Successful embolization controlled active bleeding in a 76-year-old woman with diffuse idiopathic skeletal hyperostosis (DISH) [1] after a lumbar fracture. She originally presented with back pain following a fall. Initial computed tomography (CT) revealed fractures of the first and second lumbar vertebrae (L1, L2) with DISH extending from T8 to L2 (Figure 1A). Two days later, she was pale in complexion with hypotension (92/60 mmHg) and tachycardia (130 bpm). Contrast-enhanced CT revealed extravasation within the L2 vertebral body, indicative of left L2 and L3 arteries' involvement (Figure 1B). Emergency transcatheter arterial embolization was performed. To prevent reflux of embolic material into the aorta and spinal arteries including Adamkiewicz, the microcatheter was advanced beyond the vertebral limbus under fluoroscopic guidance. Selective angiography confirmed extravasation from the left L2 and L3 arteries (Figure 1C), which were embolized using a 1:2 mixture of N-butyl cyanoacrylate that achieved hemostasis after confirming absence of spinal arteries (Figure 1D).
Patients with DISH have an elevated risk of vertebral fracture compared to the general population due to rigidity and ossification [2]. The condition may cause various complications including injuries to intercostal and lumbar arteries, leading to active bleeding within relatively loose tissue spaces [3, 4]. This case demonstrates the importance of prompt intervention in DISH-related fractures with vascular complications, and it highlights the efficacy of embolization for controlling vertebral body bleeding.
The authors have nothing to report.
Written informed consent was obtained from the patient's family for the publication.
The authors declare no conflicts of interest.
The data that supports the findings of this study is available from the corresponding author upon reasonable request.
{"title":"Successful Embolization for Lumbar Fracture Bleeding in Diffuse Idiopathic Skeletal Hyperostosis","authors":"Nobu Fukumoto, Sadao Kawasaki, Naoaki Shibata, Shigeki Nemoto, Shigeaki Inoue","doi":"10.1002/ams2.70106","DOIUrl":"https://doi.org/10.1002/ams2.70106","url":null,"abstract":"<p>Successful embolization controlled active bleeding in a 76-year-old woman with diffuse idiopathic skeletal hyperostosis (DISH) [<span>1</span>] after a lumbar fracture. She originally presented with back pain following a fall. Initial computed tomography (CT) revealed fractures of the first and second lumbar vertebrae (L1, L2) with DISH extending from T8 to L2 (Figure 1A). Two days later, she was pale in complexion with hypotension (92/60 mmHg) and tachycardia (130 bpm). Contrast-enhanced CT revealed extravasation within the L2 vertebral body, indicative of left L2 and L3 arteries' involvement (Figure 1B). Emergency transcatheter arterial embolization was performed. To prevent reflux of embolic material into the aorta and spinal arteries including Adamkiewicz, the microcatheter was advanced beyond the vertebral limbus under fluoroscopic guidance. Selective angiography confirmed extravasation from the left L2 and L3 arteries (Figure 1C), which were embolized using a 1:2 mixture of <i>N</i>-butyl cyanoacrylate that achieved hemostasis after confirming absence of spinal arteries (Figure 1D).</p><p>Patients with DISH have an elevated risk of vertebral fracture compared to the general population due to rigidity and ossification [<span>2</span>]. The condition may cause various complications including injuries to intercostal and lumbar arteries, leading to active bleeding within relatively loose tissue spaces [<span>3, 4</span>]. This case demonstrates the importance of prompt intervention in DISH-related fractures with vascular complications, and it highlights the efficacy of embolization for controlling vertebral body bleeding.</p><p>The authors have nothing to report.</p><p>Written informed consent was obtained from the patient's family for the publication.</p><p>The authors declare no conflicts of interest.</p><p>The data that supports the findings of this study is available from the corresponding author upon reasonable request.</p>","PeriodicalId":7196,"journal":{"name":"Acute Medicine & Surgery","volume":"12 1","pages":""},"PeriodicalIF":1.3,"publicationDate":"2025-11-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/ams2.70106","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145619304","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<p>We read with great interest Nakada et al.'s large, nationwide analysis of the lactate/albumin ratio (LAR) measured on hospital arrival and its association with neurological outcomes after out-of-hospital cardiac arrest (OHCA) [<span>1</span>]. The authors should be commended for leveraging the Japanese Association for Acute Medicine (JAAM-OHCA) registry to test a biologically plausible composite biomarker across a broad population (<i>n</i> = 28,098) and for performing subgroup analyses addressing admission status and receipt of active post-resuscitation therapies. Their finding that LAR improved discrimination over lactate or albumin alone and modestly enhanced a reference model is relevant to early risk stratification in a condition where timely prognostic information is valuable. Nevertheless, several issues temper the translational value of the results.</p><p>First, the timing and selection for blood sampling were not standardized and depended on clinicians' discretion. This introduces selection bias, as patients undergoing longer evaluation or surviving slightly longer were more likely to have albumin measured, while albumin assays typically require more processing time than lactate [<span>2</span>]. Such variability may exaggerate LAR's prognostic value and likely contributed to the diminished incremental effect observed in admitted patients. Standardized, early sampling protocols would strengthen future validation.</p><p>Second, although discrimination metrics such as area under the curve (AUC), integrated discrimination improvement (IDI), and net reclassification improvement (NRI) were reported, the clinical impact remains unclear. An AUC of 0.83 is encouraging, yet the absolute gain over the reference model and its effect on decision thresholds were not quantified. Reporting predictive values, calibration, and net clinical benefit would clarify whether LAR provides practical guidance rather than only statistical improvement [<span>3</span>].</p><p>Third, residual confounding is possible. Albumin levels are influenced by chronic liver disease, nutritional status, and fluid balance [<span>4</span>], while lactate is affected by sepsis, epinephrine dosing, and prehospital variables [<span>5</span>]. These were not accounted for in the models, which may bias associations. Adjustment for comorbidity burden or sensitivity analyses excluding patients with advanced chronic disease would improve robustness.</p><p>Finally, operational considerations limit generalizability. Japan's emergency medical service (EMS) system, where field termination is rare, shapes the case mix and may not reflect other settings. External prospective validation with standardized sampling and serial biomarker kinetics will be essential to confirm clinical applicability.</p><p>In conclusion, Nakada et al. provide important large-scale evidence that LAR is associated with neurological outcomes after OHCA and improves prognostic discrimination beyond single biomarkers. F
