria included the following: (i) ≥5 days of hospital stay, (ii) increasing D-dimer levels across 3 measuring days, (iii) D-dimer levels ≥15 µg/mL. Patients who met these screening criteria underwent contrast-enhanced computed tomography (CE-CT) to detect VTE. RESULTS: During the study period, 108 cases satisfied the screening criteria; 73 of these underwent CE-CT, 34 of whom were diagnosed with VTE (positive predictive value, 46.6%). The median hospital stay on satisfying the screening criteria and before undergoing CE-CT was 7 and 10 days, respectively. No patient had VTE symptoms at the time of diagnosis. Also, none of the remaining 347 patients who did not satisfy the screening criteria had VTE symptoms. CONCLUSION: The screening criteria using D-dimer presented herein can be used as reference for efficiently detecting VTE in severe trauma patients.

An adult case of laryngopharyngeal burn by drinking hot water.

Case: A 61-year-old man who was hospitalized with schizophrenia in a psychiatric hospital drank hot water estimated to be 90°C. Eight hours after injury, laryngopharynx edema gradually progressed, and his breathing deteriorated. Upon arrival at our emergency room, we secured his respiratory tract by nasal intubation under a bronchoscope. Outcome: The edema gradually improved after peaking at hospital day 2, and he was extubated on hospital day 18. There were no apparent respiratory or esophageal problems, and he was discharged back to the psychiatric hospital on day 28. Conclusion: These types of laryngopharynx burns caused by ingesting hot foods or drinks have been rarely reported for adults. In cases of adults, when the patient is in a special situation such as having a psychiatric disorder, it is necessary to assume that the laryngopharynx burns might be aggravated.

Portable system for monitoring of regional cerebral oxygen saturation during prehospital cardiopulmonary resuscitation: a pilot study.

Aim: We aimed to create a system for monitoring of regional cerebral oxygen saturation (rSO 2) in patients with prehospital cardiopulmonary arrest and clarify the changes in rSO 2 during cardiopulmonary resuscitation. Methods: We measured rSO 2 in cardiopulmonary arrest patients who were transferred by the emergency response vehicle of Nagasaki University Hospital. We developed a portable rSO 2 monitor (HAND ai TOS), which is small enough to carry during prehospital treatment. The sensor is attached to the forehead of the patient and monitors rSO 2 continuously during treatment and transfer. Results: No difficulties were experienced in monitoring rSO 2 during patient treatment and transfer. Median time (interquartile range) from the emergency medical service call to emergency response vehicle arrival was 15.0 min (11.0-19.5 min). Median rSO 2 on emergency response vehicle arrival at the scene was 46.3% (44.0-48.2%) (n = 9; median age, 74.0 years; four men, five women). Median rSO 2 showed significant increase within 5 min after return of spontaneous circulation (n = 6, 46.6% versus 58.7%, P < 0.05). There was no significant increase in rSO 2 during prehospital cardiopulmonary resuscitation until return of spontaneous circulation was established. Conclusions: We developed an rSO 2 monitoring system for use during prehospital cardiopulmonary resuscitation. The monitoring system showed a significant increase in rSO 2 after return of spontaneous circulation, whereas there was no significant increase in rSO 2 during cardiopulmonary resuscitation after intubation but before return of spontaneous circulation.

Suppression of reactive oxygen species develops lymph node metastasis in colorectal cancer.

BACKGROUND/AIMS: Recent evidence indicates that reactive oxygen species (ROS) can induce a wide type of cellular responses from proliferation to senescence and cell death. ROS may not be an absolute carcinogenic factor or cancer suppressor. The aim of this study was to assess the biological paradox of ROS in colorectal cancer cells. METHODOLOGY: Blood specimens were obtained from the drainage vein of the tumor during operation in 135 patients with colorectal cancer. Serum ROS levels were measured using the derivatives of reactive oxygen metabolites (d-ROM) test. RESULTS: Serum ROS levels increased significantly in tumor size larger than 40mm (p<0.01). On the other hand, serum ROS levels decreased significantly in patients with lymph node metastasis (p<0.01). Multiple linear regression models showed a significant association of serum ROS levels with serum carcinoembryonic antigen (CEA) levels (p<0.01) and lymph node metastasis (p=0.026). CONCLUSIONS: In colorectal cancer cells, the increase of intracellular ROS is first associated with cell growth and invasion. However, a further increase inhibits cancer cell proliferation, whereas any decrease in ROS concentration needs to stimulate lymph node metastasis. Thus, a precise understanding how ROS are generated and involved in lymph node metastasis will help us to design better therapeutic strategies.

Changes in quality of life after hepatectomy and living donor liver transplantation.

