Kodai Suzuki

Reduced Immunocompetent B Cells and Increased Secondary Infection in Elderly Patients With Severe Sepsis

ABSTRACT Lymphocyte exhaustion was recently recognized as a mechanism of immunosuppression in sepsis. While B cells are known to play pivotal roles in bacterial infection and sepsis, changes in B-cell-mediated humoral immunity have not been evaluated in critically ill septic patients. We aimed to investigate changes in humoral immunity caused by defective B-cell function during severe sepsis. Thirty-three severe sepsis patients and 44 healthy subjects were prospectively enrolled. Blood was collected from patients within 72 h of and 8 to 11 h after sepsis onset to measure B-cell subtypes, serum immunoglobulin M concentration, and CpG-B oligodeoxynucleotide-induced immunoglobulin M (IgM) production ex vivo. Participants were divided into two age groups: adults (18–64 years) and elderly (≥65 years). The fraction of CD21–/low exhausted B cells in acute sepsis patients (3.18%) was higher than that observed in healthy donors (0.77%, respectively, P <0.01). Significantly, serum IgM in elderly septic patients (≥65 years) was negatively correlated with acute physiology and chronic health evaluation II score (r = –0.57, P <0.05). Consistently, in B cells stimulated ex vivo, both aging and sepsis induced significant reductions in supernatant IgM (P <0.01). This finding was clinically relevant, as elderly patients with decreased IgM production might be more susceptible to infection by Gram-negative bacteria and fungi. Reduced immunocompetent B cells may be related to increased secondary infection after sepsis, especially in the elderly. Finally, impaired humoral immunity with increased CD21−/low exhausted B cells and insufficient immunoglobulin M production may be a critical immunological change in sepsis.

Comparative Effectiveness of Emergency Resuscitative Thoracotomy versus Closed Chest Compressions among Patients with Critical Blunt Trauma: A Nationwide Cohort Study in Japan

Background Although emergency resuscitative thoracotomy is performed as a salvage maneuver for critical blunt trauma patients, evidence supporting superior effectiveness of emergency resuscitative thoracotomy compared to conventional closed-chest compressions remains insufficient. The objective of this study was to investigate whether emergency resuscitative thoracotomy at the emergency department or in the operating room was associated with favourable outcomes after blunt trauma and to compare its effectiveness with that of closed-chest compressions. Methods This was a retrospective nationwide cohort study. Data were obtained from the Japan Trauma Data Bank for the period between 2004 and 2012. The primary and secondary outcomes were patient survival rates 24 h and 28 d after emergency department arrival. Statistical analyses were performed using multivariable generalized mixed-effects regression analysis. We adjusted for the effects of different hospitals by introducing random intercepts in regression analysis to account for the differential quality of emergency resuscitative thoracotomy at hospitals where patients in cardiac arrest were treated. Sensitivity analyses were performed using propensity score matching. Results In total, 1,377 consecutive, critical blunt trauma patients who received cardiopulmonary resuscitation in the emergency department or operating room were included in the study. Of these patients, 484 (35.1%) underwent emergency resuscitative thoracotomy and 893 (64.9%) received closed-chest compressions. Compared to closed-chest compressions, emergency resuscitative thoracotomy was associated with lower survival rate 24 h after emergency department arrival (4.5% vs. 17.5%, respectively, P < 0.001) and 28 d after arrival (1.2% vs. 6.0%, respectively, P < 0.001). Multivariable generalized mixed-effects regression analysis with and without a propensity score-matched dataset revealed that the odds ratio for an unfavorable survival rate after 24 h was lower for emergency resuscitative thoracotomy than for closed-chest compressions (P < 0.001). Conclusions Emergency resuscitative thoracotomy was independently associated with decreased odds of a favorable survival rate compared to closed-chest compressions.

