Development and validation of a prehospital termination of resuscitation (TOR) rule for out - of hospital cardiac arrest (OHCA) cases using general purpose artificial intelligence (AI).

BACKGROUND: Prehospital identification of futile resuscitation efforts (defined as a predicted probability of survival lower than 1%) for out-of-hospital cardiac arrest (OHCA) may reduce unnecessary transport. Reliable prediction variables for OHCA 'termination of resuscitation' (TOR) rules are needed to guide treatment decisions. The Universal TOR rule uses only three variables (Absence of Prehospital ROSC, Event not witnessed by EMS and no shock delivered on the scene) has been externally validated and is used by many EMS systems. Deep learning, an artificial intelligence (AI) platform is an attractive model to guide the development of TOR rule for OHCA. The purpose of this study was to assess the feasibility of developing an AI-TOR rule for neurologically favorable outcomes using general purpose AI and compare its performance to the Universal TOR rule. METHODS: We identified OHCA cases of presumed cardiac etiology who were 18 years of age or older from 2016 to 2019 in the All-Japan Utstein Registry. We divided the dataset into 2 parts, the first half (2016-2017) was used as a training dataset for rule development and second half (2018-2019) for validation. The AI software (Prediction One®) created the model using the training dataset with internal cross-validation. It also evaluated the prediction accuracy and displayed the ranking of influencing variables. We performed validation using the second half cases and calculated the prediction model AUC. The top four of the 11 variables identified in the model were then selected as prognostic factors to be used in an AI-TOR rule, and sensitivity, specificity, positive predictive value, and negative predictive value were calculated from validation cohort. This was then compared to the performance of the Universal TOR rule using same dataset. RESULTS: There were 504,561 OHCA cases, 18 years of age or older, 302,799 cases were presumed cardiac origin. Of these, 149,425 cases were used for the training dataset and 153,374 cases for the validation dataset. The model developed by AI using 11 variables had an AUC of 0.969, and its AUC for the validation dataset was 0.965. The top four influencing variables for neurologically favorable outcome were Prehospital ROSC, witnessed by EMS, Age (68 years old and younger) and nonasystole. The AUC calculated using the 4 variables for the AI-TOR rule was 0.953, and its AUC for the validation dataset was 0.952 (95%CI 0.949 -0.954). Of 80,198 patients in the validation cohort that satisfied all four criteria for the AI-TOR rule, 58 (0.07%) had a neurologically favorable one-month survival. The specificity of AI-TOR rule was 0.990, and the PPV was 0.999 for predicting lack of neurologically favorable survival, both the specificity and PPV were higher than that achieved with the universal TOR (0.959, 0.998). CONCLUSIONS: The accuracy of prediction models using AI software to determine outcomes in OHCA was excellent and the AI-TOR rule's variables from prediction model performed better than the Universal TOR rule. External validation of our findings as well as further research into the utility of using AI platforms for TOR prediction in clinical practice is needed.

Evaluation of characteristics and prognosis of COVID-19 patients requiring invasive mechanical ventilation during dominance of nonvariant, alpha, delta, and omicron variants in tertiary hospitals of Japan.

BACKGROUND: In November 2021, the B.1.1.529 (omicron) variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was detected in South Africa and subsequently rapidly spread around the world. Despite the reduced severity of the omicron variants, many patients become severely ill after infection and undergo invasive mechanical ventilation, but there are few reports on their background and prognosis throughout all variant periods. This study aimed to evaluate risk factors affecting patients requiring invasive mechanical ventilation with each variant of COVID-19 pandemic in Japan from nonvariants to omicron variants. METHOD: This retrospective observational study was conducted at the Department of Emergency and Critical Care Medicine, Kansai Medical University Hospital and Kansai Medical University Medical Center, Osaka, Japan, from March 2020 to March 2023. Eligible patients were those who underwent invasive ventilation for COVID-19 pneumonia. We set the primary endpoint as in-hospital mortality. Multivariable logistic regression analysis adjusted for clinically important variables was performed to evaluate the clinical outcomes. RESULTS: We included 377 patients: 118 in the Nonvariant group, 154 in the Alpha group, 42 in the Delta group, and 63 patients in the Omicron group. Mortality rates for each group were 23.7% for the Nonvariant group, 12.3% for the Alpha group, 7.1% for the Delta group, and 30.5% for the Omicron group. Patient age was significantly associated with increased mortality (adjusted odds ratio [AOR]: 1.097; 95% confidence interval [CI]: 1.057-0.138, P < 0.001). Immunodeficiency (AOR: 3.388, 95% CI: 1.377-8.333, P = 0.008), initial SOFA score (AOR: 1.190, 95% CI: 1.056-1.341, P = 0.004), dialysis prior to COVID-19 (AOR: 3.695, 95% CI: 1.117-11.663, P = 0.026), and smoking history (AOR: 2.548, 95% CI: 1.153-5.628, P = 0.021) were significantly associated with increased mortality. Differences in variants were not significant factors associated with high mortality. CONCLUSION: We compared the background and prognosis of patients with COVID-19 pneumonia requiring invasive mechanical ventilation between SARS-CoV-2 variants. In these patients, differences in variants did not affect prognosis. Hospital mortality in critically ill COVID-19 patients was significantly higher in the older patients with bacterial coinfection, or patients with immunodeficiency, COPD, and chronic renal failure on dialysis.

