Non-linear association between the time required to reaching temperature targets and the neurological outcome in patients undergoing targeted temperature management after out-of-hospital cardiac arrest: Observational multicentre cohort study

Purpose

We evaluated associations between outcomes and time to achieving temperature targets during targeted temperature management of out-of-hospital cardiac arrest.

Methods

Using Comprehensive Registry of Intensive Care for out-of-hospital cardiac arrest Survival (CRITICAL) study, we enrolled all patients transported to participating hospitals from 1 July 2012 through 31 December 2017 aged ≥ 18 years with out-of-hospital cardiac arrest of cardiac aetiology and who received targeted temperature management in Osaka, Japan. Primary outcome was Cerebral Performance Category scale of 1 or 2 one month after cardiac arrest, designated as "one-month favourable neurological outcome". Non-linear multivariable logistic regression analyses assessed the primary outcome based on time to reaching temperature targets. In patients subdivided into quintiles based on time to achieving temperature targets, multivariable logistic regression calculated adjusted odds ratios and 95% confidence intervals.

Results

We analysed 473 patients. In non-linear multivariable logistic regression analysis, p value for non-linearity was < 0.01. In the first quintile (< 26.7 minutes), second quintile (26.8-89.9 minutes), third quintile (90.0-175.1 minutes), fourth quintile (175.2-352.1 minutes), and fifth quintile (≥ 352.2 minutes), one-month favourable neurological outcome was 32.6% (31/95), 40.0% (36/90), 53.5% (53/99), 57.4% (54/94), and 37.9% (36/95), respectively. Adjusted odds ratios with 95% confidence intervals for one-month favourable neurological outcome in the first, second, third, and fifth quintiles compared with the fourth quintile were 0.38 (0.20 to 0.72), 0.43 (0.23 to 0.81), 0.77 (0.41 to 1.44), and 0.46 (0.25 to 0.87), respectively.

Conclusion

Non-linear multivariable logistic regression analysis could clearly describe the association between neurological outcome in patients with out-of-hospital cardiac arrest and the time from the introduction of targeted temperature management to reaching the temperature targets.

Basic life support for non-traumatic out-of-hospital cardiac arrests during school-supervised sports activities in children: A nationwide observational study in Japan

Objective

To investigate the prognostic impact of bystander-initiated cardiopulmonary resuscitation (CPR) and public-access automated external defibrillator (AED) use on non-traumatic out-of-hospital cardiac arrest (OHCA) occurring during school-supervised sports activities in children.

Methods

From a nationwide database of pediatric OHCAs occurring under school supervision in Japan, data between April 2008 and December 2020 were obtained. We analyzed non-traumatic OHCAs that occurred during school-supervised sports activities among schoolchildren from elementary, junior high, high, and technical colleges. A multivariable logistic regression model was used to evaluate the effect of basic life support (BLS) on 1-month survival with favorable neurological outcomes after OHCA.

Results

In total, 318 OHCA cases were analyzed. The 1-month survival with favorable neurological outcomes was 64.8% (164/253) in cases receiving both bystander-CPR and AED application, 40.7% (11/27) in cases receiving CPR only, 38.5% (5/13) in patients receiving AED application only, and 28.0% (7/25) in cases receiving no bystander intervention. Compared with cases receiving no BLS, cases receiving both CPR and AED had a significantly higher proportion of 1-month survival with favorable neurological outcomes (adjusted odds ratio [AOR]: 3.97, 95% confidence interval [CI]: 1.32-11.90, p = 0.014). However, compared to cases receiving no BLS, there was no significant difference in the outcome in the cases receiving CPR only (AOR: 1.35, 95% CI: 0.34-5.29, p = 0.671) and the cases receiving AED application only (AOR: 1.26, 95% CI: 0.25-6.38, p = 0.778).

Conclusion

The combination of CPR and AED as BLS performed by bystanders for non-traumatic OHCA during school-supervised sports activities improved the outcomes.

Pioneer and PRDM transcription factors coordinate bivalent epigenetic states to safeguard cell fate

Pioneer transcription factors (TFs) regulate cell fate by establishing transcriptionally primed and active states. However, cell fate control requires the coordination of both lineage-specific gene activation and repression of alternative-lineage programs, a process that is poorly understood. Here, we demonstrate that the pioneer TF FOXA coordinates with PRDM1 TF to recruit nucleosome remodeling and deacetylation (NuRD) complexes and Polycomb repressive complexes (PRCs), which establish highly occupied, accessible nucleosome conformation with bivalent epigenetic states, thereby preventing precocious and alternative-lineage gene expression during human endoderm differentiation. Similarly, the pioneer TF OCT4 coordinates with PRDM14 to form bivalent enhancers and repress cell differentiation programs in human pluripotent stem cells, suggesting that this may be a common and critical function of pioneer TFs. We propose that pioneer and PRDM TFs coordinate to safeguard cell fate through epigenetic repression mechanisms.

In-hospital extracorporeal cardiopulmonary resuscitation for patients with out-of-hospital cardiac arrest: an analysis by time-dependent propensity score matching using a nationwide database in Japan

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) has been proposed as a rescue therapy for patients with refractory cardiac arrest. This study aimed to evaluate the association between ECPR and clinical outcomes among patients with out-of-hospital cardiac arrest (OHCA) using risk-set matching with a time-dependent propensity score.

METHODS

This was a secondary analysis of the JAAM-OHCA registry data, a nationwide multicenter prospective study of patients with OHCA, from June 2014 and December 2019, that included adults (≥ 18 years) with OHCA. Initial cardiac rhythm was classified as shockable and non-shockable. Patients who received ECPR were sequentially matched with the control, within the same time (minutes) based on time-dependent propensity scores calculated from potential confounders. The odds ratios with 95% confidence intervals (CI) for 30-day survival and 30-day favorable neurological outcomes were estimated for ECPR cases using a conditional logistic model.

RESULTS

Of 57,754 patients in the JAAM-OHCA registry, we selected 1826 patients with an initial shockable rhythm (treated with ECPR, n = 913 and control, n = 913) and a cohort of 740 patients with an initial non-shockable rhythm (treated with ECPR, n = 370 and control, n = 370). In these matched cohorts, the odds ratio for 30-day survival in the ECPR group was 1.76 [95%CI 1.38-2.25] for shockable rhythm and 5.37 [95%CI 2.53-11.43] for non-shockable rhythm, compared to controls. For favorable neurological outcomes, the odds ratio in the ECPR group was 1.11 [95%CI 0.82-1.49] for shockable rhythm and 4.25 [95%CI 1.43-12.63] for non-shockable rhythm, compared to controls.

CONCLUSION

ECPR was associated with increased 30-day survival in patients with OHCA with initial shockable and even non-shockable rhythms. Further research is warranted to investigate the reproducibility of the results and who is the best candidate for ECPR.

Annual patterns in the outcomes and post-arrest care for pediatric out-of-hospital cardiac arrest: A nationwide multicenter prospective registry in Japan

AIM

Out-of-hospital cardiac arrest (OHCA) has a poor prognosis in children; however, the annual patterns of prognosis and treatment have not been fully investigated.

METHODS

From the Japanese Association for Acute Medicine OHCA registry, a multicenter prospective observational registry in Japan, we identified pediatric patients (zero to 17 years old) between June 2014 and December 2019. The primary outcome was one-month survival. We investigated the annual patterns in patient characteristics, treatment, and one-month prognosis.

RESULTS

During the study period, 1188 patients were eligible for analysis. For all years, the zero-year-old group accounted for a large percentage of the total population (between 30% and 40%). There were significant increases in the rates of bystander-initiated cardiopulmonary resuscitation (CPR; from 50.6% to 62.3%, p = 0.003), dispatcher instructions (from 44.7% to 65.7%, p = 0.001), and adrenaline administration (from 2.4% to 6.9%, p = 0.014) over time, whereas the rate of advanced airway management decreased significantly (from 17.7% to 8.8%, p = 0.003). The odds ratios for one-month survival adjusted for potential resuscitation factors also did not change significantly (from 7.1% to 10.3%, adjusted odds ratio for one-year increment = 0.98, confidence interval: 0.86-1.11).

CONCLUSION

Despite an increase in the rate of bystander-initiated CPR and pre-hospital adrenaline administration, there was no significant change in one-month survival.

Intra-Aortic Balloon Pump among Shockable Out-of-Hospital Cardiac Arrest Patients: A Propensity-Weighted Analysis in a Multicenter, Nationwide Observational Study in Japan (The JAAM-OHCA Registry)

BACKGROUND

The effectiveness of IABP for shockable out-of-hospital cardiac arrest (OHCA) has not been extensively investigated. This study aimed to investigate whether the use of an intra-aortic balloon pump (IABP) for non-traumatic shockable OHCA patients was associated with favorable neurological outcomes.

