Toshifumi Uejima

Incidence and survival rate of bystander-witnessed out-of-hospital cardiac arrest with cardiac etiology in Osaka, Japan: a population-based study according to the Utstein style

PURPOSE To clarify the incidence and survival rate of bystander-witnessed out-of-hospital cardiac arrests (OHCA) with cardiac etiology in Osaka Prefecture, Japan, with a population of nearly 9 million according to the Utstein style. SUBJECTS AND METHODS 5047 consecutive OHCA cases were treated by ambulance personnel during the 12-month period starting since 1 May 1998. 974 cases were considered to be bystander-witnessed OHCA with cardiac etiology and analyzed using the Utstein style. RESULTS Of the 974 cases (100%), 50 cases (5.1%) survived after 1 month and 28 (2.9%) of them after 1 year. The Ventricular fibrillation (VF)/ventricular tachycardia (VT) group comprised 164 (16.8%) cases and there were statistically differences between the two groups as below (the VF/VT group vs. the non-VF/VT group): gender (male: 76.8 vs. 60.7%), age (61.7+/-14.7 vs. 68.7+/-17.1), history of ischemic heart disease (IHD) (30.5 vs. 15.3%), performance rate of bystander cardiopulmonary resuscitation (CPR) (34.1 vs. 21.4%) and time interval between receipt of an emergency call and arrival at the scene (5.5+/-2.9 vs. 6.0+/-2.9 min). CONCLUSION The incidence of bystander-witnessed (OHCA) with cardiac etiology and VF or VT were remarkably low compared with those reported by other studies conducted in some areas of Europe or the USA.

Characteristics of bath-related burns in Japan

A retrospective study of bath-related burn injuries was carried out at our institution. A total of 216 patients with burns were admitted between 1982 and 1996. Bath-related burns were identified in 58 patients (26.9%). The number of patients with bath-related burns increased throughout the study period. The percentage body surface area burned was 43.8 +/- 25.7% in the bath-related burn group and 27.3 +/- 28.3% in the bath-unrelated burn group. This difference was significant. There was no significant difference between the two groups with respect to mortality rate. The mechanism by which the patients sustained a bath-related burn clearly differed according to age. The percentage of burns which are bath-related and the severity of bath-related burns are higher in Japan than in any other country. This can be attributed to lifestyle, bathing systems, bathroom architecture, housing conditions and an increase in the elderly population. These burns can be prevented. Education based on this study will play a critical role in the prevention of the bath-related burn injuries.

High D-dimer levels predict a poor outcome in patients with severe trauma, even with high fibrinogen levels on arrival : a multicenter retrospective study

ABSTRACT Elevated D-dimer level in trauma patients is associated with tissue damage severity and is an indicator of hyperfibrinolysis during the early phase of trauma. To investigate the interacting effects of fibrinogen and D-dimer levels on arrival at the emergency department for massive transfusion and mortality in severe trauma patients in a multicenter retrospective study. This study included 519 adult trauma patients with an injury severity score ≥16. Patients with ≥10 units of red cell concentrate transfusion and/or death during the first 24 h were classified as having a poor outcome. Receiver operating characteristic curve analysis for predicting poor outcome showed the optimal cut-off fibrinogen and D-dimer values to be 190 mg/dL and 38 mg/L, respectively. On the basis of these values, patients were divided into four groups: low D-dimer (<38 mg/L)/high fibrinogen (>190 mg/dL), low D-dimer (<38 mg/L)/low fibrinogen (⩽190 mg/dL), high D-dimer (≥38 mg/L)/high fibrinogen (>190 mg/dL), and high D-dimer (≥38 mg/L)/low fibrinogen (⩽190 mg/dL). The survival rate was lower in the high D-dimer/low fibrinogen group than in the other groups. Moreover, the survival rate was lower in the high D-dimer/high fibrinogen group than in the low D-dimer/high fibrinogen and low D-dimer/low fibrinogen groups. High D-dimer level on arrival is a strong predictor of early death or requirement for massive transfusion in severe trauma patients, even with high fibrinogen levels.

Traumatic laceration of the intracranial vertebral artery causing fatal subarachnoid hemorrhage: Case report

A 36-year-old man who had been drinking alcohol had a fatal subarachnoid hemorrhage immediately after suffering a moderate craniofacial injury. Autopsy revealed a 3-mm longitudinal laceration of the left intracranial vertebral artery proximal to the posterior inferior cerebellar artery. There was no finding of arterial dissection. We discuss the mechanisms of the traumatic laceration of the vertebral artery in relation to traumatic dissection of the vertebral artery.

