研究者詳細 - 山元　良

論文 - 山元　良

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Sparsity of burn centers and prolonged length of hospital stay: A nationwide study.

Yamamoto R, Sato Y, Sasaki J

Burns : journal of the International Society for Burn Injuries （Burns） 47 （ 7 ） 1478 - 1485 2021年08月

共著, ISSN 0305-4179

Introduction: The optimal distribution of burn centers remains unclear. We aimed to determine the appropriate number of burn centers per population (density) and examined a nationwide registry with the hypothesis that low-density burn centers would be associated with unfavorable outcomes. Patients and methods: A retrospective study was conducted using the Japanese Society of Burn Injury registry (2011–2021). Burn center density was defined as the number of burn centers per one million population in each prefecture, and centers were trisected on the basis of density. Hospital-free days until day 30 were compared between patients at high-, middle-, and low-density centers. Inverse probability weighting was conducted to adjust baseline characteristics, including age, burn mechanism, and burn severity. Results: We included 6764, 6209, and 2200 patients at high-, middle-, and low-density burn centers, respectively. After adjusting for patient demographics and burn severity, patients at high- and middle-density centers (≥0.4 centers per one million population) had longer hospital-free days compared with those at low-density centers (11 [0–23] vs 11 [0–23] vs 8 [0–22] days; p < 0.001). Conclusions: Low burn center density (<0.4 centers per one million population) was associated with longer hospital stay, whereas no higher limit was determined.

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Physician-staffed ambulance and increased in-hospital mortality of hypotensive trauma patients following prolonged prehospital stay: A nationwide study

Yamamoto R., Suzuki M., Yoshizawa J., Nishida Y., Junichi S.

Journal of Trauma and Acute Care Surgery （Journal of Trauma and Acute Care Surgery） 91 （ 2 ） 336 - 343 2021年08月

共著, ISSN 21630755

BACKGROUND The benefits of physician-staffed emergency medical services (EMS) for trauma patients remain unclear because of the conflicting results on survival. Some studies suggested potential delays in definitive hemostasis due to prolonged prehospital stay when physicians are dispatched to the scene. We examined hypotensive trauma patients who were transported by ambulance, with the hypothesis that physician-staffed ambulances would be associated with increased in-hospital mortality, compared with EMS personnel-staffed ambulances. METHODS A retrospective cohort study that included hypotensive trauma patients (systolic blood pressure ≤ 90 mm Hg at the scene) transported by ambulance was conducted using the Japan Trauma Data Bank (2004-2019). Physician-staffed ambulances are capable of resuscitative procedures, such as thoracotomy and surgical airway management, while EMS personnel-staffed ambulances could only provide advanced life support. In-hospital mortality and prehospital time until the hospital arrival were compared between patients who were classified based on the type of ambulance. Inverse probability weighting was conducted to adjust baseline characteristics including age, sex, comorbidities, mechanism of injury, vital signs at the scene, injury severity, and ambulance dispatch time. RESULTS Among 14,652 patients eligible for the study, 738 were transported by a physician-staffed ambulance. In-hospital mortality was higher in the physician-staffed ambulance than in the EMS personnel-staffed ambulance (201/699 [28.8%] vs. 2287/13,090 [17.5%]; odds ratio, 1.90 [1.61-2.26]; adjusted odds ratio, 1.22 [1.14-1.30]; p < 0.01), and the physician-staffed ambulance showed longer prehospital time (50 [36-66] vs. 37 [29-48] min, difference = 12 [11-12] min, p < 0.01). Such potential harm of the physician-staffed ambulance was only observed among patients who arrived at the hospital with persistent hypotension (systolic blood pressure < 90 mm Hg on hospital arrival) in subgroup analyses. CONCLUSION Physician-staffed ambulances were associated with prolonged prehospital stay and increased in-hospital mortality among hypotensive trauma patients compared with EMS personnel-staffed ambulance. LEVEL OF EVIDENCE Therapeutic, level IV.

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Characteristics of burn injury during COVID-19 pandemic in Tokyo: A descriptive study.