{"title":"Comment on “Predictive Effects of the Lactate/Albumin Ratio on Neurological Outcomes in Patients After Out-of-Hospital Cardiac Arrest”","authors":"Shyam Sundar Sah, Abhishek Kumbhalwar","doi":"10.1002/ams2.70102","DOIUrl":"https://doi.org/10.1002/ams2.70102","url":null,"abstract":"<p>We read with great interest Nakada et al.'s large, nationwide analysis of the lactate/albumin ratio (LAR) measured on hospital arrival and its association with neurological outcomes after out-of-hospital cardiac arrest (OHCA) [<span>1</span>]. The authors should be commended for leveraging the Japanese Association for Acute Medicine (JAAM-OHCA) registry to test a biologically plausible composite biomarker across a broad population (<i>n</i> = 28,098) and for performing subgroup analyses addressing admission status and receipt of active post-resuscitation therapies. Their finding that LAR improved discrimination over lactate or albumin alone and modestly enhanced a reference model is relevant to early risk stratification in a condition where timely prognostic information is valuable. Nevertheless, several issues temper the translational value of the results.</p><p>First, the timing and selection for blood sampling were not standardized and depended on clinicians' discretion. This introduces selection bias, as patients undergoing longer evaluation or surviving slightly longer were more likely to have albumin measured, while albumin assays typically require more processing time than lactate [<span>2</span>]. Such variability may exaggerate LAR's prognostic value and likely contributed to the diminished incremental effect observed in admitted patients. Standardized, early sampling protocols would strengthen future validation.</p><p>Second, although discrimination metrics such as area under the curve (AUC), integrated discrimination improvement (IDI), and net reclassification improvement (NRI) were reported, the clinical impact remains unclear. An AUC of 0.83 is encouraging, yet the absolute gain over the reference model and its effect on decision thresholds were not quantified. Reporting predictive values, calibration, and net clinical benefit would clarify whether LAR provides practical guidance rather than only statistical improvement [<span>3</span>].</p><p>Third, residual confounding is possible. Albumin levels are influenced by chronic liver disease, nutritional status, and fluid balance [<span>4</span>], while lactate is affected by sepsis, epinephrine dosing, and prehospital variables [<span>5</span>]. These were not accounted for in the models, which may bias associations. Adjustment for comorbidity burden or sensitivity analyses excluding patients with advanced chronic disease would improve robustness.</p><p>Finally, operational considerations limit generalizability. Japan's emergency medical service (EMS) system, where field termination is rare, shapes the case mix and may not reflect other settings. External prospective validation with standardized sampling and serial biomarker kinetics will be essential to confirm clinical applicability.</p><p>In conclusion, Nakada et al. provide important large-scale evidence that LAR is associated with neurological outcomes after OHCA and improves prognostic discrimination beyond single biomarkers. F","PeriodicalId":7196,"journal":{"name":"Acute Medicine & Surgery","volume":"12 1","pages":""},"PeriodicalIF":1.3,"publicationDate":"2025-11-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/ams2.70102","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145581237","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<p>We sincerely appreciate the constructive and thoughtful comments provided on our article, “Predictive effects of the lactate/albumin ratio on neurological outcomes in patients after out-of-hospital cardiac arrest,” published in <i>Acute Medicine & Surgery</i> [<span>1</span>].</p><p>As Dr. Shyam Sundar Sah and Dr. Abhishek Kumbhalwar pointed out, the absence of a standardized protocol for the timing and implementation of blood tests may have introduced selection bias. Although both serum albumin and lactate levels are typically measured during the early resuscitation phase in Japanese clinical settings, some patients may have been excluded because resuscitation was terminated before albumin results became available, which could have introduced selection bias. Although these limitations were acknowledged in our manuscript, establishing a standardized blood sampling protocol remains important for future studies.</p><p>As the main objective of this observational study was to assess the association between lactate/albumin ratio and neurological outcomes, our analysis was limited to evaluating discrimination. Further research should address calibration and clinical usefulness to clarify whether prediction-guided interventions can improve patient outcomes [<span>2</span>].</p><p>We also agree that the lack of detailed data on comorbidities and baseline conditions affecting albumin and lactate is an important limitation. Nonetheless, serum albumin partially reflects long-term patient background, such as chronic illness and nutritional status [<span>3</span>]. Although factors like epinephrine dose and sepsis were not directly adjusted for, they may influence neurological outcomes themselves. Thus, lactate may act as an intermediate factor, and the lactate/albumin ratio might capture the overall prognostic profile more comprehensively.</p><p>Finally, as you noted, in Japan, field termination of resuscitation is permitted only under specific circumstances, which may limit external generalizability compared with other countries [<span>4</span>]. Therefore, we additionally performed a sensitivity analysis excluding patients who met the advanced life support termination-of-resuscitation rule, defined by five criteria: no emergency medical service-witnessed arrest, no bystander automated external defibrillator use or emergency medical service defibrillation, no prehospital return of spontaneous circulation, no bystander-witnessed arrest, and no bystander cardiopulmonary resuscitation [<span>5</span>]. As a result, 6136 patients who met the termination-of-resuscitation rule were excluded, leaving 21,962 out-of-hospital cardiac arrest patients for analysis. When comparing the predictive performance for favorable neurological outcomes (cerebral performance category 1–2) at 30 days, we observed a similar trend to the main analysis, in which lactate/albumin ratio showed significantly better predictive ability than lactate or albumin (Figure 1). This finding
