Association between eGFR and neurological outcomes among patients with out-of-hospital cardiac arrest: A nationwide prospective study in Japan.

Aim: We aimed to investigate the association between estimated glomerular filtration rate and prognosis in out-of-hospital cardiac arrest patients and explore the heterogeneity of the association. Methods: Patients experiencing out-of-hospital cardiac arrest due to medical causes and registered in the JAAM-OHCA Registry between June 2014 and December 2019 were stratified into shockable rhythm, pulseless electrical activity, and asystole groups according to the cardiac rhythm at the scene. The primary outcome was a 1-month favorable neurological status. Adjusted odds ratios with 95% confidence intervals were calculated to investigate the association between estimated glomerular filtration rate and outcomes using a logistic model. Results: Of the 19,443 patients included, 2769 had initial shockable rhythm at the scene, 5339 had pulseless electrical activity, and 11,335 had asystole. As the estimated glomerular filtration rate decreased, the adjusted odds ratio for a 1-month favorable neurological status decreased among those with initial shockable rhythm (estimated glomerular filtration rate, adjusted odds ratio [95% CI]: 45-59 mL/min/1.73 m2, 0.61 [0.47-0.79]; 30-44 mL/min/1.73 m2, 0.45 [0.32-0.62]; 15-29 mL/min/1.73 m2, 0.35 [0.20-0.63]; and <15 mL/min/1.73 m2, 0.14 [0.07-0.27]). Estimated glomerular filtration rate was associated with neurological outcomes in patients aged <65 years with initial shockable rhythm but not in those aged >65 years or patients with initial pulseless electrical activity or asystole. Conclusion: The estimated glomerular filtration rate is associated with neurological prognosis in out-of-hospital cardiac arrest patients with initial shockable rhythm at the scene but not in those with initial non-shockable rhythm.

Application of the TiPS65 score for out-of-hospital cardiac arrest patients with initial non-shockable rhythm treated with ECPR.

Background: The TiPS65 score is a validated scoring system used to predict neurological outcomes in out-of-hospital cardiac arrest (OHCA) patients with shockable rhythm treated with extracorporeal cardiopulmonary resuscitation (ECPR). This study aimed to assess the predictive performance of the TiPS65 score in OHCA patients with initial non-shockable rhythm treated with ECPR. Methods: This was a secondary analysis using the JAAM-OHCA registry, a multicenter prospective cohort study. The study included adult OHCA patients with initial non-shockable rhythm who underwent ECPR. The TiPS65 score assigned one point to each of four variables: time to hospital ≤25 minutes, pH value ≥7.0 on initial blood gas assessment, shockable on hospital arrival, and age younger than 65 years. Based on the sum score, the predictive performance for 1-month survival and favorable neurological outcomes, defined as the Cerebral Performance Category 1 or 2, was evaluated. Results: Among 57,754 patients in the registry, 370 were included in the analysis. The overall one-month survival and favorable neurological outcome were 11.1% (41/370) and 4.2% (15/370), respectively. The 1-month survival rates based on the TiPS65 score were as follows: 11.2% (12/107) for 0 points, 9.3% (14/150) for 1 point, 10.0% (9/90) for 2 points, and 26.1% (6/23) for ≥3 points. Similarly, the 1-month favorable neurological outcomes were: 5.6% (6/107) for 0 points, 2.7% (4/150) for 1 point, 4.4% (4/90) for 2 points, and 4.3% (1/23) for ≥3 points. The area under the curve was 0.535 (95% CI: 0.437-0.630) for 1-month survival and 0.530 (95% CI: 0.372-0.683) for 1-month neurological outcome. Conclusion: This study demonstrates that the TiPS65 score has limited prognostic performance among OHCA patients with initial non-shockable rhythm treated with ECPR. Further research is warranted to develop a predictive tool specifically focused on OHCA with initial non-shockable rhythm to aid in determining candidates for ECPR.