METHODS

From the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest registry, a nationwide multicenter prospective registry, we enrolled adult patients with non-traumatic and shockable OHCA for whom resuscitation was attempted, and who were transported to participating hospitals between 2014 and 2019. The primary outcome was 1-month survival with favorable neurological outcomes after OHCA. After adopting the propensity score (PS) inverse probability of weighting (IPW), we evaluated the association between IABP and favorable neurological outcomes.

RESULTS

Of 57,754 patients in the database, we included a total of 2738 adult non-traumatic shockable patients. In the original cohort, the primary outcome was lower in the IABP group (OR with 95% confidence intervals (CIs)), 0.57 (0.48-0.68), whereas, in the IPW cohort, it was not different between patients with and without IABP (OR, 1.18; 95% CI, 0.91-1.53).

CONCLUSION

In adult patients with non-traumatic shockable OHCA, IABP use was not associated with 1-month survival with favorable neurological outcomes.

Surgical and Oncological Outcomes of Wedge Resection Versus Segment 4b + 5 Resection for T2 and T3 Gallbladder Cancer: a Meta-Analysis

BACKGROUND

Liver resection is the standard operative procedure for patients with T2 and T3 gallbladder cancers (GBC). However, the optimal extent of hepatectomy remains unclear.

METHODS

We conducted a systematic literature search and meta-analysis to assess the safety and long-term outcomes of wedge resection (WR) vs. segment 4b + 5 resection (SR) in patients with T2 and T3 GBC. We reviewed surgical outcomes (i.e., postoperative complications and bile leak) and oncological outcomes (i.e., liver metastasis, disease-free survival (DFS), and overall survival (OS)).

RESULTS

The initial search yielded 1178 records. Seven studies reported assessments of the above-mentioned outcomes in 1795 patients. WR had significantly fewer postoperative complications than SR, with an odds ratio of 0.40 (95% confidence interval, 0.26 - 0.60; p < 0.001), although there were no significant differences in bile leak between WR and SR. There were no significant differences in oncological outcomes such as liver metastases, 5-year DFS, and OS.

CONCLUSIONS

For patients with both T2 and T3 GBC, WR was superior to SR in terms of surgical outcome and comparable to SR in terms of oncological outcomes. WR that achieves margin-negative resection may be a suitable procedure for patients with both T2 and T3 GBC.

Association between blood urea nitrogen to creatinine ratio and neurologically favourable outcomes in out-of-hospital cardiac arrest in adults: A multicentre cohort study

BACKGROUND

We aimed to investigate the association between blood urea nitrogen to creatinine ratio (BCR) and survival with favourable neurological outcomes in patients with out-of-hospital cardiac arrest (OHCA).

METHODS

This prospective, multicentre, observational study conducted in Osaka, Japan enrolled consecutive OHCA patients transported to 16 participating institutions from 2012 through 2019. We included adult patients with non-traumatic OHCA who achieved a return of spontaneous circulation and whose blood urea nitrogen and creatinine levels on hospital arrival were available. Based on BCR values, they were divided into: 'low BCR' (BCR <10), 'normal BCR' (10 ≤ BCR < 20), 'high BCR' (20 ≤ BCR < 30), and 'very high BCR' (BCR ≥ 30). We evaluated the association between BCR values and neurologically favourable outcomes, defined as cerebral performance category score of 1 or 2 at one month after OHCA.

RESULTS

Among 4415 eligible patients, the 'normal BCR' group had the highest favourable neurological outcome [19.4 % (461/2372)], followed by 'high BCR' [12.5 % (141/1127)], 'low BCR' [11.2 % (50/445)], and 'very high BCR' groups [6.6 % (31/471)]. In the multivariable analysis, adjusted odds ratios for 'low BCR', 'high BCR', and 'very high BCR' compared with 'normal BCR' for favourable neurological outcomes were 0.58 [95 % confidence interval (CI 0.37-0.91)], 0.70 (95 % CI 0.49-0.99), and 0.40 (95 % CI 0.21-0.76), respectively. Cubic spline analysis indicated that the association between BCR and favourable neurological outcomes was non-linear (p for non-linearity = 0.003). In subgroup analysis, there was an interaction between the aetiology of arrest and BCR in neurological outcome (p for interaction <0.001); favourable neurological outcome of cardiogenic OHCA patients was lower when the BCR was higher or lower, but not in non-cardiogenic OHCA patients.

CONCLUSIONS

Both higher and lower BCR were associated with poor neurological outcomes compared to normal BCR, especially in cardiogenic OHCA patients.

Diagnostic test accuracy of life-threatening electrocardiographic findings (ST-elevation myocardial infarction equivalents) for acute coronary syndrome after out-of-hospital cardiac arrest without ST-segment elevation

AIM

Life-threatening electrocardiographic (ECG) findings aid in the diagnosis of acute coronary syndrome (ACS), which has not been well-evaluated in patients with out-of-hospital cardiac arrest (OHCA). This study aimed to evaluate the diagnostic test accuracy (DTA) of ST-elevation myocardial infarction (STEMI) equivalents following the return of spontaneous circulation (ROSC) in patients with OHCA to identify patients with ACS.

METHODS

Using the database of the Comprehensive Registry of In-Hospital Intensive Care for OHCA Survival study from 2012 to 2017, patients aged ≥18 years with non-traumatic OHCA and ventricular fibrillation or pulseless ventricular tachycardia on the arrival of emergency medical service personnel or arrival at the emergency department, who achieved ROSC, were included. Patients without ST-segment elevation or complete left bundle branch block on ECG and those who did not undergo ECG or coronary angiography, were excluded from the study. We evaluated the DTA of STEMI equivalents for the diagnosis of ACS: isolated T-wave inversion, ST-segment depression, Wellens' signs, and ST-segment elevation in lead aVR.

RESULTS

Isolated T-wave inversion and Wellens' signs had high specificity for ACS with 0.95 (95% confidence interval [CI], 0.87-0.99) and 0.92 (95% CI, 0.82-0.97), respectively, but their positive likelihood ratios were low, with a wide range of 95% CI: 1.89 (95% CI, 0.51-7.02) and 0.81 (95% CI, 0.25-2.68), respectively.

CONCLUSION

The DTA of STEMI equivalents for the diagnosis of ACS was low among patients with OHCA. Further investigation considering the measurement timing of the ECG after ROSC is required.

Application of adult prehospital resuscitation rules to pediatric out of hospital cardiac arrest

BACKGROUND

Prehospital termination of resuscitation (TOR) rules can be recommended for adults with out-of-hospital cardiac arrests (OHCAs). This study aimed to investigate whether adult basic life support (BLS) and advanced life support (ALS) TOR rules can predict neurologically unfavorable one-month outcome for pediatric OHCA patients.

METHODS

From a nationwide population-based observational cohort study, we extracted data of consecutive pediatric OHCA patients (0-17 years old) from January 1, 2005, to December 31, 2011. The BLS TOR rule has three criteria, whereas the ALS TOR rule includes two additional criteria. We selected pediatric OHCA patients that met all criteria for each TOR rule and calculated the specificity and positive predictive value (PPV) of each TOR rule for identifying pediatric OHCA patients who did not have neurologically favorable one-month outcome.

RESULTS

Of the 12,740 pediatric OHCA patients eligible for the evaluation of the BLS TOR rule, 10,803 patients met the BLS TOR rule, with a specificity of 0.785 and a PPV of 0.987 for predicting a lack of neurologically favorable one-month survival. Of the 2,091 for the ALS TOR rule, 381 patients met the ALS TOR rule, with a specificity of 0.986 and a PPV of 0.997 for predicting neurologically unfavorable one-month outcome.

CONCLUSIONS

The adult BLS and ALS TOR rules had a high PPV for predicting pediatric OHCA patients without a neurologically favorable survival at one month after onset.

External validation of the TiPS65 score for predicting good neurological outcomes in patients with out-of-hospital cardiac arrest treated with extracorporeal cardiopulmonary resuscitation

AIM

Estimating prognosis of patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) is essential for selecting candidates. The TiPS65 score can predict neurological outcomes of patients with out-of-hospital cardiac arrest (OHCA) treated with ECPR. We aimed to perform an external validation of this score.

METHODS

Data from the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest registry, a multicentred, nationwide, prospectively registered database, were analysed. All adult patients with OHCA and shockable rhythm and treated with ECPR between January 2018 to December 2019 were included. In the TiPS65 score, age, call-to-hospital arrival time, initial cardiac rhythm at hospital arrival, and initial pH value were used as predictors. The primary outcome was 30-day survival with favourable neurological outcomes (Cerebral Performance Category 1 or 2). Discrimination, using the C-statistic, and predictive performances of each score, such as sensitivity and specificity, were investigated.

RESULTS

Of 590 included patients (517 [81.6%] men; median [interquartile range] age, 60 [50-69] years), 64 (10.8%) reported favourable neurological outcomes. The C-statistic of the TiPS65 score was 0.729 (95% confidence interval (CI): 0.672-0.786). When the cut-off of TiPS65 score was set to >1, the sensitivity and specificity were 0.906 (95%CI: 0.807-0.965) and 0.430 (95%CI: 0.387-0.473), respectively; conversely, when the cut-off was set to >3, they were 0.172 (95%CI: 0.089-0.287) and 0.971 (95%CI: 0.953-0.984), respectively.

