塩塚 潤二

IMPORTANCE: The optimal intensity of care for older patients (age ≥80 years) in intensive care units (ICUs) remains uncertain. Although institutional variation in critical care practice has been described, less is known about case-mix-adjusted variation in life-sustaining treatment use among older patients admitted to ICUs and whether greater institutional treatment intensity is associated with improved survival. OBJECTIVE: To quantify institutional variation in the use of life-sustaining treatments for older patients among ICUs and examine the association of treatment intensity with in-hospital mortality. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used nationwide data from the Japanese Intensive Care Patient Database (JIPAD) for patients aged 80 years or older admitted to 127 ICUs at JIPAD-participating institutions in Japan between April 1, 2015, and March 31, 2023. EXPOSURES: Intensive care unit admission and age 80 years or older. MAIN OUTCOMES AND MEASURES: Institutional treatment intensity was quantified using standardized treatment ratio (STR), defined as the ratio of observed-to-expected life-sustaining treatment use after adjustment for patient-level characteristics. The association between STR category and in-hospital mortality was evaluated using both logistic regression and hierarchical bayesian multilevel logistic regression models. RESULTS: Among 60 713 patients (median age, 84 years [IQR, 82-87 years]; 32 302 male [53.2%]), the crude institutional rate of life-sustaining treatment use ranged from 4.8% (8 of 167 patients) to 38.0% (322 of 847 patients). After adjustment for patient case mix, the STR ranged from 0.24 (95% CI, 0.11-0.48) to 2.34 (95% CI, 1.91-2.85) across participating ICUs. In multilevel analyses adjusted for patient- and institution-level factors, higher institutional treatment intensity was not associated with in-hospital survival compared with intermediate treatment intensity (high STR category: odds ratio, 1.17; 95% credible interval, 0.91-1.39). CONCLUSIONS AND RELEVANCE: In this cohort study of older patients admitted to ICUs, institutional use of life-sustaining treatments varied substantially even after case-mix adjustment and higher institutional treatment intensity was not associated with better in-hospital survival. These findings suggest that increasing treatment intensity alone may not be associated with improved outcomes in this population and support the need for better approaches to identify patients most likely to benefit from intensive treatment.

INTRODUCTION: With the rapid increase in the ageing population, the use of procedural sedation and analgesia (PSA) for diagnostic procedures such as prostate biopsy in older adults is increasing. However, elderly patients are particularly susceptible to respiratory depression during PSA testing and have a significantly higher risk of hypoxaemia during procedures requiring deep sedation. Although propofol combined with fentanyl is commonly used, it frequently causes hypoxaemia and apnoea. Remimazolam, a novel ultrashort-acting benzodiazepine, may be a safer alternative with less respiratory compromise; however, the supporting evidence remains limited. This study aims to assess whether remimazolam combined with fentanyl reduces the incidence of respiratory depression compared with propofol combined with fentanyl in elderly patients undergoing prostate biopsy under deep sedation requiring immobility. METHODS AND ANALYSIS: This is a single-centre, participant and assessor-blinded (with pragmatic blinding of participants), parallel-group, superiority randomised controlled trial conducted at the Jichi Medical University Saitama Medical Centre, Japan. Eligible participants are men aged ≥70 years who are scheduled to undergo prostate biopsy under intravenous sedation. Participants will be randomised in a 1:1 ratio to receive either remimazolam or propofol, each administered in combination with fentanyl at a fixed effect-site concentration. The primary outcome is the incidence of severe apnoea (≥1 min). The primary analysis will follow the intention-to-treat principle, implemented practically as a full analysis set analysed using a complete case approach. Sensitivity analyses will include a per-protocol analysis and multiple imputations of missing data. A subgroup analysis of patients aged ≥75 years was performed. ETHICS AND DISSEMINATION: This study was approved by the Jichi Medical University Central Clinical Research Ethics Committee (approval number: 24JMU001S-2) and was registered with the Japan Registry of Clinical Trials on 11 November 2024. Written informed consent was obtained from all participants before enrolment. These findings will be disseminated through publications in peer-reviewed journals and presentations at scientific conferences. TRIAL REGISTRATION NUMBER: jRCTs031240478.

