Severe sepsis and septic shock are the leading causes of death in intensive care units, and hence, in order to reduce mortality rates there is a great need for new discoveries. Genetic factors have been reported to alter clinical outcome of sepsis, and single nucleotide polymorphisms (SNPs) associations have been shown using cohorts of patients who had sepsis in various ethnicities. However, genetic studies for Japanese patients with sepsis are insufficiently powered for the development of personalized medicine. Therefore, we reviewed evidences reported in genetic polymorphisms studies that tested for genetic effect on clinical outcome of sepsis using cohorts with n >100 and reported after the year 2000 to develop personalized medicine for sepsis in Japan. Genetic variations in innate immunity, cytokine, chemokine, coagulation system, hormone, water channel and immunoglobulin have been interrogated. Of these genetic polymorphisms, TLR1, IL-1 receptor-associated kinases (IRAKs), NF-κB inducing kinase (NIK), nucleotide-binding oligomerization domain 2 (NOD2), IL-17A, protein C (PROC), β2-adrenergic receptor (ADRB2) and angiotensin II type 1 receptor-associated protein (AGTRAP) are significantly associated with an altered clinical outcome of sepsis in at least 2 separate cohorts. In addition, there is a large body of single cohort studies in which significant associations between SNPs and altered clinical outcome of sepsis have been reported as a hypothesis generating results, such as Mannose binding lectin and CXCL 2 polymorphisms with need for further validation. The genotypic frequencies of polymorphisms can vary across ethnicities, and the frequencies of functional SNPs that alter clinical outcome are no exception. In order to avoid population stratification effects due to differences in allele frequencies across different ethnicities, further genetic studies using Japanese patients are essential to achieve personalized medicine for these patients in need.

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Background: Many studies have commented on the usefulness of helicopter emergency medical services (HEMS) for the transportation of trauma patients. However, several studies have also noted that the majority of patients transported by HEMS to Level I trauma centers had minor injuries, and warned of inappropriate use of HEMS and the need for appropriate prehospital triage. In Japan, information about the injury severity of trauma patients transported by HEMS is lacking, and the appropriateness of field triage performed by HEMS is not clear. The purpose of this study was to investigate the validity of HEMS transportation in terms of the injury severity of trauma patients who were transported to our Emergency and Critical Care Medical Center (ECCMC) in Fukushima, Japan. Methods: We retrospectively evaluated all trauma patients who were brought to our ECCMC from the scene of an accident between March 1, 2009 and January 31, 2012. We compared Injury Severity Score (ISS), Revised Trauma Score (RTS), and probability of survival (Ps) as indicators of trauma severity, and emergency operation rate, intensive care unit (ICU) admission rate, and mechanical ventilation rate as indicators of specialized trauma care between patients transported by HEMS and those transported by ground ambulance (GA).
Results: We identified 450 trauma patients (324 males and 126 females, aged 51±24 years), of which 110 (24.4%) were transported by HEMS. The HEMS group had significantly more severe trauma than the GA group (ISS: 17.7±11.5 vs. 12.4±9.5, p<0.001; RTS: 6.8±1.8 vs. 7.4±1.1, p<0.01; Ps: 0.82±0.29 vs. 0.92±0.19, p<0.01, respectively), and needed significantly more specialized trauma care (emergency operation rate: 32.7% vs. 20.6%, p<0.01; ICU admission rate: 52.7% vs. 32.6%, p<0.001; mechanical ventilation rate: 41.8% vs. 17.6%, p<0.001, respectively).
Discussion: HEMS field triage by flight medical teams is almost ideal in terms of the injury severity of patients transported to our ECCMC. This triage is one of the great advantages of the service. Dispatchers should activate HEMS without hesitation if severe injury is suspected. Some over-triage by dispatchers is justified because flight medical teams provide important secondary triage, including further evaluation of trauma severity and choosing of the most appropriate hospital for treatment.

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Objective: Patients with acute lung injury (ALI) / acute respiratory distress syndrome (ARDS) accompanied with sepsis were divided into groups with direct and indirect lung injuries. Clinical courses after administration of sivelestat, a selective neutrophil elastase inhibitor, were compared using high-resolution CT (HRCT).
Subjects and Methods: The subjects were 20 patients with ALI/ARDS who received HRCT at seven medical emergency care centers in Kanagawa Prefecture from January 2006 to March 2008, and in whom continuous intravenous administration of sivelestat hydrate at a dose of 0.2 mg/kg/hr for 5 days or more was started upon diagnosis. Changes of lung oxygenation and chest X-ray and HRCT findings were evaluated. HRCT findings for consolidation, ground-glass opacity, thickening of the interlobular septum, and traction bronchiectasis were scored, and the clinical courses of patients with direct lung injury (ALI/ARDS due to severe pneumonia) and indirect lung injury (ALI/ARDS due to other infections) were compared to evaluate the effects of sivelestat.
Result: The rates of improvement of lung oxygenation in the direct (n=10) and indirect (n=10) lung injury groups were 60% and 100%, respectively, with a tendency for greater efficacy of sivelestat for indirect lung injury. There were no differences in chest X-ray scores, but the “acute-phase” HRCT score (total of the consolidation and ground-glass opacity scores) showed greater improvement in the indirect lung injury group, with strong correspondence to the change in lung oxygenation.
Conclusion: Clinical courses in subjects receiving sivelestat were better in those with indirect lung injury compared to cases with direct lung injury. HRCT was found to be useful for determining the pathological stage of ALI/ARDS and the appropriate timing of drug administration.

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We report a case of necrotizing fasciitis caused by group G streptococci. A 76-year-old man had swelling of his left foot and fever. On arrival, he presented with swelling and redness localized to the distal end of his left ankle. The swelling and redness spread immediately, and vacuoles and cutaneous necrosis appeared. The patient's condition was diagnosed as necrotizing fasciitis, for which he was treated with broad-spectrum antibiotics from day 1. On day 2 after admission, the necrotic tissue from his left leg was debrided. Serous pus obtained from the necrotized tissue and the vacuoles showed growth of group G Streptococcus dysgalactiae subsp. equisimilis. Subsequently, we changed the antibiotics to ampicillin. Skin grafts were placed 43 days and 92 days after admission. His condition improved, and he was discharged from the hospital on day 111. In recent years, the incidence of necrotizing fasciitis caused not only by group A streptococci but also by group G streptococci has increased. Thus, we require appropriate antibiotics and debridement to treat such patients.

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