CONCLUSIONS

The TiPS65 score shows reasonable discrimination and predictive performances. This score can be supportive in the decision-making process for the selection of eligible patients for ECPR in clinical settings.

Characteristics of Pediatric Nasal Foreign Body Cases That Required Multiple Removal Procedures: A Single Tertiary Medical Center Cross-Sectional Study

OBJECTIVES

Removal of nasal foreign bodies in children should be completed as few numbers of times as possible to reduce the burden on the child. This study aimed to reveal the characteristics of pediatric nasal foreign body cases that required multiple removal procedure and to investigate the appropriate removal method for each shape of foreign body.

METHODS

We retrospectively reviewed patients who visited a pediatric emergency department because of nasal foreign body from November 1, 2018, to October 31, 2020. We compared the characteristics of patients, foreign bodies, and treatment between the success and failure groups in the first removal procedure. Moreover, we described the detail of patients in the failure group. We also showed final successful removal methods according to the shape of the foreign bodies.

RESULTS

We included 104 children in our analysis. Between the success and failure groups in the first removal procedure, there was no statistically significant difference in the characteristics of patients and foreign bodies but a significant difference in the removal method ( P < 0.001). In the failure groups, the most frequent number of times required for removal is 2 and the most common methods in the first removal procedure was the parent's kiss, most of which were performed on spherical foreign bodies in younger children, Finally, only 7 cases (6.7%) failed to remove the foreign body. According to the shape of the foreign bodies, the percentage of forceps and clamps used for successful removal was high in every shape.

CONCLUSIONS

There was a significant difference in the removal method between the success and failure groups in the first removal procedure, but finally, most foreign bodies were removed by emergency physicians. Therefore, further research is needed to determine the appropriate removal method for each patient and foreign body.

Clinical outcomes among out-of-hospital cardiac arrest patients treated by extracorporeal cardiopulmonary resuscitation: The CRITICAL study in Osaka

AIM

Extracorporeal cardiopulmonary resuscitation (ECPR) is performed in refractory out-of-hospital cardiac arrest (OHCA) patients, and the eligibility has been conventionally determined based on three criteria (initial cardiac rhythm, time to hospital arrival within 45 minutes, and age <75 years) in Japan. Owing to limited information, this study descriptively determined neurological outcomes after applying the three criteria among OHCA patients who underwent ECPR.

METHODS

This study conducted a post-hoc analysis of data from the Comprehensive Registry of Intensive Care for OHCA Survival (CRITICAL) study. This was a multi-institutional prospective observational study of OHCA patients in Osaka Prefecture, Japan. All adult (aged ≥18 years) OHCA patients with internal medical causes treated with ECPR between 1 July 2012 and 31 December 2019 were evaluated. We described one-month neurological favourable outcomes based on the three criteria (initial shockable, time to hospital arrival within 45 minutes, and age <75 years), and we compared them using the chi-square test.

RESULTS

Among 18,379 patients screened from the CRITICAL study database, we included 517 OHCA patients treated by ECPR; 311 (60.2%) patients met all three criteria. Favourable neurological outcomes were as follows: patients meeting no or one criterion: 2.3% (1/43), those meeting two criteria: 8% (13/163), and those meeting all criteria: 16.1% (50/311) (P-value = 0.004).

CONCLUSIONS

In this study, approximately 60% of patients treated by ECPR met the three criteria (initial shockable, time to hospital arrival within 45 minutes, and age <75 years), and the greater the number of criteria met, the better were the neurological outcomes achieved.

Usefulness and accuracy of segmental adrenal venous sampling on localisation and functional diagnosis of various adrenal lesions in primary aldosteronism

AIM

To clarify the usefulness and accuracy of segmental adrenal venous sampling (sAVS) on localisation and functional diagnosis of various adrenal lesions in primary aldosteronism.

MATERIALS AND METHODS

Consecutive patients (n=162) who underwent adrenalectomy and 138 patients indicated for medication following sAVS were analysed retrospectively. Based on immunohistopathological diagnosis, the positive predictive value (PPV) of computed tomography (CT)-detectable aldosterone-producing adenoma (APA) was calculated. Moreover, endocrinological and sAVS characteristics were analysed quantitatively and qualitatively among APA, CT-undetectable aldosterone-producing nodules (APNs), multiple aldosterone-producing micronodules (MAPM), and medication groups.

RESULTS

The PPV of APA by sAVS was 137/141 (97.1%; 95% confidence interval, 92.9-99.2%). Compared to the medication cases, the APA group showed stronger disease activity clinically and significant differences in adrenal hormones, such as a higher aldosterone level and aldosterone-to-cortisol ratio, and lower cortisol levels in the adrenal central vein and aldosterone maximum tributaries on the dominant side after cosyntropin stimulation. The APA group shows focal aldosterone hypersecretion, such as mean number of aldosterone elevated segments (1.7 ± 0.7 versus 2 ± 0.9, p=0.003) and presence of aldosterone-not-elevated segments (93% versus 41%, p<0.001). Clinically and in terms of sAVS, APN and MAPM showed similar characteristics to APA and to the medication cases, respectively.

CONCLUSION

sAVS can localise functionally active tissues of CT-detectable and CT-undetectable lesions enabling decisions on surgical or medical treatment.

The Prognostic Relevance of Preoperative CEA and CA19-9 for Ampulla of Vater Carcinoma

BACKGROUND/AIM

Increased serum levels of carcinoembryonic antigen (CEA) and carbohydrate antigen 199 (CA19-9) are established prognostic factors in ampulla of Vater carcinoma (AC). We determined the best cut-off values of preoperative CEA and CA19-9 and compared the prognostic power of preoperative CEA with that of preoperative CA19-9 for overall survival (OS).

PATIENTS AND METHODS

A total of 116 consecutive patients without jaundice who underwent macroscopic curative resection for AC between January 2002 and August 2019 were enrolled.

RESULTS

Using the minimum p-value approach based on the OS, the optimal CEA cut-off value was found to be 6.5 ng/ml; however, the cut-off value of CA19-9 could not be determined, as no significant p value was identified. The OS of the patients with CEA >6.5 ng/ml (n=5; 3-year OS, 20.0%) was significantly worse than that with CEA ≤6.5 ng/ml (n=111; 3-year OS, 76.6%; p<0.001). A Cox proportional hazards analysis for OS revealed CEA >6.5 ng/ml (hazard ratio=4.01, p=0.019) to be an independent prognostic factor.

CONCLUSION

In patients with AC, although the CA19-9 optimal cut-off value could not be determined, CEA >6.5 ng/ml independently affected long-term survival after resection.

POS1349 IMMUNOGLOBULIN G4-RELATED KIDNEY DISEASE’S PREDISPOSITION TO CHRONIC RENAL DYSFUNCTION, COMPLICATIONS OF MALIGNANCY, AND MORTALITY: A LONG-TERM NATIONWIDE MULTICENTER STUDY IN JAPAN

Background

In immunoglobulin G4-related kidney disease (IgG4-RKD), persistent renal insufficiency may be observed despite the good initial response to glucocorticoids[1, 2]. However, its long-term prognosis in relation to renal function as well as malignancy and mortality has not been well clarified.

Objectives

To clarify the long-term renal prognosis, complications of malignancy, mortality, and factors related to those outcomes in IgG4-RKD.

Methods

We retrospectively reviewed the medical records of patients with IgG4-RKD diagnosed by the expert members of the IgG4-RKD working group in the Japanese Society of Nephrology. We investigated clinical, radiological, and histopathological features at baseline and course of renal function, complications of malignancy, and mortality during the long-term observation periods (median 71 months) in 75 patients. Using collected data, we calculated the crude incidence rates (IR) of chronic kidney disease (CKD) status, malignancy, and death. Cox regression analyses were performed to assess CKD-related factors. Additionally, we calculated the standardized incidence ratio (SIR) of malignancy and standardized mortality ratio (SMR) using national Japan statistics.

Results

Fifty-nine patients were male, and 16 were female (median age 70 years). At diagnosis, their median eGFR was 45.1 mL/min/1.73m2 (interquartile range [IQR] 28.6-69.9). Seventy-two patients (96%) were treated with prednisolone at a median initial dose of 30 (IQR 30-39) mg/day, leading to a reasonable initial improvement of renal function. The IR of CKD was 30.2/100 person-years, and 66.7% (50/75) of the patients showed CKD at the last visit. Age- and sex-adjusted Cox regression analyses indicated that lower eGFR (per 10 mL/min/1.73m2, hazard ratio [HR] 0.70, 95% confidence interval [CI] 0.61-0.80), pre-existing hypertension (HR 2.39, 95% CI 1.32-4.34), and wider areas with inflammation (>50% vs. <10%, HR 2.55, 95% CI 1.07-6.08) or fibrosis (>50% vs. <5%, HR 2.84, 95% CI 1.18-6.85) in the biopsied renal specimens at treatment initiation had a significant impact on the time to CKD. Eight patients (10.7%) died during follow-up due to malignancy, severe infection, cerebral hemorrhage, or myocardial infarction. The crude mortality rate was 1.76/100 person-years, and a SMR calculated according to national Japan statistics was 0.97 (95% CI 0.42-1.90). On the other hand, 15 patients were diagnosed as having malignancies during follow-up. The IR of malignancy was 3.71/100 person-years, and the SIR of malignancy was 1.80 (95% CI 1.03-2.93).