Efficacy of the shoelace technique for extremity fasciotomy wounds due to compartment syndrome.

BACKGROUND: The shoelace technique for compartment syndrome allows application of sustained tightening tension to an entire wound and intermittent tightening of the shoelace without requiring its replacement or anesthesia. We retrospectively evaluated the usefulness of the shoelace technique in the management of extremity fasciotomy wounds before and after its introduction in our institution. METHODS: We targeted 25 patients who were diagnosed as having compartment syndrome and underwent extremity fasciotomy at our hospital from April 2012 to December 2021. The N group, comprising 12 patients treated without the shoelace technique, and the S group, comprising 13 patients treated with the shoelace technique, were compared retrospectively for each outcome. RESULTS: There were no significant differences between the two groups in patient background. Compared with the N group patients, all of the S group patients avoided skin grafting (S group: n = 0, 0%; N group: n = 6, 50.0%; p < 0.01). However, there was no significant difference in the number of days to final wound closure (S group: 39.5 [IQR 24.3-58.0] days; N group: 24.0 [IQR 18.5-31.0] days, p = 0.06). CONCLUSIONS: We considered the shoelace technique to be a useful wound closure method for fasciotomy wounds caused by compartment syndrome because it can significantly reduce the need for skin grafting and tends to shorten the wound closure period.

Improved neurologically favorable survival after OHCA is associated with increased pre-hospital advanced airway management at the prefecture level in Japan.

Out-of-hospital cardiac arrest (OHCA) has high incidence and mortality. The survival benefit of pre-hospital advanced airway management (AAM) for OHCA remains controversial. In Japan, pre-hospital AAM are performed for OHCA by emergency medical services (EMS), however the relationship between resuscitation outcomes and AAM at the prefecture level has not been evaluated. The purpose of this study was to describe the association between AAM and neurologically favorable survival (cerebral performance category (CPC) ≦2) at prefecture level. This was a retrospective, population-based study of adult OHCA patients (≧ 18) from January 1, 2014 to December 31, 2017 in Japan. We excluded patients with EMS witnessed arrests. We also only included patients that had care provided by an ELST with the ability to provided AAM and excluded cases that involved prehospital care delivered by a physician. We categorized OHCA into four quartiles (four group: G1-G4) based on frequency of pre-hospital AAM approach rate by prefecture, which is the smallest geographical classification unit, and evaluated the relationship between frequency of pre-hospital AAM approach rates and CPC ≦ 2 for each quartile. Multivariable logistic regression was used to assess effectiveness of AAM on neurologically favorable survival. Among 493,577 OHCA cases, 403,707 matched our inclusion criteria. The number of CPC ≦ 2 survivors increased from G1 to G4 (p for trend < 0.001). In the adjusted multivariable regression, higher frequency of pre-hospital AAM approach was associated with CPC ≦ 2 (p < 0.001). High prefecture frequency of pre-hospital AAM approach was associated with neurologically favorable survival (CPC ≦ 2) in OHCA.

Study of damage control strategy for non-traumatic diseases: a single-center observational study.

BACKGROUND: Damage control strategy (DCS) has been introduced not only for trauma but also for acute abdomen, but its indications and usefulness have not been clarified. We examined clinical characteristics of patients who underwent DCS and compared clinical characteristics and results with and without DCS in patients with septic shock. METHODS: We targeted a series of endogenous abdominal diseases in Kansai Medical University Hospital from April 2013 to March 2019. Clinical characteristics of 26 patients who underwent DCS were examined. Then, clinical characteristics and results were compared between the DCS group (n = 26) and non-DCS group (n = 31) in 57 patients with septic shock during the same period. RESULTS: All 26 patients who underwent DCS had septic shock, low mean arterial pressure (MAP) before the start of surgery, and required high-dose norepinephrine administration intraoperatively. Their discharge mortality rate was 12%. Among the patients with septic shock, the DCS group had a higher SOFA score (P = 0.008) and MAP was lower preoperatively, but it did not increase even with intraoperative administration of large amounts of fluid replacement and vasoconstrictor. There was no significant difference in 28-day mortality and discharge mortality between the two groups. CONCLUSIONS: DCS may be useful in patients with severe septic shock.

