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Objective Head injuries are an important problem in pediatric emergency care. The majority of head injuries are mild. Even when abnormalities are noted on computed tomography (CT), most patients have good outcomes. We aimed to evaluate the clinical course of pediatric patients who had head injuries and Glasgow Coma Scale (GCS) scores of 15, in whom abnormal findings were noted on head CT, to determine the impact of radiographic features on the need for hospitalization and clinical progression. Methods We retrospectively examined patients under 15 years of age with isolated mild head injuries, GCS scores of 15, and abnormal CT findings, and visited the emergency department between September 2011 and March 2019. Results Ninety-nine patients were included in the study. The median age was 2 years (0–15 years), and 61 (62%) patients were male. Eighty-six (87%) patients were hospitalized, and the median hospital stay was 1 day (1–10 days). Sixty-eight (69%) patients underwent repeat CT, and 12 (18%) patients showed signs of radiographic progression. These 12 patients had subdural or epidural hematomas, and surgical intervention was required for two patients (2%). In patients with isolated skull fracture or subarachnoid hemorrhage alone, no deterioration was noted radiographically or clinically. Conclusion Pediatric head injuries with GCS scores of 15 may rarely require surgical intervention, even when CT shows abnormalities. In particular, patients diagnosed with isolated skull fracture or subarachnoid hemorrhage on CT may not require routine hospitalization. A validation study is needed to confirm the findings of this study.

Purpose Coronavirus disease 2019 (COVID-19) has placed a great burden on critical care services worldwide. Data regarding critically ill COVID-19 patients and their demand of critical care services outside of initial COVID-19 epicenters are lacking. This study described clinical characteristics and outcomes of critically ill COVID-19 patients and the capacity of a COVID-19-dedicated intensive care unit (ICU) in Kobe, Japan. Methods This retrospective observational study included critically ill COVID-19 patients admitted to a 14-bed COVID-19-dedicated ICU in Kobe between March 3, 2020 and June 21, 2020. Clinical and daily ICU occupancy data were obtained from electrical medical records. The last follow-up day was June 28, 2020. Results Of 32 patients included, the median hospital follow-up period was 27 (interquartile range 19–50) days. The median age was 68 (57–76) years; 23 (72%) were men and 25 (78%) had at least one comorbidity. Nineteen (59%) patients received invasive mechanical ventilation for a median duration of 14 (8–27) days. Until all patients were discharged from the ICU on June 5, 2020, the median daily ICU occupancy was 50% (36–71%). As of June 28, 2020, six (19%) died during hospitalization. Of 26 (81%) survivors, 23 (72%) were discharged from the hospital and three (9%) remained in the hospital. Conclusion During the first months of the outbreak in Kobe, most critically ill patients were men aged ≥ 60 years with at least one comorbidity and on mechanical ventilation; the ICU capacity was not strained, and the case-fatality rate was 19%. Supplementary Information The online version contains supplementary material available at 10.1007/s00540-021-02897-w.

It may need to pay attention to the sustention of moderate cardiotoxicity and delayed elevation of plasma 10‐hydroxynortriptyline level in severe amitriptyline overdose case.

Introduction Tube thoracostomy is an important treatment for traumatic hemothorax and pneumothorax. The optimal tube diameter remains unclear. To reduce invasiveness, we use small-bore chest tubes (≤20 Fr) for all trauma patients for whom tube thoracostomy is indicated in our emergency department (ED). The aim of this study was to investigate the effectiveness and safety of small-bore tube thoracostomy for traumatic hemothorax or pneumothorax. Method We conducted a retrospective observational study at a single emergency medical center. This study included adult patients (≥18 years old) who had undergone tube thoracostomy for chest trauma in the ED during the 5 years from October 2013 to September 2018. We used 20 Fr chest tubes or 8 Fr pigtail catheters. The examined outcome was tube-related complications, such as tube obstruction, retained hemothorax, and unresolved pneumothorax. Results A total of 107 tube thoracostomies were performed in 102 patients. The mean Injury Severity Score of these patients was 17.8 (±9.6), and the mean duration of the tube placement period was 3.9 days (±1.8). Eight patients developed tube-related complications (7.8%) (retained hemothorax: 4 patients (3.9%), unresolved pneumothorax: 4 patients (3.9%)). None of these cases were caused by tube obstruction. Although the drainage itself was effective, they underwent definitive invasive interventions to stop bleeding or air leak. Conclusion Our study showed that the use of small-bore (≤20 Fr) chest tubes to treat traumatic hemothorax/pneumothorax achieved the purposes of tube thoracostomy. It might be possible to safely manage chest trauma with small-bore chest tubes.

