Japanese Association For Acute Medicine Research Articles

External Validation of Updated Prediction Models for Neurological Outcomes at 90 Days in Patients With Out-of-Hospital Cardiac Arrest.

Few prediction models for individuals with early-stage out-of-hospital cardiac arrest (OHCA) have undergone external validation. This study aimed to externally validate updated prediction models for OHCA outcomes using a large nationwide dataset. We performed a secondary analysis of the JAAM-OHCA (Comprehensive Registry of In-Hospital Intensive Care for Out-of-Hospital Cardiac Arrest Survival and the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest) registry. Previously developed prediction models for patients with cardiac arrest who achieved the return of spontaneous circulation were updated. External validation was conducted using data from 56 institutions from the JAAM-OHCA registry. The primary outcome was a dichotomized 90-day cerebral performance category score. Two models were updated using the derivation set (n=3337). Model 1 included patient demographics, prehospital information, and the initial rhythm upon hospital admission; Model 2 included information obtained in the hospital immediately after the return of spontaneous circulation. In the validation set (n=4250), Models 1 and 2 exhibited a C-statistic of 0.945 (95% CI, 0.935-0.955) and 0.958 (95% CI, 0.951-0.960), respectively. Both models were well-calibrated to the observed outcomes. The decision curve analysis showed that Model 2 demonstrated higher net benefits at all risk thresholds than Model 1. A web-based calculator was developed to estimate the probability of poor outcomes (https://pcas-prediction.shinyapps.io/90d_lasso/). The updated models offer valuable information to medical professionals in the prediction of long-term neurological outcomes for patients with OHCA, potentially playing a vital role in clinical decision-making processes.

Performance of a large language model on Japanese emergency medicine board certification examinations.

Background Emergency physicians need a broad range of knowledge and skills to address critical medical, traumatic, and environmental conditions. Artificial intelligence (AI), including large language models (LLMs), has potential applications in healthcare settings; however, the performance of LLMs in emergency medicine remains unclear.Methods To evaluate the reliability of information provided by ChatGPT, an LLM was given the questions set by the Japanese Association of Acute Medicine in its board certification examinations over a period of 5 years (2018-2022) and programmed to answer them twice. Statistical analysis was used to assess agreement of the two responses.Results The LLM successfully answered 465 of the 475 text-based questions, achieving an overall correct response rate of 62.3%. For questions without images, the rate of correct answers was 65.9%. For questions with images that were not explained to the LLM, the rate of correct answers was only 52.0%. The annual rates of correct answers to questions without images ranged from 56.3% to 78.8%. Accuracy was better for scenario-based questions (69.1%) than for stand-alone questions (62.1%). Agreement between the two responses was substantial (kappa = 0.70). Factual error accounted for 82% of the incorrectly answered questions.Conclusion An LLM performed satisfactorily on an emergency medicine board certification examination in Japanese and without images. However, factual errors in the responses highlight the need for physician oversight when using LLMs.

Proposed Collaboration Project Symposium of the 51st Annual Meeting of the Japanese Association for Acute Medicine and the 6th meetings of the EMS Asia 2023 Tokyo

Proposed Collaboration Project Symposium of the 51st Annual Meeting of the Japanese Association for Acute Medicine and the 6th meetings of the EMS Asia 2023 Tokyo

The Danish Disseminated Intravascular Coagulation (DANDIC) Cohort Study: Incidence and Prognosis