{"title":"Response to “Comment on ‘Predictive Effects of the Lactate/Albumin Ratio on Neurological Outcomes in Patients After Out-Of-Hospital Cardiac Arrest’”","authors":"Koki Nakada, Yuki Miyamoto, Toshinari Kawama, Toshihiro Hatakeyama, Tetsuhisa Kitamura, Tasuku Matsuyama","doi":"10.1002/ams2.70099","DOIUrl":"https://doi.org/10.1002/ams2.70099","url":null,"abstract":"<p>We sincerely appreciate the constructive and thoughtful comments provided on our article, “Predictive effects of the lactate/albumin ratio on neurological outcomes in patients after out-of-hospital cardiac arrest,” published in <i>Acute Medicine & Surgery</i> [<span>1</span>].</p><p>As Dr. Shyam Sundar Sah and Dr. Abhishek Kumbhalwar pointed out, the absence of a standardized protocol for the timing and implementation of blood tests may have introduced selection bias. Although both serum albumin and lactate levels are typically measured during the early resuscitation phase in Japanese clinical settings, some patients may have been excluded because resuscitation was terminated before albumin results became available, which could have introduced selection bias. Although these limitations were acknowledged in our manuscript, establishing a standardized blood sampling protocol remains important for future studies.</p><p>As the main objective of this observational study was to assess the association between lactate/albumin ratio and neurological outcomes, our analysis was limited to evaluating discrimination. Further research should address calibration and clinical usefulness to clarify whether prediction-guided interventions can improve patient outcomes [<span>2</span>].</p><p>We also agree that the lack of detailed data on comorbidities and baseline conditions affecting albumin and lactate is an important limitation. Nonetheless, serum albumin partially reflects long-term patient background, such as chronic illness and nutritional status [<span>3</span>]. Although factors like epinephrine dose and sepsis were not directly adjusted for, they may influence neurological outcomes themselves. Thus, lactate may act as an intermediate factor, and the lactate/albumin ratio might capture the overall prognostic profile more comprehensively.</p><p>Finally, as you noted, in Japan, field termination of resuscitation is permitted only under specific circumstances, which may limit external generalizability compared with other countries [<span>4</span>]. Therefore, we additionally performed a sensitivity analysis excluding patients who met the advanced life support termination-of-resuscitation rule, defined by five criteria: no emergency medical service-witnessed arrest, no bystander automated external defibrillator use or emergency medical service defibrillation, no prehospital return of spontaneous circulation, no bystander-witnessed arrest, and no bystander cardiopulmonary resuscitation [<span>5</span>]. As a result, 6136 patients who met the termination-of-resuscitation rule were excluded, leaving 21,962 out-of-hospital cardiac arrest patients for analysis. When comparing the predictive performance for favorable neurological outcomes (cerebral performance category 1–2) at 30 days, we observed a similar trend to the main analysis, in which lactate/albumin ratio showed significantly better predictive ability than lactate or albumin (Figure 1). This finding","PeriodicalId":7196,"journal":{"name":"Acute Medicine & Surgery","volume":"12 1","pages":""},"PeriodicalIF":1.3,"publicationDate":"2025-11-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/ams2.70099","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145581242","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<p>We thank the authors for sharing an instructive case of remifentanil-induced chest wall rigidity (“wooden chest syndrome”) in a 4-month-old infant with hepatic failure [<span>1</span>]. Terzi and Gün highlight a rare but clinically critical phenomenon that may emerge abruptly, compromise ventilation, and require immediate recognition and intervention [<span>1</span>].</p><p>As we noted in our review, remifentanil's organ-independent metabolism can be advantageous when hepatic function is impaired [<span>2</span>]. At the same time, as the authors illustrate, chest wall rigidity can occur even at modest doses in neonates and young infants—populations with unique pharmacodynamic vulnerability (heightened μ-opioid sensitivity and limited respiratory reserve). These practical bedside cues—sudden increases in peak inspiratory pressure, reduced tidal volumes, poor chest excursion, and rapid desaturation—should prompt consideration of opioid-induced rigidity alongside bronchospasm, endotracheal tube obstruction, or ventilator circuit problems.</p><p>Prevention is paramount. We would emphasize four key strategies: (1) avoiding bolus dosing when feasible; (2) starting infusions slowly at the lowest effective rate; (3) ensuring thoughtful sequencing with hypnotics/sedatives (adequate hypnosis before opioid up-titration); and (4) maintaining vigilant monitoring of airway pressures and ventilation, especially during induction, painful procedures, and dose changes. At present, which infants should be considered “high risk” remains insufficiently defined; plausible risk factors include very young age or prematurity, bolus exposure or rapid up-titration, co-administration of potent hypnotics, underlying respiratory or neurologic vulnerability, and metabolic/organ dysfunction, but these require confirmation. In high-risk infants, it is prudent to pre-plan an escalation pathway and ensure immediate availability of airway adjuncts, naloxone, and short-acting neuromuscular blockade.</p><p>When rigidity occurs, management should be decisive and stepwise: promptly stop or reduce the opioid; optimize oxygenation and ventilation; administer naloxone if clinically appropriate; and, if ventilation remains inadequate, consider a short-acting neuromuscular blocker. The authors' successful re-initiation of remifentanil at a lower infusion rate after stabilization is clinically reassuring and consistent with careful, protocolized titration under close monitoring.</p><p>Importantly, much of the available remifentanil evidence comes from adult intensive care unit (ICU) populations [<span>3</span>]. Pediatric ICU data remain comparatively limited, particularly for infants and for those with organ dysfunction. This case therefore underscores the need for standardized prevention, monitoring, and rescue bundles tailored to infants, and for multicenter, prospective studies clarifying age-specific dosing, bolus exposure risks, co-administration strategies, and early warning thres