What is known and objective Amlodipine overdose is common; however, the dose and timing of intravenous lipid emulsion (ILE) therapy as a management strategy remain debatable. Case description A 73-year-old man received a single bolus (1.5 mL/kg) of ILE therapy following massive ingestion of multiple drugs, including amlodipine. After approximately 20 hours of ILE therapy, the serum amlodipine level that had decreased from 90.2 to 49.9 ng/mL increased to 70.8 ng/mL. What is new and conclusion A single bolus (1.5 mL/kg) of ILE therapy is probably insufficient to completely capture and partition serum amlodipine following amlodipine overdose.

Aim Extracorporeal cardiopulmonary resuscitation (ECPR) is the emerging resuscitative strategy to save refractory ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) patients. We investigated whether the receiving hospitals’ ECPR capabilities are associated with outcomes in out-of-hospital cardiac arrest (OHCA) patients who have refractory VF or pulseless VT. Methods In a population-based cohort study performed in Kobe City, Japan, between 2010 and 2017, we identified all OHCA patients who had refractory VF or pulseless VT. Based on their ECPR capabilities, hospitals were categorised into ECPR facilities and conventional cardiopulmonary resuscitation (CCPR) facilities. We compared patient survivals between ECPR facilities and CCPR facilities by applying inverse probability weighting using a propensity score. Results Of all 10,971 OHCA patients, 518 had refractory VF or pulseless VT. The proportion of favourable neurologic outcomes was 43/188 (22.9%) in ECPR facilities and 28/330 (8.5%) in CCPR facilities. In the propensity analysis, hospitals’ ECPR capabilities were associated with favourable neurologic outcomes (adjusted risk difference [ARD], 9.7% [95% confidence interval [CI], 3.7%–15.7%]; adjusted risk ratio [ARR], 2.01 [95% CI, 1.31–3.09]), and overall survival (87/188 [46.3%] vs. 67/330 [20.3%]; ARD, 19.0% [95% CI, 11.1%–26.9%]; ARR, 1.88 [95% CI, 1.45–2.44]). Conclusions Hospitals’ ECPR capabilities were associated with favourable neurologic outcomes in OHCA patients who had refractory VF or pulseless VT. We should take each hospital’s ECPR capability into consideration when developing a regional system of care for OHCA.

Few studies have assessed the duration of the postictal state after a generalized convulsion (GC) in adults. This study aimed to investigate the postictal duration after a GC and the factors associated with it.Patients aged ≥16 years who presented to the emergency department of a community general hospital with an unprovoked GC from January 2015 through December 2016 were evaluated retrospectively. A GC was defined as a bilateral convulsion with apparent impaired consciousness including a generalized tonic-clonic seizure.We evaluated 209 consecutive GCs (median age, 42 years) with the median postictal duration of 0.75 h. The univariate analyses indicated that the median duration of the postictal state was significantly longer: in elderly patients (aged ≥65 years) than in younger patients (aged65 years) (2 h vs. 0.7 h, p = 0.0005); in patients with higher modified Rankin scale (mRS) scores (≥3) at baseline than in those with lower scores (≤2) (2.5 h vs. 0.7 h, p 0.0001); in patients with longer seizure duration (≥30 min) than in those with shorter duration (55 h vs. 0.7 h, p 0.0001); in patients who were given emergency antiepileptic drugs than in those who were not (16 h vs. 0.6 h, p 0.0001); and in patients who were intubated than in those who were not (63.5 h vs. 0.75 h, p = 0.0009). Multiple linear regression analyses indicated that older age, higher mRS scores at baseline, longer seizure duration, and administration of emergency antiepileptic drugs were independently associated with longer postictal duration.Age, baseline functional disability, and seizure duration were factors associated with the duration of the postictal state after a GC.