Increased CT Use and No Change in Injury Severity among Child Motor Vehicle Victims: A National Trauma Database Study in Japan.

The number of fatalities associated with traffic accidents has been declining owing to improvements in vehicle safety performance and changes in the law. However, injuries in children can lead to social and economic losses. We examined 10-year changes in the characteristics of traffic trauma among pediatric motor vehicle passengers by analyzing data from the Japan Trauma Data Bank (JTDB). Among the 36,715 injured motor vehicle passengers under the age of 15 years who were registered in the JTDB from 2004 to 2019, we compared the groups injured during 2004-2007 (n = 94) and 2017-2019 (n = 203). Physiologically, the 2004-2007 group had a lower body temperature and Glasgow Coma Scale score as well as a higher mortality. Anatomical severity was higher in the 2004-2007 group for the head, face, and neck, according to the Abbreviated Injury Scale. In terms of treatment, only craniotomy as a primary surgery was significantly lower in the 2017-2019 group. The 2017-2019 group had significantly higher rates of receiving whole-body computed tomography (CT). Because the rate of performing CT has increased, with no changes in the injury severities of the trunk and extremities, limiting the number of CT examinations is suggested for pediatric motor vehicle passengers involved in road traffic collisions. The severity of trunk and extremity injuries has not improved in more than 10 years; further preventive measures for these injuries should be considered.

Effectiveness of Administration of Fibrinogen Concentrate as Prevention of Hypofibrinogenemia in Patients with Traumatic Brain Injury with a Higher Risk for Severe Hyperfibrinolysis: Single Center Before-and-After Study.

BACKGROUND: Coagulopathy is often observed in severe traumatic brain injury (sTBI), and hyperfibrinolysis (HF) is associated with a poor prognosis. Although the efficacy of fibrinogen concentrate (FC) in multiple trauma has been reported, its efficacy in sTBI is unclear. Therefore, we delineated severe HF risk factors despite fresh frozen plasma transfusion. Using these risk factors, we defined high-risk patients and determined whether FC administration to this group improved fibrinogen level. METHODS: In the first part of this study, successive adults with sTBI treated at our hospital between April 2016 and March 2019 were reviewed. Patients underwent transfusion as per our conventional protocol and were divided into two groups based on whether fibrinogen levels of ≥ 150 mg/dL were maintained 3-6 h after arrival to delineate the risk factors of severe HF. In the second part of the study, we conducted a before-and-after study in patients with sTBI who were at a higher risk for severe HF (presence of at least one of the risk factors identified in the first part of the study), comparing those treated with FC between April 2019 and March 2021 (FC group) with those treated with conventional transfusion before FC between April 2016 and March 2019. The primary outcome was maintenance of fibrinogen levels, and the secondary outcome was 30-day mortality. RESULTS: In the first part of the study, 78 patients were included. Twenty-three patients did not maintain fibrinogen levels ≥ 150 mg/dL. A D-dimer level on arrival > 50 µg/mL, a fibrinogen level on arrival < 200 mg/dL, depressed skull fracture, and multiple trauma were severe HF risk factors. In the second part, compared with 46 patients who were identified as being at high risk for severe HF but were not administered FC (non-FC group), fibrinogen levels ≥ 150 mg/dL 3-6 h after arrival were maintained in 14 of 15 patients in the FC group (odds ratio: 0.07; 95% confidence interval: 0.01-0.59). Although there were significant differences in fibrinogen levels, no significant differences were observed in terms of 30-day mortality between the groups. CONCLUSIONS: Coagulation abnormalities on arrival, severe skull fracture, and multiple trauma are severe HF risk factors. FC administration may contribute to rapid correction of developing hypofibrinogenemia.

Physiological status and anatomical severity factors associated with child versus adult bicyclist fatalities based on a national trauma dataset.