Comparison of two pediatric flail chest cases

Flail chest is a rare complication in pediatric patients with blunt chest trauma. There is no general consensus on which treatment is most appropriate for flail chest in pediatric patients, although it has been reported that surgical fixation is associated with beneficial outcomes for flail chest in adults.The present report described two pediatric cases of flail chest, which was rare in pediatric blunt trauma. In small children, functional residual capacity is smaller, and the thorax is pliable due to high thoracic compliance. Therefore, it is only advisable to select intubation and mechanical ventilation treatment. Likewise, in pediatric flail chest, the available evidence does not suggest that ventilator management protocols should be adopted routinely, and the treatment for pediatric flail chest was not established completely.There were not huge different between the described patients, including injury severity and ventilation setting. However, one had a relapse of flail chest after extubation and chest taping was required, while the other patient’s condition was stable after decannulation.As described above, it is difficult to predict a recurrence of flail chest in pediatric patients even if treatment goes well. Therefore, T-piece trial should be considered prior to extubation.

Ultrastructural Alteration of Pulmonary Capillary Endothelial Glycocalyx During Endotoxemia

Background The most recent diagnostic criteria for sepsis include organ failure. Microvascular endothelial injury is believed to lead to the multiple organ failure seen in sepsis, although the precise mechanism is still controversial. ARDS is the primary complication during the sequential development of multiple organ dysfunction in sepsis, and endothelial injury is deeply involved. Sugar‐protein glycocalyx coats all healthy vascular endothelium, and its disruption is one factor believed to contribute to microvascular endothelial dysfunction during sepsis. The goal of this study was to observe the three‐dimensional ultrastructural alterations in the pulmonary capillary endothelium, including the glycocalyx, during sepsis‐induced pulmonary vasculitis. Methods This study investigated the three‐dimensional ultrastructure of pulmonary vascular endothelial glycocalyx in a mouse lipopolysaccharide‐induced endotoxemia model. Lungs were fixed with lanthanum‐containing alkaline fixative to preserve the glycocalyx. Results On both scanning and transmission electron microscopic imaging, the capillary endothelial glycocalyx appeared as a moss‐like structure entirely covering the endothelial cell surface in normal mice. In the septic lung following liposaccharide injection, however, this structure was severely disrupted; it appeared to be peeling away and coagulated. In addition, syndecan‐1 levels were significantly reduced in the septic lung, and numerous spherical structures containing glycocalyx were observed on the endothelial surface. Conclusions It appears that endothelial glycocalyx in the lung is markedly disrupted under experimental endotoxemia conditions. This finding supports the notion that disruption of the glycocalyx is causally related to the microvascular endothelial dysfunction that is characteristic of sepsis‐induced ARDS.

Simple pneumopericardium due to blunt trauma progressing to tension pneumopericardium during transportation

Patients with simple pneumopericardium due to blunt thoracic trauma occasionally progressed to tension pneumopericardium, although pneumopericardium is believed to be benign in general. A 65-year-old man had both arms caught in a grinding machine and his face struck hard at work. He was diagnosed with bilateral degloving injuries of both arms and mediastinal emphysema on computed tomography. He required transfer to an advanced emergency medical service center for treatment. Although he was hemodynamically stable then, the patients condition deteriorated during transportation. The patient returned to the local hospital as cardiopulmonary resuscitation continued, repeat computed tomography was performed, which showed a substantial pneumopericardium and exacerbation of mediastinal and subcutaneous emphysema. After then, cardiopulmonary resuscitation was discontinued because there was no response. For the patient to be rescued in this situation, thoracotomy is required, although it should be reserved for patients with evidence of hemodynamic compromise attributable to cardiac tamponade.

Cardiopulmonary Resuscitation Performance may Improve with Consideration of Performer’s Characteristics

Background: In basic life support, chest compressions are a very important and basic skill. Acquiring the ability to perform chest compressions is affected by individual characteristics such as physique and physical strength, although all persons can learn to Perform Cardiopulmonary Resuscitation (CPR), including chest compressions. The aim of this study was to examine differences in physique between males and females and Basic Life Support (BLS) skill using a portable manikin with automated corrective feedback.Methods: Participants were 120 fourth-year preclinical dental school students (87 males, 33 females). For skill assessment, students performed chest compressions and single rescuer CPR using a Laerdal Resusci Anne Skill Reporter TM manikin for 2 minutes each before and after CPR. Outcome measures were (1) compression depth (mm), (2) compression rate (number of compressions per minute), (3) compression release depth (recoil, mm), and (4) hand position before and after the BLS course.Results: After the BLS course, compression depth and rate improved significantly. Both before and after the BLS course, male students performed deeper chest compressions than female students. In females, the duration of acceptable chest compressions was significantly shorter than in males.Conclusion: CPR performance was significantly different between males and females, probably due to differences in physique. Therefore, it is necessary for individualized instruction adapted to the learner’s characteristics.