Conclusion

This study suggests that pre-treated renal insufficiency and extensive renal inflammatory and fibrotic lesions are related to CKD under glucocorticoid therapy in IgG4-RKD. Similarly with the whole IgG4-related disease, IgG4-RKD may have an increased incidence of malignancy but a mortality rate equivalent to the age- and sex-matched Japanese population.

References

[1]Saeki T et al. The clinical course of patients with IgG4-related kidney disease. Kidney Int. 2013 Oct;84(4):826-33.

[2]Mizushima I et al. Factors related to renal cortical atrophy development after glucocorticoid therapy in IgG4-related kidney disease: a retrospective multicenter study. Arthritis Res Ther. 2016 Nov 25;18(1):273.

Disclosure of Interests

None declared

Association between initial body temperature on hospital arrival and neurological outcome among patients with out-of-hospital cardiac arrest: a multicenter cohort study (the CRITICAL study in Osaka, Japan)

Background

The association between spontaneous initial body temperature on hospital arrival and neurological outcomes has not been sufficiently studied in patients after out-of-hospital cardiac arrest (OHCA).

Methods

From the prospective database of the Comprehensive Registry of Intensive Care for OHCA Survival (CRITICAL) study in Osaka, Japan, we enrolled all patients with OHCA of medical origin aged > 18 years for whom resuscitation was attempted and who were transported to participating hospitals between 2012 and 2019. We excluded patients who were not witnessed by bystanders and treated by a doctor car or helicopter, which is a car/helicopter with a physician. The patients were categorized into three groups according to their temperature on hospital arrival: ≤35.9 °C, 36.0–36.9 °C (normothermia), and ≥ 37.0 °C. The primary outcome was 1-month survival, with a cerebral performance category of 1 or 2. Multivariable logistic regression analyses were performed to evaluate the association between temperature and outcomes (normothermia was used as the reference). We also assessed this association using cubic spline regression analysis.

Results

Of the 18,379 patients in our database, 5014 witnessed adult OHCA patients of medical origin from 16 hospitals were included. When analyzing 3318 patients, OHCA patients with an initial body temperature of ≥37.0 °C upon hospital arrival were associated with decreased favorable neurological outcomes (6.6% [19/286] odds ratio, 0.51; 95% confidence interval, 0.27–0.95) compared to patients with normothermia (16.4% [180/1100]), whereas those with an initial body temperature of ≤35.9 °C were not associated with decreased favorable neurological outcomes (11.1% [214/1932]; odds ratio, 0.78; 95% confidence interval, 0.56–1.07). The cubic regression splines demonstrated that a higher body temperature on arrival was associated with decreased favorable neurological outcomes, and a lower body temperature was not associated with decreased favorable neurological outcomes.

Conclusions

In adult patients with OHCA of medical origin, a higher body temperature on arrival was associated with decreased favorable neurologic outcomes.

Prediction of pouchitis after ileal pouch-anal anastomosis in patients with ulcerative colitis using artificial intelligence and deep learning

BACKGROUND

Pouchitis is one of the major postoperative complications of ulcerative colitis (UC), and it is still difficult to predict the development of pouchitis after ileal pouch-anal anastomosis (IPAA) in UC patients. In this study, we examined whether a deep learning (DL) model could predict the development of pouchitis.

METHODS

UC patients who underwent two-stage restorative proctocolectomy with IPAA at Keio University Hospital were included in this retrospective analysis. The modified pouchitis disease activity index (mPDAI) was evaluated by the clinical and endoscopic findings. Pouchitis was defined as an mPDAI ≥ 5.860; endoscopic pouch images before ileostomy closure were collected. A convolutional neural network was used as the DL model, and the prediction rates of pouchitis after ileostomy closure were evaluated by fivefold cross-validation.

RESULTS

A total of 43 patients were included (24 males and 19 females, mean age 39.2 ± 13.2 years). Pouchitis occurred in 14 (33%) patients after ileostomy closure. In less than half of the patients, mPDAI scores matched before and after ileostomy closure. Most of patients whose mPDAI scores did not match before and after ileostomy closure had worse mPDAI scores after than before. The prediction rate of pouchitis calculated by the area under the curve using the DL model was 84%. Conversely, the prediction rate of pouchitis using mPDAI before ileostomy closure was 62%.

CONCLUSION

The prediction rate of pouchitis using the DL model was more than 20% higher than that using mPDAI, suggesting the utility of the DL model as a prediction model for the development of pouchitis. It could also be used to determine early interventions for pouchitis.

Evaluation of histopathological heterogeneity of colorectal cancer liver metastasis sites after preoperative chemotherapy

Patients with liver metastases from colorectal cancer (CRLMs) frequently receive chemotherapy prior to liver resection. Histopathological assessment of the resected specimen can evaluate the response to chemotherapy. The present study analyzed the association between histopathological changes in the primary site and liver metastases. The present study comprised 45 patients with resectable CRLMs at the Surgical Oncology Department of Gifu University School of Medicine (Gifu, Japan) between January 2006 and August 2015. The study included 24 men and 21 women. The primary colonic tumor was located in the right side in 13 (28.9%) patients and the left side in 32 (71.9%) patients. The present study evaluated patients with metastatic colorectal cancer (31/45) after excluding those in whom histopathological heterogeneity between the primary and liver metastasis changed to grade 3 after chemotherapy. The group that underwent hepatectomy after chemotherapy (n=25) was compared with the group that underwent hepatectomy alone (n=6). In 16 (53.3%) out of 25 patients, histopathological heterogeneity of the liver metastasis was lost (P=0.04). In conclusion, chemotherapy appeared to change histopathological heterogeneity. The present study suggested that the histopathological change of intratumoral heterogeneity is reflected by the response to chemotherapy.

Clustering out‐of‐hospital cardiac arrest patients with non‐shockable rhythm by machine learning latent class analysis

Aim

We aimed to identify subphenotypes among patients with out‐of‐hospital cardiac arrest (OHCA) with initial non‐shockable rhythm by applying machine learning latent class analysis and examining the associations between subphenotypes and neurological outcomes.

Methods

This study was a retrospective analysis within a multi‐institutional prospective observational cohort study of OHCA patients in Osaka, Japan (the CRITICAL study). The data of adult OHCA patients with medical causes and initial non‐shockable rhythm presenting with OHCA between 2012 and 2016 were included in machine learning latent class analysis models, which identified subphenotypes, and patients who presented in 2017 were included in a dataset validating the subphenotypes. We investigated associations between subphenotypes and 30‐day neurological outcomes.

Results

Among the 12,594 patients in the CRITICAL study database, 4,849 were included in the dataset used to classify subphenotypes (median age: 75 years, 60.2% male), and 1,465 were included in the validation dataset (median age: 76 years, 59.0% male). Latent class analysis identified four subphenotypes. Odds ratios and 95% confidence intervals for a favorable 30‐day neurological outcome among patients with these subphenotypes, using group 4 for comparison, were as follows; group 1, 0.01 (0.001–0.046); group 2, 0.097 (0.051–0.171); and group 3, 0.175 (0.073–0.358). Associations between subphenotypes and 30‐day neurological outcomes were validated using the validation dataset.

Conclusion

We identified four subphenotypes of OHCA patients with initial non‐shockable rhythm. These patient subgroups presented with different characteristics associated with 30‐day survival and neurological outcomes.

Clinical Phenotyping of Out-of-Hospital Cardiac Arrest Patients With Shockable Rhythm - Machine Learning-Based Unsupervised Cluster Analysis

BACKGROUND

The hypothesis of this study is that latent class analysis could identify the subphenotypes of out-of-hospital cardiac arrest (OHCA) patients associated with the outcomes and allow us to explore heterogeneity in the effects of extracorporeal cardiopulmonary resuscitation (ECPR).Methods and Results:This study was a retrospective analysis of a multicenter prospective observational study (CRITICAL study) of OHCA patients. It included adult OHCA patients with initial shockable rhythm. Patients from 2012 to 2016 (development dataset) were included in the latent class analysis, and those from 2017 (validation dataset) were included for evaluation. The association between subphenotypes and outcomes was investigated. Further, the heterogeneity of the association between ECPR implementation and outcomes was explored. In the study results, a total of 920 patients were included for latent class analysis. Three subphenotypes (Groups 1, 2, and 3) were identified, mainly characterized by the distribution of partial pressure of O₂(PO₂), partial pressure of CO₂(PCO₂) value of blood gas assessment, cardiac rhythm on hospital arrival, and estimated glomerular filtration rate. The 30-day survival outcomes were varied across the groups: 15.7% in Group 1; 30.7% in Group 2; and 85.9% in Group 3. Further, the association between ECPR and 30-day survival outcomes by subphenotype groups in the development dataset was as varied. These results were validated using the validation dataset.