Introduction: Disseminated intravascular coagulation (DIC) is a serious condition with poor prognosis and limited treatment options. Despite being a devastating disorder, data on the incidence and prognosis remains limited. Previous studies are more than 10 years old, were limited to selected patients e.g., patients admitted to university hospitals, and were unable to track transitions in sites of care. In this study, we examined the incidence and prognosis, including time trends, of DIC. Methods: Potential DIC cases were identified from the hospital laboratory database by coagulation biomarkers in the Central Denmark Region, Denmark. Patients were eligible for inclusion if they were above 18 years of age and had an International Society on Thrombosis and Haemostasis (ISTH) DIC score of five or higher or a Japanese Association for Acute Medicine (JAAM) DIC score of four or higher. An underlying disease compatible with DIC was also required for inclusion and was assessed by medical chart review. The underlying diseases were infection, malignant disorder, obstetric complications, trauma, cardiac arrest, and other less common conditions. Exclusion criteria were other conditions affecting the coagulation system. 6748 medical charts were reviewed, and 2565 patients were included in the cohort from January 2013 to December 2020. Incidence rates were computed by the number of cases per year divided with the midyear population in the Central Denmark Region and were age and sex standardized to the year 2020. Survival was determined by Kaplan-Meier estimates. Results: Out of the 2565 patients, the median age was 64 years (25th-75th percentile, 48-74 years) and 1439 (56.1%) were male. At inclusion 1055 patients had an ISTH DIC score of 5-6, 145 an ISTH DIC score of 7-8, 2014 a JAAM DIC score of 4-6 and 302 a JAAM DIC score of 7-8. The overall incidence rate per 100,000 person-years declined from 33.1 in 2013 [95% confidence interval (CI), 29.6 to 36.8] to 24.0 in 2020 [95% CI, 21.1 to 27.1]. Overall 30-day survival remained relatively unchanged at 65.0% in 2013 [95% CI, 59.9% to 70.6%] and 58.7% in 2020 [95% CI, 52.9% to 65.0%]. The incidence rate of patients with an ISTH score of 5-6 at baseline was 14.1 in 2013 [95% CI, 11.8 to 16.5] and 10.8 in 2020 [95% CI, 8.9 to 12.8]. The incidence rate of patients with an ISTH score of 7-8 at baseline remained nearly constant at 1.4 in 2013 [95% CI, 0.7 to 2.1] and 1.2 in 2020 [95% CI, 0.6 to 2.0]. Thirty-day survival was 56.2% [95% CI, 53.3% to 59.3%] for patients with an ISTH DIC score of 5-6 and 33.8% [95% CI, 26.9% to 42.4%] for patients with an ISTH DIC score of 7-8. Patients with JAAM DIC scores of 4-6 at baseline showed a decline in incidence rate from 25.8 in 2013 [95% CI, 22.7 to 29.9] to 19.4 in 2020 [95% CI, 16.8 to 22.1]. However, the incidence rate of patients with JAAM DIC scores of 7-8 remained steady at 3.6 in 2013 [95% CI, 2.4 to 4.8] and 2.3 in 2020 [95% CI, 1.4 to 3.2]. Patients with a JAAM DIC score of 4-6 at baseline had a 30-day survival rate of 62.2% [95% CI, 60.0% to 64.3%] while patients with a JAAM DIC score of 7-8 had a lower 30-day survival of 53.6% [95% CI, 48.3% to 59.6%]. Conclusion: The overall incidence of DIC declined during the study period, but overall mortality remained unchanged. The incidence rate was higher among patients with a low baseline ISTH or JAAM DIC score than among patients with a high baseline score. Survival rate was also higher for patients with a low DIC score at baseline, suggesting that DIC score at baseline may be a predictor of survival.

Abstract 157: Differences in Mid-Term Neurological Changes From 30 to 90 Days According to Age; is Plasticity Following Brain Injury After Cardiac Arrest Observed in Children or Young Adults?

Introduction: In clinical practice, younger patients following cardiac arrest (CA) are usually expected to recover, even though they are at high risk for poor neurological outcome. The aim of this study was to evaluate the differences of mid-term neurological improvements from 30 to 90 days after CA according to age. Methods: A retrospective observational study was conducted using data from the Japanese Association for Acute Medicine (JAAM) out-of-hospital cardiac arrest (OHCA) registry; a nationwide, prospective database including information on OHCA patients. All CA patients of any age except <1years who had recovered spontaneous circulation and survived after 30 days were analyzed. Patients who already showed cerebral performance category (CPC) (or pediatric CPC [PCPC]) of 1 at 30 days were excluded. We evaluated the proportion of patients in each age category (aged 1-17 [children and adolescents], 18-39 [young adults], 40-64 [middle-aged adults], 65-79 [older adults], ≥80 [elderly] years) who improved in either CPC or PCPC between the 30 and 90 days after CA by using a multivariate logistic regression analysis. Results: Of the 68,111 patients in the registry, 1,449 patients for whom 30- and 90-day CPC (or PCPC) data were available were analyzed. Among them, a total of 186 patients (13%) showed improvement in their 90-day CPC (or PCPC). Multivariate logistic regression analysis showed that patients aged 18-39, 40-64 and 65-79 years were more likely to have improved 90-day CPC compared with those aged ≥ 80 years (Odds ratios: 2.67 [1.19-5.96], 2.33[1.37-3.95] and 1.87 [1.13-3.11], respectively). Adjusted spline curve showed that patients ranging from children to middle-aged adults had an expectation of improved neurological changes (Figure). Conclusions: The expectation of improved neurological changes following an OHCA was higher in patient aged 18-39, 40-64 and 65-79 years compared to those aged >80 years, while it was not in patients aged 1-17 years.

