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BACKGROUND Initial management of severe traumatic brain injury is important and includes treatment decision-making and prediction of prognosis. We examined whether biomarkers at admission could be useful prognostic predictors. We focused on electrolytes and blood glucose, which can be measured easily at any facility and for which results can be obtained promptly, before those of other biomarkers, such as D-dimer. METHODS All trauma patients with head injuries treated at Chiba Hokusoh Hospital between 2014 and 2017 were investigated. Cases of multiple trauma accompanied by fatal trauma, hemorrhagic shock, or cardiopulmonary arrest, and pediatric cases, were excluded from this study. Blood gas data at the initial hospital visit were reviewed retrospectively. A poor outcome was defined as death during hospitalization or a vegetative state due to head injury. Factors related to poor outcomes were analyzed. RESULTS Of the 185 male and 79 female patients studied, 34 had poor outcomes. Poor outcome was significantly correlated with potassium (P = 0.003), glucose (P < 0.001), and glucose-to-potassium ratio (P < 0.001) at arrival. The odds ratio was 4.079 for a glucose-to-potassium ratio of ≥50. CONCLUSIONS We evaluated blood gas data at the initial hospital visit, as these results can be obtained more quickly than those of other biomarkers assessed previously. Serum glucose-to-potassium ratio at admission may be a potential predictor of prognosis for severe traumatic brain injury.

Antimicrobial prophylaxis is not generally recommended for patients with severe acute pancreatitis (SAP) owing to the limited clinical benefits. Nonetheless, it is frequently administered in actual practice given the patients' critical condition and the lack of solid evidence showing adverse effects of antimicrobial prophylaxis. We evaluated herein an association between antimicrobial prophylaxis and invasive pancreatic candidiasis as an adverse effect in patients with SAP.This is a retrospective cohort study of all consecutive patients with SAP who were admitted to the study institutions (n = 44) between January 1, 2009, and December 31, 2013. We performed multivariable logistic regression analysis adjusting for the extent of pancreatic necrosis and surgical interventions for invasive pancreatic candidiasis.Of the 1097 patients with SAP, 850 (77.5%) received antimicrobial prophylaxis, and 21 (1.9%) had invasive pancreatic candidiasis. In multivariable logistic regression analysis, antimicrobial prophylaxis was significantly associated with the development of invasive pancreatic candidiasis (adjusted odds ratio, 4.23; 95% confidence interval, 1.14-27.6) (P = 0.029).The results suggest that antimicrobial prophylaxis may contribute to the development of invasive pancreatic candidiasis, and therefore, the routine use of antimicrobial prophylaxis for SAP may be discouraged.

BackgroundThe ‘golden hour’ is a well-known concept, suggesting that shortening time from injury to definitive care is critically important for better outcome of trauma patients. However, there was no established evidence to support it. We aimed to validate the association between time to definitive care and mortality in hemodynamically unstable patients for the current trauma care settings.MethodsThe data were collected from the Japan Trauma Data Bank between 2006 and 2015. The inclusion criteria were patients with systolic blood pressure (SBP) 110 beats/min or SBP 110 beats/min) shock group.Results1169 patients were enrolled in this study. Of these, 386 (33.0%) died. Median time from injury to definitive care was 137 min. Only 61 patients (5.2%) received definitive care within 60 min. The GAM models demonstrated that mortality remained stable for the early phase, followed by a decrease over time. The severe shock group presented with a paradoxical decline of mortality with time, whereas the moderate shock group had a time-dependent increase in mortality.DiscussionWe did not observe the association of shorter time to definitive care with a decrease in mortality. However, this was likely an offset result of severe and moderate shock groups. The result indicated that early definitive care could have a positive impact on survival outcome of patients with moderate shock.Level of evidenceLevel Ⅳ, prognostic study

Background: Recently, for patients with sepsis, under-infusion, that hastens the progression to multiple organ failure and death, has been avoided; however, the rate of over-infusion and resulting complications, such as mortality has increased. There are few indicators of over-infusion, such as transpulmonary thermodilution; therefore, minimally invasive, simple, and quick indicators of over-infusion are needed. This pilot study aimed to determine the association between brain natriuretic peptide (BNP) and global end-diastolic volume index (GEDI).Methods: This was a post-hoc analysis of a multicenter prospective randomized controlled study, performed in the intensive care units (ICU) of 10 separate hospitals in Japan from September 2013 to March 2016. Patients with sepsis who were expected to require mechanical ventilation for more than 48 hours were included. We measured BNP and GEDI every 24 hours from ICU admission until next 72 hours. The primary outcome was the correlation between BNP and GEDI that was assessed in two ways: 1) GEDI considered a continuous variable, and 2) GEDI divided into two groups based on a cutoff of 850 ml/m2, which is the upper limit of normal GEDI. We used a univariable generalized linear mixed-effects model in which patients are considered as a random effect.Results: Fifty-seven patients were analyzed. GEDI remained under the upper limit of normal GEDI (850 ml/m2) from ICU admission to 72 h, and there were no significant changes in the trends of BNP and GEDI over time. BNP tended to be higher in group 1 (GEDI >850 ml/m2) from ICU admission to 72 h, but there was no significant difference in the BNP values. The regression coefficient and 95%CI of BNP for GEDI were 2.5 and 1.3 to 3.7 when considered as a continuous variable, and 166 and -273 to 605 when divided into two groups based on GEDI cutoff of 850 ml/m2. Conclusion: There could be a weak but significant correlation between GEDI and BNP considering GEDI as a continuous variable. Using BNP as an indicator of over-infusion may be possible; however, further studies are needed.Trial registration: None.