Lacosamide poisoning improved by hemodialysis.

Background: Lacosamide (LCM) is a third-generation antiepileptic drug that has been proven to be effective and safe, with few side-effects. Case Presentation: A woman aged in her 20s was transported to our hospital because of decreased consciousness. Many drugs, such as LCM (328 tablets) and perampanel hydrate (81 tablets), were found in her car. Her Glasgow Coma Scale score was 14. She was intubated and managed with mechanical ventilation, and she was treated with activated charcoal. Subsequently, hemodialysis (HD) was initiated due to the appearance of clonic convulsions. After 4 h of HD, no seizures were noted. The patient was weaned from the ventilator 18 h after admission and discharged on day 4. Her blood LCM level was 91.7 µg/mL on admission and 68.1 and 18.3 µg/ml before and after HD, respectively. Conclusion: Hemodialysis was carried out in this severe case of LCM poisoning and was found to be effective.

Outcomes of patients with OHCA of presumed cardiac etiology that did not achieve prehospital restoration of spontaneous circulation: The All-Japan Utstein Registry experience.

BACKGROUND: Correct identification of futile prehospital resuscitation for out-of-hospital cardiac arrest (OHCA) may reduce unnecessary transports. Prehospital return of spontaneous circulation (ROSC) is considered by many to be an important predictor of outcome. The purpose of this study was to evaluate OHCA victims without prehospital ROSC characteristics and their outcomes in relation to the universal Termination of Resuscitation (TOR) rule. METHODS: A retrospective, population-based review of OHCA victims without prehospital ROSC from January 1, 2010 to December 31, 2017 in the All-Japan Utstein Registry. We compared those that met the universal TOR rule and those that did not for the primary outcome: one-month survival with neurologically favorable Cerebral Performance Category (CPC) 1 or 2. RESULTS: 989,929 OHCA cases, 18 years of age or older, were registered in the All-Japan Utstein Registry and 525,801 cases were of presumed cardiac origin and had no prehospital ROSC. Of these, the one-month CPC was 1 or 2 for 3957 cases (0.8%). In the 'no ROSC' group who also met the TOR rule, the number of cases was 433,571 with a one-month survival of 0.9% (3799 cases), and the proportion with a CPC 1or 2 was 0.2% (699 cases). CONCLUSIONS: Continued resuscitation and transport of cases with no field ROSC who fulfill the TOR rule is futile and could be considered for adoption in Japan.

Propofol suppresses ventricular arrhythmias: a case report of acute caffeine intoxication.

BACKGROUND: Caffeine is widely used as a stimulant drug throughout the world, and fatal arrhythmia is a known side-effect. We experienced a patient with caffeine intoxication causing fatal arrhythmias who was successfully treated with the infusion of propofol. CASE PRESENTATION: A 27-year-old woman was transferred to our hospital with nausea and poor general condition after intentional ingestion of 23.2 g of caffeine tablets. She was in cardiac arrest due to ventricular fibrillation just before hospital arrival. Advanced life support including defibrillation was started immediately, and we succeeded in resuscitating her 23 min later. Although she suffered from polymorphic ventricular premature beats and frequent transition to ventricular fibrillation, propofol administration converted her from a ventricular arrhythmia to sinus rhythm. CONCLUSION: We report this case focusing on the cardiovascular effects of propofol and the lipid sink phenomenon. As a result, propofol could have the potential to suppress ventricular arrhythmias.

Factors associated with bowel necrosis in patients with hepatic portal venous gas and pneumatosis intestinalis.

AIM: Historically, the presence of hepatic portal venous gas (HPVG) and pneumatosis intestinalis (PI) have been reported to be associated with bowel necrosis and fatal outcome. However, there are no criteria to judge whether bowel necrosis has occurred. We aimed to examine the factors associated with bowel necrosis in patients with HPVG and PI. METHODS: The study comprised 25 patients who were diagnosed as having HPVG and/or PI based on computed tomography (CT) findings in the Department of Emergency and Critical Care Medicine, Kansai Medical University Hospital (Osaka, Japan) between April 2013 and August 2017. We compared various factors, including clinical history, severity of present illness, laboratory data, and CT findings, and examined whether they were related to bowel necrosis. RESULTS: Both Sequential Organ Failure Assessment scores and total bilirubin levels were significantly higher in the necrosis group than those in the non-necrosis group (P = 0.03 and P = 0.02, respectively). The quantity of portal venous gas observed on computed tomography was associated with bowel necrosis in patients with HPVG. In contrast, the presence of air-type PI, defined as PI with emphysema covering the total circumference of the intestine in the absence of wall edema, and the presence of free air were significantly higher in the non-necrosis group (both P < 0.01). CONCLUSIONS: This study showed that the quantity of HPVG was associated with bowel necrosis, whereas the presence of free air or air-type PI was associated with non-necrosis of the bowel.