CONCLUSIONS

The latent class analysis identified 3 subphenotypes with different survival outcomes and potential heterogeneity in the effects of ECPR.

Evaluation of Suspected Autosomal Alport Syndrome Synonymous Variants

Background

Alport syndrome is an inherited disorder characterized by progressive renal disease, variable sensorineural hearing loss, and ocular abnormalities. Although many pathogenic variants in COL4A3 and COL4A4 have been identified in patients with autosomal Alport syndrome, synonymous mutations in these genes have rarely been identified.

Methods

We conducted in silico splicing analysis using Human Splicing Finder (HSF) and Alamut to predict splicing domain strength and disruption of the sites. Furthermore, we performed in vitro splicing assays using minigene constructs and mRNA analysis of patient samples to determine the pathogenicity of four synonymous variants detected in four patients with suspected autosomal dominant Alport syndrome (COL4A3 [c.693G>A (p.Val231=)] and COL4A4 [c.1353C>T (p.Gly451=), c.735G>A (p.Pro245=), and c.870G>A (p.Lys290=)]).

Results

Both in vivo and in vitro splicing assays showed exon skipping in two out of the four synonymous variants identified (c.735G>A and c.870G>A in COL4A4). Prediction analysis of wild-type and mutated COL4A4 sequences using HSF and Alamut suggested these two variants may lead to the loss of binding sites for several splicing factors, e.g., in acceptor sites and exonic splicing enhancers. The other two variants did not induce aberrant splicing.

Conclusions

This study highlights the pitfalls of classifying the functional consequences of variants by a simple approach. Certain synonymous variants, although they do not alter the amino acid sequence of the encoded protein, can dramatically affect pre-mRNA splicing, as shown in two of our patients. Our findings indicate that transcript analysis should be carried out to evaluate synonymous variants detected in patients with autosomal dominant Alport syndrome.

Development and validation of early prediction for neurological outcome at 90 days after return of spontaneous circulation in out-of-hospital cardiac arrest

AIM

To develop and validate a model for the early prediction of long-term neurological outcome in patients with non-traumatic out-of-hospital cardiac arrest (OHCA).

METHODS

We analysed multicentre OHCA registry data of adult patients with non-traumatic OHCA who experienced return of spontaneous circulation (ROSC) and had been admitted to the intensive care unit between 2013 and 2017. We allocated 1329 (2013-2015) and 1025 patients (2016-2017) to the derivation and validation sets, respectively. The primary outcome was the dichotomized cerebral performance category (CPC) at 90 days, defined as good (CPC 1-2) or poor (CPC 3-5). We developed 2 models: model 1 included variables without laboratory data, and model 2 included variables with laboratory data available immediately after ROSC. Logistic regression with least absolute shrinkage and selection operator regularization was employed for model development. Measures of discrimination, accuracy, and calibration (C-statistics, Brier score, calibration plot, and net benefit) were assessed in the validation set.

RESULTS

The C-statistic (95% confidence intervals) of models 1 and 2 in the validation set was 0.947 (0.930-0.964) and 0.950 (0.934-0.966), respectively. The Brier score of models 1 and 2 in the validation set was 0.0622 and 0.0606, respectively. The calibration plot showed that both models were well-calibrated to the observed outcome. Decision curve analysis indicated that model 2 was similar to model 1.

CONCLUSION

The prediction tool containing detailed in-hospital information showed good performance for predicting neurological outcome at 90 days immediately after ROSC in patients with OHCA.

Pancreatic metastasis from renal cell carcinoma presenting as gastrointestinal hemorrhage: a case report

In some patients with metastatic renal cell carcinoma to the pancreas, gastrointestinal hemorrhages occur, but because of the rarity of this condition, treatment strategies have not been established. A 71-year-old man who had undergone a nephrectomy for renal cell carcinoma (RCC) went to a hospital in a state of shock. Computed tomography revealed a hypervascularized tumor in the head of the pancreas, suggesting metastatic RCC. Upper endoscopy revealed bleeding in the duodenum due to tumor invasion. An emergency angiogram showed that the tumor received its blood supply mainly from the gastroduodenal artery. Transarterial embolization (TAE) of the gastroduodenal artery was performed and bleeding was controlled. Two months after TAE, elective pancreaticoduodenectomy was performed. The patient currently continues to undergo outpatient follow-up 2 years later without recurrence. TAE was very effective in controlling the acute phase of severe gastrointestinal hemorrhage from pancreatic metastasis of RCC.

Laparoscopic appendectomy during the second trimester of a twin pregnancy

Acute appendicitis during pregnancy may lead to increased maternal and fetal risks. Laparoscopic appendectomy is commonly performed during pregnancy. Compared with open appendectomy in pregnant women, laparoscopic appendectomy has shown non-inferior safety for pregnancy outcomes and superior safety for surgical outcomes. Over the last few decades, the occurrence of twin pregnancy has been increasing. Performing an operation on a patient with a twin pregnancy is more difficult than with a singleton pregnancy. Only a few operations of this kind have been reported. Here, we present a case of a 20-week twin pregnant woman who presented with acute appendicitis. Laparoscopic appendectomy was performed, and no maternal complications occurred. This report contributes to discussions on the safety of the laparoscopic approach for appendicitis during twin pregnancies.

Thoracic esophageal injury due to a neck stab wound: a case report

BACKGROUND

Traumatic esophageal injury leads to severe complications such as mediastinitis, pyothorax, and tracheoesophageal fistula. Although prompt diagnosis and treatment are required, there are no established protocols to guide diagnosis or treatment. In particular, thoracic esophageal injury tends to be diagnosed later than cervical esophageal injury because it has few specific symptoms. We report a case of thoracic esophageal injury caused by a cervical stab wound; the patient was stabbed with a sharp blade.

CASE PRESENTATION

A 74-year-old woman was attacked with a knife while sleeping at home. The patient was taken to the emergency room with an injury localized to the left section of her neck. She was suspected of a left jugular vein and recurrent laryngeal nerve injury from cervical hematoma and hoarseness. On the day following the injury, computed tomography revealed a thoracic esophageal injury. Emergency surgery was performed for an esophageal perforation and mediastinal abscesses. Although delayed diagnosis resulted in suture failure, the patient was able to resume oral intake of food a month later following enteral feeding with a gastrostomy. Esophageal injuries due to sharp trauma are rare, and most are cervical esophageal injuries. There are very few reports on thoracic esophageal injuries.

CONCLUSIONS

The possibility of thoracic esophageal injury should always be considered when dealing with neck stab wounds, particularly those caused by an attack.

Long-term antihypertensive drug use and risk of cancer: The Japan Public Health Center-based prospective study

Antihypertensive drugs have been reported as both promotors and suppressors of cancers and this relationship has been known for several decades. We examined a large‐scale prospective cohort study in Japan to assess the relationship between long‐term antihypertensive drug use, for 10 y, and carcinogenesis. We divided participants into 4 categories according to the period of antihypertensive drug use, and calculated the hazard ratios (HRs), 95% confidence intervals (CIs), and P trends using the Cox proportional hazard model. In all cancers, there was a significant difference in the medication period and the adjusted HR, as well as a significant difference in the P trend. Furthermore, more than 10 y use of antihypertensive drugs significantly increased the adjusted HR in colorectal cancer (multivariable HR: 1.18, 95% CI: 1.01‐1.37 in the >10 y use group; P for trend = .033) and renal cancer (multivariable HR: 3.76, 95% CI: 2.32‐6.10 in the 5‐10 y use group; multivariable HR: 2.14, 95% CI: 1.29‐3.56 in the >10 y use group; P for trend < .001). The highest adjusted HR in renal cancer among antihypertensive drug users was observed in the analysis performed on patients in which the outcomes were calculated from 3 y after the 10‐y follow‐up survey and by sex. A large‐scale cohort study in Japan suggested that long‐term use of antihypertensive drugs may be associated with an increased incidence of colorectal and renal cancer.

Target Temperature Management and Survival with Favorable Neurological Outcome After Out-of-Hospital Cardiac Arrest in Children: A Nationwide Multicenter Prospective Study in Japan

To assess whether target temperature management (TTM) is effective for 1-month survival with favorable neurological outcome among pediatric patients who achieved return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA). The Japanese Association for Acute Medicine-out-of-hospital cardiac arrest (JAAM-OHCA) Registry, a multicenter prospective observational registry in Japan, included OHCA patients aged ≤17 years who achieved ROSC between June 2014 and December 2017. The primary outcome was 1-month survival with favorable neurological outcomes, defined as pediatric cerebral performance category 1 or 2. We conducted a propensity score analysis with inverse-probability-of-treatment weighting (IPTW) and evaluated the effect of TTM using logistic regression models with IPTW. A total of 167 patients [120 in the non-TTM group (71.9%) and 47 in the TTM group (28.1%)] were eligible for our analysis. The proportion of patients demonstrating 1-month survival with favorable neurological outcomes was 25.5% (12/47) in the TTM group and 16.7% (20/120) in the non-TTM group; there were no significant differences in favorable neurological outcomes (odds ratio, 1.36; 95% confidence interval, 0.55-3.35) between the non-TTM and TTM groups after performing adjustments with IPTW. In our study population composed of pediatric patients who achieved ROSC after OHCA, we did not find a positive association between TTM implementation and 1-month survival with favorable neurological outcomes.

