Streptococcal Toxic Shock Syndrome Due to Invasive Coloproctitis Caused by Group G Streptococcus: A Case Report and Literature Review.

Streptococcus dysgalactiae subsp. equisimillis (SDSE) is classified as a group G streptococcus (GGS). In systemic SDSE infection, septic shock is easily induced and has a high mortality of 44%. The case was a 78-year-old man presented with fever and chills of 20 hours duration. He was in shock at the presentation and developed melena on day nine. CT images showed bowel wall thickening with emphysema and bedside colonoscopy showed active bleeding in the descending colon and rectum. Blood cultures were positive for Streptococcus dysgalactiae and a diagnosis of streptococcal toxic shock syndrome (STSS) due to SDSE was made. Urgent Hartmann procedure with laparotomy for removal of descending and rectal colon was performed to relieve his shock status. His shock status was reversed after surgery. Surgical specimens confirmed the presence of SDSE on the intestinal mucosa. This is the first case of STSS due to SDSE infection of the intestinal wall. Resection of infected tissue in the setting of multiple organ dysfunction syndrome and necrotizing enterocolitis is indicated in such cases.

Planned Versus On-Demand Relaparotomy Strategy in Initial Surgery for Non-occlusive Mesenteric Ischemia.

BACKGROUND: There has been insufficient evidence regarding a treatment strategy for patients with non-occlusive mesenteric ischemia (NOMI) due to the lack of large-scale studies. We aimed to evaluate the clinical benefit of strategic planned relaparotomy in patients with NOMI using detailed perioperative information. METHODS: We conducted a multicenter retrospective cohort study that included NOMI patients who underwent laparotomy. In-hospital mortality, 28-day mortality, incidence of total adverse events, ventilator-free days, and intensive care unit (ICU)-free days were compared between groups experiencing the planned and on-demand relaparotomy strategies. Analyses were performed using a multivariate mixed effects model and a propensity score matching model after adjusting for pre-operative, intra-operative, and hospital-related confounders. RESULTS: A total of 181 patients from 17 hospitals were included, of whom 107 (59.1%) were treated using the planned relaparotomy strategy. The multivariate mixed effects regression model indicated no significant differences for in-hospital mortality (61 patients [57.0%] in the planned relaparotomy group vs. 28 patients [37.8%] in the on-demand relaparotomy group; adjusted odds ratio [95% confidence interval] = 1.94 [0.78-4.80]), as well as in 28-day mortality, adverse events, and ICU-free days. Significant reduction in ventilator-free days was observed in the planned relaparotomy group. Propensity score matching analysis of 61 matched pairs with comparable patient severity did not show superiority of the planned relaparotomy strategy. CONCLUSIONS: The planned relaparotomy strategy, compared with on-demand relaparotomy strategy, did not show clinical benefits after the initial surgery of patients with NOMI. Further studies estimating potential subpopulations who may benefit from this strategy are required.

Can the global end-diastolic volume index guide fluid management in septic patients? A multicenter randomized controlled trial.

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.

Protective effect and mechanism of IL-10 on renal ischemia-reperfusion injury.

Interleukin (IL)-10, a cytokine with anti-inflammatory effects, is produced by blood cells and cells of various organs. Ischemia-reperfusion injury (IRI) is a systemic inflammatory disease caused by a systemic circulation of pro-inflammatory cytokines and chemokines produced from blood cells or organs damaged by ischemia. Apoptosis, a key event after IRI, is correlated with the degree of injury. Here we investigated the effects and mechanism of IL-10 in renal IRI. Compared to wild-type (WT) mice with a renal IRI, IL-10 knockout (IL-10 KO) mice with IRI demonstrated decreased renal function as represented by blood urea nitrogen and serum creatinine, upregulated early acute kidney injury (AKI) biomarkers such as kidney injury molecule-1 (Kim-1), increased mRNA expression of the pro-inflammatory cytokines IL-1ß, IL-6, and IL-18 and a chemokine (regulated on activation, normal T cell expressed and secreted; RANTES), and increased expression of the pro-apoptosis factors Bax and cleaved caspase-3. When tubular epithelial cells (TECs) from IL-10 KO mice were put in a hypoxic state and added with recombinant IL-10, their expression of Bax decreased. Our findings demonstrated that IL-10 suppressed the production of pro-inflammatory cytokines, renal dysfunction, and the expression of pro-apoptosis factors after IRI.

