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Can Blood Ammonia Level, Prehospital Time, and Return of Spontaneous Circulation Predict Neurological Outcomes of Out-of-Hospital Cardiac Arrest Patients? A Nationwide, Retrospective Cohort Study. 国際誌

Tsuyoshi Nojima, Hiromichi Naito, Takafumi Obara, Kohei Ageta, Hiromasa Yakushiji, Tetsuya Yumoto, Noritomo Fujisaki, Atsunori Nakao

Journal of clinical medicine 11 ( 9 ) 2022年5月

記述言語：英語掲載種別：研究論文（学術雑誌）

BACKGROUND: This study aimed to test if blood ammonia levels at hospital arrival, considering prehospital time and the patient's condition (whether return of spontaneous circulation [ROSC] was achieved at hospital arrival), can predict neurological outcomes after out-of-hospital cardiac arrest (OHCA). METHODS: This was a retrospective cohort study on data from a nationwide OHCA registry in Japan. Patients over 17 years old and whose blood ammonia levels had been recorded were included. The primary outcome was favorable neurological outcome at 30 days after OHCA. Blood ammonia levels, prehospital time, and the combination of the two were evaluated using the receiver operating characteristic curve to predict favorable outcomes. Then, cut-off blood ammonia values were determined based on whether ROSC was achieved at hospital arrival. RESULTS: Blood ammonia levels alone were sufficient to predict favorable outcomes. The overall cut-off ammonia value for favorable outcomes was 138 μg/dL; values were different for patients with ROSC (96.5 μg/dL) and those without ROSC (156 μg/dL) at hospital arrival. CONCLUSIONS: Our results using patient data from a large OHCA registry showed that blood ammonia levels at hospital arrival can predict neurological outcomes, with different cut-off values for patients with or without ROSC at hospital arrival.

DOI： 10.3390/jcm11092566

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智の探求:プレホスピタルと医療機関における心肺蘇生を望まない患者への対応 DNAR指示を有する院外心停止の特徴、病院前処置、転機に関する検討

田邉綾, 内藤宏道, 野島剛, 塚原紘平, 山田太平, 中尾篤典

日本臨床救急医学会雑誌 25 ( 2 ) 275 - 275 2022年5月

脳卒中様症状を呈した急性大動脈解離の1例

加藤篤之, 野島剛, 小原隆史, 塚原紘平, 内藤宏道, 中尾篤典

日本臨床救急医学会雑誌 25 ( 2 ) 329 - 329 2022年5月

人工呼吸管理中の喀痰評価の個人差に関する調査喀痰評価デバイス開発に向けて

平山隆浩, 木口隆, 野島剛, 青景聡之, 渡邉暁洋, 内藤宏道, 中尾博之, 中尾篤典

日本臨床救急医学会雑誌 25 ( 2 ) 388 - 388 2022年5月

Association between timing of speech and language therapy initiation and outcomes among post-extubation dysphagia patients: a multicenter retrospective cohort study. 国際誌

Takashi Hongo, Ryohei Yamamoto, Keibun Liu, Takahiko Yaguchi, Hisashi Dote, Ryusuke Saito, Tomoyuki Masuyama, Kosuke Nakatsuka, Shinichi Watanabe, Takahiro Kanaya, Tomoya Yamaguchi, Tetsuya Yumoto, Hiromichi Naito, Atsunori Nakao

