Coronary collaterals assessed with myocardial contrast echocardiography in healed myocardial infarction.

The epicardial coronary collateral vessels are visualized with coronary angiography, but this method does not provide significant information about the myocardial perfusion supplied with the collaterals. In this study, myocardial contrast echocardiography (MCE) was performed to assess the coronary collaterals in 29 patients with old myocardial infarction. MCE was performed by intracoronary injection of 2 ml agitated amidotrizoate sodium meglumine. The peak background-subtracted gray level (PGL) in the infarct area was determined from the digitized echocardiographic images obtained before and after injection into the noninfarct and donor artery. PGL was compared with the 3-point coronary angiographic grades of collaterals. PGL in the infarct area was significantly lower in patients with poor collaterals than in patients with moderate to good collaterals (5 +/- 4 vs 18 +/- 8 U mean +/- standard deviation, p less than 0.01). PGL in the infarct area was less than 10 U in the 3 patients with severe asynergy despite the moderate to good collateral supply, suggesting that activity of the collaterals was not good enough to preserve the wall motion effectively. It is concluded that (1) the degree of MCE enhancement in the infarct area generally corresponded to the collateral grades assessed with coronary angiography, and (2) MCE may provide a measure of the collateral perfusion.

Pathologic involvement of the left ventricle in chronic cor pulmonale.

To determine whether or not the left ventricle is pathologically involved in patients with chronic cor pulmonale, right and left ventricular weights, wall thickness, myocyte diameters, and percentage of fibrosis in 18 autopsied hearts were examined in patients with chronic pulmonary disease (CPD); ten had right ventricular hypertrophy on their electrocardiograms, and eight were without right ventricular hypertrophy. Five with extracardiopulmonary disease were used as controls. The weight of the right ventricle was significantly increased in CPD when compared to control subjects. Walls of both ventricles were significantly thicker in CPD. Myocyte diameters of both ventricles were significantly greater in CPD. The percentage of fibrosis in the right ventricle was significantly greater in CPD. The percentage of fibrosis in the left ventricle was significantly greater only in patients with right ventricular hypertrophy. We concluded that the left ventricle was also involved pathologically in patients with chronic cor pulmonale in the end stage of the disease.

Occipital lobe infarction caused by tentorial herniation.

Occipital lobe infarction caused by tentorial herniation was described based on computed tomography findings in nine patients. The whole area of the occipital lobe was involved in five patients; some areas were spared in the others. Infarction other than the ipsilateral occipital lobe was seen in four areas of nine patients: the ispsilateral posterior limb of the internal capsule, contralateral Ammon's horn, and two contralateral occipital lobes. Hemorrhagic infarction was seen in two patients.

Moyamoya-like diseases associated with ventricular hemorrhages: report of three cases.

Three rare cases of moyamoya-like diseases with moyamoya type vessels caused by spontaneous internal carotid artery occlusion, spontaneous middle cerebral artery occlusion, and internal carotid artery occlusion due to cervical irradiation are presented. They resulted in ventricular hemorrhages. One patient died and two survived. Postoperatively, the collateral circulation of the survivors was evaluated by single photon emission tomography using N-isopropyl-[123I]-p-iodoamphetamine. The effectiveness of reconstructive surgery is shown, and moyamoya-like diseases that have been reported are reviewed.

Complications associated with barbiturate therapy.

Fifty-six patients with elevated intracranial pressure caused by cerebrovascular accident, head injury, etc., were the subjects of this study. They were divided into three groups: low dose barbiturate therapy (15 patients), high dose barbiturate therapy (24 patients), and control group (17 patients). Barbiturate therapy was instituted using thiamylal, and the complications caused by barbiturate therapy were recorded. In the control group, complications occurred in the liver of two patients, but there were no renal or pulmonary complications. Pulmonary, renal, and hepatic complications were common in the barbiturate groups. Complications in the high dose therapy group were significantly more common than in the control group. Opportunistic infections occurred in ten patients, with seven patients having pneumonia. Only one patient, with pneumonia, was seen in the control group. The deaths of three patients were influenced by complications associated with barbiturate therapy, while the single death in the control group was not associated with the complication of barbiturate therapy.

The Tokyo subway sarin attack: disaster management, Part 1: Community emergency response.