Trends in In-Hospital Advanced Management and Survival of Out-of-Hospital Cardiac Arrest Among Adults From 2013 to 2017 - A Multicenter, Prospective Registry in Osaka, Japan

BACKGROUND

The aim of our study was to investigate in detail the temporal trends in in-hospital characteristics, actual management, and survival, including neurological status, among adult out-of-hospital cardiac arrest (OHCA) patients in recent years.Methods and Results:From the prospective database of the Comprehensive Registry of Intensive Care for OHCA Survival (CRITICAL) study in Osaka, Japan, we enrolled all OHCA patients aged ≥18 years for whom resuscitation was attempted, and who were transported to participating hospitals between the years 2013 and 2017. The primary outcome measure was 1-month survival with favorable neurological outcome after OHCA. Temporal trends in in-hospital management and favorable neurological outcome among adult OHCA patients were assessed. Of the 11,924 patients in the database, we included a total of 10,228 adult patients from 16 hospitals. As for in-hospital advanced treatments, extracorporeal cardiopulmonary resuscitation (ECPR) use increased from 2.4% in 2013 to 4.3% in 2017 (P for trend <0.001). However, the proportion of adult OHCA patients with favorable neurological outcome did not change during the study period (from 5.7% in 2013 to 4.4% in 2017, adjusted odds ratio (OR) for 1-year increment: 0.98 (95% confidence interval: 0.94-1.23)).

CONCLUSIONS

In this target population, in-hospital management such as ECPR increased slightly between 2013 and 2017, but 1-month survival with favorable neurological outcome after adult OHCA did not improve significantly.

The association between hypozincemia and aortic stenosis prevalence in hemodialysis patients: a single-center cross-sectional study

Background

Hypozincemia contributes to phosphate-induced vascular calcification in model animals of renal failure, but the association between hypozincemia and aortic stenosis (AS) prevalence in patients with end-stage kidney disease remains unreported in clinical settings.

Methods

To investigate the association between hypozincemia and AS prevalence in patients undergoing hemodialysis, we designed a single-center cross-sectional study. Our outcome “AS” was defined as prevalence of moderate or severe AS or surgical history for AS. Depending on serum zinc levels, we divided patients undergoing hemodialysis into deciles. The association between hypozincemia and AS prevalence was analyzed via logistic regression adjusted for age, sex, dialysis vintage, diabetes history, serum albumin, and history of taking calcium-containing phosphate binder.

Results

Ninety-three patients undergoing hemodialysis were eligible. The mean serum zinc level was 61.3 ± 13.9 μg/dL. Twelve patients who belonged to 1st decile had serum zinc levels ≤ 48 μg/dL. Of these twelve patients, six patients (50 %) had AS. On the other hand, of eighty one patients who belonged to 2nd–10th deciles (serum zinc levels > 48 μg/dL), thirteen patients (16 %) had AS. Hypozincemia (serum zinc levels ≤ 48 μg/dL) was associated with AS prevalence (P = 0.038; odds ratio 4.43; 95% confidence interval 1.09–18.0).

Conclusions

AS was more prevalent in patients undergoing hemodialysis with severe hypozincemia in our cross-sectional study, although interventional studies are required to elucidate the benefit of zinc supplementation for AS progression.

Development and Validation of a Clinical Score to Predict Neurological Outcomes in Patients With Out-of-Hospital Cardiac Arrest Treated With Extracorporeal Cardiopulmonary Resuscitation

IMPORTANCE

Extracorporeal cardiopulmonary resuscitation (ECPR) is expected to improve the neurological outcomes of patients with refractory cardiac arrest; however, it is invasive, expensive, and requires substantial human resources. The ability to predict neurological outcomes would assist in patient selection for ECPR.

OBJECTIVE

To develop and validate a prediction model for neurological outcomes of patients with out-of-hospital cardiac arrest with shockable rhythm treated with ECPR.

DESIGN, SETTING, AND PARTICIPANTS

This prognostic study analyzed data from the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest registry, a multi-institutional nationwide cohort study that included 87 emergency departments in Japan. All adult patients with out-of-hospital cardiac arrest and shockable rhythm who were treated with ECPR between June 2014 and December 2017 were included. Patients were randomly assigned to the development and validation cohorts based on the institutions. The analysis was conducted between November 2019 and August 2020.

EXPOSURES

Age (<65 years), time from call to hospital arrival (≤25 minutes), initial cardiac rhythm on hospital arrival (shockable), and initial pH value (≥7.0).

MAIN OUTCOMES AND MEASURES

The primary outcome was 1-month survival with favorable neurological outcome, defined by Cerebral Performance Category 1 or 2. In the development cohort, a simple scoring system was developed to predict this outcome using a logistic regression model. The diagnostic ability and calibration of the scoring system were assessed in the validation cohort.

RESULTS

A total of 916 patients were included, 458 in the development cohort (median [interquartile range {IQR}] age, 61 [47-69] years, 377 [82.3%] men) and 458 in the validation cohort (median [IQR] age, 60 [49-68] years; 393 [85.8%] men). The cohorts had the same proportion of favorable neurological outcome (57 patients [12.4%]). The prediction scoring system was developed, attributing a score of 1 for each clinical predictor. Patients were divided into 4 groups, corresponding to their scores on the prediction model, as follows: very low probability (score 0), low probability (score 1), middle probability (score 2), and high probability (score 3-4) of good neurological outcome. The mean predicted probabilities in the groups stratified by score were as follows: very low, 1.6% (95% CI, 1.6%-1.6%); low, 4.4% (95% CI, 4.2%-4.6%); middle, 12.5% (95% CI, 12.1%-12.8%); and high, 30.8% (95% CI, 29.1%-32.5%). In the validation cohort, the C statistic of the scoring system was 0.724 (95% CI, 0.652-0.786). The predicted probability was evaluated as well calibrated to the observed favorable outcome in both cohorts by visual assessment of the calibration plot.

CONCLUSIONS AND RELEVANCE

In this study, the scoring system had good discrimination and calibration performance to predict favorable neurological outcomes of patients with out-of-hospital cardiac arrest and shockable rhythm who were treated with ECPR.

The Prognostic Relevance of the Number and Location of Positive Lymph Nodes for Ampulla of Vater Carcinoma

BACKGROUND

Lymph node metastasis (LNM) has been regarded as one of the prognostic factors in patients with ampulla of Vater carcinoma (AC). However, the consensus about an optimal cutoff value of the number of LNMs and the definition of the regional lymph nodes (RLNs) has not been achieved.

METHODS

This study included 114 consecutive patients who underwent pancreatoduodenectomy for AC between January 2002 and March 2019.

RESULTS

The minimum p value approach for the greatest difference in the overall survival classified the number of LNM into none (N0, n = 66), from 1 to 2 (N1, n = 32), and ≥3 LNM (N2, n = 11) (p = 0.004). Distant LNM was defined as M1 (n = 5). Significant differences in relapse-free survival (RFS) were found between N0 and N1 (p < 0.001), N1 and N2 (p = 0.047), and N1 and M1 (p = 0.044) but not between N2 and M1 (p = 0.683). Moreover, the patients with regional LNM were classified into two groups: Np group (n = 35, LNM only in pancreatic head region) and Nd group (n = 8, LNM in other regional location). Significant differences in the RFS were found between N0 and Np (p < 0.001), Np and Nd (p = 0.004), and Np and M1 (p = 0.033) but not between Nd and M1 (p = 0.883). A Cox proportional hazards analysis for RFS revealed that ≥ 3 LNMs (hazards ratio [HR], 3.22) and LNM except for pancreatic head region (HR, 4.27) were individually independent worse prognostic factors.

CONCLUSIONS

≥3 LNMs and regional LNM except for pancreatic head region were associated with poor prognosis comparable to that of the patients with M1.

Feasibility of the Reconstruction with Fascia Lata Patch on the Abdominal Wall Defect After Resection of the Abdominal Desmoid Tumor

Introduction

The abdominal desmoid tumor shows invasive development and high local recurrence rate. The primary treatment method is complete removal of the tumor because of the high recurrence rate; however, the problem for the surgeon is the reconstruction of the abdominal wall after resection of the abdominal desmoid tumor.