BACKGROUND/AIMS: Quality of life has become important as an outcome in addition to conventional outcomes such as disease-free and overall survival. In this study, we compared the fluctuations of quality of life after hepatectomy and living donor liver transplantation. METHODOLOGY: Thirteen adult patients undergoing hepatectomy and 7 with living donor liver transplantation were enrolled. The SF-36, which can objectively measure health-related generic physical and mental quality of life, was completed before surgery and at 3, 6, 9 and 12 months after surgery. RESULTS: Before surgery, the scores of 7 out of 8 domains in SF36 were significantly lower in the transplantation group than in the hepatectomy group. After hepatectomy, quality of life dropped temporarily and subsequently gradually recovered toward the baseline, while after transplantation, quality of life, especially mental function, tended to be improved beyond the baseline. Consequently, the quality of life of the transplantation patients became comparable to that of the hepatectomy patients 12 months after surgery. CONCLUSIONS: Living donor liver transplantation was demonstrated to be a sensible therapeutic intervention for liver failure and malignances from the point of view of improvement in physical and mental quality of life.

Laparoscopic middle pancreatectomy under a pancreatic duct-navigation surgery.

Recent developments of diagnostic modalities have increased detection of many benign and low malignant pancreatic lesions, and then various minimally invasive surgeries and/or pancreatic function preserving surgeries have been devised for such lesions. Laparoscopic pancreatic surgery has developed rapidly in recent years, and its minimal invasiveness is expected. This report describes a laparoscopic middle pancreatectomy under a pancreatic duct-navigation surgery for a localized main pancreatic duct stenosis, and this method is effective to benign and low malignant pancreatic lesions in the points of minimal invasiveness and function preservation.

Management of cytomegalovirus infection after living donor liver transplantation.

BACKGROUND/AIMS: Few studies on Cytomegalovirus (CMV) infection in adult-to-adult living donor liver transplantation (LDLT) have been reported. The aim of this study was to analyze the incidence, risk factors and management of CMV infection after LDLT. METHODOLOGY: Retrospective analysis was performed with 72 consecutive adult cases. RESULTS: CMV antigenemia was demonstrated in 31 (43.1%) patients and 9 patients (12.5%) manifested fever. Twelve patients were treated with intravenous ganciclovir (GCV) injection. There was improvement in 10 patients; foscanet concomitant with CMV-IG was administered in one patient who had an adverse effect resulting in improvement and another one resulted in death from sepsis. Twelve patients were given oral valganciclovir (VGCV) and all showed improvement. ABO incompatible transplantation was associated with CMV infection after LDLT in both the univariate (p=0.005) and multivariate analyses (p=0.04). After discharge 12 out of 63 patients (19%) suffered from CMV infection and all of them were taking steroid. CONCLUSIONS: ABO incompatible transplantation was demonstrated as a risk factor for CMV infection during hospitalization. After discharge immunosuppressive status seemed to be more essential as a predictor for CMV infection. Routine examination to detect CMV antigenemia is needed especially in patients with potentially over-immunosuppressive conditions in out-patient clinics.

Curcumin improves the survival rate after a massive hepatectomy in rats.

BACKGROUND/AIMS: Curcumin possesses anti-inflammatory and antioxidant effects. Curcumin pretreatment provided a hepatoprotective effect in rat models of chemically-induced hepatotoxicities and ischemia/reperfusion injuries. In this study, we examined whether curcumin could improve the survival rate of rats undergoing a 90% hepatectomy. METHODOLOGY: Rats were administered 340 mg/kg oral curcumin formulated with phosphatidylcholine (curcumin group) or vehicle (control group) for 7 consecutive days and 2 hours prior to the massive hepatectomy. RESULTS: Six of the 13 rats pretreated with curcumin survived, whereas all 13 rats pretreated with vehicle died within day 2 following a massive hepatectomy. A histological examination showed the lobular structure to be disturbed in the rats pretreated with vehicle, whereas the hepatic lobular structure remained relatively stable without necrosis in the rats pretreated with curcumin. The contents of heme oxygenase-1 (HO-1) protein in the control group were low in the preoperative phase. In contrast, the levels of HO-1 protein in the curcumin group were high at the preoperative phase, and thereafter remained at high levels until day 7 following surgery. CONCLUSIONS: Our results suggest that curcumin improves the survival rate by increasing the antioxidant activity in rats after a massive hepatectomy.

Hemophagocytic syndrome after liver transplantation: report of two cases.

We report two cases of hemophagocytic syndrome (HPS), a rare but fatal complication after living-donor liver transplantation (LDLT). Despite their recovery from pancytopenia following treatment with steroid pulse therapy, granulocyte stimulating factor, and intravenous γ-globulin, both patients died. The outcomes reported in cases published in English are devastating, with only 4 survivors among the total 14 patients including ours. Pancytopenia is frequently recognized postoperatively in liver transplant recipients, although its cause is difficult to establish. When pancytopenia accompanying persistent high fever is recognized in LDLT recipients, HPS should be suspected and bone marrow aspiration performed as promptly as possible because of the poor prognosis of this syndrome. There is still no optimal treatment for HPS after liver transplantation.