The Tokyo subway sarin attack was the second documented incident of nerve gas poisoning in Japan. Prior to the Tokyo subway sarin attack, there had never been such a large-scale disaster caused by nerve gas in peacetime history. This article provides details related to how the community emergency medical services (EMS) system responded from the viewpoint of disaster management, the problems encountered, and how they were addressed. The authors' assessment was that if EMTs, under Japanese law, had been allowed to maintain an airway with an endotracheal tube or use a laryngeal mask airway without physician oversight, more patients might have been saved during this chemical exposure disaster. Given current legal restrictions, advanced airway control at the scene will require that doctors become more actively involved in out-of-hospital treatment. Other recommendations are: 1) that integration and cooperation of concerned organizations be established through disaster drills; 2) that poison information centers act as regional mediators of all toxicologic information; 3) that a real-time, multidirectional communication system be established; 4) that multiple channels of communication be available for disaster care; 5) that public organizations have access to mobile decontamination facilities; and 6) that respiratory protection and chemical-resistant suits with gloves and boots be available for out-of-hospital providers during chemical disasters.

The Tokyo subway sarin attack: disaster management, Part 2: Hospital response.

The Tokyo subway sarin attack was the second documented incident of nerve gas poisoning in Japan. The authors report how St. Luke's Hospital dealt with this disaster from the viewpoint of disaster management. Recommendations derived from the experience include the following: Each hospital in Japan should prepare an emergent decontamination area and have available chemical-resistant suits and masks. Ventilation in the ED and main treatment areas should be well planned at the time a hospital is designed. Hospital disaster planning must include guidance in mass casualties, an emergency staff call-up system, and an efficient emergency medical chart system. Hospitals should establish an information network during routine practice so that it can be called upon at the time of a disaster. The long-term effects of sarin should be monitored, with such investigation ideally organized and integrated by the Japanese government.

The Tokyo subway sarin attack: disaster management, Part 3: National and international responses.

The authors report the national and international responses to the disaster produced by the Tokyo subway sarin attack. From a worldwide historical perspective, there had never been such a large-scale disaster caused by nerve gas during peacetime. Therefore, this event should be studied from various viewpoints in cooperation with members of the international community. To this end, the Japanese government should help coordinate a large-scale and detailed investigation of the Tokyo subway sarin attack, including the long-term effects of sarin. The authors also recommend that the Japanese Self Defense Forces should be used more effectively in large-scale disasters. The system of direct control of disaster management by the Japanese government could be useful in a large-scale disaster.

An enzyme-linked immunosorbent assay for plasma-paraquat levels of poisoned patients.

To investigate the efficacy of medical treatments, plasma-paraquat levels were measured in patients who had ingested the liquid weedkiller, Gramoxon, containing paraquat. We determined the levels by an enzyme-linked immunosorbent assay (ELISA) using a murine paraquat-specific monoclonal antibody developed by Niewola et al. (Clin. Chim. Acta, 148 (1985) 149-156). Using this ELISA, concentrations of paraquat in the range 1.56-100 ng/ml could be measured. This assay method had good precision and was suitable for measurement of low levels of paraquat. The therapeutic treatments were most effective on the day of admission. The plasma-paraquat levels of poisoned patients decreased significantly. However, the levels tended to increase again during the pause period of the haemoperfusion and this increase was serious for fatal cases. It is clear that elimination of poison not only from blood but also from tissues is necessary to lower the mortality rate.

Non-ischemic myocardial fibrosis after long-term asbestos exposure.

To determine whether or not myocardial fibrosis in the left ventricle increases after exposure to asbestos fiber, we studied myocardial fibrosis in 42 autopsied hearts; 17 of asbestosis (AS) and 18 of chronic pulmonary disease (CP) without pneumoconiosis. Seven patients with extracardiopulmonary disease were used as a control group (CONT). The extent of myocardial fibrosis in the left ventricle was significantly greater in the AS group compared to the other groups (AS 3.6 +/- 1.3% vs. CP 2.4 +/- 1.0% vs. CONT 1.6 +/- 0.8%). There was a significant difference in the appearance ratio of focal fibrosis between the asbestosis group and the other groups. Focal fibrosis was observed in none of 7 control patients, in 3 of 18 patients with chronic pulmonary disease and in 9 of 17 patients with asbestosis. We concluded that characteristic myocardial fibrosis was observed in humans after long-term asbestos exposure.