Case Presentation

A 63-year-old man underwent open drainage and ileostomy for the perforation of ileocecal tumor. After 3 months, he underwent right hemicolectomy and ileostomy closure. Pathological examination revealed no malignancy, and the ileocecal tumor showed the presence of abscess. He noticed a palpable mass in the left abdomen. Enhanced abdominal computed tomography (CT) revealed a large abdominal incisional hernia and an enhanced mass of 40 mm in the left rectus muscle. Needle biopsy was performed and the diagnosis was desmoid tumor. He underwent resection of the desmoid tumor and repair of hernia. We performed wide local resection, with a 2-cm surgical margin. The hernia was repaired by simple closure, and the defect in the left abdomen was repaired with reconstruction using the fascia lata patch through plastic surgery.

Conclusion

We encountered a case of abdominal wall desmoid tumor combined with a large abdominal incisional hernia. We selected the use of autologous fascia based on the risk of recurrence. The patient has not shown recurrence of incisional hernia or desmoid tumor 22 months after surgery. The use of fascia lata patch can be considered as a satisfactory alternative for such reconstruction cases.

Predictive accuracy of biomarkers for survival among cardiac arrest patients with hypothermia: a prospective observational cohort study in Japan

Background

There is limited information on the predictive accuracy of commonly used predictors, such as lactate, pH or serum potassium for the survival among out-of-hospital cardiac arrest (OHCA) patients with hypothermia. This study aimed to identify the predictive accuracy of these biomarkers for survival among OHCA patients with hypothermia.

Methods

In this retrospective analysis, we analyzed the data from a multicenter, prospective nationwide registry among OHCA patients transported to emergency departments in Japan (the JAAM-OHCA Registry). We included all adult (≥18 years) OHCA patients with hypothermia (≤32.0 °C) who were registered from June 2014 to December 2017 and whose blood test results on hospital arrival were recorded. We calculated the predictive accuracy of pH, lactate, and potassium for 1-month survival.

Results

Of the 34,754 patients in the JAAM-OHCA database, we included 754 patients from 66 hospitals. The 1-month survival was 5.8% (44/754). The areas under the curve of the predictors and 95% confidence interval were as follows: pH 0.829 [0.767–0.877] and lactate 0.843 [0.793–0.882]. On setting the cutoff points of 6.9 in pH and 120 mg/dL (13.3 mmol/L) in lactate, the predictors had a high sensitivity (lactate: 0.91; pH 0.91) and a low negative likelihood ratio (lactate: 0.14; pH 0.13), which are suitable to exclude survival to 1 month. Furthermore, in additional analysis that included only the patients with potassium values available, a cutoff point of 7.0 (mmol/L) for serum potassium had high sensitivity (0.96) and a low negative likelihood ratio (0.09).

Conclusion

This study indicated the predictive accuracy of serum lactate, pH, and potassium for 1-month survival among adult OHCA patients with hypothermia. These biomarkers may help define a more appropriate resuscitation strategy.

Thoracoscopic subtotal esophagectomy via a right thoracic cavity approach to treat an intractable fistula after 20 months from onset of an idiopathic esophageal rupture: A case report

An intractable fistula caused by idiopathic esophageal rupture is a rare but severe condition. In the present case, a 69-year-old man had been treated conservatively at another hospital for esophageal rupture but had developed an abscess in the left thoracic cavity due to an intractable fistula at the rupture site. He was referred to our hospital for treatment 19 months after the esophageal rupture. On admission, the intractable fistula was found to be continuous with an abscess in the left thoracic cavity. Preoperative continuous enteral nutrition was administered to improve the patient's nutritional status, and drainage was performed to reduce the size of the abscess. Then, to minimize the invasion of the intractable fistula, thoracoscopic subtotal esophagectomy was performed via a right thoracic cavity approach 20 months after the esophageal rupture. Preoperative management and thoracoscopic surgery via an opposite chest cavity approach was found to be safe and feasible for the intractable fistula caused by idiopathic esophageal rupture.

Ascending colon cancer with synchronous right external iliac lymph node metastasis

A 75-year-old woman was diagnosed with anemia during hospitalization for the treatment of right superior ophthalmic arteriovenous fistula. Colonoscopy revealed an entire circumference of type 2 tumor in the ascending colon. Computed tomography showed ascending colon wall thickening, a tumor with a maximum diameter of 32 mm on the right external iliac artery and multiple low-density nodules in the spleen. We performed right hemicolectomy with D3 lymph node dissection, splenectomy and right external iliac lymph node dissection. Histopathological finding revealed moderately-differentiated adenocarcinoma in ascending colon and right external iliac lymph node. The lesion of spleen was diagnosed as splenic lymphangioma. The patient was discharged on postoperative day 18. Additional treatments, including chemotherapy, were not performed, and no recurrences were seen up to 66 months after surgery. We herein report an uncommon event of ascending colon cancer with synchronous right external iliac lymph node metastasis, which was successfully treated by surgical resection, made feasible when the distant lymph node metastasis is localized.

Association between low pH and unfavorable neurological outcome among out-of-hospital cardiac arrest patients treated by extracorporeal CPR: a prospective observational cohort study in Japan

Background

We aimed to identify the association of pH value in blood gas assessment with neurological outcome among out-of-hospital cardiac arrest (OHCA) patients treated by extracorporeal cardiopulmonary resuscitation (ECPR).

Methods

We retrospectively analyzed the database of a multicenter prospective observational study on OHCA patients in Osaka prefecture, Japan (CRITICAL study), from July 1, 2012 to December 31, 2016. We included adult OHCA patients treated by ECPR. Patients with OHCA from external causes such as trauma were excluded. We conducted logistic regression analysis to identify the odds ratio (OR) and 95% confidence interval (CI) of the pH value for 1 month favorable neurological outcome adjusted for potential confounders including sex, age, witnessed by bystander, CPR by bystander, pre-hospital initial cardiac rhythm, and cardiac rhythm on hospital arrival.

Results

Among the 9822 patients in the database, 260 patients were finally included in the analysis. The three groups were Tertile 1: pH ≥ 7.030, Tertile 2: pH 6.875–7.029, and Tertile 3: pH < 6.875. The adjusted OR of Tertiles 2 and 3 compared with Tertile 1 for 1 month favorable neurological outcome were 0.26 (95% CI 0.10–0.63) and 0.24 (95% CI 0.09–0.61), respectively.

Conclusions

This multi-institutional observational study showed that low pH value (< 7.03) before the implementation of ECPR was associated with 1 month unfavorable neurological outcome among OHCA patients treated with ECPR. It may be helpful to consider the candidate for ECPR.

Effect of high ligation on survival of patients undergoing surgery for primary colorectal cancer and synchronous liver metastases

Background

Although R0 surgery is recommended for stage IV colorectal cancer, the degree of required lymphadenectomy has not been established. The aim of this study was to investigate the prognostic impact of high ligation (HL) of the feeding artery and the number of retrieved lymph nodes after R0 surgery for colorectal cancer and synchronous colorectal cancer liver metastasis (CRLM).

Methods

This was a multi‐institutional retrospective analysis of patients with colorectal cancer and synchronous CRLM who had R0 surgery between January 1997 and December 2007. Clinical and pathological features were compared in patients who underwent HL and those who had a low ligation (LL). Kaplan–Meier analysis was performed to estimate the effect of HL on overall survival (OS). The impact of several risk factors on survival was analysed using the Cox proportional hazards model.

Results

Of 549 patients, 409 (74·5 per cent) had HL. Median follow‐up was 51·4 months. HL significantly improved the 5‐year OS rate (58·2 per cent versus 49·3 per cent for LL; P = 0·017). Multivariable analysis revealed HL to be a significant prognostic factor compared with LL (5‐year mortality: hazard ratio (HR) 0·68, 95 per cent c.i. 0·51 to 0·90; P = 0·007). In subgroup analysis, the positive effect of HL on OS was greatest in patients with lymph node metastasis.

Conclusion

HL of the feeding artery was associated with improved OS in patients with colorectal cancer and synchronous CRLM after R0 surgery.

Intranodal lymphangiography for chyle leakage after esophagectomy: A case report

Postoperative chylothorax after esophagectomy is a relatively rare complication, but treatment can sometimes be complicated. We report 3 cases of Lipiodol lymphangiography via inguinal lymph node puncture that was effective for chyle leakage occurring after esophagectomy. Case 1: A 67-year-old man with stage IIIA esophageal squamous cell carcinoma underwent radical esophagectomy by video-assisted thoracic surgery (VATS) following neoadjuvant chemotherapy (NAC). After enteral feeding, right pleural effusion drainage increased sharply and changed to white color that was diagnosed as chylothorax. Conservative treatment was started on postoperative day (POD) 15. On POD 50, intranodal Lipiodol lymphangiography and thoracic duct ligation were performed, resulting in complete improvement by the next day. Case 2: A 69-year-old man with stage IIIC esophageal cancer was treated salvage operation following chemoradiation. Postoperative chylothorax was diagnosed on POD 6. Despite conservative treatment, the pleural fluid volume did not decrease. Intranodal Lipiodol lymphangiography performed on POD 13 showed contrast medium draining from the thoracic duct near the tracheal bifurcation. Thoracotomy for thoracic duct ligation was performed on POD 15. Thereafter, drainage from the thoracic drain decreased significantly, and the right thoracic drain was removed 4 days later. Case 3: A 65-year-old man with Stage IVA hypopharyngeal cancer and Stage IIIA esophageal cancer underwent total pharyngopharyngeal esophagectomy by VATS following NAC. Postoperative chylothorax was diagnosed on POD 7. Despite conservative treatment, the pleural fluid volume did not decrease. Intranodal Lipiodol lymphangiography performed on POD 19 completely visualized the thoracic duct and showed no outflow of contrast from the main thoracic duct into the mediastinum. Pleural fluid decreased remarkably after lymphangiography. Intranodal Lipiodol lymphangiography for postoperative chylothorax accurately visualizes flow within the thoracic duct and clearly depicts its positional relationship with other organs. Besides lymphangiography is not only helps to determine the site of chyle leakage but can also be effective for curing chylothorax by less invasive and safer method.

