Kunihiro Shirai

Japanese guidelines for the management of acute pancreatitis: Japanese Guidelines 2015.

Japanese (JPN) guidelines for the management of acute pancreatitis were published in 2006. The severity assessment criteria for acute pancreatitis were later revised by the Japanese Ministry of Health, Labour and Welfare (MHLW) in 2008, leading to their publication as the JPN Guidelines 2010. Following the 2012 revision of the Atlanta Classifications of Acute Pancreatitis, in which the classifications of regional complications of pancreatitis were revised, the development of a minimally invasive method for local complications of pancreatitis spread, and emerging evidence was gathered and revised into the JPN Guidelines.

Simultaneous determination of eight β-lactam antibiotics in human serum by liquid chromatography-tandem mass spectrometry.

A liquid chromatography-tandem mass spectrometry (LC-MS/MS) method was developed for the simultaneous determination of eight β-lactam antibiotics, including ampicillin, cefazolin, cefepime, cefmetazole, cefotaxime, doripenem, meropenem, and piperacillin, in human serum. Sample specimens were subjected to solid phase extraction (SPE) using Waters Oasis® HLB cartridges (30 mg). Chromatographic separation was performed with a high-resolution octadecyl silica column compatible with hydrophilic compounds, using a gradient of 10mM aqueous ammonium formate containing 0.1% formic acid-methanol. Antibiotics were detected by a triple quadrupole mass spectrometer (MS/MS) with electrospray ionization and quantified by the multiple reaction monitoring mode. A total run time of 13 min was applied. Linearity in the calibration was obtained over a range of 0.1-50 μg/mL of the β-lactam antibiotics, except for doripenem. The lower limit of quantification was 0.005-0.5 μg/mL, using 50 μL serum. The recovery rate exceeded 80.2% for these analytes, except for doripenem (49.1%) and meropenem (62.3%). The present method is applicable to routine therapeutic monitoring of β-lactam antibiotics in clinical practice.

Effect of enteral diet enriched with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in patients with sepsis-induced acute respiratory distress syndrome

BackgroundIn this study, the effects of an enteral diet enriched with eicosapentaenoic acid (EPA), γ-linolenic acid (GLA), and antioxidants were compared with a standard enteral diet in critically ill patients with sepsis-induced acute respiratory distress syndrome (ARDS).MethodsThis study was a single-center, prospective, randomized, single-blind, controlled trial in our Advanced Critical Care Center. Patients were randomized to receive a continuous EPA, GLA, and antioxidant-enriched diet (study group), or an isocaloric standard diet (control group).ResultsTwenty-three of 46 patients were in the study group, and the other 23 were in the control group. Duration of mechanical ventilation, incidence of new nosocomial infections, changes over time in Sequential Organ Failure Assessment (SOFA) scores, and 60-day mortality were not significantly different between the two groups. The ratio of partial pressure of oxygen to fraction of inspired oxygen on day 7 was significantly higher in the study group (233.0 [185.5–282.8] vs. 274.0 [225.5–310.8], p = 0.021). Duration of ICU stay was significantly shorter in the study group than in the control group (24.0 [20.0–30.0] vs. 15.0 [11.0–24.0], p = 0.008).ConclusionsAn enteral diet enriched with EPA, GLA, and antioxidants did not improve duration of mechanical ventilation, SOFA score, incidence of new nosocomial infections, or mortality but did favorably influence duration of ICU stay in critically ill patients with sepsis-induced ARDS.

Usefulness of serum cystatin C to determine the dose of vancomycin in critically ill patients

Objectives  Serum creatinine (Scr) is not a reliable marker of renal function in critically ill patients because of an enhancement of protein catabolism, which makes it difficult to adjust the dosage of renally eliminated drugs such as antibiotics. This study aimed to investigate whether serum cystatin C (Scys‐C) could be used as a reliable marker of renal function.

Continuous Regional Arterial Infusion of Protease Inhibitors Has No Efficacy in the Treatment of Severe Acute Pancreatitis: A Retrospective Multicenter Cohort Study.

Objective The aim of this study is to assess the effectiveness of continuous regional arterial infusion (CRAI) of protease inhibitors in patients with severe acute pancreatitis (SAP) including acute necrotizing pancreatitis. Methods This retrospective study was conducted among 44 institutions in Japan from 2009 to 2013. Patients 18 years or older diagnosed with SAP according to the criteria of the Japanese Ministry of Health, Labour and Welfare study group (2008) were consecutively enrolled. We evaluated the association between CRAI of protease inhibitors and mortality, incidence of infection, and the need for surgical intervention using multivariable logistic regression analysis. Results Of 1159 patients admitted, 1097 patients with all required data were included for analysis. Three hundred and seventy-four (34.1%) patients underwent CRAI of protease inhibitors and 723 (65.9%) did not. In multivariable analysis, CRAI of protease inhibitors was not associated with a reduction in mortality, infection rate, or need for surgical intervention (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.47–1.32, P = 0.36; OR 0.97, 95% CI 0.61–1.54, P = 0.89; OR 0.76, 95% CI 0.50–1.15, P = 0.19; respectively). Conclusions Continuous regional arterial infusion of protease inhibitors was not efficacious in the treatment of patients with SAP.