We retrospectively examined the differences between paramedic triage and final diagnosis in the cases that were transported to our hospital between May 2016 and March 2019. About 30% of the patients with suspected stroke were diagnosed other than stroke. Some of the patients without suspected stroke were diagnosed with large vessel occlusion and were treated with mechanical thrombectomy. The time from arrival at the hospital to treatment was significantly longer in the patients without suspected stroke than with suspected stroke. To achieve a better prehospital care, we need to accept a wide range of stroke mimics, and to continuously feedback the paramedics about the importance of paralysis, cortical symptoms in stroke.

Aim To evaluate whether vital signs can predict whether hypoglycemia can be eliminated as the cause of impaired consciousness in prehospital settings. Methods We extracted the data of patients who underwent blood glucose measurements by paramedics in Kobe City, Japan from April 2015 to March 2019. We used receiver operating characteristic curves and calculated the area under the curve (AUC) to evaluate the validity of the vital signs in distinguishing hypoglycemia. We also calculated stratum‐specific likelihood ratios to examine the threshold at which hypoglycemia becomes less likely for each vital sign. Results Of the 1,791 patients, 1,242 were eligible for analysis. Hypoglycemia was observed in 324 patients (26.1%). Significant differences in each vital sign were noted between the hypoglycemic and non‐hypoglycemic groups. Body temperature was moderately accurate in differentiating between the two groups (AUC, 0.71; 95% confidence interval, 0.68–0.74). Furthermore, in patients with systolic blood pressure, Body temperature was moderately accurate in differentiating hypoglycemia and non‐hypoglycemia in the prehospital setting. If there is a high temperature or hypotension, it is less likely that hypoglycemia is the cause of impaired consciousness.

Aim Extracorporeal cardiopulmonary resuscitation (ECPR) is an evolving resuscitative method for refractory cardiopulmonary arrests. However, considering the substantial healthcare costs and resources involved, there is an urgent need for a full economic evaluation. We therefore assessed the cost-effectiveness of ECPR for refractory ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT). Methods We developed a decision model to estimate lifetime costs and outcomes for out-of-hospital cardiac arrest patients with VF/pVT who received either ECPR or conventional cardiopulmonary resuscitation. Quality-adjusted life-years (QALY) was used as the main outcome measure. This model was a combination of a decision tree model for the acute phase based on a prospective observational study (SAVE-J study), together with a Markov model for long-term follow-up periods extrapolated from published data. To evaluate the robustness of this model, we conducted a comprehensive deterministic sensitivity analysis (DSA) and a probabilistic sensitivity analysis (PSA). Results ECPR was cost-effective, with an incremental cost of ¥3,521,189 (Є30,227), an incremental effectiveness of 1.34 QALY, and an incremental cost-effectiveness ratio of ¥2,619,692 (Є22,489) per QALY gained. DSA revealed that the present model was most sensitive to probability of Cerebral Performance Category 1 after ECPR (¥2,153,977/QALY to ¥3,186,475/QALY), patient age (¥2,170,112/QALY to ¥3,334,252/QALY), and long-term medical cost for modified Rankin Scale 0 (¥2,280,352/QALY to ¥2,855,330/QALY). PSA indicated ECPR to be cost-effective and below the willingness-to-pay threshold of ¥5,000,000 with an 86.7 % possibility. Conclusions ECPR was an economically acceptable resuscitative strategy, and the results of the present study were robust even when considering the uncertainty of all parameters.