Evaluation of severity indexes of patients with paraquat poisoning.

1. Three indexes for evaluating the severity of paraquat poisoning based on plasma-paraquat concentration are presently in use; the curves of Proudfood et al. and Scherrmann et al. and the SIPP. Their effectiveness in determining the prognosis of patients with paraquat poisoning was evaluated. 2. To determine which index was more accurate, contigency tables of the three indexes were obtained and compared; Proudfoot's curve vs the SIPP Scherrmann's curve vs the SIPP. Proudfoot's curve and the SIPP were applied to patients admitted within 24 h after intoxication. Scherrmann's curve and the SIPP were applied to patients admitted more than 24 h after intoxication. The proportions of patients with true positive and true negative results to total patients were compared by a ratio test. 3. Proudfoot's curve was found to be more accurate than the SIPP for predicting the prognosis of patients admitted within 24 h (P less than 0.05). No significant difference, however, was noted between Scherrmann's curve and the SIPP in determining the prognosis of patients admitted after more than 24 h. 4. In conclusion, Proudfoot's curve proved a better index for predicting the outcome of patients who were admitted within 24 h. However, for the prognosis of patients admitted more than 24 h after the ingestion of paraquat, further study is required.

Effect of aggressive haemoperfusion on the clinical course of patients with paraquat poisoning.

The effect of aggressive haemoperfusion; i.e. haemoperfusion of 10 h or more during the first 24 h after ingestion, on the clinical course of paraquat poisoning was studied. Among 40 patients admitted within 15 h after ingestion of paraquat with an SIPP of less than 100 (h x micrograms ml-1), 21 received aggressive haemoperfusion and 19 received conventional haemoperfusion; i.e. haemoperfusion of less than 10 h during the same period. Survival rates of patients with severity between an SIPP of 100 and Proudfoot's curve in the two groups were compared by the log-rank test. Aggressive haemoperfusion did not improve the outcome but did improve the survival rates; that is, the number of patients surviving at particular points in time (P < 0.05). The length of haemoperfusion for the aggressive haemoperfusion group was longer than that for the conventional group on the first day (P < 0.001), but the difference was insignificant during the following two days. Neither the time from ingestion to haemoperfusion, urine volume from the first to third day, nor initial plasma-paraquat concentrations and SIPP were significant between groups. These findings imply that aggressive haemoperfusion reduces the severity of paraquat poisoning and elongates survival time. We, therefore, propose that the efficacy of more aggressive haemoperfusion, such as the 'continuous haemoperfusion' proposed by Okonek et al., should be further studied.

Preoperative diagnosis of obturator hernia by computed tomography in six patients.

Obturator hernia is a rare condition, and the prognosis of patients with this condition is poor. A retrospective study was performed on six patients with obturator hernia between 1993 and 1998. They had been diagnosed preoperatively by computed tomography (CT). The initial CT scan of the abdomen, including the pelvic area, revealed an incarcerated bowel in the obturator foramen of all six patients. All patients underwent laparotomy on the day of admission. Resection of the small bowel was performed in three patients, and release of the small bowel was performed in the remaining three patients. There were no perioperative deaths. In elderly women who have evidence by abdominal plain X-ray studies of small bowel obstruction, we recommend performing CT scan of the abdomen, including CT scan of the pelvic area, for detection of obturator hernia.

Regional cerebral blood flow in the persistent vegetative state.

Regional cerebral blood flow (CBF) in eight patients in a persistent vegetative state was measured and compared with that in five healthy volunteers. The patients were classified into three groups: Group 1 (locked-in syndrome) consisted of a single patient, Group 2 (typical vegetative state) of five patients, and Group 3 (prolonged coma) of two patients. CBF was measured early after onset by single photon emission computed tomography with 123I-N-isopropyl-p-iodo-amphetamine and/or 99mTc-hexamethyl-propyleneamine oxime. The regions of interest (ROIs) were the bilateral frontal, temporal, parietal, occipital, and cerebellar areas and basal ganglia. The values obtained in these areas were averaged, and the ratio for each ROI [(the value in the ROI/the mean value) x 100] was calculated. "Hyperfrontal distribution" of CBF was found to be rare in both the normal condition and the vegetative state. Higher CBF values were noted in the left than in the right frontal area in four of the five volunteers but in only four of the eight patients. CBF distribution in the frontal lobe was characteristic for each group: Group 1 showed high CBF bilaterally, although the elevation was statistically significant only on the right side, and Group 3 exhibited significantly low values. In Group 2, CBF was variable but, for the most part, within normal limits. Awareness was closely correlated with frontal lobe function and alteration of CBF in the frontal region.