Yamamoto R, Sato Y, Matsumura K, Sasaki J

Burns open : an international open access journal for burn injuries （Burns Open） 5 （ 4 ） 40 - 45 2021年07月

共著

Introduction: Coronavirus disease 2019 (COVID-19) has drastically changed everyday life worldwide. This study aimed to determine how COVID-19 affected the characteristics and outcomes of patients with severe burn injury by examining a city-wide burn database in Tokyo. Patients and methods: A descriptive study was conducted in 14 burn centers using the Tokyo Burn Unit Association registry from 1999 to 2020. The pandemic started in 2020, while the stay-at-home order lasted from April to May. The demographics, mechanisms, severity, and clinical outcomes were assessed before and during these two time periods. Results: In total, 7061 patients with burn injury were enrolled. During the pandemic, there were less patients during the pandemic than previous years, except for April–May; this decreased toward the end of 2020. There were also more scald/contact burns in the upper extremity, less intended and assault injuries, shorter length of hospital stay, and lower in-hospital mortality. During the stay-at-home order, there was increased incidence of flame burns, inhalation injuries, and in-hospital mortality, as well as higher total body surface area of full-thickness burns. Conclusions: This study described the characteristics of burns during the COVID-19 pandemic. The association between the stay-at-home order and severity of burns should be further examined.

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Japanese Rapid/Living recommendations on drug management for COVID-19.

Yamakawa K, Yamamoto R, Ishimaru G, Hashimoto H, Terayama T, Hara Y, Hasegawa D, Ishihara T, Imura H, Okano H, Narita C, Mayumi T, Yasuda H, Yamada K, Yamada H, Kawasaki T, Shime N, Doi K, Egi M, Ogura H, Aihara M, Tanaka H, Nishida O, Special Committee of the Japanese Clinical Practice Guidelines for the Management of Sepsis, Septic Shock 2020 (J‐SSCG 2020), the COVID‐19 Task Force.

Acute medicine & surgery 8 （ 1 ） e664 2021年05月

共著

The coronavirus disease (COVID-19) has spread worldwide since early 2020, and there are still no signs of resolution. The Japanese Clinical Practice Guidelines for the Management of Sepsis and Septic Shock (J-SSCG) 2020 Special Committee created the Japanese rapid/living recommendations on drug management for COVID-19 using the experience of creating the J-SSCGs. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach was used to determine the certainty of the evidence and strength of the recommendations. The first edition of this guideline was released on 9 September, 2020, and this document is the revised edition (version 3.1) (released 30 March, 2021). Clinical questions (CQs) were set for the following seven drugs: favipiravir (CQ1), remdesivir (CQ2), hydroxychloroquine (CQ3), corticosteroids (CQ4), tocilizumab (CQ5), ciclesonide (CQ6), and anticoagulants (CQ7). Favipiravir is recommended for patients with mild COVID-19 not requiring supplemental oxygen (GRADE 2C); remdesivir for moderate COVID-19 patients requiring supplemental oxygen/hospitalization (GRADE 2B). Hydroxychloroquine is not recommended for all COVID-19 patients (GRADE 1B). Corticosteroids are recommended for moderate COVID-19 patients requiring supplemental oxygen/hospitalization (GRADE 1B) and severe COVID-19 patients requiring ventilator management/intensive care (GRADE 1A); however, their use is not recommended for mild COVID-19 patients not requiring supplemental oxygen (GRADE 1B). Tocilizumab is recommended for moderate COVID-19 patients requiring supplemental oxygen/hospitalization (GRADE 2B). Anticoagulant therapy is recommended for moderate COVID-19 patients requiring supplemental oxygen/hospitalization and severe COVID-19 patients requiring ventilator management/intensive care (GRADE 2C). We hope that these clinical practice guidelines will aid medical professionals involved in the care of COVID-19 patients.

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A case of abdominal compartment syndrome caused by amniotic fluid embolism treated with ABTHERA™ therapy: World's first report in the obstetric field

Hirata M., Hasegawa K., Kasuga Y., Haiden A., Ikenoue S., Yamamoto R., Tanaka M., Sasaki J., Ochiai D.