Sternoclavicular joint septic arthritis with chest wall abscess in a healthy adult: a case report

BackgroundSeptic arthritis of the sternoclavicular joint is rare. It can be associated with serious complications such as osteomyelitis, chest wall abscess, and mediastinitis. In this report, we describe a case of an otherwise healthy adult with septic arthritis of the sternoclavicular joint with chest wall abscess.Case presentationA 68-year-old Japanese man presented to our hospital complaining of pain and erythema near the right sternoclavicular joint. Despite 1 week of oral antibiotics, his symptoms did not improve. Computed tomography revealed an abscess with air around the right pectoralis major muscle. After being transferred to a tertiary hospital, emergency surgery was performed. Operative findings included necrotic tissue around the right sternoclavicular joint and sternoclavicular joint destruction, which was debrided and packed open. Methicillin-susceptible Staphylococcus aureus was identified in blood and wound cultures. Negative pressure wound therapy and hyperbaric oxygen therapy were performed for infection control and wound healing. The patient’s general condition improved, and good granulation tissue developed. The wound was closed using a V-Y flap on hospital day 48. The patient has been free of relapse for 3 years.ConclusionsSeptic arthritis of the sternoclavicular joint is an unusual infection, especially in otherwise healthy adults. Because it is associated with serious complications such as chest wall abscess, prompt diagnosis and appropriate treatment are required.

Plasmapheresis therapy has no triglyceride-lowering effect in patients with hypertriglyceridemic pancreatitis.

Kyohei Miyamoto, Masayasu Horibe, Masamitsu Sanui, Mitsuhito Sasaki, Daisuke Sugiyama, Seiya Kato, Takahiro Yamashita, Takashi Goto, Eisuke Iwasaki, Kunihiro Shirai, Kyoji Oe, Hirotaka Sawano, Takuya Oda, Hideto Yasuda, Yuki Ogura, Kaoru Hirose, Katsuya Kitamura, Nobutaka Chiba, Tetsu Ozaki, Taku Oshima, Tomonori Yamamoto, Keiji Nagata, Tetsuya Mine, Koji Saito, Motohiro Sekino, Tomoki Furuya, Naoyuki Matsuda, Mineji Hayakawa, Takanori Kanai and Toshihiko Mayumi

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.

Premonitory Symptom of Septic Shock in Heart Rate Variability

Delay of administering therapy increases the mortality of septic patients. Diagnosing sepsis, however, depends on the decision of an experienced specialist of whether to perform a blood test. Therefore, we believe that a real-time, non-invasive monitoring system for sepsis is useful to promote early intervention. Heart rate variability (HRV), a measure of autonomic nervous system (ANS) activity, has been suggested as an indicator of septic shock. When analyzing electrocardiograms of patients admitted in the intensive care unit (ICU), an important challenge is to distinguish HRV originating in the ANS from other factors such as arrhythmia. A stochastic model is used in this study to extract HRV caused by ANS automatically. Applying the proposed process before HRV estimation, we identified a distinctive V-shaped temporal pattern in HRV as a signal of sepsis. Our investigation continues to explain how that temporal pattern is useful to develop a real-time sepsis monitoring system for sepsis occurrence.

Septic Shock Prediction by Real Time Monitoring of Heart Rate Variability

We propose a method for septic shock prediction by real time monitoring of heart rate variability (HRV) for patients in intensive care unit (ICU). An objective criterion that is related to septic occurrence and can be measured automatically in real time is required to detect septic occurrence. Although HRV is a candidate of such criteria, an automatic estimation of HRV has been difficult because there are many arrhythmias in ICU patients. In this study, we employed a stochastic model on R-R interval series, namely heartbeat interval series, in order to detect abnormal heartbeats in normal R-R interval series automatically. Abnormal heartbeats and very low frequency components are eliminated from R-R series by using the stochastic model. Applying the elimination process before HRV estimation, we identified a distinctive V-shaped temporal pattern in HRV series before septic shock was occurred. The V-shaped pattern is applicable as a signal of septic occurrence. We finally propose a real-time monitoring for sepsis occurrence by using the V-shaped pattern in HRV.