Abstract 147: Is Effect Size of Targeted Temperature Management Different for Pediatric Post-Cardiac Arrest Syndrome According to the Severity?

Introduction: The beneficial effect of target temperature management (TTM) for pediatric post-cardiac arrest syndrome (PCAS) patients is controversial, and there are few studies on the differential effects of TTM according to the risk classification. Objective: The aim of this study was to evaluate the differential effects of TTM for pediatric PCAS patients according to a risk classification tool we previously developed, rCAST. Methods: We used data from the Japanese nationwide out-of-hospital cardiac arrest (OHCA) registry of the Japanese Association for Acute Medicine. We classified eligible pediatric PCAS patients (aged ≤18 years) who achieved return of spontaneous circulation (ROSC) according to the quintile of score points on the rCAST. The effect of TTM for their neurological outcome was evaluated for each severity group. And then, focusing on the severity group that appeared to benefit from TTM, we also evaluated the effect of TTM by the propensity score analysis with several adjustment factors. Good neurological outcome was defined as a Cerebral Performance Categories score or Pediatric Cerebral Performance Categories score ≤2 at 30 days. Results: Among 1,526 OHCA pediatric patients in the registry, data of 307 PCAS patients who achieved ROSC were analyzed. The proportion of patients with a good neurological outcome was higher among those who underwent TTM compared to those who did not in the first to forth quintile (TTM vs non-TTM; 81% [21/26] vs 58% [21/36] [p=0.10] in the first, 11% [2/19] vs 7% [2/31] [p=0.63] in the second, 12% [2/17] vs 0% [0/55] [p=0.053] in the third, and 11% [1/9] vs 0% [0/21] [p=0.30] in the fourth). In the group of the fifth quantile (rCAST ≥ 18.5), no patients showed good neurological outcome regardless of TTM (0% [0/20] vs 0% [0/73]). The propensity score analysis showed that TTM was significantly associated with their good neurological outcome in the patients classified into the first to fourth quantile group (Odds ratio; 1.21 [1.04-1.40], p = 0.014). Conclusions: TTM was significantly associated with a good neurological outcome in the pediatric PCAS patients with rCAST ≤ 18.0. All patients with rCAST ≥ 18.5 showed poor neurological outcomes even if they underwent TTM.

Abstract 396: A Novel Machine Learning Approach for Identifying Subgroups With Differential Responses to Amiodarone in Patients With Cardiac Arrest With Shockable Rhythm

Introduction: Although there is a possibility that the effectiveness of amiodarone may differ among a particular subgroup, there are few studies on the differential effects of amiodarone for the out-of-hospital cardiac arrest (OHCA) patients with a shockable rhythm. Objective: To identify subgroups with differential responses to amiodarone in OHCA with shockable rhythm by a novel machine learning approach. Methods: We used data from the Japanese nationwide OHCA registry of the Japanese Association for Acute Medicine. The OHCA patients who had initial shockable rhythm upon hospital arrival were included. The primary outcome was a good neurological outcome at 30 days, defined as a Cerebral Performance Categories score ≤2. We developed a linear score by outcome weighting learning (OWL) method with logistic loss to identify subgroups with differential effects of amiodarone. The difference in the effect of amiodarone between subgroups based on the developed score was evaluated by repeated cross-validation (RCV), and hypothesis testing was performed by the permutation method. Results: Among 68,111 OHCA patients in the registry, data of 2333 patients with initial shockable rhythm upon hospital arrival were analyzed. Our developed score showed that the longer duration from call to EMS to hospital arrival, hypothermia at hospital arrival, and no defibrillation until hospital arrival were important variables that had a trend of increasing the beneficial effect of amiodarone (Table). The effect of amiodarone on neurological outcomes varied significantly among the subgroups identified by the developed scores (OR: 1.05 (95%CI: 0.99-1.13), P [RCV] = 0.038). Conclusions: We successfully developed a model that discriminates between the patients for whom amiodarone had a harmful effect on their neurological outcome from those for whom amiodarone had a beneficial effect. In the patients for whom amiodarone had a harmful effect, the other treatment approaches may be needed.

Intra-Aortic Balloon Pump among Shockable Out-of-Hospital Cardiac Arrest Patients: A Propensity-Weighted Analysis in a Multicenter, Nationwide Observational Study in Japan (The JAAM-OHCA Registry).