Background To compare the efficacy of three antiseptic solutions [0.5%, and 1.0% alcohol/chlorhexidine gluconate (CHG), and 10% aqueous povidone-iodine (PVI)] for the prevention of intravascular catheter colonization, we conducted a randomized controlled trial in patients from 16 intensive care units in Japan. Methods Adult patients undergoing central venous or arterial catheter insertions were randomized to have one of three antiseptic solutions applied during catheter insertion and dressing changes. The primary endpoint was the incidence of catheter colonization, and the secondary endpoint was the incidence of catheter-related bloodstream infections (CRBSI). Results Of 1132 catheters randomized, 796 (70%) were included in the full analysis set. Catheter-tip colonization incidence was 3.7, 3.9, and 10.5 events per 1000 catheter-days in 0.5% CHG, 1% CHG, and PVI groups, respectively (p = 0.03). Pairwise comparisons of catheter colonization between groups showed a significantly higher catheter colonization risk in the PVI group (0.5% CHG vs. PVI: hazard ratio, HR 0.33 [95% confidence interval, CI 0.12–0.95], p = 0.04; 1.0% CHG vs. PVI: HR 0.35 [95% CI 0.13–0.93], p = 0.04). Sensitivity analyses including all patients by multiple imputations showed consistent quantitative conclusions (0.5% CHG vs. PVI: HR 0.34, p = 0.03; 1.0% CHG vs. PVI: HR 0.35, p = 0.04). No significant differences were observed in the incidence of CRBSI between groups. Conclusions Both 0.5% and 1.0% alcohol CHG are superior to 10% aqueous PVI for the prevention of intravascular catheter colonization. Trial registration Japanese Primary Registries Network; No.: UMIN000008725 Registered on 1 September 2012 Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1890-z) contains supplementary material, which is available to authorized users.

Objective Pneumonia is a common but serious illness that continues to present significant morbidity and mortality. Although the effect of severity at admission on outcome has been well reported, the role of comorbidity is still not widely understood. The Charlson Comorbidity Index measures comorbidity with a well-established history of predicting long-term outcome but its utility in pneumonia prognosis is still limited. Here, we use the Charlson Comorbidity Index and hospital surveillance data to investigate associations between comorbidities and in-hospital mortality due to community-acquired pneumonia. Results Among the 535 eligible adult patients (69.0% male, median [IQR] age, 79 [70–84] years), 100 (18.7%) acquired severe to extremely severe pneumonia. The median [IQR] CCI was 1 [1–3]. Malignancy (129 of 535, 24.1%), chronic pulmonary diseases (113 of 535, 21.1%) and congestive heart failure (103 of 535, 19.3%) were frequent. Higher Charlson Comorbidity Index scores were associated with higher risk of in-hospital mortality (OR 1.28; 95% CI 1.07–1.53). These results support the inclusion of comorbid burden in predicting community-acquired pneumonia outcome.

Aim An index that accurately measures intravascular volume is paramount for the optimal resuscitation of sepsis. Selecting an adequate indicator to substitute for central venous pressure (CVP) has remained an issue. The objective of our study was to compare the usefulness of standard early goal‐directed therapy (EGDT) with CVP (EGDT‐CVP) and modified EGDT with global end‐diastolic volume index (GEDI; EGDT‐GEDI) for sepsis. Methods This was a multicenter prospective randomized controlled study. All patients with sepsis who were expected to require mechanical ventilator support for a minimum of 48 h were included. The patients were classified into an EGDT‐CVP group and an EGDT‐GEDI group. All participants underwent the extubation protocol. The primary outcome was the ventilator‐free days over a 28‐day period. Results The ventilator‐free days was not significantly different between the two groups (P = 0.59). However, the EGDT‐GEDI group showed a trend of shorter ventilator support duration (5.1 days [2.0–8.7 days] versus 3.9 days [2.4–5.7 days], P = 0.27) and length of stay in the intensive care unit (7.2 days [3.8–10.7 days] versus 5.1 days [3.7–8.8 days], P = 0.05) and a smaller 3‐day infusion balance than the EGDT‐CVP group (4,405 mL [1,092–8,163 mL] versus 3,046 mL [830–6,806 mL], P = 0.34), but the differences were not statistically significant. Conclusion Although there was no significant efficacy, EGDT guided by GEDI showed a trend of shorter length of stay in the intensive care unit and lower 3‐day infusion balance than the EGDT‐CVP group in sepsis. The GEDI monitoring did not appear to improve the ventilator‐free days over a 28‐day period., We undertook a randomized controlled trial to assess the usefulness of the global end‐diastolic volume index (GEDI) as the mark of fluid resuscitation. GEDI did not appear to improve the ventilator‐free days over a 28‐day period or the length of stay in the intensive care unit to reduce excess fluid administration. The GEDI monitoring group showed a trend of a lower mean 72‐h infusion balance than the central venous pressure monitoring group.