Administration of cultured autologous bone marrow stromal cells into cerebrospinal fluid in spinal injury patients: a pilot study.

PURPOSE: To determine whether intrathecal administration of cultured autologous bone marrow stromal cells (BMSCs) is safe and feasible for treatment of subacute spinal injury. METHODS: Five patients with complete tetraplegia due to cervical spinal injury on admission were included. A small amount of bone marrow was obtained during surgery for spinal fusion. BMSCs were cultured, reaching 107-108 cells. The properties and functional efficacy of the BMSCs were verified with surface marker analysis and a neurite extension test. BMSCs were administered by lumbar puncture. The patients were closely observed for 6 months, and the Committee on Effectiveness and Safety of Clinical Treatment (CESCT) evaluated safety. RESULTS: No adverse responses were observed in biochemical and radiographic examinations. The CESCT did not recognize any harmful effects of the transplantation, and concluded it was safe for treatment. The patients were further followed up for 1 to 4 years with no adverse responses. The recovery of American Spinal Injury Association Impairment Scale (AIS) B and C patients at transplantation was rapid and remarkable, but gradual or limited in AIS A patients. CONCLUSION: This study demonstrated that intrathecal administration of cultured autologous BMSCs is safe and feasible for treatment of spinal cord injury.

Effects of hypertonic saline on CD4+CD25+Foxp3+ regulatory T cells after hemorrhagic shock in relation to iNOS and cytokines.

BACKGROUND: Hemorrhagic shock and resuscitation induce immunosuppression. CD4(+)CD25(+)Foxp3(+) regulatory T Cells (Foxp3(+) Tregs), iNOS and cytokines may affect these severe conditions such as acute respiratory distress syndrome and multiple organ failure after hemorrhagic shock and resuscitation. Foxp3(+) Tregs have been described to be specific and play a key role in the control of the immune system. Immune condition may be restored by hypertonic saline resuscitation that inhibits pro-inflammatory effects of cytokine. Our aim was to investigate how hypertonic saline resuscitation affected Foxp3(+) Tregs after hemorrhagic shock and resuscitation in relation to iNOS and cytokines. METHODS: Male C57BL6/J and B6.129P2- NOS2(tm1Lau)/J (iNOS gene knockout) mice were used in creating hemorrhagic shock model. Mice were divided into two groups, each according to the type of resuscitation. (1) Wild HS: resuscitation with hypertonic saline (4 mL/Kg of 7.5% NaCl) and the shed blood (SB); (2) wild 2LR: resuscitation with lactated Ringer's solution and the SB; (3) iNOS knockout HS: similarly resuscitated as wild HS; (4) iNOS knockout 2LR: similarly resuscitated as wild 2LR. Samples of thymus and spleen were harvested at 2, 6, 24, 48, and 72 h after resuscitation. CD4(+) T cells and Foxp3(+) Tregs were analyzed at 24, 48, and 72 h. At 2, 6, 24, and 48 h, plasma cytokines were assayed and expression of iNOS (NOS2) was also measured by immunofluorescence. RESULTS: NOS2 of HS and 2LR wild groups at 2 and 6 h in spleen increased compared with the control group. At 6h, NOS2 in HS wild group was significantly lower than in 2LR wild group. Plasma levels of interleukin (IL)-6, TNF- α, MCP-1, and IL-10 increased at 2 h. Both in wild type and iNOS knockout mice, hypertonic saline resuscitation decreased plasma IL-6, TNF-α, and MCP-1 levels at 2 h; CD4(+) T cells in spleen and thymus decreased at 24, 48, and 72 h, and Foxp3(+) Tregs in spleen at 48 h increased, however, hypertonic saline resuscitation did not affect the Foxp3(+). CONCLUSIONS: These results show that in early phase, the inflammatory cytokines in plasma might affect iNOS expression and cytokines. Further, this study showed that hypertonic saline resuscitation and suppression of iNOS might improve immunosuppressive reaction after hemorrhagic shock.