The effectiveness of IABP for shockable out-of-hospital cardiac arrest (OHCA) has not been extensively investigated. This study aimed to investigate whether the use of an intra-aortic balloon pump (IABP) for non-traumatic shockable OHCA patients was associated with favorable neurological outcomes. From the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest registry, a nationwide multicenter prospective registry, we enrolled adult patients with non-traumatic and shockable OHCA for whom resuscitation was attempted, and who were transported to participating hospitals between 2014 and 2019. The primary outcome was 1-month survival with favorable neurological outcomes after OHCA. After adopting the propensity score (PS) inverse probability of weighting (IPW), we evaluated the association between IABP and favorable neurological outcomes. Of 57,754 patients in the database, we included a total of 2738 adult non-traumatic shockable patients. In the original cohort, the primary outcome was lower in the IABP group (OR with 95% confidence intervals (CIs)), 0.57 (0.48-0.68), whereas, in the IPW cohort, it was not different between patients with and without IABP (OR, 1.18; 95% CI, 0.91-1.53). In adult patients with non-traumatic shockable OHCA, IABP use was not associated with 1-month survival with favorable neurological outcomes.

Efficacy of the Continuous Resuscitation Training with the Gap Period Due to the COVID-19 Pandemic

(1) Objective: This study evaluates the effects of simulation education at our institute on cardiac arrest resuscitation regarding knowledge, attitude, and practice (KAP) over a five-year period (2016–2020). (2) Subjects: Staff responded to the annual survey questionnaires followed by monthly training in Basic Life Support/Advanced Cardiovascular Life Support (BLS/ACLS) and Immediate Cardiac Life Support (ICLS) of the Japanese Association for Acute Medicine (JAAM) in 2016, 2017, and 2018. Additionally, in-house training was implemented in 2019 without post-assessment followed by training suspension in 2020 due to the COVID-19 pandemic. The last delivery of the survey questionnaires was in late 2020 for KAP retention measurement. (3) Measurements and Results: The self-efficacy level of BLS/ACLS/ICLS KAP of the survey respondents was analyzed using a five-point Likert scale. The mean self-efficacy level of BLS/ACLS/ICLS KAP increased over time, and that of the trained people was three-fold that of the untrained people. Trainees that had no cardiopulmonary resuscitation (CPR) experience gained the BLS/ACLS/ICLS key-point self-efficacy level, which we call the “Grip 14” in this study, as high as their untrained counterparts who had three-time CPR experience. Training suspension lessened the BLS/ACLS/ICLS KAP in both groups. (4) Conclusions: Continuous training enhances not only the BLS/ACLS/ICLS KAP of trainees but also of their untrained colleagues. The training likely had the same efficacy as the CPR experience.

Comparison of the prognostic value of four different critical illness scores in patients with sepsis-induced coagulopathy.

In patients with sepsis-induced coagulopathy (SIC), the Chinese DIC scoring system (CDSS) of the Chinese Society of Thrombosis and Hemostasis score, the Japanese Association for Acute Medicine (JAAM) score, the International Society of Thrombosis and Hemostasis (ISTH), and the Can Rapid risk stratification of Unstable angina patients Suppress Adverse outcomes with Early implementation of the ACC/AHA Guidelines (CRUSADE) score were compared for their predictive significance (SIC). From August 2021 through August 2022, 92 SIC patients hospitalized in our hospital's Department of Critical Care Medicine served as study participants. Groups of patients were created with a bad prognosis (n = 35) and a favorable prognosis (n = 57) 14 days following admission. Electronic medical records were used to compile patient information such as demographics (gender, age, and body mass index), medical history (hypertension, diabetes, chronic obstructive pulmonary disease, and chronic kidney disease), treatment (mechanical ventilation, APACHE II score at admission), and outcomes (results). All patients' JAAM, CDSS, ISTH, and CRUSADE scores were recorded. The APACHE II scores of the group with a poor prognosis were noticeably (p < 0.05) higher upon admission than those of the group with a favorable prognosis. The poor prognosis group had higher JAAM, ISTH, CDSS, and CRUSADE scores than the good prognosis group (all p < 0.05). Partial coagulation indicators in fibrinogen, D-dimer, activated partial thromboplastin time, and prothrombin time were positively linked with JAAM, ISTH, CDSS, and CRUSADE (all p < 0.05). At admission, the JAAM, ISTH, CDSS, CRUSADE, and APACHE II scores were independently linked with SIC patients' prognosis (all p < 0.05) in a multivariate logistic regression analysis. According to receiver operating characteristic analysis, the area under the curve for predicting the prognosis of SIC patients using the JAAM, ISTH, CDSS, and CRUSADE4 scores was 0.896, 0.870, 0.852, and 0.737, respectively, with 95% CI being 0.840-0.952, 0.805-0.936, 0.783-0.922 and 0.629-0.845, respectively (all p < 0.05). The prognosis of SIC patients may be predicted in part by their JAAM, ISTH, CDSS, and CRUSADE4 scores, with the CDSS score being the most accurate. This research provides important recommendations for improving the care of patients with SIC.

