論文

Background: The global population is aging rapidly. However, research on the characteristics of burn injuries in extremely old individuals remains limited. The current study aimed to identify the characteristics of burn injuries among elderly people by examining a city-wide burn database in Tokyo. Methods: This observational study was conducted at 14 burn centers, and data from the Tokyo Burn Unit Association registry from 1999 to 2020 were used. Demographic characteristics, burn mechanisms and severity, and clinical outcomes were compared among three age groups: >80 (very old), 65–79 (old), and 18–64 years. Results: In total, 11,876 patients with burn, including 1,150 aged > 80 years, 1,916 aged 65–79 years, and 8,810 aged 18–64 years, were analyzed. Older patients had a higher incidence of flame burns, burns in the closed space, and trunk, perineum, and lower extremity injuries. The older population had a greater injury severity, longer length of hospital stay, and higher in-hospital mortality rate. Similar trends were observed in the very old population. Conclusion: This study elucidated the characteristics of burn injuries, which included injury mechanisms and anatomical burn sites, among elderly individuals.

Purpose: We examined the effect of a high-target mean arterial pressure (MAP) on septic shock in a previously underrepresented region. Methods: A multicentre, pragmatic, open-label, randomised controlled trial was conducted in 29 hospitals in Japan, where the prevalence of chronic hypertension among older individuals is 66.9%. Patients who were diagnosed with septic shock, aged ≥ 65 years, and admitted to an intensive care unit were randomised 1:1 to the high (target MAP = 80–85 mmHg) or control (target MAP = 65–70 mmHg) groups from 1 July 2021 to 12 December 2023. The target MAP was maintained for 72 h or until vasopressors were no longer required. The primary outcome was the 90-day all-cause mortality. Secondary outcomes included organ support-free days and adverse events. Results: The trial was terminated early on the basis of the interim analysis results, suggesting the harm of the high-target strategy. Of the 518 patients, 258 were in the high-target group, and 260 were in the control group. By 90 days after randomisation, 101 patients (39.3%) in the high-target group and 74 (28.6%) in the control group had died from any cause (risk difference = 10.7; 95% confidence interval, 2.6–18.9). Renal replacement therapy-free days at 28 days were shorter in the high-target group. No clinical benefits for any outcome were observed in any subpopulation, including those with known chronic hypertension. Conclusion: Among older patients with septic shock, high-target MAP significantly increased mortality compared with standard care. Trial registration: UMIN Clinical Trials Registry; UMIN000041775; 13 September 2020.

Background: The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for hemorrhagic shock in the torso has become increasingly common as a bridge to definitive hemostasis. Hydrogen molecules, distributed throughout the bloodstream, alleviate ischemic injury but cannot reach ischemic organs during REBOA use. This study investigates whether intra-aortic irrigation with hydrogen-dissolved saline under REBOA use delivers hydrogen to the intestine in a swine hemorrhagic shock model. Methods: We induced volume-regulated hemorrhagic shock in a 40 kg female swine. Following this, hydrogen-dissolved saline irrigation was initiated through an intra-aortic catheter positioned distal to the REBOA balloon. Hydrogen concentration in the portal vein was determined in four models: controlled hemorrhagic shock with full REBOA inflation during the standard occlusion time, uncontrolled hemorrhagic shock with liver injury and full REBOA inflation during the extended occlusion time, uncontrolled hemorrhagic shock with liver injury and partial REBOA inflation during the extended occlusion time, and as the control model, controlled hemorrhagic shock with full REBOA inflation during the standard occlusion time with normal saline irrigation without hydrogen. Results: Hydrogen concentration in the portal vein was found to be 0.224 mg/L (13.998%) in the controlled hemorrhagic shock model with full REBOA inflation, 0.049 mg/L (3.063%) in the uncontrolled hemorrhagic shock model with liver injury and full REBOA inflation, 0.018 mg/L (1.125%) in the uncontrolled hemorrhagic shock model with liver injury and partial REBOA inflation, and 0.002 mg/L (0.015%) in the control model. These results demonstrate the presence of hydrogen in the portal vein under different REBOA applications. Conclusions: Increased hydrogen concentration in the portal vein indicated that hydrogen was delivered to the intestine. These findings suggest an approach for drug administration during REBOA use. However, further investigations are required to establish its application in clinical settings.

