Clinical Application of Coagulation Biomarkers

Coagulopathy is of intense interest in the fields of emergency medicine, with many recent studies of coagulation biomarkers for clinical use. The occurrence of disseminated intravascular coagulation (DIC) also resulted in the activation of studies about the coagulopathy. At present DIC has been admitted in many clinical conditions and many coagulation biomarkers have been studied. Fibrin degradation product (FDP) and D-dimer are one type of coagulation biomarker. A characteristic of FDP and D-dimer is the rapid and dynamic elevation of their levels when fibrinolysis occurs in several acute diseases. In this chapter, we present the clinical application of FDP and D-dimer. In trauma, FDP and -dimer have been used for the evaluation of trauma severity, to predict the likelihood of hemorrhage and to evaluate the need for the transfusion of packed red blood cells. In cardiac pulmonary arrest (CPA), FDP and D-dimer have been useful for predicting the return of spontaneous circulation. Thus, the measurement of coagulation biomarkers is useful in the diagnosis and/or treatment of trauma and CPA

Primary Thymic Mucosa-Associated Lymphoid Tissue Lymphoma: Diagnostic Tips

AbstractMucosa-associated lymphoid tissue (MALT) lymphoma arising in the thymus is extremely rare and little is known regarding its clinicopathological features. This study examined the clinicopathological features of nine cases of thymic MALT lymphoma. Most patients had autoimmune disease or hyperglobulinemia, and they also had cysts in the tumors. Both increased serum autoantibody levels and polyclonal serum immunoglobulin levels remained essentially unchanged after total thymectomy in all patients. Thymic MALT lymphoma needs to be included in the differential diagnosis in Asian patients with a cystic thymic mass accompanied by autoimmune disease or hyperglobulinemia

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016)

Background and purposeThe Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 and published in the Journal of JSICM, [2017; Volume 24 (supplement 2)] https://doi.org/10.3918/jsicm.24S0001 and Journal of Japanese Association for Acute Medicine [2017; Volume 28, (supplement 1)] http://onlinelibrary.wiley.com/doi/10.1002/jja2.2017.28.issue-S1/issuetoc.This abridged English edition of the J-SSCG 2016 was produced with permission from the Japanese Association of Acute Medicine and the Japanese Society for Intensive Care Medicine.MethodsMembers of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ) and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two-thirds (> 66.6%) majority vote of each of the 19 committee members.ResultsA total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J-SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation, and its supporting evidence were also added to each recommendation statement. We conducted meta-analyses for 29 CQs. Thirty-seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for five CQs.ConclusionsBased on the evidence gathered, we were able to formulate Japanese-specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non-specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals

Prediction of arterial extravasation in pelvic fracture patients with stable hemodynamics using coagulation biomarkers

Abstract Background Determining the presence of an active arterial hemorrhage in the acute phase is important as a treatment strategy in patients with pelvic fracture. The purpose of this study was to evaluate whether coagulation biomarkers could predict arterial extravasation, especially in pelvic fracture patients with stable hemodynamics. Methods We studied patients with a pelvic fracture who had a systolic blood pressure above 90 mmHg and lactate level less than 5.0 mmol/L on hospital arrival. Patients were divided into two groups: those with arterial extravasation on enhanced computed tomography (CT) or angiography (extravasation [+] group) and those without arterial extravasation (extravasation [−] group). Coagulation biomarkers measured on arrival were statistically compared between the two groups. Predictive ability of arterial extravasation using coagulation biomarkers was evaluated by receiver-operating characteristic analyses provided area under the receiver-operating characteristic curves (AUROC) and diagnostic indicators with optimal cutoff point including sensitivity, specificity, positive and negative predictive values, and diagnostic odds ratio (DOR). Results Sixty patients were analyzed. Fibrin degradation products (FDP), D-dimer, prothrombin time–international normalized ratio (PT–INR), and the ratio of FDP to fibrinogen were significantly higher in the extravasation (+) group than in the extravasation (−) group (FDP, 242 μg/mL [145–355] vs. 96 μg/mL [58–153]; D-dimer, 81 μg/mL [41–140] vs. 39 μg/mL [21–75]; PT–INR, 1.09 [1.05–1.24] vs. 1.02 [0.98–1.08]; and ratio of FDP to fibrinogen, 1.06 [0.85–2.01] vs. 0.46 [0.25–0.74]). The highest AUROC was with a ratio of FDP to fibrinogen of 0.777 (95% confidence interval, 0.656–0.898), and the highest predictive ability in terms of DOR was with a ratio of FDP to fibrinogen (sensitivity, 0.76; specificity, 0.76; DOR 9.90). Conclusion Coagulation biomarker could predict of arterial extravasation in pelvic fracture patients with stable hemodynamics

Successful Intervention for Descending Necrotizing Mediastinitis : A Case Report

Descending necrotizing mediastinitis(DNM) is a rare, however, highly fatal disease originating from odontogenic, pharyngeal, or cervical infectious sources that descend along facial planes into the mediastinum. We report a case who underwent surgical drainage using a mediastinoscope for the treatment of DNM and had successful postoperative course. Cervicothoracic CT should be performed immediately for diagnosis and for evaluating the extent of infection and necrosis, and effective drainage and debridement with suitable approach is required as soon as possible if DNM is suspected

Gastrointestinal Complications after Cardiovascular Surgery with Cardiopulmonary Bypass

Purpose: The purpose of this study was to examine the incidence, clinical features, treatment and outcome of patients with gastrointestinal complications after cardiovascular surgery in our hospital. Patients and Methods: Between January 1992 to February 2004, 835 patients were operated with cardiopulmonary bypass (CPB) at Gunma University Hospital. Of these, 12 (1.4%) patients had postoperative gastrointestinal complications. The mean age of 12 patients was 59 years old ranging from 7 to 71. Valve replacements were performed in six patients, CABG in three, and others in three. Results: Gastrointestinal bleeding occurred in seven patients. Six of them recovered with non-surgical procedure, and one died of hemorrhagic shock following an emergency operation. Acute cholecystitis occurred in three patients and all of them were successfully managed by percutenous transhepatic gall bladder drainage (PTGBD). Two patients with gastrointestinal perforation underwent an emergent operation, however, both of them died of sepsis. The total mortality rate of 12 patients was 25%. Conclusion: The occurrence of gastrointestinal complications after cardiovascular surgery with cardiopulmonary bypass is low, however, is frequently fatal. Preoperative careful evaluation of patients is required for the postoperative management of those complications

The significance of strong ion gap for predicting return of spontaneous circulation in patients with cardiopulmonary arrest

Useful parameters that can predict return of spontaneous circulation (ROSC) in patients with cardiopulmonary arrest (CPA) have not been established. We previously reported the usefulness of anion gap (AG) and albumin-corrected anion gap (ACAG) calculated from a blood sample obtained on arrival at the hospital for the prediction of ROSC. Otherwise, it has been reported that strong ion gap (SIG), which shows the difference between the levels of fully dissociated cations and anions in the serum, is useful to predict the prognosis of critically ill patients