Supplemental doses of antithrombin (AT) are widely used to treat sepsis-induced disseminated intravascular coagulation (DIC) in Japan. However, evidence on the benefits of AT supplementation for DIC is insufficient. This multicenter retrospective observational study aimed to clarify the effect of AT supplementation on sepsis-induced DIC using propensity score analyses. Data from 3,195 consecutive adult patients admitted to 42 intensive care units for severe sepsis treatment were retrospectively analyzed; 1,784 patients were diagnosed with DIC (n = 715, AT group; n = 1,069, control group). Inverse probability of treatment-weighted propensity score analysis indicated a statistically significant association between AT supplementation and lower in-hospital all-cause mortality (n = 1,784, odds ratio [95% confidence intervals]: 0.748 [0.572-0.978], P = 0.034). However, quintile-stratified propensity score analysis (n = 1,784, odds ratio: 0.823 [0.646-1.050], P = 0.117) and propensity score matching analysis (461 matching pairs, odds ratio: 0.855 [0.649-1.125], P = 0.263) did not show this association. In the early days after intensive care unit admission, the survival rate was statistically higher in the propensity score-matched AT group than in the propensity score-matched control group (P = 0.007). In DIC patients without concomitant heparin administration, similar results were observed. In conclusion, AT supplementation may be associated with reduced in-hospital all-cause mortality in patients with sepsis-induced DIC. However, the statistical robustness of this connection was not strong. In addition, although the number of transfusions needed in patients with AT supplementation increased, severe bleeding complications did not.

Background Advanced automatic collision notification (AACN) is a system for predicting occupant injury from collision information. If the helicopter emergency medical services (HEMS) physician can be alerted by AACN, it may be possible to reduce the time to patient contact. Objective The purpose of this study was to validate the feasibility of early HEMS dispatch via AACN. Methods A full-scale validation study was conducted. A car equipped with AACN was made to collide with a wall. Immediately after the collision, the HEMS was alerted directly by the operation center, which received the information from AACN. Elapsed times were recorded and compared with those inferred from the normal, real-world HEMS emergency request process. Results AACN information was sent to the operation center only 7 s after the collision; the HEMS was dispatched after 3 min. The helicopter landed at the temporary helipad 18 min later. Finally, medical intervention was started 21 min after the collision. Without AACN, it was estimated that the HEMS would be requested 14 min after the collision by fire department personnel. The start of treatment was estimated to be at 32 min, which was 11 min later than that associated with the use of AACN. Conclusions The dispatch of the HEMS using the AACN can shorten the start time of treatment for patients in motor vehicle collisions. This study demonstrated that it is feasible to automatically alert and activate the HEMS via AACN.

Severe trauma injuries, such as open pelvic fractures and degloving injuries, have recently become salvageable. However, extensive soft-tissue defects often remain and can lead to disuse atrophy of the extremities, prolonged hospital stays, and numerous other problems. Such injuries can be easily and effectively treated by a general trauma surgeon performing the pedicled omental flap technique. We report on 2 highly diverse and complicated cases of soft-tissue defect that were both successfully treated with this technique. One case was an extensive right-sided defect of the pelvic soft-tissue in a 20-year-old woman. The other case was in a 55-year-old man who underwent emergency artificial vessel replacement surgery for a femoral artery tear with severe damage to the surrounding muscle. Although the surgery was successful, a methicillin-resistant Staphylococcus aureus infection developed around the artificial vessel 10 days after surgery. In both cases, the pedicled omental flap technique was successfully performed and yielded epithelization without serious infection and with the infection subsiding with wound-area healing. To our knowledge, the pedicled omental flap technique has rarely been used to treat severe trauma, and our results suggest its usefulness for both preventing infection in large wounds and healing infected wounds.

Background The administration of low-dose intravenous immunoglobulin G (IVIgG) (5 g/day for 3 days; approximate total 0.3 g/kg) is widely used as an adjunctive treatment for patients with sepsis in Japan, but its efficacy in the reduction of mortality has not been evaluated. We investigated whether the administration of low-dose IVIgG is associated with clinically important outcomes including intensive care unit (ICU) and in-hospital mortality. Methods This is a post-hoc subgroup analysis of data from a retrospective cohort study, the Japan Septic Disseminated Intravascular Coagulation (JSEPTIC DIC) study. The JSEPTIC DIC study was conducted in 42 ICUs in 40 institutions throughout Japan, and it investigated associations between sepsis-related coagulopathy, anticoagulation therapies, and clinical outcomes of 3195 adult patients with sepsis and septic shock admitted to ICUs from January 2011 through December 2013. To investigate associations between low-dose IVIgG administration and mortalities, propensity score-based matching analysis was used. Results IVIgG was administered to 960 patients (30.8%). Patients who received IVIgG were more severely ill than those who did not (Acute Physiology and Chronic Health Evaluation (APACHE) II score 24.2 ± 8.8 vs 22.6 ± 8.7, p

The aim of this study was to investigate the outcomes of severe acute pancreatitis (SAP) according to the segment presenting with low enhanced pancreatic parenchyma (LEPP) on early contrast-enhanced computed tomography.This was a post hoc analysis of a multicenter, retrospective study conducted at 44 institutions in Japan. Patients diagnosed as having SAP according to the Japanese Severity Score between January 2009 and December 2013 were included. We compared the effect of LEPP in each segment on mortality.A total of 1097 patients were assessed. The numbers of patients with LEPP in the pancreatic head (Ph), body (Pb), or tail (Pt) were 272, 273, and 204 (with some overlaps), respectively. In multivariate analysis, LEPP in Ph and Pt was significantly related to mortality (odds ratio [OR], 1.94; 95% confidence interval [CI], 1.11-3.40 [P0.05], for LEPP in Ph; OR, 2.44; 95% CI, 1.27-4.67 [P0.05], for LEPP in Pt), but LEPP in Pb was unrelated to mortality (OR, 0.70; 95% CI, 0.35-1.37; P = 0.30).Presence of LEPP in Ph and Pt on early contrast-enhanced computed tomography was independently associated with increased mortality in SAP. These patients require close observation to ensure timely and adequate intervention.

