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Neuromuscular blocking agents (NMBAs) can control shivering during targeted temperature management (TTM) of patients with cardiac arrest. However, the effectiveness of NMBA use during TTM on neurologic outcomes remains unclear. We aimed to evaluate the association between NMBA use during TTM and favorable neurologic outcomes after out-of-hospital cardiac arrest (OHCA). A multicenter, prospective, observational cohort study from 2019 to 2021. It included OHCA patients who received TTM after hospitalization. We conducted overlap weight propensity-score analyses after multiple imputation to evaluate the effect of NMBAs during TTM. The primary outcome was a favorable neurological outcome, defined as a cerebral performance category of 1 or 2 at discharge. Subgroup analyses were conducted based on initial monitored rhythm and brain computed tomography findings. Of the 516 eligible patients, 337 received NMBAs during TTM. In crude analysis, the proportion of patients with favorable neurological outcome was significantly higher in the NMBA group (38.3% vs. 16.8%; risk difference (RD): 21.5%; 95% confidence interval (CI): 14.0% to 29.1%). In weighted analysis, a significantly higher proportion of patients in the NMBA group had a favorable neurological outcome compared to the non-NMBA group (32.7% vs. 20.9%; RD: 11.8%; 95% CI: 1.2% to 22.3%). In the subgroup with an initial shockable rhythm and no hypoxic encephalopathy, the NMBA group showed significantly higher proportions of favorable neurological outcomes. The use of NMBAs during TTM was significantly associated with favorable neurologic outcomes at discharge for OHCA patients. NMBAs may have benefits in selected patients with initial shockable rhythm and without poor prognostic computed tomography findings. [ABSTRACT FROM AUTHOR]

In out-of-hospital cardiac arrest (OHCA) patients with extracorporeal cardiopulmonary resuscitation (ECPR), the association between low-flow time, the duration between the initiation of conventional cardiopulmonary resuscitation and the establishment of ECPR, and outcomes has not been clearly determined. This was a secondary analysis of the retrospective multicenter registry in Japan. This study registered patients ≥18 years old who were admitted to the emergency department for OHCA and underwent ECPR between January, 2013 and December, 2018. Low-flow time was defined as the time from initiation of conventional cardiopulmonary resuscitation to the establishment of ECPR, and patients were categorized into two groups according to the visualized association of the restricted cubic spline curve. The primary outcome was survival discharge. Cubic spline analyses and multivariable logistic regression analyses were performed to assess the nonlinear associations between low-flow time and outcomes. A total of 1,524 patients were included. The median age was 60 years, and the median low-flow time was 52 (42‐53) mins. The overall survival at hospital discharge and favorable neurological outcomes were 27.8% and 14.2%, respectively. The cubic spline analysis showed a decreased trend of survival discharge rates and favorable neurological outcomes with shorter low-flow time between 20 and 60 mins, with little change between the following 60 and 80 mins. The multivariable logistic regression analyses showed that patients with long low-flow time (>40 mins) compared to those with short low-flow time (0‐40 mins) had significantly worse survival (adjusted odds ratio 0.42; 95% confidence intervals, 0.31-0.57) and neurological outcomes (0.65; 0.45-0.95, respectively). The survival discharge and neurological outcomes of patients with low-flow time shorter than 40 min are better than those of patients with longer low-flow time. [ABSTRACT FROM AUTHOR]

Despite recent advances in the management of severe traumatic brain injury, the role of decompressive craniectomy remains unclear. The purpose of this study was to compare practice patterns and patient outcomes between 2 study periods over the past decade. This is a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Project database. We included patients (age ≥18 years) with isolated severe traumatic brain injury. The patients were divided into the early (2013–2014) and late (2017–2018) groups. The primary outcome was the rate of craniectomy, and secondary outcomes included in-hospital mortality and discharge disposition. A subgroup analysis of patients undergoing intracranial pressure monitoring was also performed. A multivariable logistic regression analysis assessed the association between the early/late period and study outcomes. A total of 29,942 patients were included. In the logistic regression analysis, the late period was associated with decreased use of craniectomy (odds ratio: 0.58, P <.001). Although the late period was associated with higher in-hospital mortality (odds ratio: 1.10, P =.013), it was also associated with a higher likelihood of discharge to home/rehab (odds ratio: 1.61, P <.001). Similarly, the subgroup analysis of patients with intracranial pressure monitoring showed that the late period was associated with a lower craniectomy rate (odds ratio: 0.26, P <.001) and a higher likelihood of discharge to home/rehab (odds ratio:1.98, P <.001). The use of craniectomy for severe traumatic brain injury has decreased over the study period. Although further studies are warranted, these trends may reflect recent changes in the management of patients with severe traumatic brain injury. [Display omitted] [ABSTRACT FROM AUTHOR]