OBJECTIVE: Postoperative walking ability has been identified as a crucial prognostic indicator for older patients undergoing major cardiac surgeries. This study was designed to investigate the predictive value of preoperative lower extremity muscle mass and muscle echo intensity for postoperative walking ability in older patients undergoing cardiac surgeries. DESIGN: A prospective observational study. SETTING: A single-center study conducted at a university hospital. PARTICIPANTS: A total of 109 elective cardiac surgery patients, 65 years of age or older, were prospectively enrolled. INTERVENTIONS: Preoperative muscle mass and quality of the rectus femoris were assessed using muscle cross-sectional area and echo intensity on ultrasound images, respectively. MEASUREMENTS AND MAIN RESULTS: The primary outcome of interest was the walking distance achieved in a 6-minute walk test after cardiac surgery. Multiple regression analysis was performed to identify factors independently associated with 6-minute walk distance after surgery. Higher muscle cross-sectional area and lower echo intensity of the rectus femoris, measured by ultrasonography, were associated with a significantly longer 6-minute walk distance upon discharge. Higher muscle mass and lower echo intensity were also significantly associated with shorter hospital length of stay. CONCLUSIONS: The preoperative measurement of cross-sectional area and echo intensity of the quadriceps muscles can be used as a predictor of postoperative 6-minute walk distance in elderly patients undergoing cardiac surgery.

OBJECTIVES: The spillover impact of the COVID-19 pandemic on patients without COVID-19 in ICUs should be assessed. We aimed to assess the association of ICUs' medical burden and capacity changes with clinical outcomes in such patients during the COVID-19 pandemic. DESIGN: Retrospective cohort study. SETTING: Twenty-three ICUs in Japan. PATIENTS: Patients without COVID-19 in ICUs from January 2019 to February 2023. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: These ICUs completed a web-based questionnaire on medical burden and capacity limitations in November 2023, and they were classified as having a limited capacity if their scores exceeded the median; otherwise, they were categorized as having a maintained capacity. The primary outcome was the standardized mortality ratio (SMR), calculated with the Acute Physiology and Chronic Health Evaluation III-j model, compared with the pre-pandemic level. Using individual-level patient data, a generalized linear Poisson mixed-effects model including an offset-time term was employed to assess the association of capacity limitation, the number of patients with COVID-19, and ICU bed occupancy on the day of admission, with hazard ratios for in-hospital death. Nine and fourteen ICUs had a limited capacity (25,568 patients) and a maintained capacity (45,068 patients), respectively. SMRs increased in four epidemic waves in the ICUs with a limited capacity but in only one wave in those with a maintained capacity. After adjustment, capacity limitation (hazard ratio, 1.19; 95% CI, 1.01-1.41; p = 0.04) and the number of patients with severe COVID-19 (per five patients; hazard ratio, 1.09; 95% CI, 1.03-1.16; p = 0.002) were associated with in-hospital mortality, but ICU bed occupancy was not. CONCLUSIONS: SMRs increased more frequently in ICUs with a limited capacity during the pandemic. Our findings emphasize the need for proactive strategies to mitigate medical burden and capacity limitations for future preparedness.

Bevacizumab, a humanized monoclonal antibody against vascular endothelial growth factor (VEGF), is used in combination with chemotherapy for various malignancies, including metastatic colorectal cancer. While effective, bevacizumab can inhibit normal blood vessel growth, leading to cardiovascular side effects not typically associated with conventional chemotherapy. We report a rare case, from an international perspective, of a 73-year-old man with a history of gastric cancer and newly diagnosed metastatic colorectal cancer complicated by a pre-existing abdominal aortic aneurysm (AAA) measuring 52 mm. The aneurysm was initially managed conservatively, as the multidisciplinary team (MDT) and the patient agreed to prioritize chemotherapy despite the known rupture risk, given his wish to avoid delaying treatment for his cancer. After the diagnosis of colorectal cancer during chemotherapy, bevacizumab was added to his regimen. He developed a rupture of the AAA two days after the fourth dose. Emergent open surgical repair was successfully performed without wound healing complications. This case highlights the potential risk of large-vessel complications associated with bevacizumab, especially in patients with known vascular anomalies. Careful imaging assessment and monitoring are imperative when considering bevacizumab for patients at risk of aortic rupture. In selected cases, prophylactic measures such as preemptive aneurysm repair should be contemplated to optimize safety.