Maebashi Red Cross Hospital

A 46-year-old man suffered thoracic spine fracture dislocation in a motorcycle accident, presenting with complete lower extremity paralysis. Imaging revealed a T8 vertebral dislocation and complete spinal cord transection. Urgent surgery approximately 36 hours postinjury included posterior fixation, bone grafting, duraplasty, and spinal cord stump-plasty. Postoperatively, his neurological status remained unchanged. Minimal cerebrospinal fluid leakage resolved; no other major complications developed. He is stable and mobile through a wheelchair. Prompt surgical stabilization and dural repair can be essential to prevent life-threatening complications in complete thoracic spinal cord transection. This case illustrates 1 possible management strategy for this exceptionally severe and rare injury pattern.

背景・目的：腎機能が低下した患者では99mTc-MDPの体内クリアランスが遅延し，診断に寄与しない不必要な放射線被ばくが生じる．本研究は，日常の骨シンチグラフィ撮像から簡便に得られる大腿部バックグラウンド値（以下，BG値と略す）を体内残存放射能の代替指標として用い，腎機能に基づいた実践的な投与量最適化プロトコルを開発することを目的とした．

要旨重症外傷患者に対する全血輸血が，米国トラウマセンターを中心に導入されつつある。全血輸血は古くから戦傷医療の現場で実施されてきた歴史があり，米国ではこの戦傷医療の経験をもとに，早期から全血輸血をガイドラインに組み込んできた。近年では，一般市民に対する医療現場でも，従来の成分製剤による輸血治療に加えて，とくに血小板を含む全血製剤を使用することで予後の改善が報告されている。本総説では，全血輸血および成分輸血の歴史，全血製剤の種類と定義，成分製剤および全血製剤中の血小板機能，本邦における全血製剤の使用状況，既存の全血輸血に関する研究，さらに本邦における全血導入により期待される効果と課題について述べる。外傷患者における全血輸血に関する明確なエビデンスは依然として不足しているが，現時点の報告からはその有用性が高く期待される。本邦においても，外傷患者のさらなる予後改善を目指し，全血輸血の導入が検討されることが望まれる。

Central nervous system (CNS) prophylaxis is recommended for patients with diffuse large B-cell lymphoma (DLBCL) who are at high risk of CNS relapse. This study aimed to determine the impact of CNS prophylaxis on CNS relapse rates and overall survival (OS) in this patient population, as well as the optimal method for CNS prophylaxis. This was a retrospective analysis of 178 patients with DLBCL at high risk of CNS relapse who were treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP) or its derivatives with (N = 60) or without (N = 118) CNS prophylaxis. The 2-year CNS relapse rate was 17.6% in the all-prophylaxis group (HD-MTX 17.4%, IT 48.1%, and HD-MTX + IT 6.2%) and 13.0% in the non-prophylaxis group, with no significant difference between groups. However, HD-MTX + IT decreased the risk of CNS relapse. After a median follow-up of 72.8months, HD-MTX + IT addition significantly improved the 5-year OS (HD-MTX 73.5%, IT 44.4%, HD-MTX + IT 93.2%; non-prophylaxis group 58.0%; p = 0.013). This advantage was maintained in the multivariate analysis (hazard ratio: 0.160; 95% confidence interval: 0.039-0.663; p = 0.012). CNS prophylaxis with HD-MTX + IT improved the prognosis of patients with DLBCL at high risk of CNS relapse.

The simple patch closure technique is an alternative method for repairing ventricular septal rupture following myocardial infarction. This single-center study aimed to investigate the outcomes of ventricular septal rupture repair. This retrospective study included 23 patients who underwent initial surgery using the simple patch-closure technique between January 2009 and August 2024. Three primary endpoints were established: the rupture recurrence rate, in-hospital mortality rate, and mid-term survival rate. Survival curves were constructed using the Kaplan-Meier method. The mean patient age was 71.0years, and 13 patients were male. Intraoperative transesophageal echocardiography detected no residual shunts; however, five (21.7%) patients experienced rupture recurrence at a median of 21 (range, 12-150) days postoperatively, all requiring reoperation. The hospital mortality rate was 8.7%, with one death each in the early and late surgery groups. The 60month survival rate was 75.7% over a median follow-up period of 36months (range: 4-149months). The simple patch closure technique is safe and effective for ventricular septal rupture repair, even in early surgery; however, recurrence remains a challenge. Preventive measures, such as bovine pericardial patches and the double-patch technique for extensive infarctions, warrant further validation through larger studies with longer follow-up periods.