{"title":"Response to “Remifentanil-Induced Chest Wall Rigidity in an Infant With Hepatic Failure”","authors":"Hiromu Okano, Hiroshi Okamoto","doi":"10.1002/ams2.70104","DOIUrl":"https://doi.org/10.1002/ams2.70104","url":null,"abstract":"<p>We thank the authors for sharing an instructive case of remifentanil-induced chest wall rigidity (“wooden chest syndrome”) in a 4-month-old infant with hepatic failure [<span>1</span>]. Terzi and Gün highlight a rare but clinically critical phenomenon that may emerge abruptly, compromise ventilation, and require immediate recognition and intervention [<span>1</span>].</p><p>As we noted in our review, remifentanil's organ-independent metabolism can be advantageous when hepatic function is impaired [<span>2</span>]. At the same time, as the authors illustrate, chest wall rigidity can occur even at modest doses in neonates and young infants—populations with unique pharmacodynamic vulnerability (heightened μ-opioid sensitivity and limited respiratory reserve). These practical bedside cues—sudden increases in peak inspiratory pressure, reduced tidal volumes, poor chest excursion, and rapid desaturation—should prompt consideration of opioid-induced rigidity alongside bronchospasm, endotracheal tube obstruction, or ventilator circuit problems.</p><p>Prevention is paramount. We would emphasize four key strategies: (1) avoiding bolus dosing when feasible; (2) starting infusions slowly at the lowest effective rate; (3) ensuring thoughtful sequencing with hypnotics/sedatives (adequate hypnosis before opioid up-titration); and (4) maintaining vigilant monitoring of airway pressures and ventilation, especially during induction, painful procedures, and dose changes. At present, which infants should be considered “high risk” remains insufficiently defined; plausible risk factors include very young age or prematurity, bolus exposure or rapid up-titration, co-administration of potent hypnotics, underlying respiratory or neurologic vulnerability, and metabolic/organ dysfunction, but these require confirmation. In high-risk infants, it is prudent to pre-plan an escalation pathway and ensure immediate availability of airway adjuncts, naloxone, and short-acting neuromuscular blockade.</p><p>When rigidity occurs, management should be decisive and stepwise: promptly stop or reduce the opioid; optimize oxygenation and ventilation; administer naloxone if clinically appropriate; and, if ventilation remains inadequate, consider a short-acting neuromuscular blocker. The authors' successful re-initiation of remifentanil at a lower infusion rate after stabilization is clinically reassuring and consistent with careful, protocolized titration under close monitoring.</p><p>Importantly, much of the available remifentanil evidence comes from adult intensive care unit (ICU) populations [<span>3</span>]. Pediatric ICU data remain comparatively limited, particularly for infants and for those with organ dysfunction. This case therefore underscores the need for standardized prevention, monitoring, and rescue bundles tailored to infants, and for multicenter, prospective studies clarifying age-specific dosing, bolus exposure risks, co-administration strategies, and early warning thres","PeriodicalId":7196,"journal":{"name":"Acute Medicine & Surgery","volume":"12 1","pages":""},"PeriodicalIF":1.3,"publicationDate":"2025-11-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/ams2.70104","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145581241","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
We read with interest the recent article, “Remifentanil use in intensive care units: Current evidence and future perspectives” by Okano et al. The article suggests that remifentanil should be preferred for analgesia in patients with hepatic failure because plasma esterases metabolise it [1]. We wish to share a related pediatric case. A 4-month-old boy with acute hepatic failure was admitted to the pediatric intensive care unit and intubated. We chose remifentanil infusion (0.25 μg/kg/min) for sedation and analgesia. After ~5 h on remifentanil, the patient acutely desaturated (SpO₂ ≈ 80%), and tidal volume fell to 2 mL/kg. Endotracheal tube position was confirmed using end-tidal carbon dioxide monitoring. However, bag ventilation produced no chest movement. We suspected opioid-induced chest wall rigidity. Remifentanil was immediately stopped, and naloxone (0.1 mg/kg IV) was administered. Chest wall excursion promptly returned, and SpO₂ normalised; tidal volume improved to ~6 mL/kg on mechanical ventilation. Remifentanil was then restarted at a reduced rate (0.15 μg/kg/min) without recurrence of rigidity. As shown by Sivak and Davis, remifentanil's clearance is unaffected by end-stage hepatic or renal failure, making it suitable for use in patients with hepatic failure [2]. However, clinicians must be aware of the rare but serious risk of opioid-induced chest wall rigidity, which can also occur in intubated patients under mechanical ventilation. In such cases, warning signs include a sudden rise in peak airway pressures, reduced tidal volumes despite adequate ventilator settings, poor chest wall expansion, and unexplained oxygen desaturation [3]. Chest wall rigidity may occur with small doses, especially in neonates and infants. A recent systematic review similarly noted that chest wall rigidity is a common side effect of remifentanil in neonates and infants, emphasising prevention by slow infusion and minimal dosing [4]. Our experience is consistent with previous reports: even small opioid doses may induce rigidity in neonates and infants [3].
When rigidity occurs, it must be recognized and treated immediately. As in our patient, chest rigidity is rapidly reversible with naloxone. In our case, naloxone promptly restored adequate ventilation without needing paralysis. This pediatric case supports the use of remifentanil in hepatic failure (extrahepatic metabolism ensures predictable clearance) while highlighting “wooden chest syndrome” as a rare but critical complication. Clinicians should be alert for chest wall rigidity during opioid infusions in intubated patients and be prepared to intervene (naloxone or paralysis) to prevent hypoxemia.
The authors declare no conflicts of interest.
This article is linked to Okano et al. paper. To view this article, visit https://doi.org/10.1002/ams2.70087.