[Extreme hyperkalemia in a patient with a new glyphosate potassium herbicide poisoning: report of a case].

CASE REPORT: A 65-year-old female was transferred to our emergency and critical care center after taking two kinds of commercially available glyphosate herbicide products. On admission, her conscious level was depressed to Glasgow Coma Scale E3, V2, and M6. Vital signs were as follows ; blood pressure 83/33mmHg, pulse 59/min, and respiratory rate was 24/min. Arterial blood gas analysis showed metabolic acidosis and an extreme hyperkalemia of 9.22 mEq/L. Electrocardiogram showed absence of P wave and a tall, tapering T wave. On admission, gastric lavage was followed by an intragastric administration of activated charcoal together with cathartic. Immediately after recognition of hyperkalemia, sodium bicarbonate, glucose plus insulin, and calcium gluconate were also administered intravenously. Five hours later, plasma concentration of potassium decreased to 4.31 mEq/L, and the patient discharged on day 10. Later, it was disclosed that the new Roundup Maxload contains high concentration of glyphosate potassium. CONCLUSION: In case of Roundup poisoning, we have to take it consideration that the poisoning may results in a hyperkalemia.

Effect of hypertonic saline resuscitation on CD4+CD25+ regulatory T cells and gammadelta T cells after hemorrhagic shock and resuscitation in relation to apoptosis and iNOS.

BACKGROUND: Hemorrhagic shock and resuscitation induce immunosuppression. CD4CD25 regulatory T cells and gammadeltaT cells may affect these immunosuppressive conditions. Hypertonic saline resuscitation reduces damage to organs and apoptosis and also restores immunosuppressive condition. We investigated how hypertonic saline resuscitation affected the induction of CD4CD25 regulatory T cells and gammadeltaT cells, and their apoptosis after hemorrhagic shock and resuscitation, and its relationship to inducible nitric oxide synthase (iNOS) (nitric oxide production). METHODS: Male inbred C57BL6/J mice 8-week to 12-week-old as wild type and iNOS gene knock out (iNOS-/-), weighing 20 g to 35 g, were used. Hemorrhagic shock model of +/-40 mm Hg for 60 minutes was setup. Animals were randomly assigned to the following four resuscitation group: (1) wild HS: resuscitation with hypertonic saline (4 mL/Kg of 7.5% NaCl) and shed blood (SB), (2) wild 2LR: resuscitation with lactated Ringer's solution (two times the volume of the SB) and SB, (3) iNOS knockout HS, and (4) iNOS knockout 2LR. Untreated groups for wild and iNOS knockout mice were designated as control groups. Samples of thymus and spleen were harvested at 2 hours, 6 hours, 24 hours, and 48 hours after resuscitation. CD4CD25 regulatory T cells and gammadeltaT cells were analyzed using three-color flow cytometry. RESULTS: (1) gammadelta T cells increased earlier at 24 hours and CD4CD25 regulatory T cells increased later at 48 hours compared with controls in spleen of wild type (p < 0.01). (2) Hypertonic saline resuscitation suppressed gammadelta T cells compared with 2LR at 24 hours in iNOS knockout mice in spleen (p < 0.05). Hypertonic saline resuscitation increased apoptosis of CD4CD25 regulatory T cells at 48 hours in iNOS knockout mice in spleen (p < 0.01). (3) CD4CD25 regulatory T cells of iNOS knockout both in HS and 2LR groups at 48 hours decreased compared with wild type both in HS and 2LR groups in spleen (p < 0.01). (4) Apoptotic gammadelta T cells both in spleen and thymus in iNOS knockout mice at 48 hours increased compared with those in wild type (p < 0.05, respectively, except gammadelta T cells 2LR in spleen: p = 0.058). CONCLUSION: gammadelta T cells increased earlier at 24 hours, whereas CD4CD25 regulatory T cells increased later at 48 hours in spleen of wild type. Hypertonic saline was effective without the presence of iNOS, i.e., decreased gammadelta T cells at 24 hours and increased apoptosis of CD4CD25 regulatory T cells at 48 hours. CD4CD25 regulatory T cells at 48 hours without iNOS decreased compared with those of wild type. gammadelta T cells at 48 hours induced apoptosis under the condition without iNOS in spleen and thymus. iNOS worked as an accelerating factor for immunosuppressive condition, affected apoptosis, and immunoenhancing effect by hypertonic saline.