Taiwanese Journal of Obstetrics and Gynecology （Taiwanese Journal of Obstetrics and Gynecology） 60 （ 3 ） 579 - 580 2021年05月

研究論文（学術雑誌）, 共著, ISSN 10284559

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COVID-19 shares clinical features with anti-melanoma differentiation-associated protein 5 positive dermatomyositis and adult Still’s disease

Kondo Y., Kaneko Y., Takei H., Tamai H., Kabata H., Suhara T., Yamamoto R., Nagata H., Ishii M., Sasaki J., Hasegawa N., Fukunaga K., Takeuchi T.

Clinical and Experimental Rheumatology （Clinical and Experimental Rheumatology） 39 （ 3 ） 631 - 638 2021年05月

共著, ISSN 0392856X

Objective To investigate the similarities and differences between Coronavirus disease 2019 (COVID-19) and autoimmune and autoinflammatory rheumatic diseases characterised by hyperferritinaemia, such as antimelanoma differentiation-associated protein 5 (MDA5) autoantibody-positive dermatomyositis and adult Still’s disease. Methods We reviewed consecutive, newly diagnosed, untreated patients with COVID-19, anti-MDA5 dermatomyositis, or adult Still’s disease. We compared their clinical, laboratory, and radiological characteristics, including the prevalence of macrophage activation syndrome and lung involvement in each disease. Results The numbers of patients with COVID-19, anti-MDA5 dermatomyositis, and adult-onset Still’s disease with hyperferritinaemia (serum ferritin ≥500ng/dL) who were included for main analysis were 22, 14, and 59, respectively. COVID-19 and adult Still’s disease both featured hyperinflammatory status, such as high fever and elevated serum C-reactive protein, whereas COVID-19 and anti-MDA5 dermatomyositis both presented with severe interstitial lung disease and hypoxaemia. While two-thirds of the patients in each group met the criteria for macrophage-activated syndrome that is used in systemic juvenile idiopathic arthritis, the HScore, an indicator of haemophagocytic lymphohistiocytosis, was low in anti-MDA5 dermatomyositis and COVID-19 even in severe or critical cases. The findings of chest computed tomography were similar between COVID-19 and anti-MDA5 dermatomyositis. Conclusion COVID-19 shared clinical features with rheumatic diseases characterised by hyperferritinaemia, including anti-MDA5 dermatomyositis and adult Still’s disease. These findings should be investigated further in order to shed light on the pathogenesis of not only COVID-19 but also the aforementioned rheumatic diseases.

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The real-time reverse transcription-polymerase chain reaction threshold cycle values for severe acute respiratory syndrome coronavirus 2 predict the prognosis of coronavirus disease 2019 pneumonia

Fukushima T., Kabata H., Yamamoto R., Suhara T., Uwamino Y., Kondo Y., Masaki K., Kamata H., Nagata H., Homma K., Kaneko Y., Ishii M., Sasaki J., Morisaki H., Hasegawa N., Fukunaga K.

Respiratory Investigation （Respiratory Investigation） 59 （ 3 ） 360 - 363 2021年05月

共著, ISSN 22125345

The clinical course of coronavirus disease 2019 (COVID-19) varies from mild to critical. We retrospectively examined whether clinical and laboratory findings on admission could predict COVID-19 prognosis. Among various factors associated with COVID-19 severity, our results indicated that the real-time reverse transcription-polymerase chain reaction (RT-PCR) threshold cycle (Ct) values for severe acute respiratory syndrome coronavirus 2 were the most useful predictor of COVID-19 prognosis.

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高齢者大腿骨近位部骨折に対する積極的疼痛管理と術後せん妄についての検討

宇田川和彦, 山元良, 島谷直孝, 西田有正, 大野聡一郎, 佐々木淳一

骨折（(一社)日本骨折治療学会） 43 （ 3 ） 820 - 823 2021年05月

共著, ISSN 0287-2285

【目的】高齢者の大腿骨近位部骨折に対する積極的疼痛管理と術後せん妄の発生頻度の関連を明らかにする.【方法】2017年1月〜2019年3月までに当院当科を受診した70歳以上の大腿骨近位部骨折症例のうち,当科で手術を施行した患者を対象とした.手術終了直後より鎮痛剤の持続投与を開始した群(Scheduled群)と,術後疼痛が出現した際に必要に応じて鎮痛剤を投与した群(As Needed群)に分け,両群間で術後せん妄およびその他の合併症の発生頻度を比較検討した.【結果】対象症例は75例,Scheduled群は27例であった.年齢,既往歴,骨折形態,手術待機時間,麻酔方法,手術方法,手術時間,その他術後せん妄に影響する因子は両群間において相似していた.術後せん妄は,Scheduled群がAs Needed群よりも有意に少なく(3例(11.0%) vs 17例(35.4%),p=0.03),合併症発症率は両群間で有意差を認めなかった.【結語】高齢者の大腿骨近位部骨折に対する術後積極的疼痛管理は術後せん妄の発生を予防できる可能性が示唆された.(著者抄録)