Can Early Aggressive Administration of Fresh Frozen Plasma Improve Outcomes in Patients with Severe Blunt Trauma?—a Report by the Japanese Association for the Surgery of Trauma

Background: This study investigated the effect of a high ratio of fresh frozen plasma (FFP) to red blood cells (RBCs) within the first 6 and 24 h after admission on mortality in patients with severe, blunt trauma. Methods: This retrospective observational study included 189 blunt trauma patients with an Injury Severity Score (ISS) ≥16 requiring RBC transfusions within the first 24 h. Receiver operating characteristic (ROC) curve analysis was performed to calculate cut-off values of the FFP/RBC ratio for outcome. The patients were then divided into two groups according to the cut-off value. Patient survival was compared between groups using propensity score matching (PSM). Results: The area under the ROC curve was 0.57, and the FFP/RBC ratio was 1.0 at maximum sensitivity (0.57) and specificity (0.67). All patients were then divided into two groups (FFP/RBC ratio ≥1 or <1) and analyzed using PSM and inverse probability of treatment weighting (IPTW). The unadjusted hazard ratio (HR) was 0.44, and the adjusted HR was 0.29. The HR was 0.38 by PSM and 0.41 by IPTW. The survival rate was significantly higher in patients with an FFP/RBC ratio ≥1 within the first 6 h. Conclusions: Severe blunt trauma patients transfused with an FFP/RBC ratio ≥1 within the first 6 h had an HR of about 0.4. The transfusion of an FFP/RBC ratio ≥1 within the first 6 h was associated with the outcomes of blunt trauma patients with ISS ≥16 who need a transfusion within 24 h.

Development of Novel Criteria of the “lethal Triad” as an Indicator of Decision Making in Current Trauma Care: A Retrospective Multicenter Observational Study in Japan

Objectives: To evaluate the utility of the conventional lethal triad in current trauma care practice and to develop novel criteria as indicators of treatment strategy. Design: Retrospective observational study. Settings: Fifteen acute critical care medical centers in Japan. Patients: In total, 796 consecutive trauma patients who were admitted to emergency departments with an injury severity score of greater than or equal to 16 from January 2012 to December 2012. Interventions: None. Measurements and Main Results: All data were retrospectively collected, including laboratory data on arrival. Sensitivities to predict trauma death within 28 days of prothrombin time international normalized ratio greater than 1.50, pH less than 7.2, and body temperature less than 35°C were 15.7%, 17.5%, and 15.9%, respectively, and corresponding specificities of these were 96.4%, 96.6%, and 93.6%, respectively. The best predictors associated with hemostatic disorder and acidosis were fibrin/fibrinogen degradation product and base excess (the cutoff values were 88.8 µg/mL and –3.05 mmol/L). The optimal cutoff value of hypothermia was 36.0°C. The impact of the fibrin/fibrinogen degradation product and base excess abnormality on the outcome were approximately three- and two-folds compared with those of hypothermia. Using these variables, if the patient had a hemostatic disorder alone or a combined disorder with acidosis and hypothermia, the sensitivity and specificity were 80.7% and 66.8%. Conclusions: Because of the low sensitivity and high specificity, conventional criteria were unsuitable as prognostic indicators. Our revised criteria are assumed to be useful for predicting trauma death and have the potential to be the objective indicators for activating the damage control strategy in early trauma care.

Regulation of TCR Vγ2 gene rearrangement by the helix-loop-helix protein, E2A

V(D)J recombination of Ig and TCR genes is strictly regulated by the accessibility of target gene chromatin in a lineage- and stage-specific manner. In the mouse TCRγ locus, rearrangement of the Vγ2 gene predominates over Vγ3 rearrangement in the adult thymus. This preferential rearrangement is likely due to the differential accessibility of the individual Vγ genes, because the levels of germ line transcription and histone acetylation of the Vγ genes are well correlated with the rearrangement frequency in adult thymocytes. However, factors responsible for the differential regulation of the Vγ gene rearrangement have been largely unknown. In this study, we demonstrated that Vγ2 rearrangement in the adult thymus was substantially reduced in mice deficient for the basic helix-loop-helix protein, E2A. The decreased rearrangement is likely caused by the reduced accessibility of Vγ2 chromatin, since germ line transcription and histone acetylation of the Vγ2 gene were reduced in an E2A dosage-dependent manner. We further showed that E2A bound around the Vγ2 gene in vivo and we identified two canonical E-box sites downstream of Vγ2, to which E2A can bind in vitro. Furthermore, these two E-box sites had the ability to activate transcription upon E2A over-expression. These data suggest that E2A directly binds to and increases accessibility of Vγ2 chromatin, thereby facilitating Vγ2 rearrangement in the adult thymus.