Clinical analysis of seven patients of crushing head injury.

BACKGROUND: Crushing head injuries (CHI) are caused by static loading. This static force slowly deforms a cranium and damages some intracranial components. Severe CHI is usually fetal but substantial brain damage may not be recognized in some patients. In this article, we report seven patients who sustained CHI and analyzed clinical and radiological findings. METHODS: In seven patients who sustained CHI, the following factors were analyzed: epidemiological features, neurological findings, and neuroradiological findings. RESULTS: The present series included three males and four females. Mean age was 5.9 years. Six patients had the heads run over by automobiles. One patient had the head crushed by press machine. Epistaxis in six patients and otorrhagia in five patients was recognized. Mean Glasgow coma scale at admission was 8.1. Multiple linear fractures were recognized in four patients and skull base fractures in six patients. Pneumocephalus in five patients and cerebrospinal fluid leakage in seven patients was recognized. One patient underwent evacuation of ASDH and dural plasty. Four patients died and three survived and had only cranial nerve palsies, which recovered completely. CONCLUSION: This injury actually has seldom been countered in daily practice and clinical manifestation and neuroimaging have characteristic features. The prognosis of CHI may be polarized to fatal or excellent, and depends on whether the cranium and brain itself can tolerate the applied force.

Perimesencephalic nonaneurysmal subarachnoid hemorrhage caused by physical exertion.

The clinical characteristics of perimesencephalic nonaneurysmal subarachnoid hemorrhage (SAH) caused by physical exertion were analyzed to investigate the causes and mechanisms of perimesencephalic nonaneurysmal SAH. Nine of 209 patients with spontaneous SAH were identified as having perimesencephalic nonaneurysmal SAH. Perimesencephalic nonaneurysmal SAH in four males and three females was precipitated by exertion. Age, sex predominance, type of exertion, symptoms, loss of consciousness during bleeding, clinical grade, angiographic spasm, hydrocephalus, delayed ischemic deficit, rebleeding, hypertension, and outcome were evaluated in these seven patients. Outcomes were assessed using the Glasgow Outcome Scale. Patients showed male predominance (57.1%), relatively young age (mean 50 years), low frequency of hypertension (28.6%), good clinical grade (World Federation of Neurological Surgeons grade I or II), and excellent outcomes including no rebleeding, no symptomatic hydrocephalus, and no delayed ischemic deficits. The type of exertion was swimming in two patients, golfing in two patients, heavy lifting in two patients, and bending forward during gymnastics in one patient. Physical exertion including components of the Valsalva maneuver is an important predisposing factor for perimesencephalic nonaneurysmal SAH. Such physical exertion produces increased intrathoracic pressure, which blocks the internal jugular venous return, resulting in elevated intracranial venous pressure or mechanical swelling of the intracranial veins, and leads to venous or capillary breakdown.

Magnetic resonance images in hanging.