Accuracy for Mortality Prediction With Additive Biomarkers Including Interleukin-6 in Critically Ill Patients: A Multicenter Prospective Observational Study.

Yamamoto R, Sasaki J, Shibusawa T, Nakada TA, Mayumi T, Takasu O, Matsuda K, Shimazui T, Otsubo H, Teshima Y, Nabeta M, Moriguchi T, Oda S

Critical care explorations 3 （ 4 ） e0387 2021年04月

共著

Objectives: Several inflammation markers have been reported to be associated with unfavorable clinical outcomes in critically ill patients. We aimed to elucidate whether serum interleukin-6 concentration considered with Sequential Organ Failure Assessment score can better predict mortality in critically ill patients. Design: A prospective observational study. Setting: Five university hospitals in 2016-2018. Patients: Critically ill adult patients who met greater than or equal to two systemic inflammatory response syndrome criteria at admission were included, and those who died or were discharged within 48 hours were excluded. Interventions: Inflammatory biomarkers including interleukin (interleukin)-6, -8, and -10; tumor necrosis factor-α; C-reactive protein; and procalcitonin were blindly measured daily for 3 days. Area under the receiver operating characteristic curve for Sequential Organ Failure Assessment score at day 2 according to 28-day mortality was calculated as baseline. Combination models of Sequential Organ Failure Assessment score and additional biomarkers were developed using logistic regression, and area under the receiver operating characteristic curve calculated in each model was compared with the baseline. Measurements and Main Results: Among 161 patients included in the study, 18 (11.2%) did not survive at day 28. Univariate analysis for each biomarker identified that the interleukin-6 (days 1-3), interleukin-8 (days 0-3), and interleukin-10 (days 1-3) were higher in nonsurvivors than in survivors. Analyses of 28-day mortality prediction by a single biomarker showed interleukin-6, -8, and -10 at days 1-3 had a significant discrimination power, and the interleukin-6 at day 3 had the highest area under the receiver operating characteristic curve (0.766 [0.656-0.876]). The baseline area under the receiver operating characteristic curve for Sequential Organ Failure Assessment score predicting 28-day mortality was 0.776 (0.672-0.880). The combination model using additional interleukin-6 at day 3 had higher area under the receiver operating characteristic curve than baseline (area under the receiver operating characteristic curve = 0.844, area under the receiver operating characteristic curve improvement = 0.068 [0.002-0.133]), whereas other biomarkers did not improve accuracy in predicting 28-day mortality. Conclusions: Accuracy for 28-day mortality prediction was improved by adding serum interleukin-6 concentration to Sequential Organ Failure Assessment score.

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Japanese rapid/living recommendations on drug management for COVID-19: updated guidelines (September 2021).

Yamakawa K, Yamamoto R, Terayama T, Hashimoto H, Ishihara T, Ishimaru G, Imura H, Okano H, Narita C, Mayumi T, Yasuda H, Yamada K, Yamada H, Kawasaki T, Shime N, Doi K, Egi M, Ogura H, Aihara M, Kushimoto S, Nishida O, Special Committee of the Japanese Clinical Practice Guidelines for the Management of Sepsis and Septic Shock 2020 (J‐SSCG 2020), the COVID‐19 Task Force.

Acute medicine & surgery 8 （ 1 ） e706 2021年01月

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The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020).