Bicyclists still account for the majority of child deaths in traffic accidents, despite a gradual decrease in incidence. Therefore, we investigated factors associated with child and adult bicyclist fatalities. In this retrospective study, we used data from a national hospital-based database, the Japan Trauma Data Bank. Data from 2004 to 2019 were obtained for child cyclists (5-18 years; n = 4832) and adult cyclists (26-45 years; n = 3449). In each age group, physiological variables, outcomes, and injury severity were compared between fatal and non-fatal cases. Multivariate logistic regression was performed to determine factors associated with fatality. In adults, fatality was associated with lower values for body temperature, Glasgow Coma Scale score, and Abbreviated Injury Scale (AIS) score for the neck and upper extremities, and with higher values for respiratory rate, heart rate, focused assessment with sonography for trauma positivity rate, and AIS scores for the head, chest, and abdomen. In children, fatality was associated with lower values for body temperature and the Glasgow Coma Scale score, and with higher values for the AIS chest score. These findings point to factors associated with bicyclist fatalities and may help in the development of effective strategies to reduce these fatalities.

Open pneumothorax with extensive thoracic defects sustained in a fall: a case report.

BACKGROUND: Open pneumothorax with chest wall deficit is a rare chest trauma that is serious and can lead to severe respiratory failure; however, it is a potentially lifesaving injury if utilized appropriately. CASE PRESENTATION: Herein, we report a case of an open pneumothorax with extensive chest wall deficit due to falling from a height and highlight the importance of appropriate evaluation and intervention. The patient was a Japanese man in his 50 s who fell from the 6th floor to the 3rd floor while working at a height. The left chest wall was punctured due to injury, the thoracic cavity was open as if a left anterolateral thoracotomy had been performed, and the left lung had prolapsed from the thoracic cavity to the outside. In our emergency department, tracheal intubation with a double lumen tube for differential positive pressure ventilation and a right thoracic drain were inserted, and an emergency operation was started immediately. A pulmonary suture for lung injury and closure of the left thorax were performed during the surgery. The defect was closed with the remaining tissue, but the anterior thoracic skin with poor blood flow was necrotic, so debridement was undertaken. After his general condition was improved, pedicled latissimus dorsi myocutaneous flap was implanted. He was discharged home on the 63rd hospital day. CONCLUSIONS: Although open pneumothorax is rare and sometimes presents lurid findings, we highlighted that it is important to quickly assess the life-threatening organ injury, perform positive pressure ventilation by tracheal intubation, thoracic drainage, and wound closure simultaneously respond calmly as a team.

Adverse events of emergency surgical front of neck airway access: an observational descriptive study.

Aim: Emergency front of neck access (eFONA), such as scalpel cricothyroidotomy, is a rescue technique used to open the airway during "cannot intubate, cannot oxygenate" situations. However, little is known about the adverse events associated with the procedure. This study aimed to describe the adverse events that occur in patients who undergo eFONA and their management. Methods: This retrospective observational cohort study included emergency patients who underwent eFONA between April 2012 and August 2020. We described the patients' characteristics and the adverse events during or immediately after the procedure. Results: Among 75,529 emergency patients during the study period, 31 (0.04%) underwent an eFONA. The median (interquartile range) age was 53 (39-67) years, and 23 patients (74.2%) were men. Of all cases, 13 (41.9%) experienced adverse events. Of these, three cases (23.2%) were cephalad misplacement of the intubation tube, one case (7.7%) was cuff injury, one case (7.7%) was tube obstruction due to vomiting, and one case (7.7%) was tube kink. In cases with these adverse events, the initial attempt of eFONA failed, and alternative immediate action was necessary to secure the airway. Conclusion: This single-center retrospective observational study described several adverse events of eFONA. In particular, it is important to understand the possible life-threatening adverse events that lead to failure of securing airways such as cephalad displacement, tube obstruction, and tube kink and respond promptly to ensure a secure definitive airway for patients' safety.

Evaluation of a revised resuscitation protocol for out-of-hospital cardiac arrest patients due to COVID-19 safety protocols: a single-center retrospective study in Japan.