Nutrition therapy is important in the management of critically ill patients and is continuously evolving as new evidence emerges. The Japanese Critical Care Nutrition Guideline 2024 (JCCNG 2024) is specific to Japan and is the latest set of clinical practice guidelines for nutrition therapy in critical care that was revised from JCCNG 2016 by the Japanese Society of Intensive Care Medicine. An English version of these guidelines was created based on the contents of the original Japanese version. These guidelines were developed to help health care providers understand and provide nutrition therapy that will improve the outcomes of children and adults admitted to intensive care units or requiring intensive care, regardless of the disease. The intended users of these guidelines are all healthcare professionals involved in intensive care, including those who are not familiar with nutrition therapy. JCCNG 2024 consists of 37 clinical questions and 24 recommendations, covering immunomodulation therapy, nutrition therapy for special conditions, and nutrition therapy for children. These guidelines were developed in accordance with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system by experts from various healthcare professionals related to nutrition therapy and/or critical care. All GRADE-based recommendations, good practice statements (GPS), future research questions, and answers to background questions were finalized by consensus using the modified Delphi method. Strong recommendations for adults include early enteral nutrition (EN) within 48 h and the provision of pre/synbiotics. Weak recommendations for adults include the use of a nutrition protocol, EN rather than parenteral nutrition, the provision of higher protein doses, post-pyloric EN, continuous EN, omega-3 fatty acid-enriched EN, the provision of probiotics, and indirect calorimetry use. Weak recommendations for children include early EN within 48 h, bolus EN, and energy/protein-dense EN formulas. A nutritional assessment is recommended by GPS for both adults and children. JCCNG 2024 will be disseminated through educational activities mainly by the JCCNG Committee at various scientific meetings and seminars. Since studies on nutritional treatment for critically ill patients are being reported worldwide, these guidelines will be revised in 4 to 6 years. We hope that these guidelines will be used in clinical practice for critically ill patients and in future research.

Many articles document the efficacy of the fissureless technique, most of which focus on a right upper lobectomy. However, there are a few reports on a fissureless left upper lobectomy, especially using a robotic approach. This report presents a successful case of a robotic fissureless left upper lobectomy in a patient with a dense fissure. The total console time was 111 minutes. The postoperative course was uneventful, with the chest tube being removed on postoperative day 1. The patient was successfully discharged on postoperative day 2. The final pathology report confirmed adenocarcinoma, staged as pT1cN1M0, stage IIB. Precise preoperative evaluation using three-dimensional computed tomography broncho-angiography is essential to understand the anatomy accurately and to avoid complications in this challenging procedure.

ABSTRACTBACKGROUNDExtracorporeal membrane oxygenation (ECMO) is a vital intervention in patients with severe cardiogenic shock or respiratory failure who are unresponsive to conventional therapies. Despite advances in ECMO technology and management, complications such as infections, renal dysfunction, and post-intensive care syndrome remain significant challenges that contribute to high mortality. Existing registries have provided valuable insights but lack detailed data on infection management, rehabilitation practices, and other granular aspects of ECMO care. The Japan Intensive Care ECMO Consortium: Nationwide Effort for ECMO Care Optimization and Excellence (ECMO NEXT) study aims to address these gaps by establishing a comprehensive multicenter study in Japan.METHODSThis is a multicenter, retrospective cohort study conducted at 22 healthcare institutions in Japan, with data collected on ECMO cases between January 2018 and December 2023. Adults aged ≥18 years who underwent ECMO in the intensive care unit (ICU) during this period will be eligible. This study will focus on six predefined themes: post-decannulation fever, infection epidemiology, ventilator settings, ECMO-associated acute kidney injury and electrolyte abnormalities, rehabilitation practices, and venoarterial ECMO in toxicological emergencies and septic shock scenarios. Data—including clinical course, laboratory results, rehabilitation details, and outcomes—will be collected using a standardized electronic case report form on the Research Electronic Data Capture platform. Statistical models, including propensity score-based analyses, will be used to adjust for confounders and assess attributable risks.CONCLUSIONSThe ECMO NEXT study provides high-resolution data to address the gaps in ECMO research, particularly in ICU management and post-ECMO recovery.