[Sepsis due to Salmonella Oranienburg--a case report].

A previously healthy 15-year-old female was admitted to our hospital complaining of nausea and vomiting. She did not complain of diarrhea. A physical examination revealed a lower right quadrant abdominal tenderness without rebound or spontaneous pain and a knocking pain of the costovertebral angle. A high fever, knocking pain of costovertebral angle, and urinary findings including Gram's stain, lead us to suspect a urinary tract infection, cefotiam was administered intravenously. Spiking fever with shaking chills continued for three days, and three sets of blood cultures were positive for Salmonella Oranienburg, but her urine culture was negative. Her history was taken again, revealing an intake of a processed squid product. The product was confirmed by the local public health center to be Salmonella Oranienburg. Finally food poisoning by Salmonella Oranienburg with sepsis was diagnosed. With cefotiam she became better and was discharged from the hospital on the 10th hospital day. During admission to the hospital she did not experience any diarrhea, and her stool culture was negative. Epidemics of Salmonella Oranienburg food poisoning are relatively rare in the literature. In Japan, one has arisen as a result of contamination of a processed squid product in March 1999. However, there have been no cases without so-called gastroenteritic symptoms (abdominal pain and diarrhea) who were previously healthy and developed sepsis caused by Salmonella Oranienburg, reported in Japan. Even in previously healthy patients, with an epidemic situation of non-typhoidal salmonellosis, salmonella sepsis must be ruled out. Among such cases, those who present with spiking fever and shaking chills should be given antibiotic therapy after taking appropriate cultures.

[Disturbance of the coagulatory system in patients with head injury in acute phase].

The coagulation and fibrinolytic function of 100 cases (male 75, female 25) of trauma limited to the head was evaluated in acute phase. The coagulation and fibrinolytic function was evaluated by 6 parameters, consisting of platelet counts, PT, APTT, fibrinogen, serum FDP, and protamine sulfate test. Head injury was categorized into 5 groups according to CT findings: subdural hematoma (SDH: 13 cases), cerebral contusion (CC: 46 cases), epidural hematoma (EDH: 21 cases), skull fracture only (Fr: 14 cases), and cerebral concussion (Co: 6 cases). The results were as follows, in 19 dead cases, severe coagulopathy was observed. In intracerebral injury group (SDH + CC), serum FDP level was markedly elevated. The incidence of disseminated intravascular coagulation (DIC) following head injury was 24% (in dead cases 73.7% in survival cases 12.3%) of all cases, and mortality of cases with DIC was exceedingly high (58.3%). In 14 dead cases with DIC, the patients did not recover from DIC, and their mean survival time was only 89.2 hours. In 10 survival cases with DIC, the patients recovered from DIC. APTT was the most important to estimate the mortality of head injury. Thus, the evaluation of coagulation and fibrinolytic function in head injury in acute phase is not only important to know the occurrence of DIC, but also useful to predict the severity and prognosis of head injury.

[Nontraumatic acute subdural hematoma caused by the rupture of transdural anastomotic vessels in moyamoya disease].

A case of nontraumatic acute subdural hematoma caused by the rupture of transdural anastomotic vessels in a patient with Moyamoya disease is reported. The patient was a 55-year-old woman who was admitted to our hospital in a comatose state. A diagnosis of acute subdural hematoma associated with Moyamoya disease was made on the basis of CT and angiographic findings. No lesions suggestive of trauma, such as cerebral contusion, could be detected during surgery. Although total evacuation of the hematoma was performed, she developed the apallic syndrome and did not recover consciousness. Judging from the angiographic and operative findings, it appears that subarachnoid hemorrhage occurred first and stretched the transdural anastomotic vessels which supplied the collateral circulation. This led to tearing of some of the vessels, and their proximal ends were consequently exposed in the subdural space. The surgical treatment of acute subdural hematoma associated with Moyamoya disease requires the closest attention to avoid damage to the collateral circulation. Although we carefully arrested the bleeding without using a coagulator in order to spare the collateral vessels, the transdural anastomosis was no longer visible on postoperative angiograms. Our experience suggests that hematoma irrigation with trephination therapy, which may minimize the damage to the collateral circulation, may be the most appropriate treatment for acute subdural hematoma associated with Moyamoya disease. Furthermore, cerebral revascularization should be performed for the treatment of the circulatory disturbance intercepted by the hematoma itself or by operative manipulation.