Kounis syndrome is a form of acute coronary syndrome caused by allergic reactions. No cases of cardiac arrest caused by Kounis syndrome that arose after the administration of sugammadex have been reported. A 71-year-old female suffered two cardiac arrests. The first occurred after sugammadex was administered at the end of an operation for a right radial distal fracture. The patient was resuscitated and transferred to our intensive care unit. She was subsequently discharged home. Five months later, she suffered a second cardiac arrest after sugammadex was administered at the end of an operation for a right femoral neck fracture at our hospital. Urgent coronary angiography revealed multiple coronary spasms. Kounis syndrome was diagnosed based on the patient’s elevated serum trypsin levels and a positive result in a skin allergy test of sugammadex. In cases of cardiac arrest with unclear etiologies, Kounis syndrome should be considered.

Previous studies on status epilepticus (SE) in the elderly were conducted in tertiary centers. We aimed to delineate the features and outcomes of elderly SE patients by comparing them to those of younger patients in a comprehensive community hospital providing primary to tertiary care.We retrospectively investigated 197 consecutive adult SE patients admitted to our hospital. The clinical, electroencephalography, and diffusion-weighted imaging (DWI) findings of 112 elderly patients (aged ≥65 years) were compared to those of 85 younger patients (aged65 years).Compared to that in younger patients, SE in elderly patients more frequently presented de novo (68.8% vs. 52.9%, p = 0.02); was less likely to be tonic-clonic (55.4% vs. 83.5%, p 0.001) but more likely to be focal motor (36.6% vs. 12.9%, p 0.001); and was more frequently refractory (30.4% vs. 14.1%, p = 0.008), particularly refractory nonconvulsive SE (13.4% vs. 4.7%, p = 0.04). Lateralized periodic discharges on electroencephalography (20.9% vs. 4.8%, p = 0.001) and SE-associated hyperintensities on DWI (27.8% vs. 13.6%, p = 0.03) were more common in the elderly than in the younger SE patients. The mortality rates did not significantly differ between the groups (6.3% vs. 3.5%, p = 0.52). The percentage of poor functional outcomes did not significantly differ between the groups in cases with acute symptomatic etiology (52.0% vs. 45.7%, p = 0.63), but was higher in elderly patients with remote symptomatic and cryptogenic etiologies (33.3% vs. 12.0%, p = 0.006).SE in the elderly differed from that in younger adults in the semiology, refractoriness, electroencephalography and DWI findings, and functional outcome. Outcomes were better than previously reported.

Background Spontaneous pneumomediastinum is defined as the presence of free air in the mediastinum without any apparent concomitant factors or disease. It is uncommon but usually benign and self-limiting. Generally, patients with spontaneous pneumomediastinum are admitted to hospital, and occasionally, prophylactic antibiotics are administered to prevent mediastinitis. The purpose of this study was to describe practices concerning the feasibility of outpatient treatment and follow-up of spontaneous pneumomediastinum and the necessity of prophylactic antibiotics. Methods We conducted this study in a single emergency medical center located in Kobe, Japan. We retrospectively evaluated patients with spontaneous pneumomediastinum from January 2007 to December 2014. Spontaneous pneumomediastinum was defined as cases in which pneumomediastinum did not occur in the setting of positive pressure ventilation or severe trauma. All case records were carefully reviewed considering the demographic data, symptoms, precipitating events, diagnostic workup performed, use of prophylactic antibiotics, length of hospital stay, and complications. Results Thirty-four patients who satisfied the inclusion criteria were identified. Twenty-three patients (67.6%) were followed up on an outpatient basis, and 11 patients (32.4%) were admitted to the hospital, with a mean length of stay of 3.4 days. Prophylactic antibiotics were orally administered to 2 patients. None of the patients developed complications, such as tension pneumomediastinum, delayed pneumothorax, airway compromise, and mediastinitis. Conclusion Spontaneous pneumomediastinum is a benign condition presenting primarily in young adults, with an uneventful recovery. Therefore, patients may recover from this condition without admission or the need for prophylactic antibiotics.