A strategy for improving the prognosis of non-occlusive mesenteric ischemia (NOMI): a single-center observational study.

AIM: The purpose of this study was to determine the prognostic factors of non-occlusive mesenteric ischemia (NOMI) and to examine treatment strategies that could improve its prognosis. METHODS: We retrospectively identified 30 patients who underwent emergency laparotomy for NOMI in Kansai Medical University Hospital (Hirakata, Japan) from April 2013 to December 2017. We examined prognostic factors related to discharge outcome and also examined the prognostic impact of open abdominal management and second look operation strategy (OSS) by dividing the patients into the non-OSS group and the OSS group. RESULTS: The primary end-point was a prognostic factor for outcome at discharge of the 30 patients. The outcome at discharge was compared between the survival group and the death group. Multivariate analysis was undertaken on two items from the univariate analysis that showed a significant difference (computed tomography findings of intestinal pneumatosis and acute disseminated intravascular coagulation [DIC] score). As a result, there was a significant difference in the factors of intestinal pneumatosis (odds ratio = 0.054; 95% confidence interval, 0.005-0.607; P = 0.018) and DIC score (odds ratio = 1.892; 95% confidence interval, 1.077-3.323; P = 0.027). The secondary end-point was the treatment outcome before and after the application of OSS. Operation time was significantly shorter and the amount of bleeding was also significantly less in the OSS group. CONCLUSION: Computed tomography findings of intestinal pneumatosis and the acute disseminated intravascular coagulation score were found to be prognostic factors for survival in patients with NOMI. Aggressive laparotomy to determine the definitive diagnosis is needed and OSS could be useful to improve patient prognosis for survival from NOMI.

Study of the prognostic factor of the colon perforation case with the pan-peritonitis that needed emergency surgery: a single-center observational study.

AIM: We divided patients treated with emergency surgery for pan-peritonitis caused by colon perforation into the survival group and the death group based on outcome at postoperative day 30 and examined the prognostic factors for colon perforation. METHODS: The prognostic factors for colon perforation in 76 consecutive patients who underwent emergency surgery at Kansai Medical University Hospital (Hirakata, Japan) from April 2011 to March 2017 were investigated based on outcome at postoperative day 30. RESULTS: The average age of the 76 patients (41 men/35 women) was 73 years, and the causative disease of colon perforation was malignant/benign in 18/58 cases, with ileocecal perforation site in 8 cases, ascending colon in 6, transverse colon in 2, descending colon in 4, sigmoid colon in 49, and rectum in 7. All patients received laparotomy with irrigation drainage, and 9 patients (11.8%) were dead at 30 days. Upon comparing the 67 survivors with the 9 dead patients, we recognized a significant difference on preoperative spread of ascites on computed tomography (CT) (P = 0.002) in univariate analysis and on acute disseminated intravascular coagulation (DIC) score (odds ratio 2.289; 95% confidence interval, 1.188-4.410; P = 0.013) in multivariate analysis. CONCLUSION: In our hospital, the preoperative acute DIC score was found to be a prognostic factor for colon perforation accompanied by pan-peritonitis. Appropriate evaluation of the spread of ascites on the preoperative CT might also help predict patient prognosis.

Ventricular septal perforation after blunt chest trauma due to blows from a fist.

Case: A 40-year-old man received fist blows to his chest and abdomen. He presented with external jugular vein distention and facial congestion. Chest X-ray showed bilateral pulmonary congestion. A Levine V/VI holosystolic murmur was audible. Echocardiography showed left-to-right shunt flow across the perimembranous region of the ventricular septum. The diameter of the hole was approximately 13 mm. We diagnosed ventricular septal perforation, started an infusion, and administered vasopressors. However, circulatory dynamics could not be maintained. The ventricular septal perforation was repaired directly with mattress sutures through the right ventricle. A small residual ventricular septal perforation was detected, which was repaired with a patch sutured through the left ventricle. Outcome: The patient was discharged without cardiovascular complications 43 days after admission. Conclusion: Ventricular septal perforation following blunt chest trauma is a rare form of cardiac trauma. It is important to consider the timing of the operation and the best method to ensure cardiac repair.

