増山 智之

BACKGROUND: The aim of this study was to assess in-hospital mortality and identify its predictors in adult patients with hematological malignancies admitted to intensive care units (ICUs) in Japan. METHODS: We conducted a retrospective cohort study of adult patients with hematological malignancies admitted to ICUs participating in the Japanese Intensive care PAtient Database from 2015 to 2020. The primary outcome was in-hospital mortality. We compared survivors and non-survivors based on their characteristics at ICU admission and ICU treatments. We also assessed the relationship between institutional characteristics and in-hospital mortality. RESULTS: A total of 1,700 patients from 69 institutions were included. In-hospital mortality was 46.2%. The most common reason for ICU admission was respiratory failure (28.2%). Mechanical ventilation and continuous renal replacement therapy were used in 49.0% and 24.6% of patients, respectively. In multivariable logistic regression analysis, a higher in-hospital mortality was independently associated with type of neoplasm, Acute Physiological Assessment and Chronic Health Evaluation III score, invasive mechanical ventilation (OR 1.64, 95% CI 1.30-2.08), noninvasive ventilation (OR 1.71, 95% CI 1.22-2.41), and continuous renal replacement therapy (OR 1.98, 95% CI 1.51-2.61), whereas other patient characteristics (e.g., age, comorbidities, ICU admission source, reason for ICU admission) were not associated. There was also no association between institutional characteristics and in-hospital mortality. CONCLUSIONS: In-hospital mortality of adult patients with hematological malignancies admitted to ICUs remains high. Factors associated with in-hospital mortality in these patients differed from those in the general ICU population. Institutional characteristics were not significantly associated with in-hospital mortality.

BACKGROUND: The simplicity of the diagnostic definition of acute respiratory distress syndrome (ARDS) has led to its diagnosis in patients with new-onset or exacerbation of diffuse parenchymal lung diseases (DPLDs). This study investigated the incidence of DPLDs in patients with acute hypoxic respiratory failure who met the Berlin definition. METHODS: This Japan-based multicentre retrospective cohort study included patients on mechanical ventilation who met the Berlin definition. For all participants, diagnosis was made by pulmonology specialists in DPLD and thoracic radiology (blinded to clinical diagnoses) by reviewing an extensive database designed for DPLD diagnosis across 10 participating hospitals. RESULTS: Of 13 612 patients admitted to the intensive care unit during the study period, 272 met the Berlin definition of ARDS and were included for analysis. All underwent at least one chest computed tomography scan; none underwent lung biopsy. Briefly, 182 were designated classic ARDS (67%), 69 non-IPF (idiopathic pulmonary fibrosis) DPLDs (25%) and 21 IPF (8%) by DPLD specialists. Of the 90 patients diagnosed with DPLD (IPF or non-IPF) by specialists, 35% were diagnosed with classic ARDS by intensivists at the end of the clinical course. Diagnostic classifications of classic ARDS and IPF by DPLD specialists were associated with time-to-death (adjusted hazard ratio (HR) 1.58 (95% CI 1.03-2.45), p=0.038, and adjusted HR 1.73 (95% CI 1.01-2.97), p=0.045, respectively) and in-hospital mortality (adjusted HR 1.54 (95% CI 1.06-2.23), p=0.022 for classic ARDS) versus non-IPF DPLDs; intensivist diagnostic classifications were not. CONCLUSION: Approximately one-third of patients within the Berlin definition were retrospectively diagnosed with new-onset or acutely exacerbated DPLD by specialists.

BACKGROUND: Cerebrospinal fluid (CSF) levels of orexin show a cyclic diurnal variation in healthy subjects, which is diminished in patients with certain diseases. However, possible circadian variations in orexin levels in critically ill patients remain unknown. In this study, we evaluated the orexin concentrations in the CSF and their diurnal variation in patients undergoing thoracic aortic aneurysm repair with lumbar intrathecal catheterization for CSF drainage after non-neurosurgery. METHODS: Eligible patients with a lumbar intrathecal catheter placed for CSF drainage following aortic surgery at a single-center ICU between September 2019 and February 2020 were included. Catheters were placed before anesthesia induction, and CSF was collected at the time of catheter placement, ICU admission, and daily at 6:00, 12:00, 18:00, and 24:00 until the catheter was removed or for up to 5 days after admission to the ICU. RESULTS: Three patients (Patients A, B, and C) who underwent thoracic aortic aneurysm repair were included. Patients B and C received sedatives or hypnotics during the orexin measurement period. The baseline orexin levels for Patients A, B, and C were 219.9, 312.3, and 403.8 pg/mL, while the mean orexin levels were 319.4 ± 82.6, 372.4 ± 56.0, and 306.3 ± 48.3 pg/mL, respectively. For all three patients, orexin levels showed diurnal variations, but no consistent periodic changes. CONCLUSION: CSF orexin concentrations for patients undergoing thoracic aortic aneurysm repair in the ICU were within the reported range compared to those of previously reported healthy subjects; however, consistent periodic diurnal variations were not observed.