Hitachi Chemical DuPont MicroSystems (HDMS) has been developing photosensitive negative-tone polyimides (PI) and positive-tone poly(benzoxazole)s (PBO) for use as protection layers in semiconductor ICs or as dielectrics for re-distribution layers in wafer level packaging. These materials offer an easy manufacturing process as well as ensuring high reliability in semiconductor packages such as fan-out wafer level packaging (FOWLP). Currently, dielectrics for FOWLP applications are cured at around 230°C. However, even lower cure temperatures are now required due to the limitations in heat resistance of packaging materials, a reduction in warpage of re-constituted wafers as well as yield improvement with embedded memory ICs. To meet these challenges, HDMS has been focusing on the development of a low temperature curable PI and PBO that can also achieve high resolution and excellent cured film properties. In this paper, recent progress in our latest PI and PBO materials will be introduced.

Background The healing process of bone fracture requires a well-controlled multistage and sequential order beginning immediately after the injury. However, complications leading to nonunion exist, creating serious problems and costs for patients. Transforming growth factor-beta 1 (TGF-β1) and bone morphogenic protein 2 (BMP-2) are two major growth factors involved in human bone fracture healing by promoting various stages of bone ossification. In this study, we aimed to determine the role of these factors during the fracture healing of human long bones and assess their impacts on nonunion condition. Materials and methods We performed a comprehensive analysis of plasma TGF-β1 and BMP-2 levels in blood samples from 10 patients with proved nonunion and 10 matched patients with normal union following a predetermined time schedule. The concentrations of TGF-β1 and BMP-2 were measured at each time point using a solid-phase ELISA. Results TGF-β1 and BMP-2 levels were detectable in all patients. For all patients, a maximal peak for TGF-β1 was found at 3-week. In normal union group, TGF-β1 showed a maximal peak at 2-week while nonunion group had a delayed maximal peak at 3-week. Plasma levels of BMP-2 for all patients and for normal union group reached a maximal peak at 1-week, but nonunion group showed a delayed maximal peak at 2-week. In general, plasma TGF-β1 or BMP-2 level was not significantly different between normal union and nonunion groups. Conclusion The expression levels of TGF-β1 and BMP-2 appeared to be delayed in nonunion patients which could play an important role in developing an early marker of fracture union condition and facilitate improved patient's management.

Supporting system of choral singing Visually impaired persons may find it difficult to take part in a chorus or other singing group because they cannot see the beat indicated by conductor’s hand movements. This paper provides a chorus support system for visually impaired persons using depth image sensor. This consists of an electric music baton with an acceleration sensor, a radio module, haptic interface devices with vibration motors, a depth image sensor, and a PC. The electric music baton transmits the signal indicating the conductor’s motion to visually impaired players based on sensor acceleration. Since the conductor must give individual instruction to player, we use a depth image sensor to indicate the direction in which the conductor’s baton points. This direction is estimated based on the conductor’s posture. We also attempted to develop a chorus support system without using the electric music baton. The beat is obtained by the maximum velocity position of the conductor’s hand motion using a depth image sensor. The effectiveness of our system is clarified by several experimental results.

Severe sepsis is a major concern in the intensive care unit (ICU), although there is very little epidemiological information regarding severe sepsis in Japan. This study evaluated 3195 patients with severe sepsis in 42 ICUs throughout Japan. The patients with severe sepsis had a mean age of 70 ± 15 years and a mean Acute Physiology and Chronic Health Evaluation II score of 23 ± 9. The estimated survival rates at 28 and 90 days after ICU admission were 73.6 and 56.3 %, respectively. Electronic supplementary material The online version of this article (doi:10.1186/s40560-016-0169-9) contains supplementary material, which is available to authorized users.

Purpose This study investigated the advantages of performing urgent resuscitative surgery (URS) in the emergency department (ED); namely, our URS policy, to avoid a delay in hemorrhage control for patients with severe torso trauma and unstable vital signs. Methods We divided 264 eligible cases into a URS group (n = 97) and a non-URS group (n = 167) to compare, retrospectively, the observed survival rate with the predicted survival using the Trauma and Injury Severity Score (TRISS). Results While the revised trauma score and the injury severity score were significantly lower in the URS group than in the non-URS group, the observed survival rate was significantly higher than the predicted rate in the URS (48.5 vs. 40.2%; p = 0.038). URS group patients with a systolic blood pressure (SBP)

Background and purpose The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 and published in the Journal of JSICM, [2017; Volume 24 (supplement 2)] 10.3918/jsicm.24S0001 and Journal of Japanese Association for Acute Medicine [2017; Volume 28, (supplement 1)] http://onlinelibrary.wiley.com/doi/10.1002/jja2.2017.28.issue-S1/issuetoc. This abridged English edition of the J-SSCG 2016 was produced with permission from the Japanese Association of Acute Medicine and the Japanese Society for Intensive Care Medicine. Methods Members of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ) and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two-thirds (> 66.6%) majority vote of each of the 19 committee members. Results A total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J-SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation, and its supporting evidence were also added to each recommendation statement. We conducted meta-analyses for 29 CQs. Thirty-seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for five CQs. Conclusions Based on the evidence gathered, we were able to formulate Japanese-specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non-specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals. Electronic supplementary material The online version of this article (10.1186/s40560-017-0270-8) contains supplementary material, which is available to authorized users.