This study aimed to determine the association between cardiopulmonary resuscitation (CPR) under the coronavirus 2019 (COVID-19) safety protocols in our hospital and the prognosis of out-of-hospital cardiac arrest (OHCA) patients, in an urban area, where the prevalence of COVID-19 infection is relatively low. This was a single-center, retrospective, observational, cohort study conducted at a tertiary critical care center in Kyoto City, Japan. Adult OHCA patients arriving at our hospital under CPR between January 1, 2019, and December 31, 2020 were included. Our hospital implemented a revised resuscitation protocol for OHCA patients on April 1, 2020 to prevent COVID-19 transmission. This study defined the conventional CPR period as January 1, 2019 to March 31, 2020, and the COVID-19 safety protocol period as April 1, 2020 to December 31, 2020. Throughout the prehospital and in-hospital settings, resuscitation protocols about wearing personal protective equipment and airway management were revised in order to minimize the risk of infection; otherwise, the other resuscitation management had not been changed. The primary outcome was hospitalization survival. The secondary outcomes were return of spontaneous circulation after hospital arrival and 1-month survival after OHCA occurrence. The adjusted odds ratios with 95% confidence intervals (CI) were calculated for outcomes to compare the two study periods, and the multivariable logistic model was used to adjust for potential confounders. The study analyzed 443 patients, with a median age of 76 years (65-85), and included 261 men (58.9%). The percentage of hospitalization survivors during the entire research period was 16.9% (75/443 patients), with 18.7% (50/267) during the conventional CPR period and 14.2% (25/176) during the COVID-19 safety protocol period. The adjusted odds ratio for hospitalization survival during the COVID-19 safety protocol period was 0.61 (95% CI 0.32-1.18), as compared with conventional CPR. There were no cases of COVID-19 infection among the staff involved in the resuscitation in our hospital. There was no apparent difference in hospitalization survival between the OHCA patients resuscitated under the conventional CPR protocol compared with the current revised protocol for controlling COVID-19 transmission.

Predictive value of sarcopenic findings in the psoas muscle on CT imaging among patients with sepsis.

PURPOSE: This study aimed to determine the association between sarcopenic findings of the psoas muscle and mortality in patients with sepsis; further, it aimed to assess its clinical utility, in addition to the sequential organ failure assessment (SOFA) score, in predicting mortality. METHOD: This retrospective single-center cohort study included adult patients with sepsis, who were admitted to the intensive care unit, between January 2012 and December 2018. The cross-sectional area of the psoas muscle at the L3 level was measured using computed tomography (CT) images, following which the subjects were categorized as "Above middle," "Middle," and "Sarcopenic." The association between sarcopenic findings and 90-day mortality was investigated by logistic regression analysis. A "modified SOFA score," by adding sarcopenic findings to the SOFA score, was developed and evaluated for its predictive performance. RESULTS: Here, 255 patients with sepsis, who were admitted to the intensive care unit (median age, 76 [64-84] years; SOFA score, 9 [5-14]), were included. The adjusted odds ratio for the "Middle" and "Sarcopenic" groups for 90-day mortality was 2.40 (95% confidence interval [CI]: 0.93-6.15) and 3.67 (95% CI: 1.39-9.68), respectively. The c-statistics of the SOFA and modified SOFA score was 0.731 [95% CI: 0.650-0.799] and 0.749 [95% CI: 0.673-0.813]. On decision curve analysis, a little additional net benefit was observed on using the modified SOFA score. CONCLUSION: The results suggested an association of the sarcopenic findings of the psoas muscle on CT imaging with 90-day mortality; however, the modified SOFA had few additional clinical values to that of SOFA in predicting 90-day mortality.

Association of skull fracture with in-hospital mortality in severe traumatic brain injury patients.