Critical care (London, England) 26 ( 1 ) 98 - 98 2022年4月

記述言語：英語掲載種別：研究論文（学術雑誌）

BACKGROUND: Post-extubation dysphagia (PED) is recognized as a common complication in the intensive care unit (ICU). Speech and language therapy (SLT) can potentially help improve PED; however, the impact of the timing of SLT initiation on persistent PED has not been well investigated. This study aimed to examine the timing of SLT initiation and its effect on patient outcomes after extubation in the ICU. METHODS: We conducted this multicenter, retrospective, cohort study, collecting data from eight ICUs in Japan. Patients aged ≥ 20 years with orotracheal intubation and mechanical ventilation for longer than 48 h, and those who received SLT due to PED, defined as patients with modified water swallowing test scores of 3 or lower, were included. The primary outcome was dysphagia at hospital discharge, defined as functional oral intake scale score < 5 or death after extubation. Secondary outcomes included dysphagia or death at the seventh, 14th, or 28th day after extubation, aspiration pneumonia, and in-hospital mortality. Associations between the timing of SLT initiation and outcomes were determined using multivariable logistic regression. RESULTS: A total of 272 patients were included. Of them, 82 (30.1%) patients exhibited dysphagia or death at hospital discharge, and their time spans from extubation to SLT initiation were 1.0 days. The primary outcome revealed that every day of delay in SLT initiation post-extubation was associated with dysphagia or death at hospital discharge (adjusted odds ratio (AOR), 1.09; 95% CI, 1.02-1.18). Similarly, secondary outcomes showed associations between this per day delay in SLT initiation and dysphagia or death at the seventh day (AOR, 1.28; 95% CI, 1.05-1.55), 14th day (AOR, 1.34; 95% CI, 1.13-1.58), or 28th day (AOR, 1.21; 95% CI, 1.07-1.36) after extubation and occurrence of aspiration pneumonia (AOR, 1.09; 95% CI, 1.02-1.17), while per day delay in post-extubation SLT initiation did not affect in-hospital mortality (AOR, 1.04; 95% CI, 0.97-1.12). CONCLUSIONS: Delayed initiation of SLT in PED patients was associated with persistent dysphagia or death. Early initiation of SLT may prevent this complication post-extubation. A randomized controlled study is needed to validate these results.

DOI： 10.1186/s13054-022-03974-6

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Emotional work stress reactions of emergency medical technicians involved in transporting out-of-hospital cardiac arrest patients with "do not attempt resuscitation" orders. 国際誌

Ryo Tanabe, Takashi Hongo, Yasuhiro Mandai, Mototaka Inaba, Takashi Yorifuji, Atsunori Nakao, Jonathan Elmer, Hiromichi Naito

Resuscitation 173 61 - 68 2022年4月

記述言語：英語掲載種別：研究論文（学術雑誌）

BACKGROUND: Emergency medical technicians (EMTs) may be subjected to emotional stress during patient treatment/transport. In Japan, dispatched EMTs must attempt resuscitation in all cases of out-of-hospital cardiac arrest (OHCA), including patients with "do not attempt resuscitation" (DNAR) orders and patients whose families do not support resuscitation. We described the characteristics, prevalence, and outcomes of OHCA/DNAR patients, and aimed to identify factors associated with EMT stress when treating them. METHODS: We included OHCA patients transported by EMTs in the city of Okayama from 2015 to 2019. We identified patients with DNAR orders based on emergency medical service (EMS) records, then EMTs completed questionnaires regarding the management of those patients and EMTs' emotions. RESULTS: Among 3079 eligible OHCA patients, 122 patients (4%) had DNAR orders (DNAR group), and 2957 (96%) patients had no DNAR orders (no DNAR group). Based on responses from 243 EMT participants involved in OHCA/DNAR transports, we divided EMTs into high stress (73/243, 30%) and low stress (170/243, 70%) groups. EMTs experienced emotional stress from treating patients with family physician orders to transport (AOR: 4.74, 95% CI: 2.35-9.56) and those for whom prehospital defibrillation was performed (AOR: 20.7, 95% CI: 3.10-137.9). CONCLUSIONS: Approximately 30% of EMTs providing resuscitation to OHCA/DNAR patients experienced high levels of stress. Establishment of a prehospital emergency system incorporating physician medical direction and updated guidelines for treating patients with DNAR orders may reduce the psychosocial stress of EMTs.