Poor Long-Term Survival of Out-of-Hospital Cardiac Arrest in Children

The effect of post-cardiac arrest care in children with out-of-hospital cardiac arrest (OHCA) has not been adequately established, and the long-term outcome after pediatric OHCA has not been sufficiently investigated. We describe here detailed in-hospital characteristics, actual management, and survival, including neurological status, 90 days after OHCA occurrence in children with OHCA transported to critical care medical centers (CCMCs).We analyzed the database of the Comprehensive Registry of Intensive Care for OHCA Survival (CRITICAL) study, which is a multicenter, prospective observational data registry designed to accumulate both pre- and in-hospital data on OHCA treatments. We enrolled all consecutive pediatric patients aged <18 years who had an OHCA and for whom resuscitation was attempted and who were transported to CCMCs between 2012 and 2016.A total of 263 pediatric patients with OHCA were enrolled. The average age of the patients was 6.3 years, 38.0% were aged < 1 year, and 60.8% were male. After hospital arrival, 4.9% of these pediatric patients received defibrillation; 1.9%, extracorporeal life support; 6.5%, target temperature management; and 88.2% adrenaline administration. The proportions of patients with 90-day survival and a pediatric cerebral performance category (PCPC) score of 1 or 2 were 6.1% and 1.9%, respectively. The proportion of patients with a PCPC score of 1 or 2 at 90 days after OHCA occurrence did not significantly improve during the study period.The proportion of pediatric patients with a 90-day PCPC score of 1 or 2 transported to CCMCs was extremely low, and no significant improvements were observed during the study period.

Position of the Pancreas Division Line and Postoperative Outcomes After Distal Pancreatectomy

BACKGROUND

In distal pancreatectomy (DP), the position of the pancreas division line (PDL) changes depending on the location or nature of the tumor. Here, we investigated the relationship between PDL and postoperative complications after DP.

METHODS

We retrospectively analyzed data of 140 patients who underwent DP at Tokyo Medical and Dental University Hospital between January 2011 and September 2018. PDL was defined as the distance from the left margin of the portal vein to the edge of the pancreatic stump on the coronal plane of computed tomography.

RESULTS

The mean PDL was 15.1 (range 0-74.3) mm. PDL was significantly longer in patients with portal venous system thrombosis (PVST) than in those without PVST (47.6 vs. 0 mm, p < 0.001). The PDL_long (≥ 20 mm) group underwent surgery with a significantly shorter duration (253 vs. 294 min, p < 0.001) and experienced a lower volume of blood loss (20 vs. 256.5 mL, p < 0.001) than the PDL_short (< 20 mm) group. Six months after surgery, the increase in HbA1c level was significantly higher in the PDL_short group than in the PDL_long group (0.5 vs. 0.35%, p = 0.041). Except for PVST, there was no significant difference in postoperative complications between the two groups.

CONCLUSIONS

In DP, pancreas resection with a longer PDL resulted in a significantly shorter duration of surgery, lower estimated blood loss, and superior glucose tolerance than that with a shorter PDL.

Single-incision laparoscopic ileocecal resection in a 10-year-old child with appendiceal neuroendocrine tumor

Background

In Japan, the majority of gastrointestinal tract neuroendocrine tumors (NETs) have been reported to originate from the rectum, and appendiceal NETs are relatively rare. Preoperative diagnosis is very difficult and it is diagnosed after appendectomy. Pediatric appendiceal NET is a disease with a good prognosis. However, in rare cases, lymph node metastasis could occur and additional resection is required.

Case presentation

A 10-year-old boy complained of right lower quadrant abdominal pain and underwent an appendectomy under a diagnosis of acute appendicitis in previous hospital. The final diagnosis was appendiceal NET, so he was referred to our department for additional resection. The tumor was found in the base of the appendix and invasively reached the subserosal layer with obvious vascular invasion. His Ki-67 index was 1 to 2%, so we classified it as appendiceal NET G1 according to the WHO 2015 classification. We considered the possibility of a tumor remnant or lymph node metastasis, so we performed single-incision laparoscopy with D3 lymph node dissection. The pathological diagnosis revealed no tumor remnant but metastasis to one lymph node. He was discharged on the 9th postoperative day. There has been no recurrence at 3 years and 7 months after surgery.

Conclusion

When the tumor size is 10–20 mm, the frequency of lymph node metastasis in some reports is variable, and there is no consensus yet on the indications for additional resection. However, there are definitely a certain number of cases with lymph node metastasis that require additional resection. In the present patient, long-term survival can be obtained by additional resection. At present, factors such as the presence of vascular or lymph node invasion and the malignancy grade and tumor’s location must be considered on a case-by-case basis. Although the incidence rate of appendiceal NET is rare, the diagnosis can be made only during postoperative pathological examination; thus, reliable histopathological examination is required.

Combination chemotherapy with TAS-102 plus bevacizumab in salvage-line treatment of metastatic colorectal cancer: A single-center, retrospective study examining the prognostic value of the modified Glasgow Prognostic Score in salvage-line therapy of metastatic colorectal cancer

The combination regimen of TAS-102, a novel oral nucleoside antitumor agent containing trifluridine and tipiracil hydrochloride, with bevacizumab (C-TASK FORCE), a selective monoclonal antibody inhibitor of vascular endothelial growth factor-A, as salvage-line therapy for metastatic colorectal cancer (mCRC) was established based on its high clinical effectiveness. The aim of the present study was to evaluate the prognostic accuracy of the modified Glasgow Prognostic Score (mGPS) in patients receiving TAS-102 plus bevacizumab. The study included 17 patients (12 men and 5 women, mean age 60.4±13.4 years) with unresectable mCRC who were confirmed to have wild-type or mutant RAS genes. The patients received salvage-line treatment with TAS-102 plus bevacizumab at the Surgical Oncology Department of Gifu University School of Medicine between March 2016 and August 2018. The study population was heavily pretreated; the majority of the patients (71%) had received ≥4 prior regimens and, in addition to fluoropyrimidine, irinotecan and oxaliplatin, all had received bevacizumab (100%) and either cetuximab or panitumumab (47%). The RAS status was wild-type in 9 (53%) and mutant in 8 (47%) patients. The primary tumor locations included the right-sided colon in 5 patients (29%; cecum in 2 and transverse colon in 3 cases) and left-sided colorectum in 12 patients [71%; sigmoid colon in 4, rectosigmoid (Rs) in 4, and rectum above/below the peritoneal reflection (Ra/b) in 4 cases]. Metastatic sites included the liver in 15 (88%), lung in 13 (76%), lymph nodes in 7 (41%), and peritoneal dissemination in 5 (24%) patients. The number of metastatic sites was 1 in 3 (18%) and >2 in 14 (82%) patients. Their first staging imaging scans (after 2 cycles of therapy) were available for review in all 17 patients. At first evaluation, 5 (29%) patients had progressive disease (PD), 12 (71%) had stable disease, and none had a partial response to TAS-102 plus bevacizumab. The median overall survival (OS) of 14.1 months and progression-free survival (PFS) of 6.8 months were comparable to the 11.2 and 5.6 months, respectively, in the C-TASK FORCE study. Upon considering three groups, namely mGPS 0, mGPS 1 and mGPS 2, the median PFS times were significantly different (mGPS 0 vs. mGPS 2, P=0.02; and mGPS 1 vs. mGPS 2, P=0.06). The median PFS times in the mGPS 0, 1 and 2 groups were 12.1, 4.8 and 2.3 months, respectively. Median OS was also significantly different (mGPS 0 vs. mGPS 2, P=0.01; and mGPS 1 vs. mGPS 2, P=0.04). The median OS times in the mGPS 0, 1 and 2 groups were 14.0, not reached, and 2 months, respectively. The present study demonstrated the efficacy and safety of the TAS-102 plus bevacizumab combination as salvage-line treatment. This combination therapy (the TAS-102 plus bevacizumab) has obtained valid results with PFS OS as well as C-TASK.FORCE study. The results of the present study also confirmed the prognostic accuracy of mGPS in salvage-line treatment of patients with mCRC.