Background: Out-of-hospital cardiac arrest (OHCA) patients who convert from an initial non-shockable rhythm to a subsequent shockable rhythm reportedly have a better prognosis for survival than those without rhythm conversion. We evaluated the effectiveness of extracorporeal cardiopulmonary resuscitation (ECPR) for OHCA patients with a subsequent shockable rhythm.Methods: This study was conducted using the Japanese Association of Acute Medicine OHCA registry. We included OHCA patients with a subsequent shockable rhythm from June 2014 to December 2017. The included patients were divided into those with and without ECPR. The primary outcome was 30-day survival. Logistic regression analysis and propensity score matching were performed to compare the outcomes between patients with and without ECPR.Results: A total of 2,102 patients were analyzed, consisting of 162 with ECPR and 1,940 without ECPR. Before propensity score matching, 24 (14.8%) patients with ECPR and 61 (3.1%) patients without ECPR survived for 30 days; ECPR was associated with increased survival (P < 0.05; odds ratio [OR], 5.35; 95% confidence interval [CI], 3.09-9.02). After propensity score matching, 22/149 (14.8%) patients with ECPR and 10/149 (6.7%) patients without ECPR survived for 30 days; ECPR was associated with increased survival (P < 0.05; OR, 2.40; 95% CI, 1.04-5.91).Conclusions: ECPR was associated with increased survival among OHCA patients with a subsequent shockable rhythm. [ABSTRACT FROM AUTHOR]

Coronary artery disease (CAD) is a condition in which the arteries supplying blood to the heart become narrowed or occluded, often by the deposition of fatty plaques on the inner surfaces of the arteries. The resulting myocardial ischemia, or reduced blood supply to the heart muscle, is often intensified by exercise, and can result in pain and heart damage. In some patients, the development of collateral circulation (i.e. through other vessels) can partially compensate for the blockage in one coronary artery; a sufficient supply of blood is maintained during rest, but not during exercise. Treatment with the vasodilator drug nitroglycerin, which improves cardiac blood flow at rest, increases exercise tolerance in patients with CAD. It is often assumed to effect this improvement by increasing coronary collateral blood flow during exercise, but the actual mechanism remains poorly understood. To further investigate the mechanism of action of nitroglycerin in exercising CAD patients, a study was done in which single photon emission computed tomography (SPECT; an imaging technique for visualizing cardiac blood flow) using a radioactive isotope, thallium-201, was performed on seven patients with CAD and exercise-induced angina pectoris (CAD-related chest pain) before and after nitroglycerin treatment. Blood pressure, heart rate, and the arithmetic product of pressure and rate during peak exercise did not differ between the two conditions. The size of the area of heart muscle affected by ischemia and the severity of the ischemia (as estimated by SPECT) were significantly less following nitroglycerin treatment than before. This suggests that coronary collateral function is improved during exercise by nitroglycerin. (Consumer Summary produced by Reliance Medical Information, Inc.)

Limited information exists regarding the clinical characteristics, management practice, and outcomes of pediatric patients with isolated splenic injury in Japan. This study aimed to evaluate the characteristics, management, and outcomes, such as survival and splenic salvage rate of pediatric patients with isolated splenic injury in Japan. This study was a multicenter retrospective cohort study using patient data from the Japan Trauma Data Bank (JTDB) collected between 2004 and 2018. Pediatric patients with isolated high-grade splenic injury whose abbreviated injury scale ≥ 3 were classified according to management groups: nonoperative management (NOM); NOM with splenic artery embolization (SAE); and operative management (OM). The primary outcome was in-hospital survival and the secondary outcomes were splenic salvage rate, hospital length of stay (LOS), rate of discharging to home, and complications. There were 230 pediatric patients with isolated high-grade splenic injury during the study period. Of these, 156 (68%) were managed by NOM, 62 (27%) were managed by NOM with SAE, and 12 (5.2%) were managed by OM. No pediatric patient with isolated high-grade splenic injury died between 2004 and 2018 in Japan, and the splenic salvage rate was 97%. We identified a high survival rate and splenic salvage rate among pediatric patients with isolated high-grade splenic injury in Japan. SAE was often used, in contrast with previous reports. Level IV. • The survival rate and splenic salvage rate of pediatric patients with isolated high-grade splenic injury in Japan were 100% and 97%. • The management was 68% by nonoperative management, 27% by nonoperative management with splenic artery embolization (SAE) and 5.2% by operative management; therefore, SAE was often used. • The outcomes may be a result of the high availability of SAE which may be overutilized. [ABSTRACT FROM AUTHOR]