Background and aims Approximately 50% of critically ill patients develop physical impairment following intensive care. To overcome this impairment, major international guidelines for nutrition therapy recommend a higher protein intake than the standard dose. However, the optimal delivery route of additional protein supplementation to achieve protein target intake remains unclear. Therefore, this trial aims to identify the optimal route for supplementary protein delivery, either enteral nutrition (EN) alone or EN combined with parenteral amino acid supplementation, on physical outcomes. Methods This is a nationwide multicenter open-label randomized parallel-group trial. This study will encompass adult patients admitted to intensive care units in which EN can be initiated within 48 h of admission. Participants will be assigned to either the EN-only group (all protein provided enterally using high-protein EN formulas) or the EN + PN group (protein provided via EN combined with supplementary intravenous amino acids using standard-protein EN formulas) to achieve the target dose. The nutritional targets are 20–30 kcal/kg/day for energy and 1.5–1.8 g/kg/day for protein within 3–5 days post-EN initiation. The primary outcome is functional independence, defined as a Barthel Index score of ≥ 85, at 90 days following randomization. Ethics and dissemination The Ethics Committee of Keio University School of Medicine approved this study (approval number: 20251054). Written informed consent will be obtained from all participants or their legal representatives. Trial registration This protocol was registered at the University Hospital Medical Information Network Clinical Trials Registry on July 12, 2025 (UMIN000058441: https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000066822 )

Introduction As of yet, there are few studies of Asian patients with pseudo-pulseless electrical activity (PEA). Japanese patients with out-of-hospital cardiac arrest (OHCA) tend to be elderly, experience cardiac arrest while at home, and present with severe illness. The present study evaluated the prognostic implications of pseudo-PEA in a Japanese cohort with a high risk of OHCA. Methods The present study is a post hoc analysis of SOS-KANTO 2017, a prospective, multicentric study which included OHCA patients with PEA on hospital arrival who underwent echocardiographic assessment during resuscitation. The patients were categorized into a pseudo-PEA and a true PEA group. The primary outcome was the return of spontaneous circulation (ROSC). The secondary outcomes included survival to hospital admission, 30-day survival, and a favorable neurological status at discharge. Logistic regression was performed with cardiac activity as the primary predictor after adjusting for covariates. Results Of 894 eligible patients, 345 had pseudo-PEA, and 549 had true PEA. In total, 49.3% achieved ROSC. The pseudo-PEA group had a significantly higher rate of ROSC (87.2% vs. 25.5%; p < 0.01). On multivariable logistic regression, the pseudo-PEA group was independently associated with a high ROSC rate (odds ratio [OR]: 22.1; 95% confidence interval [CI]: 14.2–34.3), survival to hospital admission (OR: 17.8; 95% CI: 11.2–28.2), 30-day survival (OR: 51.9; 95% CI: 7.33–367), and favorable neurological outcome at discharge (OR: 14.3; 95% CI: 1.62–125). Conclusion Pseudo-PEA may be associated with a higher rate of ROSC and favorable, short and middle-term outcomes in Japanese patients with OHCA. Early echocardiographic assessment of cardiac activity may help prognostication and guide resuscitation even in high-risk populations.