要旨 Noninvasive positive pressure ventilation（NPPV）が気管挿管を望まないdo–not–intubate（DNI）患者に対して使用される頻度は増加しているが，臨床的改善が乏しい場合にNPPVを継続することの妥当性に関するデータは乏しい。今回，DNI患者にNPPVを使用し，呼吸状態が改善しない場合の転帰について検討した。2011年4月から2013年8月に，急性呼吸不全に対してNPPVが6時間以上使用されたDNI患者19例について後方視的に検討した。改善の定義を，NPPV開始後6時間の時点でFIO2

Background Metformin has been widely used as a first-line agent to treat type 2 diabetes mellitus. Lactic acidosis is a rare but serious adverse effect in patients treated with metformin. Recent studies noted a correlation between metformin accumulation and lactic acidosis. Continuous renal replacement therapy for the treatment of metformin-associated lactic acidosis has been documented in some case reports; however, there is currently no specific treatment for metformin-associated lactic acidosis. Case presentation A 70-year-old Japanese woman with type 2 diabetes mellitus presented to an emergency room with metformin-associated lactic acidosis. She was found to be hypotensive and laboratory examinations revealed severe lactic acidosis: pH 6.618, partial pressure of carbon dioxide in arterial blood 17.3 mmHg, bicarbonate 1.7 mmol/L, and lactate 18 mmol/L. Severe acidemia persisted despite supportive care including intravenously administered fluids, sodium bicarbonate, antibiotics, and vasopressors. Continuous renal replacement therapy was initiated in our intensive care unit. After dialysis for 3 days, her lactate level and pH value completely normalized. The concentration of metformin detected was 77.5 mg/L, which is one of the highest in metformin-associated lactic acidosis successfully treated without overdose. Conclusions The present case had one of the highest metformin concentrations in metformin-associated lactic acidosis successfully treated with continuous renal replacement therapy, and serum metformin concentrations may be useful for the diagnosis of metformin-associated lactic acidosis. Metformin-associated lactic acidosis is a rare but important etiology of lactic acidosis. Continuous renal replacement therapy is advantageous for the treatment of hemodynamically unstable patients with metformin-associated lactic acidosis.

Ingestion of large amounts of zinc chloride causes corrosive gastroenteritis with vomiting, abdominal pain, and diarrhea. Some individuals experience shock after ingesting large amounts of zinc chloride, resulting in fatality. Here, we present the results of an administrative autopsy performed on a 70-year-old man who ingested zinc chloride solution and died. After drinking the solution, he developed vomiting, abdominal pain, and diarrhea, and called for an ambulance. Except for tachycardia, his vital signs were stable at presentation. However, he developed hypotension and severe metabolic acidosis and died. The patient's blood zinc concentration on arrival was high at 3030μg/dL. Liver cirrhosis with cloudy yellow ascites was observed, however, there were no clear findings of gastrointestinal perforation. The gastric mucosa was gray-brown, with sclerosis present in all gastric wall layers. Zinc staining was strongly positive in all layers. There was almost no postmortem degeneration of the gastric mucosal epithelium, and hypercontracture of the smooth muscle layer was observed. Measurement of the zinc concentration in the organs revealed the highest concentration in the gastric mucosa, followed by the pancreas and spleen. Clinically, corrosive gastroenteritis was the cause of death. However, although autopsy revealed solidification in the esophagus and gastric mucosa, there were no findings in the small or large intestine. Therefore, metabolic acidosis resulting from organ damage was the direct cause of death.