{"title":"Remifentanil-Induced Chest Wall Rigidity in an Infant With Hepatic Failure","authors":"Kıvanç Terzi, Emrah Gün","doi":"10.1002/ams2.70101","DOIUrl":"https://doi.org/10.1002/ams2.70101","url":null,"abstract":"<p>We read with interest the recent article, “Remifentanil use in intensive care units: Current evidence and future perspectives” by Okano et al. The article suggests that remifentanil should be preferred for analgesia in patients with hepatic failure because plasma esterases metabolise it [<span>1</span>]. We wish to share a related pediatric case. A 4-month-old boy with acute hepatic failure was admitted to the pediatric intensive care unit and intubated. We chose remifentanil infusion (0.25 μg/kg/min) for sedation and analgesia. After ~5 h on remifentanil, the patient acutely desaturated (SpO₂ ≈ 80%), and tidal volume fell to 2 mL/kg. Endotracheal tube position was confirmed using end-tidal carbon dioxide monitoring. However, bag ventilation produced <i>no chest movement</i>. We suspected opioid-induced chest wall rigidity. Remifentanil was immediately stopped, and naloxone (0.1 mg/kg IV) was administered. Chest wall excursion promptly returned, and SpO₂ normalised; tidal volume improved to ~6 mL/kg on mechanical ventilation. Remifentanil was then restarted at a reduced rate (0.15 μg/kg/min) without recurrence of rigidity. As shown by Sivak and Davis, remifentanil's clearance is unaffected by end-stage hepatic or renal failure, making it suitable for use in patients with hepatic failure [<span>2</span>]. However, clinicians must be aware of the rare but serious risk of opioid-induced chest wall rigidity, which can also occur in intubated patients under mechanical ventilation. In such cases, warning signs include a sudden rise in peak airway pressures, reduced tidal volumes despite adequate ventilator settings, poor chest wall expansion, and unexplained oxygen desaturation [<span>3</span>]. Chest wall rigidity may occur with small doses, especially in neonates and infants. A recent systematic review similarly noted that chest wall rigidity is a common side effect of remifentanil in neonates and infants, emphasising prevention by slow infusion and minimal dosing [<span>4</span>]. Our experience is consistent with previous reports: even small opioid doses may induce rigidity in neonates and infants [<span>3</span>].</p><p>When rigidity occurs, it must be recognized and treated immediately. As in our patient, chest rigidity is rapidly reversible with naloxone. In our case, naloxone promptly restored adequate ventilation without needing paralysis. This pediatric case supports the use of remifentanil in hepatic failure (extrahepatic metabolism ensures predictable clearance) while highlighting “wooden chest syndrome” as a rare but critical complication. Clinicians should be alert for chest wall rigidity during opioid infusions in intubated patients and be prepared to intervene (naloxone or paralysis) to prevent hypoxemia.</p><p>The authors declare no conflicts of interest.</p><p>This article is linked to Okano et al. paper. To view this article, visit https://doi.org/10.1002/ams2.70087.</p>","PeriodicalId":7196,"journal":{"name":"Acute Medicine & Surgery","volume":"12 1","pages":""},"PeriodicalIF":1.3,"publicationDate":"2025-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/ams2.70101","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145581136","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<p>We read with great interest the study by Ito et al. [<span>1</span>]. This study examined the rising incidence of secondary postpartum hemorrhage (PPH) attributed to subinvolution of the placental site (SIPS) and the therapeutic role of uterine artery embolization (UAE). The authors should be commended for providing a rare contemporary dataset from Japan and emphasizing interventional radiology as a minimally invasive treatment option for this condition.</p><p>The description of SIPS as a frequently overlooked cause of late bleeding is clinically meaningful because misclassification can delay definitive treatment. Moreover, the reported 100% procedural success rate for UAE is noteworthy and supports its inclusion in modern obstetric emergency protocols. These contributions advance the recognition of an underappreciated clinical entity.</p><p>However, we wish to raise two points that affect the diagnostic interpretation and treatment decisions. First, successful embolization was defined as the absence of subsequent hemostatic intervention without accounting for rebleeding risk or functional outcomes. For patients desiring future pregnancies, uterine integrity is as important as achieving immediate hemostasis. By not stratifying embolization success according to subsequent reproductive outcomes, clinicians may overestimate the net clinical benefits when counseling patients. A relative risk reduction in acute bleeding is clinically reassuring, but the absolute trade-off in terms of potential placenta accreta spectrum disorders in future pregnancies remains unquantified. This is critical for shared decision-making at the bedside [<span>2</span>].</p><p>Second, the analytic strategy interprets the apparent increase in secondary PPH as an increase in the incidence of SIPS. However, this temporal association may partly reflect the greater availability of angiography and lower thresholds for imaging rather than a true epidemiological shift. This distinction is clinically significant; if the incidence is overestimated due to detection bias, guidelines may prematurely prioritize angiography over conservative measures, such as uterotonics or curettage, in stable patients. The downstream consequence is possible overtreatment with invasive embolization in cases where non-invasive management would suffice [<span>3</span>].</p><p>Therefore, a clinically tethered interpretation of these findings is essential for improving patient outcomes. When SIPS is suspected, clinicians should consider whether imaging-defined abnormalities represent pathology requiring embolization or physiologic vascular remodeling that may resolve with conservative therapy. Overreliance on angiographic patterns risks unnecessary interventions with implications for fertility, patient anxiety, and long-term obstetric outcomes [<span>4</span>].</p><p>Despite these concerns, this study makes an important contribution by reinforcing the role of the UAE in controlling hemorrhage refractory to
{"title":"Critical Appraisal of “Increased Incidence of Secondary PPH From Placental Site Subinvolution and Role of Interventional Radiology”","authors":"Raihan Mohammed Mohiuddin, Mohammed Misbah Ul Haq","doi":"10.1002/ams2.70103","DOIUrl":"10.1002/ams2.70103","url":null,"abstract":"<p>We read with great interest the study by Ito et al. [<span>1</span>]. This study examined the rising incidence of secondary postpartum hemorrhage (PPH) attributed to subinvolution of the placental site (SIPS) and the therapeutic role of uterine artery embolization (UAE). The authors should be commended for providing a rare contemporary dataset from Japan and emphasizing interventional radiology as a minimally invasive treatment option for this condition.</p><p>The description of SIPS as a frequently overlooked cause of late bleeding is clinically meaningful because misclassification can delay definitive treatment. Moreover, the reported 100% procedural success rate for UAE is noteworthy and supports its inclusion in modern obstetric emergency protocols. These contributions advance the recognition of an underappreciated clinical entity.</p><p>However, we wish to raise two points that affect the diagnostic interpretation and treatment decisions. First, successful embolization was defined as the absence of subsequent hemostatic intervention without accounting for rebleeding risk or functional outcomes. For patients desiring future pregnancies, uterine integrity is as important as achieving immediate hemostasis. By not stratifying embolization success according to subsequent reproductive outcomes, clinicians may overestimate the net clinical benefits when counseling patients. A relative risk reduction in acute bleeding is clinically reassuring, but the absolute trade-off in terms of potential placenta accreta spectrum disorders in future pregnancies remains unquantified. This is critical for shared decision-making at the bedside [<span>2</span>].</p><p>Second, the analytic strategy interprets the apparent increase in secondary PPH as an increase in the incidence of SIPS. However, this temporal association may partly reflect the greater availability of angiography and lower thresholds for imaging rather than a true epidemiological shift. This distinction is clinically significant; if the incidence is overestimated due to detection bias, guidelines may prematurely prioritize angiography over conservative measures, such as uterotonics or curettage, in stable patients. The downstream consequence is possible overtreatment with invasive embolization in cases where non-invasive management would suffice [<span>3</span>].</p><p>Therefore, a clinically tethered interpretation of these findings is essential for improving patient outcomes. When SIPS is suspected, clinicians should consider whether imaging-defined abnormalities represent pathology requiring embolization or physiologic vascular remodeling that may resolve with conservative therapy. Overreliance on angiographic patterns risks unnecessary interventions with implications for fertility, patient anxiety, and long-term obstetric outcomes [<span>4</span>].</p><p>Despite these concerns, this study makes an important contribution by reinforcing the role of the UAE in controlling hemorrhage refractory to","PeriodicalId":7196,"journal":{"name":"Acute Medicine & Surgery","volume":"12 1","pages":""},"PeriodicalIF":1.3,"publicationDate":"2025-11-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12628010/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145562340","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
We sincerely thank Dr. Raihan Mohammed Mohiuddin and Dr. Mohammed Misbah Ul Haq for their insightful and thoughtful comments on our study. We greatly appreciate their careful appraisal, which highlights important clinical considerations regarding diagnostic interpretation and treatment selection for secondary postpartum hemorrhage (PPH) associated with subinvolution of the placental site (SIPS).