Effect of Serum Albumin Concentration on Neurological Outcome After Out-of-Hospital Cardiac Arrest (from the CRITICAL [Comprehensive Registry of Intensive Cares for OHCA Survival] Study in Osaka, Japan)

The aim of this study was to assess whether serum albumin concentration upon hospital arrival had prognostic indications on out-of-hospital cardiac arrest (OHCA). This prospective, multicenter observational study conducted in Osaka, Japan (the CRITICAL [Comprehensive Registry of Intensive Cares for OHCA Survival] study), enrolled all patients with consecutive OHCA transported to 14 participating institutions. We included adult patients aged ≥18 years with nontraumatic OHCA who achieved return of spontaneous circulation and whose serum albumin concentration was available from July 2012 to December 2014. Based on the serum albumin concentration upon hospital arrival, patients were divided into quartiles (Q1 to Q4), namely, Q1 (<2.7 g/dl), Q2 (2.7 to 3.1 g/dl), Q3 (3.1 to 3.6 g/dl), and Q4 (≥3.6 g/dl). The primary outcome was 1-month survival with favorable neurological outcome (cerebral performance category scale 1 or 2). During the study period, a total of 1,269 patients with OHCA were eligible for our analyses. The highest proportion of favorable neurological outcome was 33.5% (109 of 325) in the Q4 group, followed by 13.2% (48 of 365), 5.0% (13 of 261), and 3.5% (11 of 318) in the Q3, Q2, and Q1 groups, respectively. In the multivariable logistic regression analysis, the proportion of favorable neurological outcome in the Q4 group was significantly higher, compared with that in the Q1 group (adjusted odds ratio 8.61; 95% confidence interval 4.28 to 17.33). The adjusted proportion of favorable neurological outcome increased in a stepwise manner across increasing quartiles (p for trend <0.001). Higher serum albumin concentration was significantly and independently associated with favorable neurological outcome in a dose-dependent manner.

Actual treatments for out-of-hospital ventricular fibrillation at critical care medical centers in Osaka: a pilot descriptive study

Although advanced treatments are provided to improve outcomes after out‐of‐hospital ventricular fibrillation, including shock‐resistant ventricular fibrillation, the actual treatments in clinical settings have been insufficiently investigated. The aim of the current study is to describe the actual treatments carried out for out‐of‐hospital ventricular fibrillation patients, including shock‐resistant ventricular fibrillation patients, at critical care medical centers.

Remote lesion in the substantia nigra caused by striatopallidal abscess.

This 19-year-old man was admitted to our institution after su ̈ering an assault to his left orbit by an umbrella tip. He was alert and fully orientated. The umbrella tip had penetrated the medial part of the left superior palpebra. Both pupils were intact. His left visual acuity was nearly una ̈ected, and no ophthalmoplegia was noted. CT scans revealed that the stab-wound reached to the right caudate nucleus and the right putamen through the medial orbital wall, the ethmoid sinus and the cribriform plate. Several tiny bone fragments, surrounded by small haematomas, were located in the right putamen. MRI taken 8 days after the injury revealed development of an abscess involving the caudate nucleus, the putamen, and the globus pallidus. A new T2-weighted hyperintense lesion in the ipsilateral substantia nigra was noted (Fig. 1). On the 9th day after the injury, a right fronto-temporal craniotomy was performed with subsequent aspiration. Culture of the abscess content revealed Bacillus sp. Postoperative CT scans showed several tiny retained bone fragments. At 27 days after the injury we removed the deep-seated residual bone fragments by microsurgery. The striatopallidal lesion resolved over time. Careful neurological examination disclosed neither hemiplegia nor movement disorders. No cerebrospinal ̄uid leakage was noted. Follow up MRIs obtained 2, 5 and 11 months after injury showed disappearance of high intensity signal of the ipsilateral substantia nigra. Acta Neurochirurgica > Springer-Verlag 1999 Printed in Austria Acta Neurochir (Wien) (1999) 141: 669±670