Rapid and accurate diagnosis of intra-abdominal injuries (IAIs) is crucial for pediatric patients with blunt abdominal trauma. However, clinical assessments can be challenging in children. We evaluated several clinical decision instruments (CDIs) designed to identify children with low risk of IAI who required acute intervention (IAI-I) at a Japanese pediatric hospital. This retrospective cohort study was conducted between April 2021 and March 2024 and included 259 pediatric patients with torso trauma. We used clinical and imaging data to compare the Pediatric Emergency Care Applied Research Network (PECARN) abdominal rule with a combination of focused assessment with sonography in trauma (FAST) with elevated aspartate aminotransferase (AST) or alanine aminotransferase (ALT) levels rule. Of the 259 pediatric patients assessed, 20 (7.7%) developed IAI. Of these, one required intervention. The PECARN abdominal rule had a sensitivity of 100% and a specificity of 65.1% for identifying IAI-I, whereas FAST with elevated AST/ALT had a sensitivity of 100% and a specificity of 82.2%. For IAI, the PECARN abdominal rule had a sensitivity of 90% and a specificity of 69.5%, whereas FAST with elevated AST/ALT had a sensitivity of 65.0% and a specificity of 88.7%. The PECARN abdominal rule had high sensitivity but moderate specificity for identifying IAI, whereas FAST with elevated AST/ALT had a higher specificity. These findings suggest that CDIs can minimize unnecessary computed tomography scans in this context. Further validation of these findings in other healthcare settings and patient populations is warranted.

We sincerely appreciate the constructive and thoughtful comments provided on our article, “Predictive effects of the lactate/albumin ratio on neurological outcomes in patients after out-of-hospital cardiac arrest,” published in Acute Medicine & Surgery [1]. As Dr. Shyam Sundar Sah and Dr. Abhishek Kumbhalwar pointed out, the absence of a standardized protocol for the timing and implementation of blood tests may have introduced selection bias. Although both serum albumin and lactate levels are typically measured during the early resuscitation phase in Japanese clinical settings, some patients may have been excluded because resuscitation was terminated before albumin results became available, which could have introduced selection bias. Although these limitations were acknowledged in our manuscript, establishing a standardized blood sampling protocol remains important for future studies. As the main objective of this observational study was to assess the association between lactate/albumin ratio and neurological outcomes, our analysis was limited to evaluating discrimination. Further research should address calibration and clinical usefulness to clarify whether prediction-guided interventions can improve patient outcomes [2]. We also agree that the lack of detailed data on comorbidities and baseline conditions affecting albumin and lactate is an important limitation. Nonetheless, serum albumin partially reflects long-term patient background, such as chronic illness and nutritional status [3]. Although factors like epinephrine dose and sepsis were not directly adjusted for, they may influence neurological outcomes themselves. Thus, lactate may act as an intermediate factor, and the lactate/albumin ratio might capture the overall prognostic profile more comprehensively. Finally, as you noted, in Japan, field termination of resuscitation is permitted only under specific circumstances, which may limit external generalizability compared with other countries [4]. Therefore, we additionally performed a sensitivity analysis excluding patients who met the advanced life support termination-of-resuscitation rule, defined by five criteria: no emergency medical service-witnessed arrest, no bystander automated external defibrillator use or emergency medical service defibrillation, no prehospital return of spontaneous circulation, no bystander-witnessed arrest, and no bystander cardiopulmonary resuscitation [5]. As a result, 6136 patients who met the termination-of-resuscitation rule were excluded, leaving 21,962 out-of-hospital cardiac arrest patients for analysis. When comparing the predictive performance for favorable neurological outcomes (cerebral performance category 1–2) at 30 days, we observed a similar trend to the main analysis, in which lactate/albumin ratio showed significantly better predictive ability than lactate or albumin (Figure 1). This finding suggested potential robustness in the model's external validity; however, further refinement and external validation were needed. We sincerely thank Dr. Shyam Sundar Sah and Dr. Abhishek Kumbhalwar for their thoughtful and constructive comments that will help guide future research in this area. The authors declare no conflicts of interest.