We investigated whether emergency thoracotomy (ET) performed in pre-hospital settings contributed to saving the lives of blunt trauma patients with impending or recent cardiac arrest.Eighty-one consecutive cardiac arrest patients with blunt trauma were performed ET before or after arrival at the emergency department (ED). These were reviewed retrospectively and were classified into the following three groups: (1) an emergency field thoracotomy was performed (EFT group, n=34); (2) a doctor dispatched to the scene, but the thoracotomy was performed in the ED (EDT-a group, n=10); and (3) no doctor dispatched to the scene, and the thoracotomy was performed in the ED (EDT-b group, n=37). The patients in the EFT and EDT-a groups were managed within the Japanese helicopter emergency medical service system with a doctor dispatched to the scene.The time between the arrival of the EMT at the scene and the start of the thoracotomy was significantly shorter in the EFT group than in the EDT-b group (19.2+/-7.9 min vs. 30.7+/-6.8 min, p0.001). In the EFT group, the "ICU admission" rate was significantly higher among the patients who experienced cardiac arrest after the EMT arrival than among the patients who experienced cardiac arrest before the EMT arrival (70% vs. 8%, p=0.001). Unfortunately, however, there were no survivors in this series.These findings indicate that "early access" to a doctor's expertise and the performance of an "emergency field thoracotomy" might be two important factors for improving the possibility of saving the lives of blunt trauma patients with impending or recent cardiac arrest.

Septic shock-associated mortality in intensive care units (ICUs) remains high, with reported rates ranging 30–50%. In particular, Gram-negative bacilli (GNB), which induce significant inflammation and consequent multiple organ failure, are the etiological bacterial agent in 40% of severe sepsis cases. Hemoperfusion using polymyxin B-immobilized fiber (PMX), which adsorbs endotoxin, is expected to reduce the inflammatory sepsis cascade due to GNB. However, the clinical efficacy of this treatment has not yet been demonstrated. Here, we aimed to verify the efficacy of endotoxin adsorption therapy using PMX through a retrospective analysis of 413 patients who received broad spectrum antimicrobial treatment for GNB-related septic shock between January 2009 and December 2012 in 11 ICUs of Japanese tertiary hospitals. After aligning the patients' treatment time phases, we classified patients in two groups depending on whether PMX hemoperfusion (PMXHP) therapy was administered or not within 24 hours after ICU admission (PMXHP group: n = 134, conventional group: n = 279). The primary study endpoint was the mortality rate at 28 days after ICU admission. The mean age was 72.4 (standard deviation: 12.6) years, and the mean Sequential Organ Failure Assessment score at ICU admission was 9.9 (3.4). The infection sites included intra-abdominal (38.0%), pulmonary (18.9%), and urinary tract (32.2%), and two thirds of all patients had GNB-related bacteremia. Notably, the mortality at 28 days after ICU admission did not differ between the groups (PMXHP: 29.1% vs. conventional: 29.0%, P = 0.98), and PMXHP therapy was not found to improve this outcome in a Cox regression analysis (hazard ratio = 1.16; 95% confidence interval, 0.81–1.64, P = 0.407). We conclude that PMX-based endotoxin adsorption within 24 hours from ICU admission was not associated with mortality among patients with septic shock due to GNB. Trial registration: University Hospital Medical Information Network Clinical Trial Registry (UMIN-CTR ID: UMIN000012748).

Background Neutrophil elastase plays an important role in the development and progression of acute respiratory distress syndrome (ARDS). Although the selective elastase inhibitor, sivelestat, is widely used in Japan for treating ARDS patients, its effectiveness remains controversial. The aim of the current study was to investigate the effects of sivelestat in ARDS patients with evidence of increased extravascular lung water by re-analyzing a large multicenter study database. Methods A post hoc analysis of the PiCCO Pulmonary Edema Study was conducted. This multicenter prospective cohort study included 23 institutions in Japan. Adult mechanically ventilated ARDS patients with an extravascular lung water index of >10 mL/kg were included and propensity score analyses were performed. The endpoints were 28-day mortality and ventilator-free days (VFDs). Results Patients were categorized into sivelestat (n = 87) and control (n = 77) groups, from which 329 inverse probability-weighted group patients (162 vs. 167) were generated. The overall 28-day mortality was 31.1% (51/164). There was no significant difference in 28-day mortality between the study groups (sivelestat vs. control; unmatched: 29.9% vs. 32.5%; difference, −2.6%, 95% confidence interval (CI), −16.8 to 14.2; inverse probability-weighted: 24.7% vs. 29.5%, difference, −4.8%, 95% CI, −14.4 to 9.6). Although administration of sivelestat did not alter the number of ventilator-free days (VFDs) in the unmatched (9.6 vs. 9.7 days; difference, 0.1, 95% CI, −3.0 to 3.1), the inverse probability-weighted analysis identified significantly more VFDs in the sivelestat group than in the control group (10.7 vs. 8.4 days, difference, −2.3, 95% CI, −4.4 to −0.2). Conclusions Although sivelestat did not significantly affect 28-day mortality, this treatment may have the potential to increase VFDs in ARDS patients with increased extravascular lung water. Prospective randomized controlled studies are required to confirm the results of the current study. Electronic supplementary material The online version of this article (doi:10.1186/s40560-014-0067-y) contains supplementary material, which is available to authorized users.