“To and Fro” Paradoxical Thrombus in the Left Heart

Please find supplementary file(s); http://dx.doi.org/10.1253/circj.CJ-18-0564 D eep vein thrombosis (DVT) often occurs after arthroplasty.1 We encountered the case of an 85-year-old woman who had received right bipolar hip arthroplasty 3 months earlier. Although edoxaban 30 mg/day had been prescribed, on her own accord the patient stopped taking the medication after 2 months. One month later, she presented with dyspnea on effort, left chest pain and leg edema. Transthoracic echocardiography (TTE) showed an elongated movable mass with portions in both atria (Figure, Movie S1). Moreover, the tip of the mass moved into and out of the left ventricle with each heart beat. Dilatation of the right ventricle was also found, and the tricuspid regurgitation pressure gradient was elevated to 60 mmHg. There were no findings indicating left heart failure. Enhanced computed tomography showed a thrombus in the main pulmonary artery as well as DVT. This indicated a combination of acute pulmonary embolism with a paradoxical embolism caused by DVT. After 2 weeks of thrombolytic therapy with heparin, the thrombus in the left atrium and the dilatation of the right ventricle Received May 11, 2018; revised manuscript received June 7, 2018; accepted June 14, 2018; released online August 24, 2018 Time for primary review: 18 days Department of Clinical Laboratory, Gifu University Hospital, Gifu (T.W., H.I.); Department of Emergency and Disaster Medicine (H.O., K. Suzuki, G.N., T.K., H.U., S.Y., S.O.), Department of Cardiology (M. Kawasaki), Gifu University Graduate School of Medicine, Gifu; and JA Gifu Koseiren Nishimino Kosei Hospital, Gifu (H.O., K. Shibuya, M. Kobayashi), Japan Mailing address: Hideshi Okada, MD, PhD, Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu 501-1194, Japan. E-mail: hideshi@ gifu-u.ac.jp ISSN-1346-9843 All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: cj@j-circ.or.jp “To and Fro” Paradoxical Thrombus in the Left Heart

A new mutation of congenital methemoglobinemia exacerbated after methylene blue treatment

Methylene blue is useful for the treatment of methemoglobinemia. However, even after the patients methemoglobin (metHb) rate has improved, careful observation is important because they could have undiagnosed congenital methemoglobinemia. In this case, a 67‐year‐old man underwent gastrointestinal endoscopy with the use of lidocaine for local anesthesia. During the examination, he complained of dyspnea and had low SpO2 despite normal PaO2 and SaO2. He was transferred to our department as a suspected case of acquired methemoglobinemia.

Rapid Attainment of Optimal Trough Concentrations in Organ Failure Mitigated by Teicoplanin

The effective treatment of infections with teicoplanin requires an initial loading dose to reach optimal trough concentrations rapidly enough. The optimal dosage of teicoplanin was previously established, and an optimal trough concentration of 15-20 μg/mL was assumed based on weight and estimated creatinine clearance. Teicoplanin treatment was performed with software-based monitoring of teicoplanin concentrations. We compared serum chemistry parameters and sequential organ failure assessment (SOFA) scores in patients with initial teicoplanin trough concentrations 0.05). Teicoplanin initial trough concentrations have been thought to contribute to improvement of organ failure. To maintain therapeutic concentrations of teicoplanin in patients with high disease severity, it was useful to ensure that initial trough values were ≥ 15 μg/mL. The initial dosage schedule of teicoplanin in emergency intensive care should consider disease severity.

Early optimization of antimicrobial therapy improves clinical outcomes of patients administered agents targeting methicillin-resistant Staphylococcus aureus

Antimicrobial stewardship is required to ensure the appropriate use of antimicrobials. However, no reports have been published on clinical outcomes of implementation of antimicrobial stewardship in patients receiving pathogen‐specific antibiotics.