We fully share their concern that an increased rate of diagnostic imaging, particularly computed tomography (CT), may contribute to potentially excessive angiographic procedures and hemostatic interventions. While uterine artery embolization (UAE) remains a highly reliable and life-saving therapy for hemodynamically unstable cases, its use in stable patients with SIPS requires more nuanced evaluation. Current evidence, though still limited, suggests that uterotonics and curettage constitute the standard initial management for stable SIPS [1].
As noted in our paper, the concept of SIPS has not yet been widely recognized in Japan. Consequently, curettage has seldom been selected as a first-line treatment. Furthermore, the ready availability of CT in Japan has facilitated early imaging; once contrast extravasation is visualized, clinicians often proceed to angiography because of its high procedural success rate and low short-term complication risk. Nevertheless, considering the potential for increased hemorrhagic complications in subsequent pregnancies, UAE should not be chosen indiscriminately.
We agree that broader awareness of SIPS and the establishment of evidence-based management algorithms are essential. In particular, for hemodynamically stable patients, a diagnostic and therapeutic pathway that begins with ultrasonography and proceeds to uterotonics and curettage—rather than immediate embolization—should be further studied and systematically implemented in Japan.
We again thank the authors for their valuable perspectives, which contribute to advancing a balanced and patient-centered approach to managing secondary PPH due to SIPS.
Sincerely.
This study conformed to the provisions of the Declaration of Helsinki (revised in Fortaleza, Brazil in October 2013).
The author has nothing to report.
The author declares no conflicts of interest.
我们衷心感谢Raihan Mohammed Mohiuddin博士和Mohammed Misbah Ul Haq博士对我们的研究提出的深刻而周到的意见。我们非常感谢他们的仔细评估，这突出了诊断解释和治疗选择相关的继发性产后出血（PPH）与胎盘部位亚退化（SIPS）的重要临床考虑。我们完全同意他们的担忧，即诊断成像，特别是计算机断层扫描（CT）的增加，可能导致潜在的过度血管造影手术和止血干预。虽然子宫动脉栓塞（UAE）对于血流动力学不稳定的病例仍然是一种高度可靠和挽救生命的治疗方法，但它在稳定的SIPS患者中的应用需要更细致的评估。目前的证据虽然仍然有限，但表明子宫强张和刮宫术是稳定SIPS bbb的标准初始治疗方法。正如我们在论文中指出的那样，SIPS的概念在日本尚未得到广泛认可。因此，刮痧很少被选为一线治疗方法。此外，CT在日本的可用性促进了早期成像；一旦发现造影剂外渗，临床医生通常会进行血管造影，因为它的手术成功率高，短期并发症风险低。然而，考虑到后续妊娠出血并发症增加的可能性，不应不加区分地选择UAE。我们一致认为，提高对SIPS的认识和建立基于证据的管理算法至关重要。特别是，对于血流动力学稳定的患者，日本应该进一步研究和系统地实施一种从超声检查开始到子宫强直和刮宫的诊断和治疗途径，而不是立即栓塞。我们再次感谢作者提供的宝贵观点，这些观点有助于推进平衡和以患者为中心的方法来管理sips引起的继发性PPH。真诚地说，本研究符合赫尔辛基宣言（2013年10月在巴西福塔莱萨修订）的规定。作者没有什么可报道的。作者声明无利益冲突。
{"title":"Response to “Critical Appraisal on Increased Incidence of Secondary Postpartum Hemorrhage due to SIPS”","authors":"Chikao Ito","doi":"10.1002/ams2.70100","DOIUrl":"10.1002/ams2.70100","url":null,"abstract":"<p>We sincerely thank Dr. Raihan Mohammed Mohiuddin and Dr. Mohammed Misbah Ul Haq for their insightful and thoughtful comments on our study. We greatly appreciate their careful appraisal, which highlights important clinical considerations regarding diagnostic interpretation and treatment selection for secondary postpartum hemorrhage (PPH) associated with subinvolution of the placental site (SIPS).</p><p>We fully share their concern that an increased rate of diagnostic imaging, particularly computed tomography (CT), may contribute to potentially excessive angiographic procedures and hemostatic interventions. While uterine artery embolization (UAE) remains a highly reliable and life-saving therapy for hemodynamically unstable cases, its use in stable patients with SIPS requires more nuanced evaluation. Current evidence, though still limited, suggests that <i>uterotonics and curettage</i> constitute the standard initial management for stable SIPS [<span>1</span>].</p><p>As noted in our paper, the concept of SIPS has not yet been widely recognized in Japan. Consequently, curettage has seldom been selected as a first-line treatment. Furthermore, the ready availability of CT in Japan has facilitated early imaging; once contrast extravasation is visualized, clinicians often proceed to angiography because of its high procedural success rate and low short-term complication risk. Nevertheless, considering the potential for increased hemorrhagic complications in subsequent pregnancies, UAE should not be chosen indiscriminately.</p><p>We agree that broader awareness of SIPS and the establishment of evidence-based management algorithms are essential. In particular, for hemodynamically stable patients, a diagnostic and therapeutic pathway that begins with ultrasonography and proceeds to <i>uterotonics and curettage</i>—rather than immediate embolization—should be further studied and systematically implemented in Japan.</p><p>We again thank the authors for their valuable perspectives, which contribute to advancing a balanced and patient-centered approach to managing secondary PPH due to SIPS.</p><p>Sincerely.</p><p>This study conformed to the provisions of the Declaration of Helsinki (revised in Fortaleza, Brazil in October 2013).</p><p>The author has nothing to report.</p><p>The author declares no conflicts of interest.</p>","PeriodicalId":7196,"journal":{"name":"Acute Medicine & Surgery","volume":"12 1","pages":""},"PeriodicalIF":1.3,"publicationDate":"2025-11-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12623147/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145555993","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Post intensive care syndrome (PICS) is a critical issue in postsepsis care; however, no reliable biomarker exists to predict PICS. We hypothesized that plasma myostatin, a cytokine involved in muscle and brain function, could serve as a predictive biomarker for PICS.
