Hitachi General Hospital

本稿は鍼灸臨床におけるレッドフラッグの概念と具体例について概説した。 レッドフラッグは見逃すと予後不良となる重大な疾患を示唆する徴候であり、 冷汗や突然発症などの共通兆候、 バイタルサインの異常、 症状別 （頭痛・肩痛・腰痛・妊婦） の危険徴候が含まれる。 鍼灸師は鍼灸安全対策ガイドラインなどに基づき、 これらを的確に評価し、 必要に応じて医療機関に紹介する使命がある。 しかし一方で、 レッドフラッグを一括して学ぶ機会は多くない。 今回の講演では、 明日からの診療がレッドフラッグを意識した診療に変わり、 患者の安全を確保できることを目指している。

Objective: To assess the safety of mini-endoscopic combined intrarenal surgery (mini-ECIRS) in patients with a poor performance status (PS). Methods: A retrospective analysis was conducted on 1132 patients who underwent mini-ECIRS at 3 hospitals between January 2015 and December 2021. Patients were classified according to their PS (PS0-1 and PS2-4 groups) and compared between the groups in terms of preoperative drainage status, such as ureteral stent or percutaneous nephrostomy (PNS), stone characteristics, surgical outcomes, and postoperative fever. Multivariate logistic regression models were used to identify the predictive factors for postoperative fever in each PS group. Results: Patients in the PS2-4 group were older and had a higher stone burden than those in the PS0-1 group. The stone-free rates and surgical success rate were similar between the PS groups, but PS2-4 patients had higher rates of postoperative fever without preoperative drainage. Stone composition analysis revealed a higher prevalence of infectious stones in the PS2-4 group. In the PS0-1 group, PNS reduced postoperative fever risk (odds ratio (OR): 0.65, 95% CI: 0.48-0.89, P = .01), and history of febrile urinary tract infection, stone burden ! 30 mm, number of involved calyces ! 4, and female sex were independent risk factors. Notably, in the PS2-4 group, PNS remained effective against postoperative fever (OR: 0.24, 95% CI: 0.07-0.80, P = .02), while no other factors were significant. Conclusion: The mini-ECIRS was effective even in PS-poor patients, and they may benefit more from preoperative PNS placement than normal PS cases.

BackgroundSepsis is a leading cause of death in intensive care units (ICU). Sepsis survivors are often left with significant morbidity, termed post-intensive care syndrome (PICS), impacting post-sepsis life. The aim was to present detailed data on the prognostic and functional long-term outcomes of ICU patients with sepsis in Japan, which is currently lacking and therefore prevents development of targeted solutions.MethodsA multicenter prospective study, involving 21 ICUs in 20 tertiary hospitals in Japan, included all consecutive adult ICU patients between November 2020 and April 2022, and diagnosed with sepsis at ICU admission (Sepsis 3). Follow-ups were performed at 3, 6, and 12 months after hospital discharge by telephone and mail. Primary outcome was death or incidence of PICS, defined by any of physical dysfunction (Barthel Index ≤ 90), cognitive dysfunction (Short Memory Questionnaire < 40), or mental disorder (any subscales for anxiety or depression of Hospital Anxiety and Depression Scale ≥ 8, or Impact of Event Scale-Revised ≥ 25). Secondary outcomes included Quality of Life (QOL), employment, and use of hospital, emergency, rehabilitation, and psychiatric services. A multivariable analysis investigated independent factors associated with each dysfunction at each follow-up.ResultsA total of 339 patients were included (median age 74 [67–82] years, 60% male, 77% septic shock, and a median SOFA of 9 [6–12]). Mortality was 23% at hospital discharge, increasing to 37% at 12 months. The rate of death or those who met PICS Criteria at hospital discharge was 89%, with a death or PICS incidence of 73%, 64%, and 65% at 3, 6, and 12 months, respectively. Limited improvements in QOL and return to work (44%), high rates of hospital readmissions (40%), frequent emergency service usage (31%), and low utilization of rehabilitation and psychiatric services (15% and 7%) were identified over the first year. The incidence of any PICS-related dysfunction was consistently an independent factor for the incidence of the same dysfunction at the following follow-ups.ConclusionsThis multicenter study identified the distinct realities of post-sepsis life in Japanese ICU patients, highlighting the unique challenges in improving their functions and returning to daily life.Trial RegistrationUniversity Hospital Medical Information Network UMIN000041433