Vasodilating prostaglandin E1 does not reproduce interleukin-1ß-induced oxygen metabolism abnormalities in rabbits.

Background: We have reported that administration of recombinant human interleukin (IL)-1ß induced circulatory shock in rabbits by causing overproduction of vasodilating prostaglandin(s) and simultaneously impaired oxygen metabolism by causing an abnormal dependence of oxygen consumption (VO2) on oxygen delivery (DO2). The present study was carried out to compare the effect of administration of exogenous PGE1 with that of IL-1ß on oxygen metabolism. Methods: Sixteen rabbits were assigned to one of three groups and given a single injection of 10 µg/kg IL-1ß (IL-1ß group, n = 5), continuous infusion of 1 µg/kg/min PGE1 (PGE1 group, n = 6), or saline (control group, n = 5). All rabbits were subjected to stepwise cardiac tamponade to decrease DO2 by inflating a balloon placed into the pericardial sac. The VO2/DO2 relation was analyzed by the dual-line method. Results: Both IL-1ß and PGE1 decreased the baseline value of mean arterial pressure by approximately 25% without inducing significant alteration of the cardiac index. With respect to the VO2/DO2 relation, the slope of the supply-independent line was significantly increased in the IL-1ß group (y = 0.13x + 6.4), but not in the PGE1 group (y = 0.01x + 10.0) compared to that in the control group (y = 0.05x + 8.7). Conclusion: These results indicate that simple vasodilation and hypotension induced by administration of PGE1 are insufficient to account for the abnormal oxygen metabolism induced by IL-1ß.

Feasibility and accuracy of second-look laparoscopy after gastrectomy for gastric cancer.

BACKGROUND: A better method for detecting early peritoneal progression is needed. This study evaluated the feasibility and accuracy of second-look laparoscopy for patients with gastric cancer treated using systemic chemotherapy after gastrectomy. METHODS: Second-look laparoscopy was conducted for patients who had no clinical evidence of distant metastases but had peritoneal metastases or positive peritoneal cytology results without visible metastatic disease at initial surgery, patients who underwent systemic chemotherapy over a 6-month period after surgery, and patients who had no clinical evidence of disease based on imaging study after completion of primary chemotherapy. RESULTS: Between November 2004 and April 2008, 21 patients underwent second-look laparoscopy. At the initial surgery, 13 of these patients underwent total gastrectomy and 8 patients underwent distal gastrectomy. One or two sheets of adhesion barrier were received by 18 patients. The median interval between initial surgery and second-look laparoscopy was 9.8 months (range, 6.6-17.5 months). All second-look procedures were completed laparoscopically, and no patients required conversion to laparotomy. None of the 21 patients experienced postlaparoscopy complications. Whereas 12 patients showed no pathologic evidence of disease, 9 patients showed disease at second-look laparoscopy. There was a significant difference in median survival between the groups with negative and positive results (p = 0.017). The median survival for the negative group has not been determined. All the patients in the positive group received further chemotherapy while showing a good performance status (PS). Six patients were PS 0, and 3 patients were PS 1. The median survival time for this group was 10.1 months. CONCLUSIONS: Second-look laparoscopy was a safe and promising approach to reassessment of peritoneal disease for patients with gastric cancer. The incidence of complications was low, particularly in this group of patients, all of whom had undergone prior gastrectomy.

[Evaluation of the preserved function of the remnant stomach in pylorus preserving-gastrectomy by gastric emptying scintigraphy].

This study evaluated the preserved function of the remnant stomach by gastric emptying scintigraphy 1 year postoperatively in 49 patients who underwent pylorus-preserving gastrectomy (PPG), and it investigated whether this examination method is a useful tool for evaluation. The residual stomach function was classified as rapid, intermediate, and delayed emptying types according to gastric emptying curves. Then, the relationships were examined between the gastric emptying types and postprandial symptoms, food intake status, body weight changes, and endoscopic findings. Seventy-three percent of the PPG patients were classified as belonging to the intermediate emptying type, and the remainder (27%) to the delayed type. The frequencies of complaints such as epigastric fullness, nausea, and vomiting were high in the delayed emptying-type patients. The intermediate emptying-type patients consumed larger amounts of food and gained more weight than the delayed emptying-type patients. In conclusion, gastric function was evaluated by gastric emptying scintigraphy in PPG patients. This method might be useful not only for evaluating the motor function of the remnant stomach, but also for predicting postoperative status. Although PPG is a function-preserving operation, it should be considered that a quarter of the patients showed delayed emptying type which related to poor quality of life.