Objectives:Skin perfusion pressure （SPP） is used to assess peripheral circulation, but its relationship with postoperative hemodynamics after cardiac surgery has not been fully evaluated.　This study aimed to clarify the association between SPP and major hemodynamic parameters in the early postoperative period and to evaluate the feasibility of SPP as a noninvasive bedside screening tool for postoperative circulation.

Methods:Twenty-one adult patients who underwent cardiac surgery with cardiopulmonary bypass between July 2016 and June 2017 were enrolled.　SPP was measured 63 times in the intensive care unit, together with mean arterial pressure （mAP）, mean pulmonary arterial pressure （mPAP）, cardiac index （CI）, mixed venous oxygen saturation （SvO₂）, and blood lactate levels.　Correlations between SPP and these variables were analyzed, followed by multiple regression analysis.

Results:SPP showed significant positive associations with mAP （r = 0.346, p = 0.005） and SvO₂ （r = 0.290, p = 0.021）.　In the multiple regression model including mAP, SvO₂, CI, lactate, and mPAP, only SvO₂ remained independently associated with SPP, yielding the regression equation:mSPP = 10.795 + 0.883 × SvO₂.

Conclusions:After cardiac surgery, SPP was associated with mean arterial pressure and mixed venous oxygen saturation, with the strongest association seen with SvO₂.　Because SPP is noninvasive and repeatable at the bedside, it may serve as a practical screening indicator for postoperative circulatory assessment.

Gallbladder torsion is a disease in which the migrating gallbladder torsions at the neck of the gallbladder, causing a sudden decrease in blood flow and the need for emergency surgery.　Early diagnosis by ultrasonography（US） and contrast-enhanced computed tomography （CECT） is recommended.

Case 1 is an 85-year-old woman.　who was referred to our department because she had a complaint of pain in the lower right abdomen, constipation, and nausea.　A simple abdominal X-ray showed clear colon gas.　Abdominal US showed diffuse thickening of the gallbladder wall.　CECT showed an enlarged gallbladder and disruption of blood flow.　The gallbladder was free from the liver bed.　She was diagnosed with gallbladder torsion and underwent an emergency laparoscopic cholecystectomy on the same day.　The gallbladder had twisted 360 degrees counterclockwise at the neck, and it was severely congested and necrotic, appearing dark red.

Case 2 was an 85-year-old woman.　She came to our hospital with complaints of lower abdominal pain and anorexia.　Abdominal US showed circumferential thickening of the gallbladder wall, decreased blood flow, narrowing of the neck of the gallbladder, and interruption of the cholecystic duct.　CECT showed hyperabsorption around the gallbladder wall, gallbladder enlargement, and wall thickening.　In addition, a spiral image was seen in the neck of the gallbladder due to torsion around the artery.　She was diagnosed with gallbladder torsion and required emergency surgery.　However, due to findings on preoperative cardiac ultrasound, it was determined that surgery at our facility would be difficult, so she was transferred to an advanced medical institution and underwent laparoscopic cholecystectomy.　The gallbladder was distorted at the neck, and the entire gallbladder was necrotic.

Since gallbladder torsion requires emergency surgery, it is important to understand the characteristic pathophysiology and imaging findings.

Background:The impact of family physicians （FPs） on the Japanese healthcare system has not been evaluated adequately.　This study aimed to compare healthcare costs of ambulatory services provided by FPs and non-FPs.

Method:We conducted a cross-sectional study using claims data from the National Health Insurance database for Kitakata City, Fukushima Prefecture, from April 2012 to March 2013.　Patients receiving ambulatory services exclusively at the Kitakata Center for Community and Family Medicine （KCCFM）, operated by certified FPs, were assigned to the "KCCFM group".　Those who received care exclusively at other clinics were assigned to the "other clinics group".　After propensity score matching, we compared healthcare costs associated with ambulatory services between the two groups.

Results:Of the 1,170 eligible patients, 119 were assigned to each group after propensity score matching.　The "KCCFM group" had significantly lower total annual medical costs （median:32,340 yen vs. 62,180 yen;p=0.003） and fewer annual visits （median:2.0 vs. 4.0;p=0.001） compared to the "other clinics group".

Conclusion:Our findings suggest that ambulatory care provided by FPs is associated with fewer patients visits and subsequently lower annual medical costs compared to care from non-FPs in Japanese primary care setting.