Background: The optimal rate of feeding advancement after initiation of early enteral nutrition (EEN) for underweight, critically ill patients is unknown. Methods: We conducted a retrospective chart review in intensive care unit (ICU) patients with a body mass index (BMI) < 20.0 kg/m2. Patients were categorized into Group R, which reached the energy target within 3 days of EEN initiation, and Group S, which reached the energy target 4 or more days after EEN initiation. Results: A total of 65 patients with a median age of 73 years were included in the study. No significant differences were observed between the two groups for all-cause mortality, ICU-free days, or length of hospital stay. Ventilator-free days (VFDs) were significantly fewer in Group R than in Group S (18.0 [0.0 - 22.0] vs. 21.0 [16.3 - 24.8] days; P = 0.046). A significantly higher number of patients requiring mechanical ventilation (MV) at hospital discharge were observed in Group R than in Group S (29% vs. 8%; P = 0.030). Multivariable analyses with adjustment for confounders found that days required to reach target energy intake after EEN initiation were significantly and independently associated with the requirement for MV at hospital discharge, but not with VFDs. Conclusion: A slow rate of feeding advancement after initiation of EEN in critically ill patients having a BMI of

Case A 16-year-old primiparous girl in the 11th week of gestation presented to our hospital with a traumatic brain injury suffered during a motorcycle accident. She was comatose on arrival to the hospital and was admitted to the intensive care unit. From day 2, she developed intermittent episodes of tachycardia with tachypnea, fever, profuse sweating, and extensor posturing. She was diagnosed with paroxysmal sympathetic hyperactivity (PSH) and treated with morphine. However, paroxysmal sympathetic hyperactivity could not be controlled and her general condition deteriorated. Intrauterine fetal death was confirmed in the 16th week of gestation, on day 37 of hospitalization. P paroxysmal sympathetic hyperactivity increased each day until delivery and dramatically improved after delivery. Outcome The patient gradually regained consciousness and was discharged to a rehabilitation hospital on day 117 after hospitalization. Conclusion Pregnancy is a risk factor for paroxysmal sympathetic hyperactivity exacerbation, and delivery can result in resolution of the condition.

Case A 22-year-old man was injured in a traffic accident and developed respiratory distress on his first day of admission. On postadmission day 3, he developed serious respiratory distress with a suddenly altered mental status. Chest computed tomography revealed a pulmonary embolism that had not been evident when he was admitted. The patient was intubated and a continuous heparin infusion was started to treat the pulmonary embolism. Palpebral conjunctival petechiae were noticed the following day, at which point the patient fulfilled Gurd's criteria for fat embolism syndrome. Within a few days, his respiratory status was improved. Brain magnetic resonance imaging also provided evidence of fat embolism syndrome. His femoral shaft fracture was repaired on day 20. Outcome The patient was discharged home on postadmission day 63. Conclusion Concomitant fat embolism syndrome and pulmonary embolism, although very rare, should be considered when a trauma patient's respiratory status worsens.

Immune checkpoint inhibitors (ICIs) have demonstrated efficacy against various types of cancers. In addition to immune-related adverse events (irAEs) induced by ICIs, exacerbation of baseline autoimmune disease has been occasionally reported. This is the first report of autoimmune hemolytic anemia (AIHA) exacerbated by pembrolizumab. An 82-year-old Japanese male was diagnosed with lung adenocarcinoma 2 years ago. The patient had chronic anemia with positive direct and indirect Coombs test prior to initiating pembrolizumab therapy at a nearby hospital. However, a definitive diagnosis of AIHA was not made at that time. Seventeen days after the first dose of pembrolizumab, the patient was admitted to the Kobe City Medical Center General Hospital with severe hemolytic anemia (Hb 3.6 g/dL). After thorough examinations including bone marrow biopsy, the patient was diagnosed with pre-existing AIHA exacerbated by pembrolizumab therapy. Two weeks after treatment with prednisone, the levels of hemoglobin became stable with the reduced frequency of blood transfusion and improvements of hemolytic findings on blood tests and the patient was discharged from the hospital. This case report highlighted the importance of determining the patient’s pre-existing autoimmune status associated with chronic anemia prior to initiating treatment with ICIs.