DOI： 10.1016/j.resuscitation.2022.01.028

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Impact of different medical direction policies on prehospital advanced airway management for out-of hospital cardiac arrest patients: A retrospective cohort study. 国際誌

Takashi Hongo, Tetsuya Yumoto, Hiromichi Naito, Takeshi Mikane, Atsunori Nakao

Resuscitation plus 9 100210 - 100210 2022年3月

記述言語：英語掲載種別：研究論文（学術雑誌）

BACKGROUND: Although optimal prehospital airway management after out-of-hospital cardiac arrest (OHCA) remains undetermined, no studies have compared different advanced airway management (AAM) policies adopted by two hospitals in charge of online medical direction by emergency physicians. We examined the impact of two different AAM policies on OHCA patient survival. METHODS: This observational cohort study included adult OHCA patients treated in Okayama City from 2013 to 2016. Patients were divided into two groups: the O group - those treated on odd days when a hospital with a policy favoring laryngeal tube ventilation (LT) supervised, and the E group - those treated on even days when the other hospital with a policy favoring endotracheal intubation (ETI) supervised. Multiple logistic regression analysis was performed to assess airway device effects. The primary outcome measure was seven-day survival. RESULTS: Of 2,406 eligible patients, 50.1% were in the O group and 49.9% were in the E group. O group patients received less ETI (1.0% vs. 12.0%) and more LT (53.3% vs. 43.0%) compared with E group patients. In univariate analysis, no differences were observed in seven-day survival (9.4% vs 10.1%). Multiple regression analysis revealed neither LT nor ETI had a significant independent effect on seven-day survival, considering bag-valve mask ventilation as a reference (OR, 0.78; 95% CI, 0.54 to 1.13, OR, 0.79; 95% CI, 0.36 to 1.72, respectively). CONCLUSION: Despite different advanced airway medical direction policies in a single city, there were no substantial impact on outcomes for OHCA patients.

DOI： 10.1016/j.resplu.2022.100210

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日本外傷学会データバンクを用いた熱傷症例の検討

野島剛, 内藤宏道, 小原隆史, 小崎吉訓, 上田浩平, 塚原紘平, 中尾篤典

熱傷 48 ( 1 ) 38 - 39 2022年3月

岡山市における重症熱傷患者搬送とコロナウイルス感染症の影響

上田浩平, 内藤宏道, 塚原紘平, 中尾篤典

熱傷 48 ( 1 ) 39 - 39 2022年3月

当院高度救命救急センターにおける小児の熱傷と感染に関するまとめ

小原隆史, 塚原紘平, 野島剛, 上田浩平, 山本浩継, 内藤宏道, 中尾篤典

熱傷 48 ( 1 ) 41 - 41 2022年3月

広範囲熱傷患者のエネルギー消費の経過

大塚貴久, 塚原絋平, 内藤宏道, 中尾篤典

熱傷 48 ( 1 ) 38 - 38 2022年3月

集学的アプローチを用いた小児外傷患者に対する保護活動の実際

上原健敬, 依光正則, 福岡史朗, 佐藤浩平, 畑利彰, 島村安則, 塚原紘平, 中尾篤典, 尾崎敏文

日本整形外科学会雑誌 96 ( 2 ) S311 - S311 2022年3月

当院EICUにおいて、熱傷患者の熱傷面積が広いほど緑膿菌は検出されるかの検証

木口隆, 加藤湖月, 野島剛, 小崎吉訓, 藤崎宣友, 塚原紘平, 内藤宏道, 中尾篤典

熱傷 48 ( 1 ) 40 - 40 2022年3月

Reusable Medical Isolation Gowns with a Liquid Barrier: Washing Gowns in the Coronavirus Disease 2019 Pandemic Era?