Egi M, Ogura H, Yatabe T, Atagi K, Inoue S, Iba T, Kakihana Y, Kawasaki T, Kushimoto S, Kuroda Y, Kotani J, Shime N, Taniguchi T, Tsuruta R, Doi K, Doi M, Nakada TA, Nakane M, Fujishima S, Hosokawa N, Masuda Y, Matsushima A, Matsuda N, Yamakawa K, Hara Y, Sakuraya M, Ohshimo S, Aoki Y, Inada M, Umemura Y, Kawai Y, Kondo Y, Saito H, Taito S, Takeda C, Terayama T, Tohira H, Hashimoto H, Hayashida K, Hifumi T, Hirose T, Fukuda T, Fujii T, Miura S, Yasuda H, Abe T, Andoh K, Iida Y, Ishihara T, Ide K, Ito K, Ito Y, Inata Y, Utsunomiya A, Unoki T, Endo K, Ouchi A, Ozaki M, Ono S, Katsura M, Kawaguchi A, Kawamura Y, Kudo D, Kubo K, Kurahashi K, Sakuramoto H, Shimoyama A, Suzuki T, Sekine S, Sekino M, Takahashi N, Takahashi S, Takahashi H, Tagami T, Tajima G, Tatsumi H, Tani M, Tsuchiya A, Tsutsumi Y, Naito T, Nagae M, Nagasawa I, Nakamura K, Nishimura T, Nunomiya S, Norisue Y, Hashimoto S, Hasegawa D, Hatakeyama J, Hara N, Higashibeppu N, Furushima N, Furusono H, Matsuishi Y, Matsuyama T, Minematsu Y, Miyashita R, Miyatake Y, Moriyasu M, Yamada T, Yamada H, Yamamoto R, Yoshida T, Yoshida Y, Yoshimura J, Yotsumoto R, Yonekura H, Wada T, Watanabe E, Aoki M, Asai H, Abe T, Igarashi Y, Iguchi N, Ishikawa M, Ishimaru G, Isokawa S, Itakura R, Imahase H, Imura H, Irinoda T, Uehara K, Ushio N, Umegaki T, Egawa Y, Enomoto Y, Ota K, Ohchi Y, Ohno T, Ohbe H, Oka K, Okada N, Okada Y, Okano H, Okamoto J, Okuda H, Ogura T, Onodera Y, Oyama Y, Kainuma M, Kako E, Kashiura M, Kato H, Kanaya A, Kaneko T, Kanehata K, Kano KI, Kawano H, Kikutani K, Kikuchi H, Kido T, Kimura S, Koami H, Kobashi D, Saiki I, Sakai M, Sakamoto A, Sato T, Shiga Y, Shimoto M, Shimoyama S, Shoko T, Sugawara Y, Sugita A, Suzuki S, Suzuki Y, Suhara T, Sonota K, Takauji S, Takashima K, Takahashi S, Takahashi Y, Takeshita J, Tanaka Y, Tampo A, Tsunoyama T, Tetsuhara K, Tokunaga K, Tomioka Y, Tomita K, Tominaga N, Toyosaki M, Toyoda Y, Naito H, Nagata I, Nagato T, Nakamura Y, Nakamori Y, Nahara I, Naraba H, Narita C, Nishioka N, Nishimura T, Nishiyama K, Nomura T, Haga T, Hagiwara Y, Hashimoto K, Hatachi T, Hamasaki T, Hayashi T, Hayashi M, Hayamizu A, Haraguchi G, Hirano Y, Fujii R, Fujita M, Fujimura N, Funakoshi H, Horiguchi M, Maki J, Masunaga N, Matsumura Y, Mayumi T, Minami K, Miyazaki Y, Miyamoto K, Murata T, Yanai M, Yano T, Yamada K, Yamada N, Yamamoto T, Yoshihiro S, Tanaka H, Nishida O

Acute medicine & surgery 8 （ 1 ） e659 2021年01月

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Perioperative clinical parameters associated with short-term mortality after colorectal perforation

Matsuoka T., Yamamoto R., Matsumura K., Kondo R., Kobayashi K., Lefor A.K., Sasaki J., Shinozaki H.