Background Posterior reversible encephalopathy syndrome (PRES) is a condition characterized by seizures, altered consciousness, visual disturbances, and headache. Characteristic findings on neuroimaging include cerebral edema, typically involving the parieto-occipital white matter. PRES has been associated with hypertension, autoimmune disease, and Henoch-Scholein purpura (HSP), but few cases have been reported, and fewer cases of PRES have been reported in children. Case Report We report the case of a 4-year-old girl who presented with blindness and semi-consciousness. The patient had no significant medical history and no abnormalities on physical examination or laboratory testing, although she had slightly elevated blood pressure. After hospitalization, the patient showed some characteristic signs of HSP and cranial magnetic resonance imaging revealed PRES as the cause of semi-consciousness. In our discussion, we examine the clinical features of PRES and remarkable points for the clinical diagnosis and management of this rare but important disease. Why Should an Emergency Physician Be Aware of This? Although reports of PRES in children are rare, PRES should be considered in the differential diagnosis of children presenting with disturbance of consciousness. Emergency physicians should consult with pediatric physicians to confirm diagnoses of PRES and determine an appropriate treatment plan, given its variable etiology. Measurements of blood pressure, which are often missing in pediatric cases, can help physicians to arrive at a correct diagnosis.

Background:Severe sepsis is commonly associated with mortality among critically ill patients and is known to cause coagulopathy. While antithrombin is an anticoagulant used in this setting, serum albumin levels are known to influence serum antithrombin levels. Therefore, this study aimed to evaluate the outcomes of antithrombin supplementation in patients with sepsis-associated coagulopathy, as well as the relationship between serum albumin levels and the effects of antithrombin supplementation.Methods:This retrospective study evaluated patients who were >18 years of age and had been admitted to either of two intensive care units for sepsis-associated coagulopathy. The groups that did and did not receive antithrombin supplementation were compared for outcomes up to 1 year after admission. Subgroup analyses were performed for patients with serum albumin levels of Results:Fifty-one patients received antithrombin supplementation and 163 patients did not. The Cox proportional hazards model revealed that antithrombin supplementation was independently associated with 28-day survival (hazard ratio [HR]: 0.374, P = 0.025) but not with 1 year survival (HR: 0.915, P = 0.752). In addition, among patients with serum albumin levels of Conclusion:Antithrombin supplementation may improve short-term survival, but not long-term survival, among patients with sepsis-associated coagulopathy.

我々は2002年４月から2009年１月までに初回同種移植を施行した，急性骨髄性白血病（40症例），ハイリスク骨髄異形成症候群（10症例）計50症例について，移植前・移植時予後因子を検討するために後方視的解析を行った．平均年齢は41.4歳．32%が移植時非寛解期であり，また44%が染色体リスク分類において予後不良群であった．３年の全生存率，無進行生存率，再発率，移植関連死亡率はそれぞれ48.8%，41.3%，38.9%，27.8%であった．移植前・移植時因子の予後に与える影響を単変量・多変量解析で検討し，染色体リスクが最も重要な因子として同定された．さらに，染色体リスクで層別化し解析を加えたところ，染色体リスクによって，移植前処置の強度および移植片対宿主病の対応を変更する，層別化治療の検討が必要と考えられる結果を得たので報告する．