INTRODUCTION: To identify the association between skull fracture (SF) and in-hospital mortality in patients with severe traumatic brain injury (TBI). MATERIALS AND METHODS: This multicenter cohort study included a retrospective analysis of data from the Japan Trauma Data Bank (JTDB). JTDB is a nationwide, prospective, observational trauma registry with data from 235 hospitals. Adult patients with severe TBI (Glasgow Coma Scale <9, head Abbreviated Injury Scale (AIS) ≥ 3, and any other AIS < 3) who were registered in the JTDB between January 2004 and December 2017 were included in the study. Patients who (a) were < 16 years old, (b) developed cardiac arrest before or at hospital arrival, and (c) had burns and penetrating injuries were excluded from the study. In-hospital mortality was the primary outcome assessed. Multivariable logistic regression analyses were performed to calculate the adjusted odds ratios (ORs) of SF and their 95% confidence intervals (CIs) for in-hospital mortality. RESULTS: A total of 9607 patients were enrolled [median age: 67 (interquartile range: 50-78) years] in the study. Among those patients, 3574 (37.2%) and 6033 (62.8%) were included in the SF and non-SF groups, respectively. The overall in-hospital mortality rate was 44.1% (4238/9607). A multivariate analysis of the association between SF and in-hospital mortality yielded a crude OR of 1.63 (95% CI: 1.47-1.80). A subgroup analysis of the association of skull vault fractures, skull base fractures, and both fractures together with in-hospital mortality yielded adjusted ORs of 1.60 (95% CI: 1.42-1.98), 1.40 (95% CI: 1.16-1.70), and 2.14 (95% CI: 1.74-2.64), respectively, relative to the non-SF group. CONCLUSIONS: This observational study showed that SF is associated with in-hospital mortality among patients with severe TBI. Furthermore, patients with both skull base and skull vault fractures were associated with higher in-hospital mortality than those with only one of these injuries.

Association between cardiac rhythm conversion and neurological outcome among cardiac arrest patients with initial shockable rhythm: a nationwide prospective study in Japan.

AIMS: Initial cardiac rhythm, particularly shockable rhythm, is a key factor in resuscitation for out-of-hospital cardiac arrest (OHCA) patients. The purpose of this study was to clarify the association between cardiac rhythm conversion and neurologic prognosis in OHCA patients with initial shockable rhythm at the scene. METHODS AND RESULTS: The study included adult patients with OHCA due to medical causes with pre-hospital initial shockable rhythm and who were still in cardiac arrest at hospital arrival. Multiple logistic regression analysis was conducted to identify the adjusted odds ratios (AORs) and 95% confidence interval (CI) of cardiac arrest rhythm at hospital arrival for 1-month favourable neurologic status and 1-month survival, adjusted for potential confounders. Of 34 754 patients in the 2014-2017 JAAM-OHCA Registry, 1880 were included in the final study analysis. The percentages of 1-month favourable neurologic status for shockable rhythm, pulseless electrical activity (PEA), and asystole at hospital arrival were 17.4% (137/789), 3.6% (18/507), and 1.5% (9/584), respectively. The AORs for 1-month favourable neurologic status comparing to OHCA patients who maintained shockable rhythm at hospital arrival were PEA, 0.19 (95% CI, 0.11-0.32) and asystole, 0.08 (95% CI, 0.04-0.16), respectively. CONCLUSION: Findings showed that the 1-month neurologic outcome in OHCA patients who converted to non-shockable rhythm at hospital arrival was very poor compared with patients who had sustained shockable rhythm. Also, patients with conversion to PEA had better neurologic prognosis than conversion to asystole.

Factors influencing vehicle passenger fatality have changed over 10 years: a nationwide hospital-based study.