ABSTRACTAimPost intensive care syndrome (PICS) is a critical issue in postsepsis care; however, no reliable biomarker exists to predict PICS. We hypothesized that plasma myostatin, a cytokine involved in muscle and brain function, could serve as a predictive biomarker for PICS.MethodsThis single‐center prospective observational study included adult patients with sepsis admitted to the intensive care unit (ICU). Plasma myostatin concentrations were measured using enzyme‐linked immunosorbent assay on days 1, 3–4, and 6–7 after sepsis diagnosis and ICU admission. PICS was assessed 6 months post‐ICU discharge via telephone interviews using the Barthel Index, Short‐Memory Questionnaire score, and Hospital Anxiety and Depression Scale. Multivariable logistic regression analysis was conducted to determine whether myostatin levels independently predicted PICS. Predictive performance was evaluated using the area under the curve (AUC).ResultsSeventy‐seven patients were enrolled (mean age: 71 ± 14 years; median SOFA score 7 [IQR: 6–11]). Plasma myostatin concentrations were 544 (311–1015) pg/mL on day 1, 495 (302–651) pg/mL on days 3–4, and 536 (385–817) pg/mL on days 6–7. Decreased plasma myostatin levels on day 1 and on days 6–7 contributed to identifying patients with cognitive and physical impairments, respectively (p = 0.04). A decreased plasma myostatin level on day 1 yielded an AUC of 0.70 for predicting cognitive impairment, whereas the day 6–7 level yielded an AUC of 0.76 for predicting physical impairment.ConclusionLower plasma myostatin concentrations in the acute phase of sepsis may serve as a biomarker for predicting PICS‐related physical and cognitive impairments.

AimMost previous research on AI‐based image diagnosis of acute cholecystitis (AC) has utilized ultrasound images. While these studies have shown promising outcomes, the results were based on still images captured by physicians, introducing inevitable selection bias. This study aims to develop a fully automated system for precise gallbladder detection among various abdominal structures, aiding clinicians in the rapid assessment of AC requiring cholecystectomy.MethodsThe dataset comprised images from 250 AC patients and 270 control participants. The VGG‐16 architecture was employed for gallbladder recognition. Post‐processing techniques such as the flood fill algorithm and centroid calculation were integrated into the model. U‐Net was utilized for segmentation and features extraction. All models were combined to develop a fully automated AC detection system.ResultsThe gallbladder identification accuracy among various abdominal organs was 95.3%, with the model effectively filtering out CT images lacking a gallbladder. In diagnosing AC, the model was tested on 120 cases, achieving an accuracy of 92.5%, sensitivity of 90.4%, and specificity of 94.1%. After integrating all components, the ensemble model achieved an overall accuracy of 86.7%. The automated process required 0.029 seconds of computation time per CT slice and 3.59 seconds per complete CT set.ConclusionsThe proposed system achieves promising performance in the automatic detection and diagnosis of gallbladder conditions in patients requiring cholecystectomy, with robust accuracy and computational efficiency. With further clinical validation, this computer‐assisted system could serve as an auxiliary tool in identifying patients requiring emergency surgery.

Successful embolization controlled active bleeding in a 76-year-old woman with diffuse idiopathic skeletal hyperostosis (DISH) [1] after a lumbar fracture. She originally presented with back pain following a fall. Initial computed tomography (CT) revealed fractures of the first and second lumbar vertebrae (L1, L2) with DISH extending from T8 to L2 (Figure 1A). Two days later, she was pale in complexion with hypotension (92/60 mmHg) and tachycardia (130 bpm). Contrast-enhanced CT revealed extravasation within the L2 vertebral body, indicative of left L2 and L3 arteries' involvement (Figure 1B). Emergency transcatheter arterial embolization was performed. To prevent reflux of embolic material into the aorta and spinal arteries including Adamkiewicz, the microcatheter was advanced beyond the vertebral limbus under fluoroscopic guidance. Selective angiography confirmed extravasation from the left L2 and L3 arteries (Figure 1C), which were embolized using a 1:2 mixture of N-butyl cyanoacrylate that achieved hemostasis after confirming absence of spinal arteries (Figure 1D). Patients with DISH have an elevated risk of vertebral fracture compared to the general population due to rigidity and ossification [2]. The condition may cause various complications including injuries to intercostal and lumbar arteries, leading to active bleeding within relatively loose tissue spaces [3, 4]. This case demonstrates the importance of prompt intervention in DISH-related fractures with vascular complications, and it highlights the efficacy of embolization for controlling vertebral body bleeding. The authors have nothing to report. Written informed consent was obtained from the patient's family for the publication. The authors declare no conflicts of interest. The data that supports the findings of this study is available from the corresponding author upon reasonable request.