Extravascular lung water (EVLW), as measured by the thermodilution method, reflects the extent of pulmonary edema. Currently, there are no clinically effective treatments for preventing increases in pulmonary vascular permeability, a hallmark of lung pathophysiology, in patients with acute lung injury/acute respiratory distress syndrome (ALI/ARDS). In this study, we examined the contributions of hemodynamic and osmolarity factors, for which appropriate interventions are expected in critical care, to EVLW in patients with ALI/ARDS. We performed a subgroup analysis of a multicenter observational study of patients with acute pulmonary edema. Overall, 207 patients with ALI/ARDS were enrolled in the study. Multivariate regression analysis was used to evaluate the associations of hemodynamic and serum osmolarity parameters with the EVLW index (EVLWI; calculated as EVLW/Ideal body weight). We analyzed factors measured on the day of enrollment (day 0), and on days 1 and 2 after enrollment. Multivariate regression analysis showed that global end-diastolic volume index (GEDVI) was significantly associated with EVLWI measured on days 0, 1, and 2 (P = 0.002, P

A 30-year-old man was injured when the large motorcycle he was riding crashed into a power pole. Upon arrival at our institution, the patient complained of abdominal pain; blood pressure at admission was 160/70 mmHg, and the heart rate was 112 bpm. Abdominal ultrasonography showed a small collection of fluid in Morrisons pouch. A chest X-ray film showed a right rib fracture. Multidetector computed tomography (MD-CT) revealed pleural effusion, a hepatic lesion, and a dissection of the abdominal aorta distal to the renal artery. Because of the complicated intraluminal injuries, the insertion of a stent graft was difficult. On the 34(th) day after injury, elective surgery was performed. Because dissection of the lumen was observed, the vessel was replaced with an artificial graft. Medial degeneration of the aorta wall was not observed upon pathological examination, and no degenerative disorders have occurred. The postoperative progress was favorable, and the patient was discharged from hospital. Language: en

In the prehospital setting, it is difficult to use the Glasgow Coma Scale (GCS) to evaluate the consciousness state using in pediatric patients with severe trauma. The Japan Coma Scale (JCS) is a consciousness scale used widely in Japan and, with its four grades, is simpler and quicker to use than the GCS. This study examined whether the JCS can predict clinical traumatic brain injury (TBI) and outcome in pediatric patients aged 3 to 15 years in the prehospital setting.

There are few reports from Japan on the analysis of fluids in survivors of body-packer syndrome. We analyzed the concentrations of stimulants in the serum, plasma and urine collected from three patients suspected of being body packers at immigration that were referred to hospitals between 2010 and 2011. The drugs were extracted with solid-phase columns and analyzed by gas chromatography-mass spectrometry (GC-MS). In all cases, wrapped, cylindrical packets of foreign bodies were detected in the intestinal tract on plain X-ray (X-P) and computed tomography (CT), and they were eventually removed surgically. In case 1, the patient presented with convulsions and tachycardia at admission to the hospital and one of the packets was found to have ruptured. In case 2, although the subject appeared to have an intestinal obstruction caused by the packets on the third day, he exhibited no symptoms on arrival and the packets did not appear to have ruptured. In case 3, the patient exhibited restlessness on the first day and one of the removed packets had ruptured. In all cases, methamphetamine (MA) and amphetamine (AP) were detected in serum, plasma and urine. In this study, we report the variation in MA and AP concentrations in survivors of body-packer syndrome. The serum and plasma concentrations of MA were high in subjects that exhibited symptoms of MA intoxication. MA and AP were also detected in the case in which the patient exhibited no symptoms of intoxication and the packets had not ruptured. These results suggest either that the stimulants may have seeped through the wrap of the packets, or that the subject had been abusing the drugs.

In recent years, demand for high-density integration of semiconductor chips has steadily increased due to miniaturization and high-performance requirements of electronics including Smartphones and Tablet PCs. In addition to 3D integration using Through-Silicon Via (TSV) technology, 2.5D integration technology using silicon interposers has also become a hot topic. Canon has identified key challenges that must be solved for successful implementation of high-density integration technologies into mass production and to meet these challenges, Canon developed the FPA-5510iV i-line lithography tool (stepper) that is now in wide use at customer sites for their most challenging processes. In this paper, Canon will explain details of FPA-5510iV features that support high-density integration. Canon will also introduce additional challenges that must be solved to ensure the success of high-density integration technologies in mass production, as well as Canon efforts to solve the remaining challenges.

Unexpected trauma is a one of the most major causes of death for children in the world. However, pediatric severe trauma patients are rare and scattered. Although there is a strong association between patient's volume of trauma center volume and outcomes in adults, such a report is less in children. In this study, we aimed to clarify the relationship of the amount of registration and outcome in pediatric trauma patients.

Background: The features of early-phase acute respiratory distress syndrome (ARDS) are leakage of fluid into the extravascular space and impairment of its reabsorption, resulting in extravascular lung water (EVLW) accumulation. The current study aimed to identify how the initial EVLW values and their change were associated with mortality. Methods: This was a post hoc analysis of the PiCCO Pulmonary Edema Study, a multicenter prospective cohort study that included 23 institutions. Single-indicator transpulmonary thermodilution-derived EVLW index (EVLWi) and conventional prognostic factors were prospectively collected over 48 h after enrollment. Associations between 28-day mortality and each variable including initial (on day 0), mean, maximum, and Δ (subtracting day 2 from day 0) EVLWi were evaluated. Results: We evaluated 192 ARDS patients (median age, 69 years (quartile, 24 years); Sequential Organ Failure Assessment (SOFA) score on admission, 10 (5); all-cause 28-day mortality, 31%). Although no significant differences were found in initial, mean, or maximum EVLWi, Δ-EVLWi was significantly higher (i.e., more reduction in EVLWi) in survivors than in non-survivors (3.0 vs. ?0.3 mL/kg, p = 0.006). Age, maximum, and Δ-SOFA scores and Δ-EVLW were the independent predictors for survival according to the Cox proportional hazard model. Patients with Δ-EVLWi > 2.8 had a significantly higher incidence of survival than those with Δ-EVLWi ? 2.8 (log-rank test, χ2 = 7.08, p = 0.008). Conclusions: Decrease in EVLWi during the first 48 h of ARDS may be associated with 28-day survival. Serial EVLWi measurements may be useful for understanding the pathophysiologic conditions in ARDS patients. A large multination confirmative trial is required., Annals of Intensive Care, 4, 27; 2014

The most common cause of ventilator-associated pneumonia (VAP) is aspiration of oral secretion through the endotracheal tube (ET). Subglottic suction drainage (SSD) has been recommended as a safety measure against aspiration due to its high effectiveness. Currently, two types of cuff shape - spindle and tapered - are predominant in high-volume, low-pressure (HVLP) ETs with SSD. However, the shape most suitable for preventing dripping onto the subglottis has not been determined. The purpose of this study was to determine whether an ET with tapered-type cuff can reduce the incidence of VAP.