Purpose: To find factors that predict the requirement of packed red blood cells (pRBC) transfusion in patients with blunt trauma on arrival at the hospital.Methods: We conducted blood tests in trauma patients whose trauma severity was suspected as being 3 and over in the Abbreviated Injury Scale. Patients were divided into the blood transfusion (BT) and control groups according to the requirement of pRBC transfusion within 24h after arrival.Results: We analyzed 347 patients (BT group, n=14; control group, n=333). On univariate analysis, there were significant differences in Glasgow Coma Scale (GCS), rate of positive FAST (focused assessment with sonography for trauma) finding, hematocrit, international normalized ratio of prothrombin time, activated partial thromboplastin time, fibrinogen (Fib), and level of fibrin degradation products (FDP). On multivariable analysis, positive FAST finding, GCS, Fib, and FDP influenced the requirement of pRBC transfusion. In the area under the receiver operating characteristic curve analysis, Fib and FDP were markers that predicted the requirement of pRBC transfusion. The FDP/Fib ratio had a better correlation with the requirement of pRBC transfusion than FDP or Fib.Conclusions: The FDP/Fib ratio can be easily measured and may be a predictor of the need for pRBC transfusion. [ABSTRACT FROM AUTHOR]

Background: It is unclear whether the number of paramedics in an ambulance improves the outcome of patients with out-of-hospital cardiac arrest (OHCA) or not.Methods and Results: This study was a prospective, observational study conducted on patients with OHCA. Patients were divided into the One-paramedic group (Group O) and the Two-or-more-paramedic group (Group T) and we analyzed the differences. Patients who were treated with only basic life support during transportation, and whose cause of cardiac arrest were extrinsic cause such as trauma and poisoning were excluded. Good neurological outcome was defined as cerebral performance category (CPC) 1 or 2. In Group O, there were 1516 patients (male/female, 922/594). In Group T, there were 2932 patients (male/female, 1798/1134). Return of spontaneous circulation (ROSC) was obtained in 528 patients (34.8%) in Group O and 1058 patients (36.1%) in Group T (p=0.589). 320 patients (21.1%) in Group O and 656 patients (22.4%) in Group T were admitted to hospital after ROSC (p=0.461). At 90days, there were 57 survivors (3.8%) in Group O and 114 survivors (3.9%) in Group T (p=0.873). At 90days, 14 patients (0.9%) in Group T had a CPC of 1 or 2, while 30 patients (1.0%) in Group T did so (p=0.87). From the results of logistic regression analysis, age [odds ratio (OR): 0.983, 95% confidence interval (CI): 0.952-0.993], witnessed OHCA (OR: 4.583, 95% CI: 1.587-13.234), and shockable rhythm as first documented (OR: 19.67, 95% CI: 9.181-42.13) were associated with good outcome.Conclusion: The number of paramedics in an ambulance did not affect the outcome in OHCA patients. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the usefulness of coagulation biomarkers, which are easy and quick to analyze in emergency settings, for prediction of arterial extravasation due to pelvic fracture.Patients and Methods: The medical records of pelvic fracture patients transferred to the emergency department of Gunma University Hospital between December 2009 and May 2015 were reviewed. Patients were divided into two groups, those with (Extra(+)) and without (Extra(-)) arterial extravasation on enhanced CT or angiography. Levels of fibrin degradation products (FDP), D-dimer, fibrinogen, the ratio of FDP to fibrinogen, the ratio of D-dimer to fibrinogen, systolic blood pressure, heart rate, the Glasgow Coma Scale, pH, base excess, hemoglobin and lactate levels, the pattern of pelvic injury, and injury severity score were measured at hospital admission, and compared between the two groups. Parameters with a significant difference between the two groups were used to construct receiver operating characteristic (ROC) curves.Results: The study included 29 patients with pelvic fracture. FDP, D-dimer, the ratio of FDP to fibrinogen and the ratio of D-dimer to fibrinogen were the most useful parameters for predicting arterial extravasation due to pelvic fracture. FDP, D-dimer, the ratio of FDP to fibrinogen, the ratio of D-dimer to fibrinogen, and hemoglobin and lactate levels were significantly higher in the Extra(+) group than in the Extra(-) group (FDP, 354.8μg/mL [median] versus 96.6μg/mL; D-dimer, 122.3μg/mL versus 42.1μg/mL; the ratio of FDP to fibrinogen, 3.39 versus 0.42; the ratio of D-dimer to fibrinogen, 1.14 versus 0.18; hemoglobin, 10.5g/dL versus 13.5g/dL; lactate, 3.5mmol/L versus 1.7mmol/L). The area under the ROC curves for FDP, D-dimer, the ratio of FDP to fibrinogen, the ratio of D-dimer to fibrinogen, hemoglobin and lactate levels were 0.900, 0.882, 0.918, 0.900, 0.815 and 0.765, respectively.Conclusion: Coagulation biomarkers, and hemoglobin and lactate levels could be useful to predict the existence of arterial extravasation due to pelvic fracture. The ratio of FDP to fibrinogen and the ratio of D-dimer to fibrinogen were the most accurate markers. Coagulation biomarkers may enable more rapid and specific treatment for pelvic fracture. [ABSTRACT FROM AUTHOR]