Risk factors for postoperative disseminated intravascular coagulation in surgical patients with non-occlusive mesenteric ischemia.

The prognostic impact of disseminated intravascular coagulation (DIC) in surgical patients with non-occlusive mesenteric ischemia (NOMI) is unclear. This study aimed to confirm the association between postoperative DIC and prognosis and to identify preoperative risk factors associated with postoperative DIC. This retrospective study included 52 patients who underwent emergency surgery for NOMI between January 2012 and March 2022. Kaplan-Meier curve analysis with the log-rank test was used to compare 30-day survival and hospital survival between patients with and without postoperative DIC. In addition, univariable and multivariable logistic regression analyses were performed to identify the preoperative risk factors for postoperative DIC. The 30-day and hospital mortality rates were 30.8% and 36.5%, respectively, and the incidence rate of DIC was 51.9%. Compared to patients without DIC, patients with DIC showed significantly lower rates of 30-day survival (41.5% vs 96%, log-rank P < 0.001) and hospital survival (30.2% vs 86.4%, log-rank, P < 0.001). Logistic regression analyses showed that the Japanese Association for Acute Medicine (JAAM) DIC score (OR = 2.697; 95% CI, 1.408-5.169; P = 0.003) and Sequential Organ Failure Assessment (SOFA) score (OR = 1.511; 95% CI, 1.111-2.055; P = 0.009) were independent risk factors for postoperative DIC in surgical patients with NOMI. The development of postoperative DIC is a significant prognostic factor for 30-day and hospital mortalities in surgical patients with NOMI. In addition, the JAAM DIC score and SOFA score have a high discriminative ability for predicting the development of postoperative DIC.

Prognostic value of the qSOFA in patients with acute exacerbation of idiopathic pulmonary fibrosis

BackgroundPatients with idiopathic pulmonary fibrosis (IPF) have a slowly progressive clinical course, although some develop acute exacerbations (AEs). An easily obtained composite score is desirable for predicting the survival rate in patients with AE of IPF (AE-IPF). We investigated the quick sequential organ failure assessment (qSOFA), originally developed to identify sepsis, as a predictor of mortality in patients with AE-IPF and compared it to other composite assessments. MethodsConsecutive patients with IPF admitted for their first AE between 2008 and 2019 were recruited retrospectively. The association between the qSOFA score obtained at admission and mortality was investigated. ResultsDuring the study period, 97 patients with AE-IPF were hospitalized. The hospital mortality was 30.9%. Multivariate logistic regression analysis revealed that both the qSOFA and the Japanese Association for Acute Medicine (JAAM)-disseminated intravascular coagulation (DIC) scores were significant predictors of hospital mortality (odds ratio [OR] 3.86, 95% confidence interval [CI] 1.43–10.3; p = 0.007 and OR 2.71, 95% CI 1.56–4.67; p = 0.0004; respectively). Kaplan–Meier survival curves showed that both scores were consistently associated with survival. Furthermore, the sum of the two scores was a more effective predictor than the individual scores. ConclusionsThe qSOFA score of patients admitted with AE-IPF was associated with both in-hospital and long-term mortality, which was also true for the JAAM-DIC score. The qSOFA score plus the JAAM-DIC score should be determined during the diagnostic evaluation of a patient with AE-IPF. Both scores combined may be more effective at predicting outcomes than individual scores.

Continuous High Positive-End Expiratory Pressure May Worsen Renal Function in Patients With Acute Respiratory Distress Syndrome: Retrospective Analyses of a Nationwide, Multicenter Observational Study in Japan.