Hanging is a devastating method of suicide and unfortunately is common in Japan. Although several CT findings of the head have been reported, there have not been any reports about magnetic resonance imaging (MRI) in hanging. We report here interesting MRI findings in a patient after hanging. A 39-year-old woman was transferred to our department after attempting suicide by hanging. Respiration had probably ceased for about three minutes but heart had not stopped when she was pulled down by her father. After her father performed cardiopulmonary resuscitation, she started to breathe immediately. She was treated conservatively in our intensive care unit for 14 days, her condition became stable. Ten days after admission, MRI demonstrated symmetrical hyperintensity on T1-weighted images and relative hyperintensity on T2 weighted images in bilateral lentiform nuclei and medial thalami. There have been several reports about characteristic MRI findings in the case of acute global cerebral ischaemia caused by severe hypoglycaemia or longstanding cardiopulmonary arrest. It was postulated that these specific findings reflected tissue degeneration, deposition of mineral substances, or lipid accumulation. These MRI findings suggest that severe acute global cerebral hypoperfusion also occurs in hanging in the same way as in long-standing cardiopulmonary arrest and that hanging has devastating sequelae.

Prognostic factors in hanging injuries.

The objectives of this study were to review variable factors influencing outcomes in hanging and to identify prognostic factors related to outcomes. Forty-seven patients presented to our department. Eleven patients survived and 36 died. A significant difference in mean hanging time was observed between survivor (11.8 +/- 8.37 minutes) and nonsurvivor (50.81 +/- 61.9). In survivors, heartbeat was recognized in 63.6% at the scene and in 90.9% on arrival. Conversely, cardiopulmonary arrest (CPA) was recognized in all nonsurvivors and heartbeat was recognized on arrival in only 5.6%. Thirty-nine (83%) had a Glasgow Coma Score (GCS) of 3 on arrival. Three (7.7%) of theses 39 patients survived. In survivors, eight patients had a GCS greater than 3. A significant difference in outcome existed between patients with a GCS of 3 and those with a GCS greater than 3. Hanging time, presence of CPA at the scene and on arrival, and GCS on arrival represented prognostic factors of outcome in hanging.

Semiquantitative scoring in children under treatment for atopic dermatitis.

BACKGROUND: Atopic dermatitis is the most frequently seen childhood allergic disease in outpatient clinics. Improvement, exacerbation, and response to treatment are typically assessed subjectively and occasionally inaccurately. METHODS: The authors developed two forms for scoring of dermal manifestations and used them to assess 56 children. The correlation between two pediatricians' scores and correspondence to established categories (mild, moderate, and severe) were determined. RESULT: The two physicians' scores for the children correlated well for both forms of scoring. Correspondence of scores as 'mild' and 'moderate' categories were significant (few children participating were 'severe'). CONCLUSION: Use of well-constructed scoring forms should improve clinical assessment of patient course and treatment response.

Hypertonic saline resuscitation reduces apoptosis and tissue damage of the small intestine in a mouse model of hemorrhagic shock.

The effect of hypertonic saline resuscitation on intestinal damage and the incidence of apoptosis after hemorrhagic shock were investigated. After anesthesia, male BALB/c mice weighing 24-34 g were hemorrhaged to the mean arterial pressure of 40 +/- 5 mmHg for 90 min. Animals were randomly assigned to four groups: 1) resuscitation with 4 mL/kg of 7.5% NaCl (hypertonic saline; HS) + shed blood (SB); 2) resuscitation with two times the volume of shed blood of lactated Ringer's solution (2LR) + SB; 3) sham (catheter only); or 4) control (no treatment). Intestinal damage was graded based on the extent of the vacuolation at the basal area of the intestinal villi. Apoptosis of the small intestines was examined with the terminal deoxynucleotidyl transferase-mediated deoxyuridine 5-triphosphate nick-end labeling method and with DNA laddering. Caspase-3 activation, heat shock protein (HSP) 70, and HSP40 were assessed by western blotting. Apoptosis of the small intestine and intestinal damage were significantly lower (P < 0.01) in the HS+SB group compared with the 2LR+SB group 2 h and 6 h after hemorrhagic shock and resuscitation, respectively. This corresponded with more DNA fragmentation in the small intestine of the 2LR+SB group compared with the HS+SB group 2 h after hemorrhage and resuscitation. In addition, we observed less caspase-3 activation in the small intestine of the HS+SB group compared with the 2LR+SB group at 2 h after resuscitation. The content of HSP40 and HSP70 in the HS+SB group was similar to that in controls, but slightly decreased in the 2LR+SB group. HS resuscitation reduced intestinal damage and apoptosis after hemorrhagic shock, suggesting that HS resuscitation may improve the outcome after hemorrhagic shock by reducing apoptosis and damage to the small intestine.