Blunt injuries constitute a major cause of death in the United States. Regionalization in trauma systems improves patients' survival and outcomes. Limited data exist on the impact of mode of transport in regionalized trauma systems. This study examines the association between trauma designation levels and survival to hospital discharge of patients with blunt trauma transported by police or ground ambulance. This retrospective-matched cohort study used the 2017 National Trauma Data Bank dataset. Adult blunt trauma patients transported by police were identified and matched (one-to-four) to those transported by ground ambulance. Demographic characteristics, injury, and clinical data were described and compared according to trauma designation levels. The survival rate was determined by the transport mode and/or the trauma designation levels. A total of 5316 blunt trauma patients were included. Mean age was 41.8 (±16.5) years, and most were males (81.8%). Most patients were transported to Level I centers and were more likely to be admitted (91.1%) compared to those transported to level II and level III trauma centers (87.5%). They also had a lower survival rate compared with the latter group ((98.7%) vs. (99.7%), p = 0.001). Survival rates were similar when comparing patients by mode of transport (p = 0.785). This remained unchanged after stratifying by the trauma designation levels (p > 0.05). Adult patients with blunt trauma transported by police or ground ambulance had similar survival across different trauma level centers. Increased police involvement in the transport of blunt trauma patients is recommended.

Warfarin, a vitamin K antagonist, is widely used for preventing and treating thromboembolic diseases. While guidelines exist for managing elevated prothrombin time-international normalized ratio (INR) in patients on warfarin, the treatment for warfarin overdose in these patients is yet to be standardized. A 41-year-old woman ingested 230 mg of warfarin with suicidal intent, along with other medications. Initially unconscious, her INR was 1.0, and laboratory results were normal. Prophylactic continuous menaquinone-4, vitamin K2, injections were administered before the INR increased. After stopping vitamin K2 72 h later, her INR rose to 1.8, but she recovered without severe coagulopathy or bleeding, despite a high initial warfarin concentration. This is the first case of warfarin overdose managed with prophylactic vitamin K2 injections before INR elevation, successfully preventing severe complications. Prophylactic vitamin K infusion may be a practical approach for warfarin overdose treatment in non-dependent patients.

To evaluate the prognostic factors in severe head trauma patients (Glasgow Coma Score (GCS) ≤ 8) with all trauma, including those with trunk injury as well as single severe head trauma (abbreviated injury scale (AIS) ≥ 3). We included 152 consecutive patients with head trauma (AIS ≥ 3) and consciousness disorders (GCS ≤ 8) who were transported to our institute from January 2017 to October 2022. Data on the patients' background, vital signs at presentation, multiple trauma (AIS ≥ 3 in two or more locations), surgical intervention, and hematological findings were examined; a retrospective analysis was conducted with the modified Rankin Scale score after 3 months assigned as the primary outcome. The patients' mean age was 57.6 ± 23.4 years (0-89), 49 patients (32.2%) had multiple trauma, and 25 patients (16.4%) had accompanying shock vital signs. In the multivariate analysis of prognosis, age (p = 0.0007) and D-dimer levels (p = 0.0007) were independent poor prognostic factors. On the contrary, patients with multiple trauma (p = 0.027) and shock vital signs at presentation (p = 0.037) had a significantly better prognosis. In the non-shock group, 97.6% (41/42) of patients aged ≥50 years and with D-dimer level of 40 μg/mL or higher had a poor prognosis after 3 months. Advanced age and high D-dimer levels are important independent associated factors in patients with severe consciousness disorder associated with head trauma; meanwhile, the prognosis is more favorable in patients whose consciousness disorders are associated with multiple trauma or circulatory failure, indicating that rapid improvement of circulatory failure may lead to better outcomes.