Background: Reduced or delayed access to medical resources on weekends could lead to worsening outcomes, in critically ill infected patients requiring intensive care unit (ICU) admission. Objective: To investigate the “weekend effect,” on critically ill infected patients in Japanese ICUs for the first time. Design: Multicenter retrospective cohort study. Methods: We examined data from Japanese ICU patients participating in the DIANA study, a multicenter international observational cohort study. This prospective investigation enrolled critically ill patients with infections admitted to the ICU. The primary endpoint was successful discharge from the ICU within 28 days of admission. Outcome measures were evaluated through both univariate and covariate Cox regression analyses, providing hazard ratios (HRs) along with estimated 95% confidence intervals (CIs). Results: Out of the 276 patients enrolled in the DIANA study across 31 facilities, 208 patients (75.4%) meeting the inclusion criteria were included in the analysis. The weekday ICU admission group comprised 156 patients (75.0%), while the weekend ICU admission group comprised 52 patients (25.0%). In the multivariate Cox regression analysis, there were no statistically significant differences observed in the rates of ICU discharge alive within 28 days and 14 days (28 days, HR: 0.94, 95% CI: 0.63–1.40; 14 days, HR: 0.97, 95% CI: 0.64–1.48). Furthermore, the overall ICU mortality rates at 28 days and 14 days after ICU admission did not show statistical significance between patients admitted on weekends and those admitted on weekdays (ICU mortality, 28 days: 13.5% vs 11.5%, p = 0.806; 14 days: 7.7% vs 10.9%, p = 0.604). Conclusion: The rates of ICU discharge alive within 28 days after ICU admission did not differ significantly between weekday and weekend admissions, both in the unadjusted and adjusted analyses. Moreover, further well-designed studies are warranted to thoroughly assess this effect.

Adjuvant anti-PD-1 (adj PD-1) antibodies are extensively used to improve survival in patients with resected melanoma. Clinical trials on adj PD-1 antibodies have revealed significant improvements in recurrence-free survival (RFS); however, few of these trials have included patients with acral melanoma (AM). Clinical data were retrospectively collected from Japanese patients who underwent resection of stage III sole AM between 2014 and 2021. Survival outcomes, including RFS, distant metastasis-free survival (DMFS), and overall survival (OS), were compared between patients without adjuvant therapy (OBS group) and those receiving adj PD-1 group. This study included 139 patients (OBS: 79; adj PD-1: 60), with a median follow-up of 2.6 years. The baseline characteristics were comparable, except for age and nodal metastasis. No significant differences in survival were observed between the OBS and adj PD-1 groups (3-year RFS: 36.7% v 27.5%, P = .13; 3-year DMFS: 51.0% v 45.3%, P = .51; 3-year OS: 65.3% v 67.4%, P = .45). Multivariate analysis showed no survival benefit of adj PD-1 (RFS: hazard ratio [HR], 1.25, P = .29; DMFS: HR, 1.03, P = .89; and OS: HR, 0.69, P = .23). Each survival outcome after propensity score matching confirmed no significant difference between the matched OBS group (n = 52) and adj PD-1 group (n = 52; 3-year RFS: 34.3% v 25.9%, P = .22; 3-year DMFS: 45.6% v 46.5%, P = .85; 3-year OS: 60.7% v 68.9%, P = .29). Adj PD-1 did not improve the prognosis in sole AM. However, further studies are essential to evaluate the efficacy of the adj anti-PD-1 antibody in AM.

Nutrition therapy is important in the management of critically ill patients and is continuously evolving as new evidence emerges. The Japanese Critical Care Nutrition Guideline 2024 (JCCNG 2024) is specific to Japan and is the latest set of clinical practice guidelines for nutrition therapy in critical care that was revised from JCCNG 2016 by the Japanese Society of Intensive Care Medicine. An English version of these guidelines was created based on the contents of the original Japanese version. These guidelines were developed to help health care providers understand and provide nutrition therapy that will improve the outcomes of children and adults admitted to intensive care units or requiring intensive care, regardless of the disease. The intended users of these guidelines are all healthcare professionals involved in intensive care, including those who are not familiar with nutrition therapy. JCCNG 2024 consists of 37 clinical questions and 24 recommendations, covering immunomodulation therapy, nutrition therapy for special conditions, and nutrition therapy for children. These guidelines were developed in accordance with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system by experts from various healthcare professionals related to nutrition therapy and/or critical care. All GRADE-based recommendations, good practice statements (GPS), future research questions, and answers to background questions were finalized by consensus using the modified Delphi method. Strong recommendations for adults include early enteral nutrition (EN) within 48 h and the provision of pre/synbiotics. Weak recommendations for adults include the use of a nutrition protocol, EN rather than parenteral nutrition, the provision of higher protein doses, post-pyloric EN, continuous EN, omega-3 fatty acid-enriched EN, the provision of probiotics, and indirect calorimetry use. Weak recommendations for children include early EN within 48 h, bolus EN, and energy/protein-dense EN formulas. A nutritional assessment is recommended by GPS for both adults and children. JCCNG 2024 will be disseminated through educational activities mainly by the JCCNG Committee at various scientific meetings and seminars. Since studies on nutritional treatment for critically ill patients are being reported worldwide, these guidelines will be revised in 4 to 6 years. We hope that these guidelines will be used in clinical practice for critically ill patients and in future research.