Traffic injury trends have changed with safety developments. To establish effective preventive measures against traffic fatalities, the factors influencing fatalities must be understood. The present study evaluated data from a national medical database to determine the changes in these factors over time, as this has not been previously investigated. This observational study retrospectively analysed data from the Japanese Trauma Data Bank. Vehicle passengers involved in collisions from 2004-2008 and 2016-2017 were included. Data were compared between the two study periods, and between fatal and non-fatal patients within each period. Multivariate logistic regression analyses were performed to determine the factors influencing fatalities. In 2016-2017, patients were older and had lower fatality rates. In 2004-2008, fatalities were more likely to involve older male front-seat passengers with low d-BP, BT, and GCS values, and high AIS of the neck and abdomen. However, in 2016-2017, fatalities were more likely to involve older males with low GCS, high AIS of the abdomen, and positive focused assessment with sonography for trauma results. Our study identified independent factors influencing vehicle passenger fatalities, which will likely continue to evolve with the aging of the population and changing manners of injury.

Association between visitation restriction during the COVID-19 pandemic and delirium incidence among emergency admission patients: a single-center retrospective observational cohort study in Japan.

Aim: This study aimed to identify the association between total visitation restriction because of the coronavirus 2019 (COVID-19) pandemic and the incidence of delirium for emergency inpatients. Methods: This was a single-center, retrospective, observational cohort study conducted at a tertiary critical care center in urban Kyoto, Japan. Adult emergency patients hospitalized between January 1, 2019, and June 30, 2020, were recruited. In response to the COVID-19 pandemic, the authors' hospital began restricted visitation on March 28, 2020. This study defined before visitation restriction as January 1, 2019, through March 31, 2020, and after visitation restriction as April 1, 2020, through June 30, 2020. We did not restrict emergency services, and there were no changes in the hospital's routine, except for visitation restrictions. The primary outcome was the incidence of delirium. The adjusted odds ratio (AOR) with 95% confidence interval (CI) for delirium incidence was calculated to compare the before and after visitation restriction periods, and the logistic model was used to adjust for seven variables: age, sex, ward type on admission, primary diagnosis, ventilator management, general anesthesia surgery, and dementia. Results: Study participants were 6264 patients, median age 74 years (56-83), and 3303 men (52.7%). The total delirium incidence in entire research period was 2.5% (158 of 6264 patients), comprising 1.8% (95/5251) before visitation restriction and 6.2% (63/1013) after visitation restriction. The AOR for delirium incidence was 3.79 (95% CI, 2.70-5.31) after visitation restriction versus before visitation restriction. Subgroup analysis showed no apparent interaction for delirium incidence. Conclusion: Visitation restriction was associated with an increased incidence of delirium in emergency inpatients.

The importance of simulation education for the management of traumatic cardiac injuries: a case series.

BACKGROUND: The management of cardiac trauma requires rapid intervention in the emergency room, facilitated by a surgeon with prior experience to have good outcomes. Many surgeons have little experience in the requisite procedures. We report here 4 patients who suffered cardiac trauma, and all 4 patients survived with good neurologic outcomes. CASE PRESENTATIONS: Patient 1 suffered blunt cardiac trauma from a motor vehicle accident and presented in shock. Cardiac tamponade was diagnosed and a cardiac rupture repaired with staples through a median sternotomy after rapid transport to the operating room. Patient 2 suffered blunt cardiac trauma and presented in shock with cardiac tamponade. Operating room median sternotomy allowed extraction of pericardial clot with recovery of physiologic stability. Patient 3 presented with self-inflicted stab wounds to the chest and was unstable. She was brought to the operating room and thoracotomy allowed identification of a left ventricle wound which was repaired with a suture. Patient 4 presented in cardiac arrest with multiple self-inflicted stab wounds to the chest. Emergency room thoracotomy allowed repair of a right ventricle laceration with recovery of vital signs. CONCLUSIONS: The management of all 4 patients was according to the principles taught in the ATOM course. Three of the 4 surgeons had no prior experience with management of cardiac trauma and credited the good outcomes to taking the ATOM course. These are uncommon injuries and formal training in their management is beneficial to patients.

Successful combination strategy of preoperative placement of an endoscopic nasopancreatic drainage catheter and pancreas preservation surgery for pancreatic injury with major pancreatic duct disruption: a case report.