Extracorporeal cardiopulmonary resuscitation (E-CPR) has attracted interest in the area of resuscitation, with its utilization in refractory cardiac arrest having recently increased. However, E-CPR has a high complication rate of approximately 30% and life-threatening complications can occur. We present a case who experienced an acute aortic dissection caused by veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Specifically, the aortic dissection was caused by an adjustment in the position of return cannula. [ABSTRACT FROM AUTHOR]

The authors used 3D angiography (3DA) in the diagnosis and follow-up studies of cerebral aneurysm. Between August 1999 and November 2002, 134 patients were diagnosed as harboring 164 aneurysms by 3DA. One hundred and ten patients had ruptured aneurysms whereas 24 patients exhibited unruptured aneurysms. One hundred and three aneurysms were surgically clipped and 20 were embolized with coils, with 67 patients undergoing postoperative 3DA. In most cases, the aneurysm''s anatomy could be easily visualized on 3DA, although in two cases conventional digital subtraction angiography (DSA) was required for further information. Measurement of aneurysm dimensions was achieved with acceptable accuracy to select the diameter of the first embolization coil. Previously clipped or embolized aneurysms could be visualized well and evaluation of the residual neck was easy in most cases. 3DA was shown to be a helpful tool in the evaluation of pre- and post-treatment of aneurysms. [Copyright &y& Elsevier]

Purpose: To compare embolization with laparotomy for the management of hemodynamically unstable patients with solid organ injury who responded to initial resuscitation.Materials and Methods: Data from a Japanese nationwide trauma registry were analyzed. Included were hemodynamically unstable patients (systolic blood pressure <90 mm Hg and blood transfusion within the first 24 hours) whose initial computed tomography assessment confirmed the presence of solid organ injuries (liver and/or spleen). A total of 224 patients were included (median age: 53 years, interquartile range: 32-69; 73.3% male; liver injury = 131 [58%] and spleen injury = 98 [44%]; median organ injury scale: 3, interquartile range: 3-4; median injury severity score: 19, interquartile range: 16-25). Patients who underwent embolization were compared with those who underwent laparotomy. The primary outcome was in-hospital survival. The data were evaluated using a propensity score matching analysis.Results: Laparotomy and embolization were performed in 133 (59.1%) and 91 (40.4%) patients, respectively. Of those, 111 (84%) and 84 (92%) patients achieved in-hospital survival after laparotomy and embolization, respectively. No significant difference in in-hospital survival (P = .053) was noted. The propensity score matching model did not reveal a significant difference in in-hospital survival (P = .276).Conclusions: No significant difference was observed between embolization and laparotomy in terms of in-hospital survival among unstable patients who responded to initial resuscitation with solid organ injury. [ABSTRACT FROM AUTHOR]