Effect of dose of hypertonic saline on its potential to prevent lung tissue damage in a mouse model of hemorrhagic shock.

Recent studies have shown that hypertonic saline (HS) resuscitation can reduce hemorrhage-induced lung damage by preventing neutrophil activation. In this study, we examined whether this protective effect can be improved by increasing the HS dose used for resuscitation. The protective effect of two HS doses was tested in a mouse model of hemorrhagic shock. BALB/c mice were bled to a mean arterial blood pressure of 35 +/- 5 mmHg for 1 h. Then the animals were resuscitated with lactated Ringer's (LR) or with HS (7.5% NaCl) at doses of 4 mL/kg or 6 mL/kg body weight, sacrificed after 24 h, and lung tissue samples were collected. Evidence of lung injury was evaluated morphologically by scoring histology specimens in a blinded fashion. In a separate set of mice, plasma Na+ and osmolarity were determined 15 min after resuscitation. Resuscitation of hemorrhaged mice with 4 and 6 mL/kg HS increased plasma Na+ concentrations by 5 and 11 mM, respectively. LR treatment reduced plasma Na+ concentrations by 6 mM and resulted in a lung injury score of 6.1 +/- 0.8, accompanied by focal thickening of alveolar membranes, congestion, pulmonary edema, and interstitial and intra-alveolar neutrophil infiltration. HS at 4 mL/kg decreased focal thickening, congestion, pulmonary edema, and neutrophil infiltration, and the injury score to 3.8 +/- 0.9, which was not significantly different from controls (3.6 +/- 0.8), and lung damage was lowest in animals that received 6 mL/kg HS (2.5 +/- 0.2, P < 0.005 vs. LR). Lung damage scores inversely correlated with plasma Na+ concentrations (r > 0.9999). Our data suggest that the protective effect of HS may be a function of the plasma Na+ concentration and that HS at 6 mL/kg is at least equally effective in reducing hemorrhage-induced lung damage compared to the more commonly used HS dose of 4 mL/kg.

Laparoscopic treatment for peripheral pancreatic duct injury after blunt abdominal trauma: report of a case.

We report the successful use of laparoscopy to treat a blunt pancreatic trauma (BPT) in a 33-year-old woman involved in a traffic accident. Computed tomography showed peripancreatic effusion and indicated an injury to the main pancreatic duct (MPD). Urgent endoscopic retrograde pancreatography (ERP) was performed. The ERP revealed a leakage of contrast medium from the peripheral pancreatic duct. The patient underwent drainage of pancreatic effusion using laparoscopic techniques. The patient had an uneventful course, and no complications have been detected a year after the operation. These results indicate that emergency ERP and laparoscopic drainage are appropriate for patients with peripancreatic effusion due to peripheral pancreatic duct injury.

Clinical analysis of 16 patients with brachial plexus injury.

Brachial plexus injury is very rare in neurosurgical practice, so many neurosurgeons have never experienced this problem in Japan. This study describes a clinical analysis of 16 patients aged 5 to 62 years (mean 32.9 years) who presented at our institution with brachial plexus injuries. Nine patients presented with paralysis and seven with paresis. Head injury was the most common associated injury in eight of 16 patients. Six patients were managed conservatively. All patients with C8-T1 paresis spontaneously recovered to a useful level. Surgery was performed in 10 patients: six neurolysis, two neurotization, and three nerve grafting procedures. All six patients who underwent neurolysis of the brachial plexus attained useful recovery. Four of five patients achieved useful recovery after nerve repair. Nerve grafting achieved a better outcome than neurotization in this study. The difference of outcome was attributed to the graft length. The management of brachial plexus injury is a great challenge, but surgical outcome can be improved if the optimal repair procedure is selected for brachial plexus injury.