Methods
This single-center prospective observational study included adult patients with sepsis admitted to the intensive care unit (ICU). Plasma myostatin concentrations were measured using enzyme-linked immunosorbent assay on days 1, 3–4, and 6–7 after sepsis diagnosis and ICU admission. PICS was assessed 6 months post-ICU discharge via telephone interviews using the Barthel Index, Short-Memory Questionnaire score, and Hospital Anxiety and Depression Scale. Multivariable logistic regression analysis was conducted to determine whether myostatin levels independently predicted PICS. Predictive performance was evaluated using the area under the curve (AUC).
Results
Seventy-seven patients were enrolled (mean age: 71 ± 14 years; median SOFA score 7 [IQR: 6–11]). Plasma myostatin concentrations were 544 (311–1015) pg/mL on day 1, 495 (302–651) pg/mL on days 3–4, and 536 (385–817) pg/mL on days 6–7. Decreased plasma myostatin levels on day 1 and on days 6–7 contributed to identifying patients with cognitive and physical impairments, respectively (p = 0.04). A decreased plasma myostatin level on day 1 yielded an AUC of 0.70 for predicting cognitive impairment, whereas the day 6–7 level yielded an AUC of 0.76 for predicting physical impairment.
Conclusion
Lower plasma myostatin concentrations in the acute phase of sepsis may serve as a biomarker for predicting PICS-related physical and cognitive impairments.
{"title":"Utility of Plasma Myostatin as a Predictive Biomarker for Post Intensive Care Syndrome in Patients With Sepsis","authors":"Ayaki Shirahata, Nobuto Nakanishi, Yuko Ono, Shigeaki Inoue, Joji Kotani","doi":"10.1002/ams2.70098","DOIUrl":"https://doi.org/10.1002/ams2.70098","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Aim</h3>\u0000 \u0000 <p>Post intensive care syndrome (PICS) is a critical issue in postsepsis care; however, no reliable biomarker exists to predict PICS. We hypothesized that plasma myostatin, a cytokine involved in muscle and brain function, could serve as a predictive biomarker for PICS.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>This single-center prospective observational study included adult patients with sepsis admitted to the intensive care unit (ICU). Plasma myostatin concentrations were measured using enzyme-linked immunosorbent assay on days 1, 3–4, and 6–7 after sepsis diagnosis and ICU admission. PICS was assessed 6 months post-ICU discharge via telephone interviews using the Barthel Index, Short-Memory Questionnaire score, and Hospital Anxiety and Depression Scale. Multivariable logistic regression analysis was conducted to determine whether myostatin levels independently predicted PICS. Predictive performance was evaluated using the area under the curve (AUC).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Seventy-seven patients were enrolled (mean age: 71 ± 14 years; median SOFA score 7 [IQR: 6–11]). Plasma myostatin concentrations were 544 (311–1015) pg/mL on day 1, 495 (302–651) pg/mL on days 3–4, and 536 (385–817) pg/mL on days 6–7. Decreased plasma myostatin levels on day 1 and on days 6–7 contributed to identifying patients with cognitive and physical impairments, respectively (<i>p</i> = 0.04). A decreased plasma myostatin level on day 1 yielded an AUC of 0.70 for predicting cognitive impairment, whereas the day 6–7 level yielded an AUC of 0.76 for predicting physical impairment.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>Lower plasma myostatin concentrations in the acute phase of sepsis may serve as a biomarker for predicting PICS-related physical and cognitive impairments.</p>\u0000 </section>\u0000 </div>","PeriodicalId":7196,"journal":{"name":"Acute Medicine & Surgery","volume":"12 1","pages":""},"PeriodicalIF":1.3,"publicationDate":"2025-11-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/ams2.70098","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145529747","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Kei Kimoto, Akira Endo, Atsushi Shiraishi, Kensuke Fujita, Takuya Kimura, Yoshihiro Hagiwara, Takayuki Ogura, J-OCTET 2 Study Group
Background
The Traumatic Bleeding Severity Score (TBSS), developed in Japan, has shown high predictive accuracy in internal validation; however, external validation has still not been performed. We conducted the first external validation of the TBSS in Japan and compared it with other massive transfusion (MT) prediction scores.
Methods
This multicenter retrospective study included severe trauma patients (aged ≥ 18 years, Injury Severity Score [ISS] ≥ 16) from 25 tertiary critical care centers (April 2018–March 2019), excluding those with isolated head injury or cardiac arrest on arrival. TBSS's accuracy for predicting MT was analyzed using the area under the curve (AUC). A complete case was the primary approach, with sensitivity analysis using multiple imputed datasets. The Trauma-Associated Severe Hemorrhage (TASH) score and Assessment of Blood Consumption (ABC) score were also evaluated for comparison.
Results
Of 1193 patients, 873 were eligible, and 365 patients were included in the complete case analysis. The median age was 63 (interquartile range [IQR]: 45–75) years, the median ISS was 25 (IQR: 20–34), 69.3% were male individuals, 98.1% experienced blunt trauma, and 24.7% received MT. TBSS' AUC was 0.86 (sensitivity: 70.1%; specificity: 88.4%). The TASH score showed a comparable AUC of 0.88 (p = 0.850), whereas the ABC score had a significantly lower AUC of 0.80 (p = 0.024). Sensitivity analysis confirmed these findings.