We sincerely thank Dr. Mishba Ur Haq et al. for their thoughtful comments, which provided valuable insight and critical appraisal of our publication “Hydrogen inhalation therapy alone may not alleviate intestinal mucosal damage in NOMI without total-layer necrosis: An experimental swine model study”. We would like to address two key comments raised. First, we agree that both the 4-h observation period and treatment intensity are areas for future consideration. Previous studies [1-3] implemented hydrogen inhalation therapy for only a few hours. Therefore, extending the duration of hydrogen inhalation could potentially yield. Unlike conditions characterized by complete ischemia–reperfusion injury, such as cardiac arrest, large-vessel occlusive stroke, or coronary artery occlusion, our NOMI model did not involve superior mesenteric artery occlusion and did not induce full-thickness necrosis. Under these conditions, a lower quantity of reactive oxygen species (ROS) potentially attenuated the measurable effects of hydrogen as an antioxidant adjunct. This interpretation aligns with our findings showing no intergroup differences in 8-OHdG levels and similar progression of histological injury grades over time. We also note that achieving uniform intensity was technically challenging due to variations in individual responses to vasopressors. While macroscopic serosal images occasionally suggested transmural necrosis, histological confirmation consistently revealed only partial layer injury. Given the limited number of animals, comprehensive histological sampling at multiple time points was not feasible. Second, we acknowledge that the limited sample size, imposed by ethical constraints of large-animal research, restricted statistical power. This study was designed as a pilot feasibility experiment, intended to generate preliminary data for subsequent investigations with adequate power and longer observation periods. In conclusion, we appreciate the reviewers' constructive criticism and share the goal of improving outcomes in NOMI. We believe that further studies exploring hydrogen therapy, as part of a multifaceted strategy, under optimized timing and dosage conditions, represent the most promising path. We hope that our preliminary findings, together with such academic dialogue, will contribute to future translational research in this challenging field. The Committee for Animal Ethics at Jichi Medical University approved the present experimental study (Approval number: 21054-01). The authors have nothing to report. The authors declare no conflicts of interest.

SARS-CoV-2 causes systemic immune dysfunction, leading to severe respiratory dysfunction and multiorgan dysfunction. Granulocyte and monocyte adsorptive apheresis (GMA) therapy is designed to regulate an excessive inflammatory response and has been proposed as a potential therapeutic strategy for coronavirus disease 2019 (COVID-19). We aimed to investigate a targeted subset of granulocytes and monocytes to be removed after GMA therapy in patients with severe COVID-19 infection. We established an exvivo experimental system to study the effects of GMA. Blood samples were collected into EDTA-treated tubes and a mixture of blood samples and cellulose acetate beads was used in GMA. After GMA, blood samples were removed, and the granulocyte and monocyte subtypes before and after GMA were determined by CyTOF mass cytometry. To analyze mass cytometry data with a self-organizing map, hierarchical clustering was used to determine the appropriate number of metaclusters from t-distributed stochastic neighbor embedding. We included seven patients with severe COVID-19 and four age- and sex-matched volunteers. Granulocyte subsets removed by GMA strongly expressed CD11b, CD16, and CD66b, and weakly expressed CD11c, consistent with mature and activated neutrophils. Monocyte subsets strongly expressed CD14, weakly expressed CD33 and CD45RO, and did not express CD16. These subsets were indicated to promote the release of inflammatory cytokines and activate T cells. The identification of the granulocyte and monocyte subsets removed after GMA in patients with severe COVID-19 may help explain the potential mechanism underlying the effectiveness of GMA in COVID-19 and other inflammatory diseases.