Hiromichi Naito, Kohei Tsukahara, Soshi Takao, Takashi Yorifuji, Atsunori Nakao

JMA journal 5 ( 1 ) 107 - 108 2022年1月

記述言語：英語掲載種別：研究論文（学術雑誌）

Healthcare providers are at risk of exposure to SARS-CoV-2 via droplets, respiratory secretions, and contact with contaminated surfaces. Personal protective equipment (PPE) is necessary for primary reliable prevention to treat patients with coronavirus disease 2019 (COVID-19). However, PPE shortages have had a significant impact on every medical facility, and outpatient clinics are especially vulnerable to shortages of medical supplies. During the first stage of the pandemic, efforts were made to reduce the use of medical supplies. Guidance and strategies were proposed to ration the use of PPE, including reusing it. However, reuse (wash) of isolation gowns has not been practically promoted despite these suggestions. Further, reusable products may have advantages for economic and ecologic reasons. We developed an adult universally sized, long-sleeved, 100% polyester, reusable/washable gown with liquid barrier protection. The isolation gown can be worn repeatedly through washing and subsequent disinfection, and it can withstand washing in 80°C hot water for 10 min and/or immersion in 0.05%-0.1% sodium hypochlorite for 30 min and then dried. This new gown's liquid barrier performance is at Association for the Advancement of Medical Instrumentation level 1, even after 20 repeated uses with low cost. The choice of barrier level for gowns should be made based on the risk of contamination. However, the healthcare setting for COVID-19 patients varies greatly with not fully elucidated transmissibility. The newly made reusable isolation gown can be one option for treating COVID-19 patients especially in low-risk settings with economical advantage. Further, preparedness for reuse may have critical implications in extreme shortage. Reconsideration should be focused on reusable gowns with liquid barrier performance and their appropriate use.

DOI： 10.31662/jmaj.2021-0075

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Adult Scurvy Presenting with Painful Purpura on the Legs

Nayu Tamura, Takafumi Obara, Taihei Yamada, Tsuyoshi Nojima, Shunsuke Nakamura, Yasuhiro Koide, Makoto Takaoka, Hiromichi Naito, Atsunori Nakao

Internal Medicine 2022年

Geriatric trauma prognosis trends over 10 years: analysis of a nationwide trauma registry. 国際誌

Takeshi Nishimura, Hiromichi Naito, Atsunori Nakao, Shinichi Nakayama

Trauma surgery & acute care open 7 ( 1 ) e000735 2022年

記述言語：英語掲載種別：研究論文（学術雑誌）

PURPOSE: With Japan's population rapidly skewing toward aging, the number of geriatric trauma patients is expected to increase. Since we need to continue to improve the quality of geriatric trauma patient care, this study aimed to evaluate in-hospital mortality trends among geriatric trauma patients in Japan over a recent 10-year period. METHODS: This was a retrospective cohort study of data from a Japanese nationwide trauma registry (the Japan National Trauma Data Bank) on patients admitted between January 1, 2008 and December 31, 2017. Geriatric patients were defined as those 65 years old and older. The primary outcome was to clarify in-hospital mortality trends and changes over these 10 years. RESULTS: We identified 265 268 eligible trauma patients. Excluding those under 65 years old and those with inadequate or unknown age data, missing prognosis, out-of-hospital cardiac arrest, and burns, 107 766 patients were enrolled in this study. The total trauma patient in-hospital mortality trend was evaluated using the Cochran-Armitage test and showed a significant decrease (p<0.001). Although severe trauma patients (Injury Severity Score (ISS) ≥16) showed a significant decreasing trend (p<0.001) over time (from 26.1% to 14.5%), less-severe trauma patients (ISS <16) did not (p=0.41) (from 2.7% to 2.1%). Mixed logistic regression analysis showed that the number of year patients stayed in the hospital was significantly associated with mortality. CONCLUSIONS: While recognizing the limitations of the current analysis, our data demonstrated that prognoses for severe trauma patients over 65 years old improved dramatically over these 10 years, especially in those with severe trauma. LEVEL OF EVIDENCE: Ⅲ-retrospective cohort study.

DOI： 10.1136/tsaco-2021-000735

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Prehospital advanced airway management of emergency medical service-witnessed traumatic out-of-hospital cardiac arrest patients: analysis of nationwide trauma registry. 国際誌

Takeshi Nishimura, Masafumi Suga, Atsunori Nakao, Satoshi Ishihara, Hiromichi Naito