Background The implementation of a protocol has been associated with improvements in the processes of care in clinical settings. Although stress ulcer prophylaxis is recommended for critically ill patients at high risk, there is currently no consensus on its use. Therefore, we herein developed a protocol for stress ulcer prophylaxis, and evaluated therapeutic outcomes in a before-after study. Methods The protocol was developed by considering the effectiveness, disadvantages (including adverse events) and cost of each agent based on previous findings. Patients who were admitted to the 8-bed emergency intensive care unit (ICU) of our hospital for more than 24 h during the year before and after implementation of the study were eligible. Each investigation item was evaluated retrospectively. Results There were 211 and 238 study patients before and after implementation of the protocol, respectively. The baseline characteristics of patients on/during ICU admission were similar in the two groups. The proportion of medicated patients was 79.6 % before and 84.5 % after protocol implementation. Before implementation of the protocol, 4.3 % of patients developed clinically important gastrointestinal bleeding, and this incidence decreased significantly to 0.8 % after its implementation (P = 0.019). The frequency at which medication was discontinued due to adverse events was slightly lower after implementation of the protocol. No significant differences were observed in the costs of stress ulcer prophylactic agents or mortality in the ICU. Conclusions The results of the present study indicated that the development and implementation of a protocol for stress ulcer prophylaxis, for which there are currently no criteria, improved a main outcome, clinically important gastrointestinal bleeding.

偶発性低体温症は全身管理と素早い復温が治療の基本となる。1997年3月から2001年4月までの約4年間に,当院で経験した12例の偶発性低体温症に対し2種類の復温方法を行った。シャワー浴用ストレッチャーを用いた温水半身浴にて復温したA群6例と,従来施行してきた温水による胃および膀胱洗浄,加温輸液の投与等で復温を図ったB群6例とを比較検討した。A群は3歳から84歳までの女性2例と男性4例で,屋外で5例が発症した。深部体温28℃以下の高度低体温が2例,28～32.2℃の中度低体温が1例,32.2～35℃の軽度度低体温が3例であった。単純な一次寒冷暴露は溺水による2例で,他の4例は薬物中毒や消耗性疾患などにより寒冷から避難できなかったためであった。一方B群は29歳から79歳までの男性6例で,A群と同様に高度低体温が2例あった。また一次寒冷暴露2例,他の疾患が背景にあるもの4例も偶然ではあるが,A群と同様である。A群6例で温水半身浴を心電図,血圧,深部温度の連続モニター管理下に施行し,90分以内に復温終了した。またバイタルサインもそれに伴い改善した。アフタードロップ等の合併症はなかった。一方対照群では復温時間が長くかかり,心電図変化の正常化も遅延する例があった。温水半身浴法群は対照群に比較して優れていた。また全身を温水中に浸漬する方法では全身管理に不都合が生じる。一方,半身浴である点は比較的侵襲も少なく,CPAや消化管出血を併発した場合など,急変時の対応にも有利である加温方法と考える。

The eradication of Helicobacter pylori often leads to platelet recovery in patients with chronic idiopathic thrombocytopenic purpura (cITP). Although this clinical observation suggests the involvement of H. pylori, little is known about the pathogenesis of cITP. We initially examined the effect of H. pylori eradication on platelet counts in 20 adult Japanese cITP patients. Then, using platelet eluates as the probe in immunoblot analyses, we examined the role of molecular mimicry in the pathogenesis of cITP. Helicobacter pylori infection was detected in 75% (15 of 20) of cITP patients. Eradication was achieved in 13 (87%) of the H. pylori-positive patients, seven (54%) of which showed increased platelet counts within the 4 months following treatment. Completely responsive patients also showed significant declines in platelet-associated immunoglobulin G (PAIgG) levels. Platelet eluates from 12 (nine H. pylori-positive and three H. pylori-negative) patients recognized H. pylori cytotoxin-associated gene A (CagA) protein, and in three completely responsive patients, levels of anti-CagA antibody in platelet eluates declined after eradication therapy. Cross-reactivity between PAIgG and H. pylori CagA protein suggests that molecular mimicry by CagA plays a key role in the pathogenesis of a subset of cITP patients.

A 15-year-old boy, who tumbled from a fourth-floor window, was transported to our hospital. Enhanced computed tomography (CT) 1.5 h after the injury showed a non-contrasted right kidney, and a repeat CT 6 h after the injury showed a growing retroperitoneal hematoma. The angiography showed complete obstruction of the right renal artery and bleeding from the subcapsular artery, which was successfully embolized. Renovascular hypertension developed on the second day after the injury; therefore, simple nephrectomy was performed.