The impact of the intra-abdominal space on liver regeneration after a partial hepatectomy in rats.

BACKGROUND: Little is known about the relationship between intra-abdominal space and liver regeneration. The present study was experimentally designed to investigate the influence of the "occupied space" or the "loss of occupied space" on a regenerating liver. METHODS: Experiment 1: Rats were randomly assigned to two groups: SO (space occupied) rats (n = 40); occupancy of intra-abdominal space followed by a two-thirds partial hepatectomy (PH) and control rats (n = 40); A PH alone. The rats in both groups were euthanized at 24, 48, 96, and 168 h after the operation. Computed tomography (CT) images were analyzed to evaluate the regenerating-direction and the shape of the regenerated remnant liver. The liver to body weight ratio and the proliferating cell nuclear antigen (PCNA) labeling index were measured at each time point. Experiment 2: A second laparotomy was performed at 168 h after the PH in both groups; occupier-removal for the SO rats and a sham operation for the control rats. The rats in both groups were euthanized at 24 and 168 h after the second operation. The liver to body weight ratio and PCNA labeling index were measured at each time point. RESULTS: Experiment 1: The remnant liver of the SO rats enlarged toward the dorsal and caudal side because liver regeneration toward the ventral side in the SO rats was inhibited with the occupier in the abdominal space at 96 h, and later, after the PH. CT images showed a statistically significant difference in the shape of the regenerated remnant liver between the control group and the SO group. The liver/body weight ratio was significantly decreased in the SO rats at 96 and 168 h after PH (P < 0.05). There was no significant difference between the groups in the PCNA labeling index. The SO rats showed a significant increase of the PCNA labeling of the inferior right lobe (10.6%) in comparison with the index of the superior right lobe (7.8%), which came in direct contact with the occupier, at 96 h after the operation (P < 0.05). The cell density of superior right lobe of the SO rats group was significantly higher than that of the control group at 168 h after operation (P < 0.05). Experiment 2: There was no statistically significant difference in the liver/body weight ratio at 168 hrs after the second operation between the groups. However, there was a statistically significant increase of the PCNA labeling index 24 h after the second operation in the occupier-removal rats in comparison with the control rats (P < 0.05). CONCLUSION: The occupied intra-abdominal space was therefore found to suppress liver regeneration after a partial hepatectomy, while the removal of such an occupied space stimulated the regeneration of the liver.

Spontaneously Ruptured Giant Splenic Cyst with Elevated Serum Levels of CA 19-9, CA 125 and Carcinoembryonic Antigen.

Splenic cyst is a relatively rare disease; however, the occurrence of complications associated with its rupture is even more rare. A 20-year-old female patient who had severe abdominal and left shoulder pain was admitted to our hospital. The patient's abdomen was hard and tender to the touch and she presented with a high fever. The patient's serum levels of the tumor markers carbohydrate antigen 19-9, cancer antigen 125 and carcinoembryonic antigen were high. Ultrasonography and computed tomography of the abdomen showed an 11-cm multilocular cystic lesion in the spleen and the presence of free intraperitoneal fluid. Peritonitis with ruptured splenic cyst was diagnosed, and the patient underwent an emergency laparotomy. The abdominal cavity was filled with purulent fluid. The cyst was localized to the spleen and had already ruptured. Total splenectomy and cyst resection were performed. The postoperative course was uneventful. The patient was discharged on day 9 following surgery. The histological findings showed the lesion to be a benign epidermoid cyst completely lined with inner stratified squamous epithelium with a capsule of connective tissue. In the immunostaining analyses, the squamous epithelium was positive for carcinoembryonic antigen. A ruptured splenic cyst causes sudden onset of severe peritonitis and elevation of serous tumor markers. An emergency operation is indicated as the treatment for a ruptured splenic cyst with peritonitis, after which a favorable outcome can be expected.

The serum level of carcinoembryonic antigen in drainage venous blood is not a sensitive predictor of metachronous hepatic metastasis for patients with colorectal cancer.