Acute medicine & surgery 9 ( 1 ) e786 2022年

記述言語：英語掲載種別：研究論文（学術雑誌）

AIM: Survival of traumatic out-of-hospital cardiac arrest (OHCA) is poor. Early use of advanced airway management (AAM) techniques, including endotracheal intubation and supraglottic devices, are expected to contribute to the improved survival of these patients. The aim of this study was to determine whether prehospital use of AAM improves the outcomes for emergency medical service (EMS)-witnessed traumatic OHCA. METHODS: A nationwide retrospective study was carried out. Trauma patients with EMS-witnessed cardiac arrest who received cardiopulmonary resuscitation during transport were included. Patients younger than 16 years and those with missing data were excluded. We compared two groups using propensity score matching. The primary outcome was survival to discharge. The secondary outcome was return of spontaneous circulation (ROSC) on hospital arrival. A logistic regression model was used to calculate odds ratios (OR) and confidence intervals (CI). RESULTS: After propensity score matching, 1,346 patients were enrolled (AAM 673 versus non-AAM 673). Forty-four AAM cases (6.5%) and 39 non-AAM cases (5.8%) survived. Logistic regression analysis did not show a contribution of AAM for survival to discharge (AAM 44/673 (6.5%), non-AAM 39/673 (5.8%); OR 1.12; 95% CI, 0.70-1.76; P = 0.64). However, AAM improved ROSC on admission (AAM 141/673 (21.0%), non-AAM 77/673 (11.4%); OR 2.05; 95% CI, 1.51-2.78; P < 0.001). This tendency was consistent throughout our subgroup analysis categorized by body region of the severe injury (head trauma, torso trauma, and extremity/spine trauma). CONCLUSIONS: Prehospital AAM among EMS-witnessed traumatic OHCA patients was not associated with survival to discharge; however, ROSC on hospital admission improved for the AAM patients.

DOI： 10.1002/ams2.786

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Hamman's Syndrome Accompanied by Diabetic Ketoacidosis; a Case Report. 国際誌

Koya Yamashita, Takashi Hongo, Tsuyoshi Nojima, Tetsuya Yumoto, Atsunori Nakao, Hiromichi Naito

Archives of academic emergency medicine 10 ( 1 ) e68 2022年

記述言語：英語

Hamman's syndrome is an uncommon clinical entity characterized by an idiopathic spontaneous pneumomediastinum as a result of a sudden increase in intra-alveolar pressure. It can be triggered by repeated vomiting or Kussmaul breathing associated with diabetic ketoacidosis (DKA). Careful attention to this particular condition is needed to avoid under-diagnosis and to provide optimal management. Herein, we report a case of an 18-year-old man complaining of chest discomfort and progressive weight loss, ultimately diagnosed with Hamman's syndrome secondary to DKA. The patient's symptoms disappeared after intravenous fluid and insulin administration, while his pneumomediastinum resolved following conservative treatment. Our report highlights the importance of recognition of the links between pneumomediastinum as a cause of chest pain in patients with DKA.

DOI： 10.22037/aaem.v10i1.1709

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Luminal Administration of a Water-soluble Carbon Monoxide-releasing Molecule (CORM-3) Mitigates Ischemia/Reperfusion Injury in Rats Following Intestinal Transplantation. 国際誌

Takafumi Obara, Hirotsugu Yamamoto, Toshiyuki Aokage, Takuro Igawa, Tsuyoshi Nojima, Takahiro Hirayama, Mizuki Seya, Michiko Ishikawa-Aoyama, Atsunori Nakao, Roberto Motterlini, Hiromichi Naito