Background/Objectives: The Global Leadership Initiative on Malnutrition (GLIM) is suggested by major societies. The etiologic criteria for inflammation in critically ill patients remain unclear. Because an initial nutritional assessment is recommended within 48 h, it is also possible to use C-reactive protein (CRP) up to 3 days after admission. The purpose of the present study is to explore the utility of CRP in identifying malnutrition and to determine whether a nutritional assessment incorporating CRP criteria can effectively identify malnourished patients in the intensive care unit (ICU). Methods: This was a retrospective cohort study of ICU patients. The primary outcome was a composite of in-hospital mortality, Barthel index < 60 at discharge, and length of hospital stay of 14 days or more. The area under the curve (AUC) for the primary outcome was calculated using CRP between days 0 and 2. We divided the patients into four groups using inflammation criteria with the optimal cut-off and low body mass index (BMI) criteria of the GLIM: CRP+/-, and BMI+/-. Results: A total of 38,981 patients were included. The AUC of the highest CRP between days 0 and 2 was 0.65, which was higher than the CRP on day 0 and the highest CRP between days 0 and 1 (0.59 and 0.63). The AUC and optimal cut-offs varied depending on diagnoses, with a maximum of 0.75 in neurology. The optimal cut-off for the maximum CRP was 3.82 mg/dL. In the four groups of CRP+BMI+, CRP+BMI-, CRP-BMI+, and CRP-BMI-, the in-hospital mortality values were 22.7, 14.4, 10.8, and 4.8% (p < 0.001 between all the groups). Conclusions: In an initial nutritional assessment of critically ill patients, it would be appropriate to use the maximum CRP over 3 days from ICU admission.

ABSTRACTObjectivesAntibiotic prescription trends in dentistry in Japan remain underexplored. This study aimed to describe these trends and evaluate the impact of the national antimicrobial stewardship program launched in 2016.MethodsUsing Japan's national administrative claims database from fiscal year (FY) 2015 to FY 2020, this cross‐sectional study comprehensively analyzed trends in antibiotic prescription by dentists. Prescription rates were computed per 1000 inhabitants yearly and standardized to the FY 2015 national population. Changes in prescription rates were evaluated using Poisson regression analysis.ResultsIn FY 2020, the total number of antibiotic prescriptions was 134.4 per 1000 inhabitants per year, showing a 6% decline over the 6‐year period (95% confidence interval, 6%–6%). Third‐generation cephalosporins constituted 52.3% of dental antibiotic prescriptions in FY 2020, though the proportion had slightly decreased. In hospitals, prescriptions of third‐generation cephalosporins decreased from 64.9% in 2015 to 20.3% in 2020, being replaced by penicillin (from 15.0% to 64.0%). However, in clinics, the magnitude of the change was small (third‐generation cephalosporins, 60.5%–53.1%; penicillin, 10.2%–22.2%).ConclusionsThird‐generation cephalosporins continue to dominate dental antibiotic prescriptions. The increase in penicillin use was much more pronounced in hospitals than in clinics. Strengthening antimicrobial stewardship, particularly in clinics where the majority of dental care is provided, is crucial.

A man in his 80s was scheduled to undergo percutaneous endoscopic gastrostomy (PEG) because he was at high risk for aspiration due to Parkinson's disease. PEG was performed using the modified introducer technique with the EndoVive Seldinger PEG kit 24 Fr 3.5 cm (Boston Scientific Japan, Tokyo, Japan). The device through which the PEG tube would be connected was implanted on the anterior wall of the middle gastric body by endoscopy. Enteral nutrition and drug infusion were started the following day. Eleven days after implantation of the device, the patient experienced abdominal pain and hematemesis, and went into shock (day 0). Abdominal computed tomography revealed emphysematous gastritis, and intravenous administration of norepinephrine and antibiotics was started. His overall condition improved, and he was discharged on day 42. Although the occurrence of gastric emphysema after PEG is rare, conservative management can ensure recovery in such patients.