Objectives: – Postintensive care frailty impairs quality of life in survivors of severe illness. While anabolic hormone deficiency and prolonged inflammation are considered key physiologic mechanisms, specific features associated with frailty progression remain unclear. This study aimed to elucidate clinical characteristics associated with frailty deterioration following recovery from septic shock in older adults. Design: – Post hoc analysis of a randomized controlled trial. Setting: – ICUs in Japan. Patients: – Adults of 65 years or older with septic shock. Measurements and Main Results: – Data were analyzed from a randomized controlled trial investigating optimal blood pressure targets in patients of 65 years or older with septic shock. Frailty at 90 days after intensive care was classified as no-to-mild, moderate, and severe based on the Clinical Frailty Scale (CFS) scores of less than or equal to 4, 5–6, and greater than or equal to 7, respectively. Baseline characteristics, treatments, and outcomes were compared across these frailty categories. Factors associated with postintensive care frailty were identified using ordinal logistic regression fitted with a generalized estimating equation model. Among 513 eligible patients, 339 patients survived to 90 days; 103 patients (30.4%) had no-to-mild frailty, 114 patients (33.6%) had moderate frailty, and 122 patients (36.0%) had severe frailty, respectively. Higher presepsis CFS scores (adjusted odds ratio [aOR], 2.03 [1.72–2.40] per 1-point increase; p < 0.001), higher sequential organ failure assessment (SOFA) scores (aOR, 1.16 [1.06–1.26] per 1-point increase; p < 0.001), and corticosteroid use (aOR, 1.72 [1.14–2.61]; p < 0.001) were independently associated with frailty. Subgroup analyses revealed that corticosteroid use was associated with frailty deterioration in patients with baseline frailty (CFS ≥ 5), whereas SOFA scores were associated with frailty in patients with tissue hypoperfusion (lactate, ≥ 2 mmol/L). Conclusions: – Baseline frailty before sepsis, organ dysfunction severity, and corticosteroid therapy independently predict severe postintensive care frailty in older adults with septic shock.

＜文献概要＞腎代替療法では,主に拡散,濾過,吸着の3つの物理学的原則により溶質除去が行われる。持続的腎代替療法(CRRT)においては,各種流量を調整することで治療モードが決定されるが,本邦のICUで最も広く使われる持続血液濾過透析においてクリアランスを規定するのは,透析液流量と濾過流量である。浄化量については,歴史的には特に濾過流量を増加させることによって予後が改善するかを検討した無作為化比較試験が複数行われたが,高流量の浄化量を用いても予後の改善は認められなかった。抗凝固薬については,未分画ヘパリンやナファモスタットメシル酸塩,海外ではクエン酸塩などが用いられるが,それぞれの特性を理解し,適切にモニタリングを行い使用することが求められる。

＜ここがポイント!＞▼透析には水や電気,設備が必要なだけでなく,専門的な知識も要し,被災による影響を受けやすい特徴がある.▼透析患者は高齢,基礎疾患を有する割合が多く,透析を受けられないことにより短期間で生命に危険のある状態となりうる.▼災害時には施設間での連携をさまざまなレベルで行い,迅速な情報収集や伝達を行うことが求められ,システムの構築が図られている.▼ライフラインの確保が重要であり,確保できない場合には支援透析を依頼し,継続透析体制を維持する必要がある.▼医療資源が不足することにより,トリアージを行う必要や個別性のある透析を行うことが難しくなることが想定される.▼平時の準備や災害発生時の移動手段,安全確保方法など,マニュアルを作成することや,あらかじめ患者とよく話し合っておくことが必要である.(著者抄録)

レムデシビルで治療した新型コロナウイルス感染症(COVID-19)7例(男性4例、女性3例、48～87歳<中央値66歳>)について報告した。7例中5例で回復もしくは改善に至っており、レムデシビル投与開始後の呼吸不全回復までの回復期間中央値は11日(8日～41日)であった。2例は死亡した。いずれも、COVID-19感染後、二次的に呼吸器感染症(それぞれ真菌性肺炎と細菌性肺炎)を合併し、不可逆的な呼吸不全に至るという経過をたどった。7例中2例において、投与開始7日後に腎障害が発生したため中止とした。