Transplantation 106 ( 7 ) 1365 - 1375 2021年12月

記述言語：英語掲載種別：研究論文（学術雑誌）

BACKGROUND: The protective effects of carbon monoxide (CO) against ischemia/reperfusion (IR) injury during organ transplantation have been extensively investigated. Likewise, CO-releasing molecules (CORMs) are known to exert a variety of pharmacological activities via liberation of controlled amounts of CO in organs. Therefore, we hypothesized that intraluminal administration of water-soluble CORM-3 during cold storage of intestinal grafts would provide protective effects against IR injury. METHODS: Orthotopic syngeneic intestinal transplantation was performed in Lewis rats following 6 h of cold preservation in Ringer solution or University of Wisconsin solution. Saline containing CORM-3 (100 µmol/L) or its inactive counterpart (iCORM-3) was intraluminally introduced in the intestinal graft before cold preservation. RESULTS: Histopathological analysis of untreated and iCORM-3-treated grafts revealed a similar erosion and blunting of the intestinal villi. These changes in the mucosa structure were significantly attenuated by intraluminal administration of CORM-3. Intestinal mucosa damage caused by IR injury led to considerable deterioration of gut barrier function 3 h postreperfusion. CORM-3 significantly inhibited upregulation of proinflammatory mRNA levels, ameliorated intestinal morphological changes, and improved graft blood flow and mucosal barrier function. Additionally, CORM-3-treated grafts increased recipient survival rates. Pharmacological blockade of soluble guanylyl cyclase activity significantly reversed the protective effects conferred by CORM-3, indicating that CO partially mediates its therapeutic actions via soluble guanylyl cyclase activation. CONCLUSION: Our study demonstrates that luminally delivered CORM-3 provides beneficial effects in cold-stored rat small intestinal grafts and could be an attractive therapeutic application of CO in the clinical setting of organ preservation and transplantation.

DOI： 10.1097/TP.0000000000004007

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The effects of inhaling hydrogen gas on macrophage polarization, fibrosis, and lung function in mice with bleomycin-induced lung injury

Toshiyuki Aokage, Mizuki Seya, Takahiro Hirayama, Tsuyoshi Nojima, Masumi Iketani, Michiko Ishikawa, Yasuhiro Terasaki, Akihiko Taniguchi, Nobuaki Miyahara, Atsunori Nakao, Ikuroh Ohsawa, Hiromichi Naito

BMC Pulmonary Medicine 21 ( 1 ) 2021年12月

掲載種別：研究論文（学術雑誌）出版者・発行元：Springer Science and Business Media LLC

<title>Abstract</title><sec>
<title>Background</title>
Acute respiratory distress syndrome, which is caused by acute lung injury, is a destructive respiratory disorder caused by a systemic inflammatory response. Persistent inflammation results in irreversible alveolar fibrosis. Because hydrogen gas possesses anti-inflammatory properties, we hypothesized that daily repeated inhalation of hydrogen gas could suppress persistent lung inflammation by inducing functional changes in macrophages, and consequently inhibit lung fibrosis during late-phase lung injury.

</sec><sec>
<title>Methods</title>
To test this hypothesis, lung injury was induced in mice by intratracheal administration of bleomycin (1.0 mg/kg). Mice were exposed to control gas (air) or hydrogen (3.2% in air) for 6 h every day for 7 or 21 days. Respiratory physiology, tissue pathology, markers of inflammation, and macrophage phenotypes were examined.

</sec><sec>
<title>Results</title>
Mice with bleomycin-induced lung injury that received daily hydrogen therapy for 21 days (BH group) exhibited higher static compliance (0.056 mL/cmH₂O, 95% CI 0.047–0.064) than mice with bleomycin-induced lung injury exposed only to air (BA group; 0.042 mL/cmH₂O, 95% CI 0.031–0.053, <italic>p</italic> = 0.02) and lower static elastance (BH 18.8 cmH₂O/mL, [95% CI 15.4–22.2] vs. BA 26.7 cmH₂O/mL [95% CI 19.6–33.8], <italic>p</italic> = 0.02). When the mRNA levels of pro-inflammatory cytokines were examined 7 days after bleomycin administration, interleukin (IL)-6, IL-4 and IL-13 were significantly lower in the BH group than in the BA group. There were significantly fewer M2-biased macrophages in the alveolar interstitium of the BH group than in the BA group (3.1% [95% CI 1.6–4.5%] vs. 1.1% [95% CI 0.3–1.8%], <italic>p</italic> = 0.008).

</sec><sec>
<title>Conclusions</title>
The results suggest that hydrogen inhalation inhibits the deterioration of respiratory physiological function and alveolar fibrosis in this model of lung injury.

</sec>

DOI： 10.1186/s12890-021-01712-2

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その他リンク： https://link.springer.com/article/10.1186/s12890-021-01712-2/fulltext.html

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