Positive end-expiratory pressure (PEEP), especially continuous high PEEP, is thought to be a risk factor for worsening renal function (WRF) due to impaired venous return and the development of renal interstitial edema. In this study, we investigated whether PEEP is a risk factor for WRF in patients with acute respiratory distress syndrome (ARDS), a representative pathology that requires continuous high PEEP for respiratory management. We performed retrospective sub-analyses of the Japanese Association for Acute Medicine, a nationwide prospective observational registry of ARDS (FORECAST ARDS registry) prospective multicenter cohort study. WRF was defined on the basis of a worsening renal Sequential Organ Failure Assessment (SOFA) score. We performed univariate and multivariable analyses to identify possible risk factors for WRF, and propensity score analyses to compare the frequency of WRF according to cutoff values for the difference in PEEP between day 1 and day 4. We analyzed 151 cases. Multivariable analysis showed that the difference in PEEP (odds ratio (OR)1.123 (95% confidence interval (CI)1.017-1.240), P = 0.022) and male sex (OR 3.287 (95% CI 1.029-10.502), P = 0.045) were risk factors for WRF. Propensity score analysis showed trends towards an increased risk for WRF in each cutoff value for the difference in PEEP: -5 cmH2O (OR 0.389 (95% CI 0.084-1.799), P = 0.229), 0 cmH2O (OR 2.222 (95% CI 0.755-6.540), P = 0.150), and 5 cmH2O (OR 3.277 (95% CI 0.940-11.425), P = 0.065). This study revealed that the difference in PEEP between days 1 and 4 was positively associated with WRF. However, a significant cutoff value for the difference in PEEP was not determined.

Targeted temperature management on outcome of older adult patients after out-of-hospital cardiac arrest

BackgroundTargeted temperature management (TTM) can potentially improve the prognosis of patients with out-of-hospital cardiac arrest (OHCA). However, the effectiveness of TTM in older adults remains unknown. Therefore, this study aimed to assess the outcomes of older adult patients with OHCA who underwent TTM. MethodsThis study was a multicenter, retrospective, nationwide observational analysis of the Japanese Association for Acute Medicine out-of-hospital cardiac arrest (JAAM-OHCA) registry. We included patients aged ≥18 years who had experienced OHCA and underwent TTM from June 1, 2014, to December 31, 2017, in Japan. The primary outcome was a 1-month neurological favorable outcome, and the secondary outcome was 1-month survival. ResultsA total of 1847 patients were included in the analysis. 79 of 389 patients aged ≥75 years (20.3%) had a 1-month neurological favorable outcome compared with 369 of 959 patients aged 18–64 years (38.5%) (adjusted odds ratios, 0.31; 95% confidence interval [CI], 0.21–0.45; P for trend <0.001). With increasing age, 1-month mortality showed an increasing trend; however, there was no significant difference. ConclusionIn this retrospective nationwide observational study in Japan, neurological outcomes worsened as age increased in patients with OHCA who underwent TTM.

Management Strategies in Septic Coagulopathy: A Review of the Current Literature.

One of the 'organs' that can be affected by sepsis is the coagulation system. Coagulopathy in sepsis may take the form of sepsis-induced coagulopathy (SIC) or sepsis-associated disseminated intravascular coagulation (DIC). It is important to identify SIC early, as at this stage of coagulopathy anticoagulants may be of the greatest benefit. The most recent diagnostic scoring systems for septic coagulopathy come from the International Society on Thrombosis and Hemostasis and the Japanese Association for Acute Medicine. Recommendations regarding the management of septic coagulopathy differ between organizations. Moreover, septic coagulopathy is an area of intense research in recent years. Therefore we searched three databases to review the most recent management strategies in septic coagulopathy. The mainstream management strategies in septic coagulopathy include the causal treatment of sepsis, unfractionated heparin, low-molecular-weight heparin, antithrombin, and recombinant human thrombomodulin. The last two have been associated with the highest survival benefit. Nevertheless, the indiscriminate use of these anticoagulants should be avoided due to the lack of mortality benefit and increased risk of bleeding. The early diagnosis of SIC and monitoring of coagulation status during sepsis is crucial for the timely management and selection of the most suitable treatment at a time. New directions in septic coagulopathy include new diagnostic biomarkers, dynamic diagnostic models, genetic markers for SIC management, and new therapeutic agents. These new research avenues may potentially result in timelier SIC diagnosis and improved management of all stages of septic coagulopathy by making it more effective, safe, and personalized.