PURPOSE: To establish whether the serum levels of carcinoembryonic antigen (CEA) in drainage venous blood (d-CEA) is a better predictor of prognosis or survival than the preoperative CEA level in peripheral venous blood (p-CEA), and how these two CEA levels compare as predictive factors for metachronous hepatic metastasis. METHODS: We examined specimens of peripheral and drainage venous blood from 119 patients with colorectal cancer. RESULTS: There was a strong positive correlation between p-CEA and d-CEA levels. The 5-year survival rates were 81.5% and 80.2% for patients with normal p-CEA and d-CEA levels (< or =5 ng/ml), respectively, and 68.4% and 71.1% for those with abnormal p-CEA and d-CEA levels (>5 ng/ml). The p-CEA and d-CEA levels were both normal in seven of ten patients with metachronous hepatic metastasis. The CEA gradient between the d-CEA and p-CEA levels (d-p CEA gradient) was not a significant predictive factor for hepatic metastases. CONCLUSIONS: There was virtually no change between preoperative p-CEA and d-CEA levels. These findings suggest that the d-CEA level is not a predictor for metachronous hepatic metastasis and that measuring p-CEA levels is sufficient in the surveillance of colorectal cancer.

Oxidative stress and tumor progression in colorectal cancer.

BACKGROUND/AIMS: Elevated oxidative status has been found in many types of cancer cells. Recent studies have shown that the enzymatic product of thymidine phosphorylase (TP) generated reactive oxygen species (ROS) within cancer cells. The aim of this study was thus to evaluate the signal transduction pathway and the role of ROS in colorectal cancer. METHODOLOGY: Blood specimens were obtained from the drainage vein of the tumor during operation in 76 patients with colorectal cancer. Serum ROS levels were measured using the derivative-Reactive Oxygen Metabolites (d-ROM) test and serum TP levels were examined by a highly sensitive ELISA method. RESULTS: There was no significant correlation between serum levels of ROS and TP. Serum ROS levels were elevated in proportion to tumor invasion and had a significant positive correlation with tumor size (p < 0.05). However, they did not increase in patients with liver metastasis. CONCLUSIONS: These findings suggest that ROS are independent of TP-triggered signaling transduction and are associated with increased tumor invasion, but not liver metastasis in patients with colorectal cancer. From this point of view, new strategies related to ROS may provide improved therapeutic results as well as a preventative effect on carcinogenesis of the colorectum.

Actual therapeutic efficacy of pre-transplant treatment on hepatocellular carcinoma and its impact on survival after salvage living donor liver transplantation.

BACKGROUND: The exact efficacy of pre-liver transplant (LT) therapy for hepatocellular carcinoma (HCC) and the impact on survival after LT remain controversial in regard to salvage LT. MATERIALS AND METHODS: Of 79 patients transplanted in Nagasaki University Hospital between August 1997 and December 2007, 29 patients (36.7%) were indicated for HCC based on the Milan criteria using computed tomography and magnetic resonance imaging. Pre-LT therapy other than liver resection had been performed in 18 cases (62.1%) for 24 lesions. Treated lesions were analyzed histologically using thin slices of the whole explanted liver. RESULTS: Pre-LT therapy included transarterial chemoembolization (TACE) for 10 lesions, percutaneous ethanol injection (PEI) + TACE for 1 lesion, PEI in 6 lesions and ablation therapy in 7 lesions. Under preoperative imaging study, 19 lesions (79.1%) were "thought-to-be" necrotic by pre-LT therapy. However, histologically, viable HCCs were still observed in 9 lesions (9/19 47%). A median interval between the first pre-therapy and LT was 22 months, while last pre-LT therapy and LT was 11 months. No sarcomatous HCC or forced portal venous tumor thrombus was found in all cases with residual lesions. One peritoneal recurrence has occurred after LT, in whom PEI and RFA had been performed before LDLT. The disease free survival after LDLT was comparable to that of cases without pre-LT therapy. CONCLUSION: Half of the preoperatively "thought-to-be" necrotic lesions still contained viable HCC cells after the pre-LT treatment. Overall, the history of pre-LT therapy does not preclude or interfere with subsequent LT, although percutaneous treatment may spread disseminated tumor cell growth under immunosuppression.

Acute deterioration of idiopathic portal hypertension requiring living donor liver transplantation: a case report.

Case reports of severe idiopathic portal hypertension (IPH) requiring liver transplantation are very rare. We report the case of a 65-year-old woman who was diagnosed as having IPH. At the age of 60 years, her initial symptom was hematemesis, due to ruptured esophageal varices. Computed tomography of the abdomen showed splenomegaly and a small amount of ascites, without liver cirrhosis. She was diagnosed as having IPH and followed-up as an outpatient. Five years later, she developed symptoms of a common cold and rapidly progressive abdominal distension. She was found to have severe liver atrophy, liver dysfunction, and massive ascites. Living donor liver transplantation was then performed, and her postoperative course was uneventful. Histopathological findings of the explanted liver showed collapse and stenosis of the peripheral portal vein. The areas of liver parenchyma were narrow, while the portal tracts and central veins were approximate one another, leading to a diagnosis of IPH. There was no liver cirrhosis. The natural history of refractory IPH could be observed in this case. Patients with end-stage liver failure due to severe IPH can be treated by liver transplantation.