European Journal of Trauma and Emergency Surgery （European Journal of Trauma and Emergency Surgery） 48 （ 4 ） 3017 - 3024 2021年

共著, ISSN 18639933

Purpose: Although early prediction of mortality is useful for the management of patients with colorectal perforations, no significant perioperative predictive factors have been identified. The purpose of this study was to identify useful prognostic factors for patients with colorectal perforation. Methods: This single-center retrospective study included consecutive patients undergoing emergency surgery for colorectal perforation from January 2012 to December 2019. The primary outcome was combined 30 day and in-hospital mortality. Patient- and disease-related factors obtained perioperatively were evaluated for mortality prediction. A scoring system was developed to enhance clinical utility. Results: Overall, 146 patients were included and 20 (14%) died after surgery. Multivariate logistic regression identified five predictive factors: age, hemodialysis, uncommon perforation etiology, plasma albumin level, and decreased platelet count. The area under the receiver operating curve for the scoring system using these parameters was 0.894 (95% CI 0.835–0.952). Patients at high-risk of mortality were classified by the proposed score with a sensitivity of 90.0% and negative predictive value of 98.0%. Conclusion: This study identified five perioperative factors significantly associated with mortality of patients with colorectal perforation. Although these parameters predict mortality of patients with colorectal perforation using a score with high discrimination, further study is required to confirm these findings.

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水素ガス吸入療法の現状と将来性

山元良, 本間康一郎, 佐野元昭, 佐々木淳一

ファルマシア（公益社団法人日本薬学会） 57 （ 1 ） 44 - 47 2021年

共著, ISSN 0014-8601

水素ガス吸入療法に関する様々な動物および臨床研究が行われており、種々の疾患・病態に対して治療効果を持つことが示唆され、人に対しての安全性が示されている。特に、急性心筋梗塞や心肺停止蘇生後症候群、さらには新型コロナウイルス感染症においての治療研究が進んでおり、心肺停止蘇生後症候群に関しては、二重盲検下ランダム化比較試験が複数の医療機関において現在進行中である。ここでは、水素ガスの将来の新規薬剤としての可能性を紹介する。

Clinical parameters and optimal candidates for early definitive fixation of extremity injury: A nationwide study

Yamamoto R., Udagawa K., Yusho Nishida , Soichiro Ono , Junichi Sasaki

Journal of Orthopaedic Science （Journal of Orthopaedic Science） 28 （ 1 ） 255 - 260 2021年

共著, ISSN 09492658

Background: While various strategies of fracture fixation for trauma patients have been discussed, optimal candidates remain unclear for early definitive fixation. The aim of this study was to integrate several clinical parameters into a scoring system and determine a cut-off value for safe early definitive surgery for extremity fractures. Methods: We retrospectively identified patients with fracture in an extremity in Japanese Trauma Data Bank from 2004 to 2019. We included adult patients who underwent open reduction and internal fixation for extremity injury before any other surgical intervention and excluded those who arrived with cardiac arrest. Several clinical parameters, such as age, vital signs, abbreviated injury scale (AIS) in the chest, and injury severity score (ISS), were examined with multivariate logistic regression models to predict in-hospital mortality, and then integrated into a scoring system based on each odds ratio. To determine a cut-off value of the scoring system for safe early definitive surgery, in-hospital mortality and/or postoperative complications were compared between patients who underwent definitive fixation within 24 h of injury and patients who did not in subgroups based on the scores. Results: Of 50,631 patients eligible for this study, 16,119 (31.8%) underwent early definitive fixation. A 0–15 scoring system with parameters including age >70 years, GCS <8, systolic blood pressure <90 mmHg, AIS in the chest ≥3, ISS ≥20, and transfusion requirement within 24 h of arrival was developed. At scores ≥10, early definitive fixation was found to be significantly associated with high in-hospital mortality, and at scores <10, in-hospital mortality was comparable between the two groups. Conclusions: We integrated clinical parameters into the scoring system with a scale of 0–15 and determined that a score of 10 is the cut-off score. We determined that patients with a score <10 can safely undergo early definitive fixation.