Diagnosis of Disseminated Intravascular Coagulation in Patients Suffering from Sepsis using the Modified International Society of Thrombosis and Haemostasis Criteria and Japanese Association of Acute Medicine Criteria

Introduction: The international task force defines sepsis as ‘life- threatening organ dysfunction caused by a dysregulated host response to infection’. Disseminated Intravascular Coagulation (DIC) is a coagulopathy syndrome that causes microvascular and macrovascular thrombosis and increases the risk of bleeding due to consumptive coagulopathy. Sepsis causes dysfunction in coagulation due to release of inflammatory markers which leads to inappropriate deposition of intravascular fibrin. In order to facilitate the diagnostic process for detecting DIC, the scoring system recommended by International Society of Thrombosis and Haemostasis (ISTH) and Japanese Association of Acute Medicine (JAAM) were used which are based on the global coagulation tests such as the platelet count, Prothrombin time, International Normalised Ratio (INR) and Fibrin Degradation Products (FDPs)/D-dimer. Aim: To determine the prevalence and outcome of DIC in patients suffering from sepsis using ISTH criteria and JAAM criteria. Materials and Methods: A prospective cohort was carried out from January 2021 to July 2022 in the haematology section of pathology department of Government Medical College and Hospital, Aurangabad, Maharashtra, India. Hundred patients suffering from clinically suspected sepsis were included in the study. Venous blood was collected from patients in Ethylene Diamine Tetra-acetic Acid (EDTA) and Citrate bulbs. The tests performed were Complete Blood Count (CBC), Prothrombin Time (PT), INR and D-Dimer. CBC was performed on Fully automated three part cell counter. PT, INR, D-Dimer testing was done on fully automated coagulometer. The above test results were used to diagnose DIC in patients suffering from sepsis using the modified ISTH and JAAM criterias. The results were analysed using Microsoft excel 2019 i.e., chi-square test was applied for p-value calculation. Results: Out of 100 patients with clinically suspected sepsis 35 patients (35%) suffered from Overt DIC using ISTH criteria and 58 patients (58%) suffered from DIC using JAAM criteria. The total mortality in patients with sepsis in the present study was 40%. The mortality in patients with DIC in sepsis using the ISTH criteria was 26 patients (74.28%) and 37 patients (63.79%) using the JAAM criteria. Conclusion: Coagulation abnormalities are widely prevalent in patients with sepsis and are likely to play a key role in multi- organ dysfunction. Both ISTH and JAAM criteria are good predictors of mortality.

Prognostic Accuracy of the Different Scoring Systems for Assessing Coagulopathy in Sepsis: A Retrospective Study.

There is no gold standard for the diagnosis of coagulation dysfunction in sepsis, and the use of the current scoring systems is still controversial. The purpose of this study was to assess the performance of sepsis-induced coagulopathy (SIC), the Japanese Association for Acute Medicine Disseminated Intravascular Coagulation (JAAM DIC), and the International Society on Thrombosis and Haemostasis overt DIC (ISTH overt-DIC). The relationship between each scoring system and 28-day all-cause mortality was examined. Among 452 patients (mean age, 65 [48,76] years), 306 [66.7%] were men, the median SOFA score was 6 [4,9], and the median APACHE II score was 15 [11,22]. A total of 132 patients (29.2%) died within 28 days. Both the diagnosis of SIC (AUROC, 0.779 [95% CI, 0.728-0.830], P < 0.001) and ISTH overt-DIC (AUROC, 0.782 [95% CI, 0.732-0.833], P < 0.001) performed equally well in the discrimination of 28-day all-cause mortality (between-group difference: SIC versus ISTH overt-DIC, -0.003 [95% CI, -0.025-0.018], P = 0.766). However, the SIC demonstrated greater calibration for 28-day all-cause mortality than ISTH overt-DIC (the coincidence of the calibration curve of the former is higher than that of the latter). The diagnosis of JAAM DIC was not independently associated with 28-day all-cause mortality in sepsis (RR, 1.115, [95% CI 0.660-1.182], P = 0.684). The SIC scoring system demonstrated superior prognostic prediction ability in comparison with the others and is the most appropriate standard for diagnosing coagulopathy in sepsis.

Effects of cardiopulmonary resuscitation instructions on the outcomes of out-of-hospital cardiac arrest: An analysis of the JAAM-OHCA registry.

To determine whether dispatcher-provided cardiopulmonary resuscitation (CPR) instructions improve the outcomes of out-of-hospital cardiac arrest (OHCA). Cases registered in the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest (JAAM-OHCA) Registry between June 2014 and December 2019 were included. Cases in which the dispatcher provided CPR instructions to the bystander were included in the "Instructions" group", and cases without CPR instructions were included in the "No Instructions" group. The primary outcome was the proportion of patients with a favorable neurological outcome, defined as a Glasgow-Pittsburgh cerebral performance category scale of 1 to 2 at 1 month after OHCA. Overall, 51,199 patients with OHCA were registered in the JAAM-OHCA Registry during the study period. Of these, 33,745 were eligible for the study, with 16,509 in the Instructions group and 17,236 in the No Instructions group. The proportion of patients with a favorable neurological outcome at 1 month after OHCA was inferior in the Instructions group than in the No Instructions group (2.3% versus 3.0%, p < 0.001). After adjustment for patient background characteristics, no association was found between CPR instructions provided by a dispatcher and favorable neurological outcomes at 1 month after OHCA (adjusted odds ratio, 1.000; 95% confidence interval, 0.869-1.151, p = 0.996). The present study found no clear clinical benefit of dispatcher-provided CPR instructions on the neurological outcomes of cases with OHCA.