Conclusion
TBSS' accuracy for predicting MT was comparable to that of the TASH score and superior to that of the ABC score. Further research is needed to determine its clinical utility and broader applicability in trauma care.
{"title":"External Validation of the Traumatic Bleeding Severity Score for the Predictive Accuracy of the Need for Massive Transfusion","authors":"Kei Kimoto, Akira Endo, Atsushi Shiraishi, Kensuke Fujita, Takuya Kimura, Yoshihiro Hagiwara, Takayuki Ogura, J-OCTET 2 Study Group","doi":"10.1002/ams2.70095","DOIUrl":"10.1002/ams2.70095","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>The Traumatic Bleeding Severity Score (TBSS), developed in Japan, has shown high predictive accuracy in internal validation; however, external validation has still not been performed. We conducted the first external validation of the TBSS in Japan and compared it with other massive transfusion (MT) prediction scores.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>This multicenter retrospective study included severe trauma patients (aged ≥ 18 years, Injury Severity Score [ISS] ≥ 16) from 25 tertiary critical care centers (April 2018–March 2019), excluding those with isolated head injury or cardiac arrest on arrival. TBSS's accuracy for predicting MT was analyzed using the area under the curve (AUC). A complete case was the primary approach, with sensitivity analysis using multiple imputed datasets. The Trauma-Associated Severe Hemorrhage (TASH) score and Assessment of Blood Consumption (ABC) score were also evaluated for comparison.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Of 1193 patients, 873 were eligible, and 365 patients were included in the complete case analysis. The median age was 63 (interquartile range [IQR]: 45–75) years, the median ISS was 25 (IQR: 20–34), 69.3% were male individuals, 98.1% experienced blunt trauma, and 24.7% received MT. TBSS' AUC was 0.86 (sensitivity: 70.1%; specificity: 88.4%). The TASH score showed a comparable AUC of 0.88 (<i>p</i> = 0.850), whereas the ABC score had a significantly lower AUC of 0.80 (<i>p</i> = 0.024). Sensitivity analysis confirmed these findings.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>TBSS' accuracy for predicting MT was comparable to that of the TASH score and superior to that of the ABC score. Further research is needed to determine its clinical utility and broader applicability in trauma care.</p>\u0000 </section>\u0000 </div>","PeriodicalId":7196,"journal":{"name":"Acute Medicine & Surgery","volume":"12 1","pages":""},"PeriodicalIF":1.3,"publicationDate":"2025-11-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12580833/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145443704","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The Glasgow Admission Prediction Score (GAPS) is a triage tool that was developed in the United Kingdom to predict hospital admission based on available patient data upon arrival at emergency departments (EDs). Despite being associated with length of hospital stay, 6-month mortality, and readmission, its validity has only been assessed in the UK. Its generalizability therefore remains unclear. This study aimed to assess the predictive performance of the GAPS for short- and intermediate-term outcomes in a Japanese ED setting.
Methods
We conducted a retrospective cohort study of ambulance-transported ED visits between December 2020 and September 2023 at a Japanese general hospital. After excluding pediatric patients and those with missing or inconsistent data, 22,179 encounters were analyzed. GAPS scores were calculated upon ED arrival and stratified into tertiles. The outcomes included 30-day mortality, 30-day emergency re-transportation, 100-day hospital readmission, and length of inpatient stay. Kaplan–Meier and Cox proportional hazards analyses were performed.
Results
Higher GAPS scores were significantly associated with less favorable outcomes. Each 1-point increase was linked to a 10.3% increase in 30-day mortality risk (hazard ratio [HR] = 1.10; 95% confidence interval: 1.10–1.11), or a four-fold increase per 15-point rise (HR = 4.32). Similar associations were observed for re-transportation (HR = 1.03) and hospital readmission (HR = 1.09). Higher GAPS scores were also associated with longer hospital stays (HR for discharge = 0.98).
Conclusion
GAPS presents a practical tool for predicting ambulance-transported ED encounter outcomes in Japan, although its broader applicability warrants further research.
{"title":"Validation of the Glasgow Admission Prediction Score in a Japanese Emergency Setting","authors":"Shigeto Horiuchi, Haruka Kamagata, Koichiro Nakano, Naoki Sawamura, Shunsaku Kohriki","doi":"10.1002/ams2.70097","DOIUrl":"https://doi.org/10.1002/ams2.70097","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Introduction</h3>\u0000 \u0000 <p>The Glasgow Admission Prediction Score (GAPS) is a triage tool that was developed in the United Kingdom to predict hospital admission based on available patient data upon arrival at emergency departments (EDs). Despite being associated with length of hospital stay, 6-month mortality, and readmission, its validity has only been assessed in the UK. Its generalizability therefore remains unclear. This study aimed to assess the predictive performance of the GAPS for short- and intermediate-term outcomes in a Japanese ED setting.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We conducted a retrospective cohort study of ambulance-transported ED visits between December 2020 and September 2023 at a Japanese general hospital. After excluding pediatric patients and those with missing or inconsistent data, 22,179 encounters were analyzed. GAPS scores were calculated upon ED arrival and stratified into tertiles. The outcomes included 30-day mortality, 30-day emergency re-transportation, 100-day hospital readmission, and length of inpatient stay. Kaplan–Meier and Cox proportional hazards analyses were performed.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Higher GAPS scores were significantly associated with less favorable outcomes. Each 1-point increase was linked to a 10.3% increase in 30-day mortality risk (hazard ratio [HR] = 1.10; 95% confidence interval: 1.10–1.11), or a four-fold increase per 15-point rise (HR = 4.32). Similar associations were observed for re-transportation (HR = 1.03) and hospital readmission (HR = 1.09). Higher GAPS scores were also associated with longer hospital stays (HR for discharge = 0.98).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>GAPS presents a practical tool for predicting ambulance-transported ED encounter outcomes in Japan, although its broader applicability warrants further research.</p>\u0000 </section>\u0000 </div>","PeriodicalId":7196,"journal":{"name":"Acute Medicine & Surgery","volume":"12 1","pages":""},"PeriodicalIF":1.3,"publicationDate":"2025-10-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/ams2.70097","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145407329","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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