BACKGROUND: The guidelines recommend pancreatic resection for grade III and IV pancreatic injuries. On the other hand, organ preservation is an important issue. Herein, we present the first case of pancreatic injury with major pancreatic duct (MPD) disruption that was treated with the combination of preoperative placement of endoscopic nasopancreatic drainage (ENPD) catheter and pancreas preservation surgery after endoscopic pancreatic stenting (EPS) failure. CASE PRESENTATION: A 70-year-old female diagnosed with pancreatic injury was admitted to our hospital. She was hemodynamically stable. ERP revealed MPD disruption, and EPS failed. An ENPD catheter was placed preoperatively at the site of injury. During laparotomy, we identified a partial-thickness laceration in the pancreatic body. At the site of injury, the tip of the ENPD catheter was found; therefore, the patient was diagnosed with grade III pancreatic body injury with MPD disruption. The extent of crush was not severe, and we had no difficulty in identifying the distal MPD segment. We inserted the ENPD catheter into the distal MPD segment. The ruptured MPD and the laceration was sutured, then pancreatic resection was prevented. She was discharged on POD 56. CONCLUSION: The treatment strategy incorporated ERP, placement of an ENPD catheter preoperatively, and a simple surgery in a hemodynamically stable patient with pancreatic injury allows the pancreas and spleen to be preserved.

Initial central venous pressure could be a prognostic marker for hemodynamic improvement of polymyxin B direct hemoperfusion: a retrospective cohort study.

BACKGROUND: Direct hemoperfusion with polymyxin B-immobilized fiber column (PMX-DHP) could improve the hemodynamic status of septic shock patients. As PMX-DHP is an invasive and costly procedure, it is desirable to estimate the therapeutic effect before performing the therapy. However, it is still unclear when this therapy should be started and what type of sepsis it should be employed for. In this study, we retrospectively examined the clinical effect of patients treated with PMX-DHP by using central venous pressure (CVP). METHODS: Seventy patients who received PMX-DHP for septic shock during the study period were recruited and divided into a low CVP group (n = 33, CVP < 12 mmHg) and a high CVP group (n = 37, CVP≧12 mmHg). The primary endpoint was vasopressor dependency index at 24 hours after starting PMX-DHP, and the secondary endpoint was the 28-day survival rate. Additionally, we performed a multivariate linear regression analysis on the difference in the vasopressor dependency index. RESULTS: The vasopressor dependency index significantly improved at 24 h in the low CVP group (0.33 to 0.16 mmHg-1; p < 0.01) but not in the high CVP group (0.43 to 0.34 mmHg-1; p = 0.41), and there was a significant difference between the two groups in the index at 24 h (p = 0.02). The 28-day survival rate was higher in the low CVP group (79 vs. 43 %; p < 0.01). Multivariate linear regression analysis showed that CVP (p = 0.04) was independently associated with the difference in the vasopressor dependency index. CONCLUSIONS: Our study indicates that the clinical effect of PMX-DHP for septic shock patients with higher CVP (≧12 mmHg) might be limited and that the initial CVP when performing PMX-DHP could function as an independent prognostic marker for the hemodynamic improvement.

[A case of advanced gastric cancer found to be remaining by gastrectomy after a clinically complete response to chemotherapy].

The patient was a 72-year-old woman diagnosed with advanced gastric cancer, hepatic portal lymph node and para-aortic lymph node metastases. After five courses of S-1/CDDP combination therapy, both the primary tumor and lymph node metastases disappeared clinically. She wished to continue chemotherapy instead of having a resection. After three more courses of S-1/CDDP therapy, gastric cancer and lymph node metastases were still completely regressed, but complications of carcinoma of the gallbladder were suspected. Gastrectomy was performed with cholecystectomy, and a histopathological examination revealed cancer cells remaining in the gastric submucosa and xanthogranulomatous cholecystitis. We consider surgical therapy for clinically completely disappearing advanced gastric cancer by chemotherapy, in addition to case report.