The survival of motor neuron (SMN) protein, responsible for the neurodegenerative disease spinal muscular atrophy (SMA), oligomerizes and forms a stable complex with seven other major components, the Gemin proteins. Besides the SMN protein, Gemin2 is a core protein that is essential for the formation of the SMN complex, although the mechanism by which it drives formation is unclear. We have found a novel interaction, a Gemin2 self-association, using the mammalian two-hybrid system and the in vitro pull-down assays. Using in vitro dissociation assays, we also found that the self-interaction of the amino-terminal SMN protein, which was confirmed in this study, became stable in the presence of Gemin2. In addition, Gemin2 knockdown using small interference RNA treatment revealed a drastic decrease in SMN oligomer formation and in the assembly activity of spliceosomal small nuclear ribonucleoprotein (snRNP). Taken together, these results indicate that Gemin2 plays an important role in snRNP assembly through the stabilization of the SMN oligomer/complex via novel self-interaction. Applying the results/techniques to amino-terminal SMN missense mutants that were recently identified from SMA patients, we successfully showed that amino-terminal self-association, Gemin2 binding, the stabilization effect of Gemin2, and snRNP assembly activity were all lowered in the mutant SMN(D44V), suggesting that instability of the amino-terminal SMN self-association may cause SMA in patients carrying this allele. [ABSTRACT FROM AUTHOR]

Optimal management of patients with chronic myeloid leukemia in chronic phase with suboptimal molecular response (MR) to frontline imatinib is undefined. We report final results from SENSOR, which evaluated efficacy/safety of nilotinib in this setting. A substudy assessed whether BIM polymorphisms impacted response to nilotinib. In this single-arm, multicenter study, Japanese patients with suboptimal MR per European LeukemiaNet 2009 criteria (complete cytogenetic response, but not major MR [MMR]) after ≥18 months of frontline imatinib received nilotinib 400 mg twice daily for 24 months. MR, BCR-ABL1 mutations/variants, and BIM polymorphisms were evaluated in a central laboratory. Primary endpoint was the MMR rate at 12 months (null hypothesis of 40%). Of 45 patients (median exposure, 22.08 months), 39 completed the study and six discontinued. At 12 and 24 months, 51.1% (95% CI, 35.8%–66.3%) and 66.7% (95% CI, 51.0%–80.0%) achieved MMR, respectively. Cumulative MMR incidence by 24 months was 75.6%. Of 40 patients analyzed, 10 of 12 (83.3%) with and 17 of 28 (60.7%) without BIM polymorphisms achieved MMR at 24 months. The safety profile was manageable with dose reductions and interruptions. Nilotinib provided clinical benefit for patients with suboptimal response to imatinib, and BIM polymorphisms did not influence MMR achievement. ClinicalTrials.gov: NCT01043874. [ABSTRACT FROM AUTHOR]

• A multiple-FOV multiple-scattering polarization lidar at 355 nm was developed. • The lidar could observe multiple scattering signals for clouds, aerosols and drizzle. • The observed features for water clouds and drizzle were consistent with the previous study. • It was found aerosol multiple scattering was more pronounced at 355 nm than 532 nm. • The calibration and measurement uncertainty for the lidar were investigated. We developed a multiple-field-of-view multiple-scattering polarization lidar at 355 nm (MFMSPL-355) to study the microphysics of clouds and aerosols, and understand the multiple scattering effects on space lidar measurements. The MFMSPL-355 is used to simulate and interpret multiple scattering signals by the 355 nm lidar installed on the Earth Clouds, Aerosol and Radiation Explorer satellite. This is the first multiple scattering lidar developed at 355 nm in the world. The system has five receiver modules and can observe both parallel and perpendicular attenuated backscatter coefficients for the on-beam direction and four off-beam directions with different tilting angles. Thus, the MFMSPL-355 can measure the single scattering signal and multiple scattering signal independently; accordingly, it can provide microphysical properties, such as the effective radius, of clouds and aerosols. We demonstrated that the MFMSPL-355 could observe multiple scattering signals for water clouds, ice clouds, aerosols, and drizzle. The observed features of the water clouds and drizzle were consistent with those observed by a previously developed 532-nm MFMSPL. Furthermore, we found that aerosol signals and their multiple scattering contributions were generally more pronounced at 355 nm, which is the advantage of performing measurements at 355 nm. Off-beam channels can offer a unique opportunity to study aerosol microphysics. [ABSTRACT FROM AUTHOR]