Introduction Acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) is characterized by features other than increased pulmonary vascular permeability. Pulmonary vascular permeability combined with increased extravascular lung water content has been considered a quantitative diagnostic criterion of ALI/ARDS. This prospective, multi-institutional, observational study aimed to clarify the clinical pathophysiological features of ALI/ARDS and establish its quantitative diagnostic criteria. Methods The extravascular lung water index (EVLWI) and the pulmonary vascular permeability index (PVPI) were measured using the transpulmonary thermodilution method in 266 patients with PaO2/FiO2 ratio ≤ 300 mmHg and bilateral infiltration on chest radiography, in 23 ICUs of academic tertiary referral hospitals. Pulmonary edema was defined as EVLWI ≥ 10 ml/kg. Three experts retrospectively determined the pathophysiological features of respiratory insufficiency by considering the patients' history, clinical presentation, chest computed tomography and radiography, echocardiography, EVLWI and brain natriuretic peptide level, and the time course of all preceding findings under systemic and respiratory therapy. Results Patients were divided into the following three categories on the basis of the pathophysiological diagnostic differentiation of respiratory insufficiency: ALI/ARDS, cardiogenic edema, and pleural effusion with atelectasis, which were noted in 207 patients, 26 patients, and 33 patients, respectively. EVLWI was greater in ALI/ARDS and cardiogenic edema patients than in patients with pleural effusion with atelectasis (18.5 ± 6.8, 14.4 ± 4.0, and 8.3 ± 2.1, respectively; P < 0.01). PVPI was higher in ALI/ARDS patients than in cardiogenic edema or pleural effusion with atelectasis patients (3.2 ± 1.4, 2.0 ± 0.8, and 1.6 ± 0.5; P < 0.01). In ALI/ARDS patients, EVLWI increased with increasing pulmonary vascular permeability (r = 0.729, P < 0.01) and was weakly correlated with intrathoracic blood volume (r = 0.236, P < 0.01). EVLWI was weakly correlated with the PaO2/FiO2 ratio in the ALI/ARDS and cardiogenic edema patients. A PVPI value of 2.6 to 2.85 provided a definitive diagnosis of ALI/ARDS (specificity, 0.90 to 0.95), and a value < 1.7 ruled out an ALI/ARDS diagnosis (specificity, 0.95). Conclusion PVPI may be a useful quantitative diagnostic tool for ARDS in patients with hypoxemic respiratory failure and radiographic infiltrates. Trial registration UMIN-CTR ID UMIN000003627

Acute respiratory distress syndrome (ARDS) is often associated with sepsis, and one recommended approach in the fluid management of ARDS is to keep sepses dry. On the other hand, optimal fluid management after the early phase of septic shock remains unknown. An excessive positive fluid balance in patients with septic shock is associated with increased mortality and morbidity. We implemented an optimal fluid management (OFM) protocol using the PiCCO system from April 2009. The purpose of this study was to examine the effect of the OFM protocol in comparison with historical controls.

VAP is associated with high mortality in trauma patients. However, detailed data on the prediction of VAP in such patients are limited. We therefore conducted a retrospective study aimed at developing a VAP predictive scoring system for trauma patients.

Purpose Atrial natriuretic peptide (ANP) has a variety of pharmacologic effects, including natriuresis, diuresis, vasodilatation, and suppression of the renin-angiotensin system. A recent study showed that ANP infusion improved hypoxemia and pulmonary hypertension in a lung injury model. On the other hand, the pulse contour cardiac output (PiCCO™) system (Pulsion Medical Systems, Munich, Germany) allows monitoring of the intravascular volume status and may be used to guide volume therapy in severe sepsis and critically ill patients. Materials and Methods We treated 10 pulmonary edema patients without heart disease with human ANP (HANP). The patients were divided into two groups: a group with normal Intrathoracic Blood Volume (ITBV) (900-1100 mL/m2) (n = 6), and a group with abnormal ITBV (n = 4), as measured by the PiCCO™ device; the extravascular lung water (EVLW) and pulmonary vascular permeability index (PVPI) in the two groups were compared. Results The average patient age was 63.9 ± 14.4 years. The normal ITBV group showed significant improvement of the EVLW (before, 16.7 ± 2.7 mL/kg; after, 10.5 ± 3.6 mL/kg; p = 0.0020) and PVPI (before, 3.2 ± 0.3; after, 2.1 ± 0.7; p = 0.0214) after the treatment. The abnormal ITBV group showed no significant improvement of either the EVLW (before, 16.3 ± 8.9 mL/kg; after, 18.8 ± 9.6 mL/kg; p = 0.8387) or PVPI (before, 2.3 ± 0.8; after, 2.7 ± 1.3; p = 0.2782) after the treatment. In both groups, the EVLW and PVPI were strongly correlated with the chest X-ray findings. Conclusion We conclude that HANP supplementation may improve the EVLW and PVPI in pulmonary edema patients without heart disease with a normal ITBV. The PiCCO™ system seems to be a useful device for the management of pulmonary edema.