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十二指腸後腹膜穿通が疑われ非手術的加療を行った十二指腸水平脚憩室症の1例

栗原智宏, 西田有正, 増澤佑哉, 前島克哉, 山元良, 佐藤幸男, 佐々木淳一

日本救急医学会雑誌（(一社)日本救急医学会） 31 （ 12 ） 2444 - 2448 2020年12月

共著, ISSN 0915-924X

十二指腸憩室症自体は結腸憩室に次ぐ頻度で珍しい疾患ではないとされているが、報告例の多くが下行脚または傍乳頭憩室であり、水平脚の報告は限定される。いずれの部位でも無症状で特別な治療を要することは少なく経過観察されることが多いが、有症状時には部位によって鑑別に苦慮することがある。十二指腸後腹膜穿通と誤認した十二指腸水平脚憩室症の1例を経験したため、文献的考察を加えて報告する。症例は50歳代の女性。突然発症した腹痛を主訴に前医に救急搬送され十二指腸後腹膜穿通の診断にて入院となった。しかし、緊急手術となった際に対応が不能とのことで翌日に当院へ転院となった。来院後、消化性潰瘍による十二指腸後腹膜穿通と診断したが、病変は限局していたため非手術的に加療を開始した。臨床経過は順調に経過したが、2週間経過しても消化管造影にて十二指腸壁外への造影剤漏出と考えられる所見が消失せず、十二指腸後腹膜穿通ではない可能性を強く疑った。以前に画像検査を施行した医療機関にCTデータの送付を依頼し確認したところ、その時から十二指腸後面に見える部分にガス像を認めており、十二指腸憩室症と診断できた。十二指腸水平脚部の憩室は比較的稀であるが、有症状時には後腹膜穿通と鑑別が困難で、侵襲的処置が選択されてしまう可能性があり注意を要する。(著者抄録)

日本版敗血症診療ガイドライン2020:Now Open! 敗血症に対するステロイド療法

藤島清太郎, 遠藤功二, 山元良, 福田龍将, 升田好樹, 日本版敗血症診療ガイドライン2020特別委員会

日本救急医学会雑誌（(一社)日本救急医学会） 31 （ 11 ） 911 - 911 2020年11月

ISSN 0915-924X

Hydrogen Gas Inhalation Attenuates Endothelial Glycocalyx Damage and Stabilizes Hemodynamics in a Rat Hemorrhagic Shock Model.

Tamura T, Sano M, Matsuoka T, Yoshizawa J, Yamamoto R, Katsumata Y, Endo J, Homma K, Kajimura M, Suzuki M, Kobayashi E, Sasaki J

Shock (Augusta, Ga.) （Shock (Augusta, Ga.)） 54 （ 3 ） 377 - 385 2020年09月

共著, ISSN 1073-2322

BACKGROUND: Hydrogen gas (H2) inhalation during hemorrhage stabilizes post-resuscitation hemodynamics, improving short-term survival in a rat hemorrhagic shock and resuscitation (HS/R) model. However, the underlying molecular mechanism of H2 in HS/R is unclear. Endothelial glycocalyx (EG) damage causes hemodynamic failure associated with HS/R. In this study, we tested the hypothesis that H2 alleviates oxidative stress by suppressing xanthine oxidoreductase (XOR) and/or preventing tumor necrosis factor-alfa (TNF-α)-mediated syndecan-1 shedding during EG damage. METHODS: HS/R was induced in rats by reducing mean arterial pressure (MAP) to 35 mm Hg for 60 min followed by resuscitation. Rats inhaled oxygen or H2 + oxygen after achieving shock either in the presence or absence of an XOR inhibitor (XOR-I) for both the groups. In a second test, rats received oxygen alone or antitumor necrosis factor (TNF)-α monoclonal antibody with oxygen or H2. Two hours after resuscitation, XOR activity, purine metabolites, cytokines, syndecan-1 were measured and survival rates were assessed 6 h after resuscitation. RESULTS: H2 and XOR-I both suppressed MAP reduction and improved survival rates. H2 did not affect XOR activity and the therapeutic effects of XOR-I and H2 were additive. H2 suppressed plasma TNF-α and syndecan-1 expression; however, no additional H2 therapeutic effect was observed in the presence of anti-TNF-α monoclonal antibody. CONCLUSIONS: H2 inhalation after shock stabilized hemodynamics and improved survival rates in an HS/R model independent of XOR. The therapeutic action of H2 was partially mediated by inhibition of TNF-α-dependent syndecan-1 shedding.