The impact of different targeted temperatures on out-of-hospital cardiac arrest outcomes in patients receiving extracorporeal membrane oxygenation: a nationwide cohort study

BackgroundTargeted temperature management (TTM) is recommended in the management of out-of-hospital cardiac arrest (OHCA) when coma persists after the return of spontaneous circulation. In the setting of extracorporeal membrane oxygenation (ECMO) for OHCA patients, TTM is associated with good neurological outcomes and is recommended in the Extracorporeal Life Support Organization guidelines. However, the optimal targeted temperature for these patients has not yet been adequately investigated. This study aimed to compare the impact of different targeted temperatures on the outcomes in OHCA patients receiving ECMO.MethodsThis was a retrospective analysis of data from the Japanese Association for Acute Medicine (JAAM)-OHCA Registry, a multicentre nationwide prospective database in Japan in which 103 institutions providing emergency care participated. OHCA patients aged ≥ 18 years who required ECMO with TTM between June 2014 and December 2019 were included in our analysis. The primary outcome was 30-day survival with favourable neurological outcomes, defined as a Glasgow–Pittsburgh cerebral performance category score of 1 or 2. Patients were divided into two groups according to their targeted temperature: normothermic TTM (n-TTM) (35–36 °C) and hypothermic TTM (h-TTM) (32–34 °C). We compared the outcomes between the two targeted temperature groups using multivariable logistic regression and inverse probability weighting (IPW).ResultsA total of 890 adult OHCA patients who received ECMO and TTM were eligible for our analysis. Of these patients, 249 (28%) and 641 (72%) were treated with n-TTM and h-TTM, respectively. The proportions of patients with 30-day favourable neurological outcomes were 16.5% (41/249) and 15.9% (102/641), in the n-TTM and h-TTM groups, respectively. No difference in neurological outcomes was observed in the multiple regression analysis [adjusted odds ratio 0.91, 95% confidence interval (CI) 0.58–1.43], and the result was constant in the IPW (odds ratio 1.01, 95% CI 0.67–1.54).ConclusionNo difference was observed between n-TTM and h-TTM in OHCA patients receiving TTM with ECMO. The current understanding that changes to the targeted temperature have little impact on the outcome of patients may remain true regardless of ECMO use.

External validation of the TiPS65 score for predicting good neurological outcomes in patients with out-of-hospital cardiac arrest treated with extracorporeal cardiopulmonary resuscitation

AimEstimating prognosis of patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) is essential for selecting candidates. The TiPS65 score can predict neurological outcomes of patients with out-of-hospital cardiac arrest (OHCA) treated with ECPR. We aimed to perform an external validation of this score. MethodsData from the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest registry, a multicentred, nationwide, prospectively registered database, were analysed. All adult patients with OHCA and shockable rhythm and treated with ECPR between January 2018 to December 2019 were included. In the TiPS65 score, age, call-to-hospital arrival time, initial cardiac rhythm at hospital arrival, and initial pH value were used as predictors. The primary outcome was 30-day survival with favourable neurological outcomes (Cerebral Performance Category 1 or 2). Discrimination, using the C-statistic, and predictive performances of each score, such as sensitivity and specificity, were investigated. ResultsOf 590 included patients (517 [81.6%] men; median [interquartile range] age, 60 [50–69] years), 64 (10.8%) reported favourable neurological outcomes. The C-statistic of the TiPS65 score was 0.729 (95% confidence interval (CI): 0.672–0.786). When the cut-off of TiPS65 score was set to >1, the sensitivity and specificity were 0.906 (95%CI: 0.807–0.965) and 0.430 (95%CI: 0.387–0.473), respectively; conversely, when the cut-off was set to >3, they were 0.172 (95%CI: 0.089–0.287) and 0.971 (95%CI: 0.953–0.984), respectively. ConclusionsThe TiPS65 score shows reasonable discrimination and predictive performances. This score can be supportive in the decision-making process for the selection of eligible patients for ECPR in clinical settings.