Prolonged mechanical ventilation (MV) is associated with high morbidity and mortality in septic patients. However, limited data are available on the prediction of prolonged MV. We conducted an observational cohort study aimed at developing a prolonged MV predictive scoring system for severe sepsis and septic shock.

Venous thromboembolism (VTE) is a common complication after major trauma, and has a high rate of morbidity and mortality. However, racial disparities in incidence of as well as risk factors for VTE exist between Asian and western populations. The risks for VTE after major trauma in Japanese patients remain unknown. Our objective was to identify risk factors for VTE after severe blunt trauma in Japanese patients.

Previous studies have focused on the accuracy of the focused assessment with sonography for trauma (FAST) examination performed in the emergency department (ED), but have not evaluated FAST performed in the field setting (field FAST). We aimed to evaluate the accuracy of field FAST by comparison with FAST performed in the ED.

The Surviving Sepsis Campaign Guideline 2008 [1] recommends starting appropriate antibiotic therapy within 1 hour after making the diagnosis of septic shock. In the ICU of our emergency center, we perform empiric antibiotic therapy for septic shock patients within 6 hours after admission.

Septic shock is a condition associated with diffuse coagulopathy and multiple organ failure, and frequently leads to death. Direct hemoperfusion using a polymyxin B-immobilized fiber column (DHP-PMX) has been used for the treatment of septic shock [1]. On the other hand, there is another kind of acute blood purification therapy, but the optimal column of continuous veno-venous hemodiafiltration (CVVHDF) is still controversial.

The PiCCO system enables hemodynamic evaluation and monitoring by two different approaches: the transpulmonary thermal dilution technique and pulse counter analysis. Optimal monitoring of cardiac preload is of paramount importance for the hemodynamic management of multiple-trauma patients with hemorrhagic shock. There have been only a few studies on the use of the PiCCO system (Pulsion, Germany) in multiple-trauma patients with hemorrhagic shock for hemodynamic monitoring. We hypothesized that performing a cardiac adequate preload evaluation with the PiCCO system would make it possible to predict latent hemorrhagic progress.

An X chromosome-linked mouse mutant (mdx) has been investigated as an animal model of Duchenne's muscular dystrophy, and has been found to have the same defect of dystrophin in the muscle surface membrane. Intracellular recordings from the mdx mouse hemidiaphragm preparations revealed low resting membrane potentials and electrical myotonia which occurred at the time of microelectrode insertion and withdrawal. Electrical myotonia of the mdx mouse was observed in 30-50% of the impaled muscle fibers at low temperature, which decreased to only 7.8% at 37 degrees C. Electrical myotonia of mdx mice was not abolished by (+)-tubocurarine. Though there was no behavioral myotonia in mdx mice, repetitive bursts of action potentials in mdx mice were based on the abnormalities of the muscle membrane since neuromuscular blockade did not abolish the repetitive bursts. Also close observation of the lenses of mdx mice revealed cataracts from the newborn stage to the adult age. Slit lamp examination of the lenses of the mdx mice revealed nuclear cataracts followed by anterior subcapsular cataract as they grew. The cataract of mdx mice is different from that of myotonic dystrophy which is usually posterior subcapsular.

A study of the dependence of the carrier mobilities on temperature and crystal thickness in orthorhombic sulphur crystals was performed using 0.4 µsec X-ray pulses in order to avoid surface effect. The saturation of the collected charge at applied fields exceeding 40 kV/cm was found to be due to the so-called “schubweg effect.” At 290°K the values of schubweg per unit field for electrons and holes are estimated at 6×10 -7 and (1-5)×10 -6 cm 2 V -1 , respectively. With the mobility data, the results lead to the lifetimes of 800 µsec for electrons and 66 µsec for holes. The number of carrier pairs generated by X-rays is relatively insensitive to temperature. The energy necessary to create an electron-hole pair lies between 16 and 30 eV. The effect of excitons on carrier generation may be important in uniform excitation by X-rays.

PURPOSE To investigate the feasibility of dynamic susceptibility-weighted contrast material-enhanced (DSC) perfusion imaging with ferucarbotran at 3.0 T, and to assess the impact of the different characteristics of gadolinium (Gd)- and ferucarbotran-based agent in rCBV measurement under pathologic condition with BBB disruption. MATERIALS AND METHODS Nine patients with suspected meningioma (4 men and 5 women; age range, 27-79 years; mean age, 61.6 +/- 17.9 years) were eligible for the study. Approval was obtained from the institutional review board. All participants provided signed informed consent prior to the study. DSC perfusion images were acquired with a T2*-weighted echo-planar imaging sequence during the first pass of a standard-dose of Gd-based agent, and of 4, 8, or 16 micromol Fe/kg of ferucarbotran-based agent in 3 patients for each dose respectively. Pre- and postenhanced T1-weighted images were obtained in all. RESULTS Ferucarbotran decreased the signal intensity in both gray and white matter in a dose-dependent fashion. Differences regarding the DeltaSI between the 4 and 8 or 8 and 16 micromol Fe/kg groups were statistically significant (P < 0.05, 1-way analysis of variance, Tukey-Kramer method) in any region. No effect of leakage of ferucarbotran was demonstrated in the intensity-time curves or in the postenhanced T1-weighted images. Relative CBV in tumor area obtained with Gd was reduced to 37.6%-86.5% compared with that obtained with ferucarbotran. CONCLUSIONS T2*-weighted DSC perfusion imaging with ferucarbotran is feasible at 3.0 T. Compared with Gd-based agent, larger particle size of ferucarbotran can diminish the effect of contrast leakage during the first pass under pathologic conditions with BBB disruption.