[Circulatory disturbance of deep cerebral veins in eclampsia].

A case of eclampsia with interesting angiographic findings is reported. A 19-year-old woman in the 35th week of gestation by date was admitted due to a sudden onset of generalized clonic convulsion and disturbance of consciousness. The diagnosis was eclampsia. On the second hospital day, extraction of a stillborn female was performed by laminaria. Thereafter, the consciousness improved rapidly and she became alert on the following day. She was discharged without neurological deficit on the 18th hospital day. A CT scan on the day of admission showed narrow lateral ventricles and symmetrical low-density lesions in and around the basal ganglia. These had almost disappeared by the 10th hospital day. Carotid angiography on admission revealed no abnormality in the arterial phase including the lenticulostriate arteries, but, early appearance of deep cerebral veins and some cortical veins was noted. These deep veins, however, were not distinct even in the venous phase. These angiographic findings suggested medullary dilatation caused by circulatory disturbance of the deep cerebral veins. Most authors have stressed the contribution of diffuse arterial vasospasm in the pathogenesis of eclampsia in relation to low-density lesions on CT scans. In the present case, we could not find vasospasm but found circulatory disturbance of the deep cerebral veins. These angiographic findings suggested that the appearance of the low-density lesions on the CT scan was most likely due to venous congestion caused by circulatory disturbance of the deep cerebral veins, since most of the deep medullary veins in the low-density lesions flowed into the deep cerebral veins.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of hypertensive intracerebral hemorrhage associated with ipsilateral internal carotid artery occlusion].

We report a case of intracerebral hemorrhage associated with ipsilateral internal carotid artery occlusion. The patient was a 54-year-old man, who developed a small cerebral hemorrhage in the left internal capsule. He was admitted with mild right hemiparesis to out hospital. Left carotid angiography showed an occlusion at the origin of the internal carotid artery. Right cerebral angiography revealed the slow filling of cerebral arteries of left hemisphere by the cross flow. He was treated conservatively. Two days after admission, the neurological examination revealed no notable abnormalities. The etiology of hemorrhage of this case is presumed as the arterial necrosis due to hypertension. There has been no report on the intracerebral hemorrhage associated with ipsilateral internal carotid artery occlusion. Our case suggests that the volume and enlargement of cerebral hemorrhage may be influenced by cerebral perfusion pressure.

[Neuromonitoring of acute internal carotid artery occlusion].

We experienced a patient with acute thrombosis of the unilateral internal carotid artery. We monitored the brain tissue temperature and intracranial pressure not only in both hemispheres simultaneously but also continuously throughout the process of brain death. The patient was a 73-year-old male who presented to our emergency room with right hemiparesis and aphasia. On admission to our department, no specific pathological findings were identified by brain CT. However a following investigation with left carotid arteriogram demonstrated a complete occlusion of the left internal carotid artery. Probes to monitor intraparenchymal temperature (Tip) and intracranial pressure(ICP) were inserted surgically into the bilateral hemispheres, and these two parameters were monitored continuously until the patient's death. Initially, Tip in the infarcted hemisphere was lower than that in the intact hemisphere, and the left hemisphere's ICP was significantly higher than that of the right one. When the ICP in the left hemisphere exceeded 40 mmHg, bilateral ICPs became equal. Brain herniation was confirmed when the ICP became progressively elevated thereafter. Subsequently the bilateral Tips became equal and lower than the bladder temperature following the brain herniation. In this case, we successfully monitored two parameters while the patient was in the process of brain death; i.e., brain ischemia, complete loss of brain circulation and subsequent decrease in the brain tissue temperature.