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日本版敗血症診療ガイドライン2020;初期蘇生・ステロイドを知る敗血症に対する副腎皮質ステロイド投与 J-SSCG2020推奨の解説

藤島清太郎, 遠藤功二, 山元良, 福田龍将, 升田好樹, 竹下淳, 富永直樹, 河野浩幸, 名原功, 豊崎光信, 豊田幸樹年, 平野洋平, 安宅一晃, 井上茂亮, 射場敏明, 垣花泰之, 川崎達也, 久志本成樹, 黒田泰弘, 小谷穣治, 志馬伸朗, 谷口巧, 鶴田良介, 土井研人, 土井松幸, 中田孝明, 中根正樹, 細川直登, 松嶋麻子, 松田直之, 矢田部智昭, 江木盛時, 小倉裕司, 田中裕, 西田修, J-SSCG2020特別委員会

日本集中治療医学会雑誌（(一社)日本集中治療医学会） 27 （ Suppl. ） 259 - 259 2020年09月

ISSN 1340-7988

Oxygen administration in patients recovering from cardiac arrest: A narrative review

Yamamoto R., Yoshizawa J.

Journal of Intensive Care （Journal of Intensive Care） 8 （ 1 ） 60 2020年08月

共著

© 2020 The Author(s). High oxygen tension in blood and/or tissue affects clinical outcomes in several diseases. Thus, the optimal target PaO2 for patients recovering from cardiac arrest (CA) has been extensively examined. Many patients develop hypoxic brain injury after the return of spontaneous circulation (ROSC); this supports the need for oxygen administration in patients after CA. Insufficient oxygen delivery due to decreased blood flow to cerebral tissue during CA results in hypoxic brain injury. By contrast, hyperoxia may increase dissolved oxygen in the blood and, subsequently, generate reactive oxygen species that are harmful to neuronal cells. This secondary brain injury is particularly concerning. Although several clinical studies demonstrated that hyperoxia during post-CA care was associated with poor neurological outcomes, considerable debate is ongoing because of inconsistent results. Potential reasons for the conflicting results include differences in the definition of hyperoxia, the timing of exposure to hyperoxia, and PaO2 values used in analyses. Despite the conflicts, exposure to PaO2 > 300 mmHg through administration of unnecessary oxygen should be avoided because no obvious benefit has been demonstrated. The feasibility of titrating oxygen administration by targeting SpO2 at approximately 94% in patients recovering from CA has been demonstrated in pilot randomized controlled trials (RCTs). Such protocols should be further examined.

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Resuscitative endovascular balloon occlusion of the aorta and traumatic out-of-hospital cardiac arrest: A nationwide study.

Yamamoto R, Suzuki M, Funabiki T, Nishida Y, Maeshima K, Sasaki J

Journal of the American College of Emergency Physicians open 1 （ 4 ） 624 - 632 2020年08月

共著

Objective: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a less-invasive method for temporary hemostasis compared with cross-clamping the aorta through resuscitative thoracotomy (RT). Although the survival benefits of REBOA remained unclear, pathophysiological benefits were identified in patients with traumatic out-of-hospital cardiac arrest (t-OHCA). We examined the clinical outcomes of t-OHCA with the hypothesis that REBOA would be associated with higher survival to discharge compared with RT. Methods: A retrospective cohort study was conducted using the Japan Trauma Data Bank (2004-2019). Adult patients with t-OHCA who had arrived without a palpable pulse and undergone aortic occlusion were included. Patients were divided into REBOA or RT groups, and propensity scores were developed using age, mechanism of injury, presence of signs of life, presence of severe head and/or chest injury, Injury Severity Score, and transportation time. Inverse probability weighting by propensity scores was performed to compare survival to discharge between the 2 groups. Results: Among 13,247 patients with t-OHCA, 1483 were included in this study. A total of 144 (9.7%) patients were treated with REBOA, and 5 of 144 (3.5%) in the REBOA group and 10 of 1339 (0.7%) in the RT group survived to discharge. The use of REBOA was significantly associated with increased survival to discharge (odds ratio, 4.78; 95% confidence interval, 1.61-14.19), which was confirmed by inverse probability weighting (adjusted odds ratio, 3.73; 95% confidence interval, 1.90-7.32). Conclusions: REBOA for t-OHCA was associated with higher survival to discharge. These results should be validated by further research.

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