Fluorine diffusion assisted by diffusing silicon on the Si(111)-(7x7) surface.

The diffusion process of fluorine (F) atoms on the Si(111)-(7x7) surface is investigated using high-temperature scanning tunneling microscopy. The kinetic parameters of F hopping agree well with those of the diffusing silicon (Si) atoms, which implies that of all reaction processes, the Si diffusion serves as the rate-determining one. Deposition of Si on the surface is found to enhance F hopping, which supports the above-mentioned observation. Theory reveals that the replacement of F adsorption sites by diffusing Si atoms is the key process in the diffusion mechanism.

[A case of fatal acute sodium azide poisoning].

A case of fatal sodium azide poisoning induced by suicidal ingestion was reported. When the patient arrived, her vital signs such as consciousness and blood pressure, were normal. But 25 hours after ingestion, she died from metabolic acidosis, ARDS (acute respiratory distress syndrome) and acute cardiac failure. We detected the azide ion in patient's serum using GCMS method and measured the blood concentration of sodium azide using the GC/NPD method. The half-life period of sodium azide in blood was calculated as about 2.5 hours.

Usefulness and pitfalls of intraoperative spinal motor evoked potential recording by direct cortical electrical stimulation.

OBJECTIVE: The aim of this study is to investigate the usefulness and problems with spinal motor evoked potential (MEP) recording, especially the reasons for failed recording. We report our personal experience over the last 8 years in patients with lesions adjacent to the primary motor cortex. METHODS: MEP records of 50 consecutive patients were retrospectively reviewed. MEP was recorded by a catheter electrode inserted in the cervical epidural space. Stimulation electrodes were placed on the cortical surface during surgery. SEP recording was also performed in 29 of 50 patients. RESULTS: MEP was obtained in 40 cases, and SEP was recorded in all 29 cases. The central sulcus was identified in 93% of patients in whom both MEP and SEP were performed, whereas in only 86% of patients who underwent only MEP. The main reason for MEP failure were inadequate exposure of the motor cortex, pre-existing hemiparesis and technical errors. Postoperative deterioration of motor function was closely related to intra-operative MEP changes. CONCLUSION: MEP is a useful tool to determine the motor cortex and to predict postoperative motor function. However, precise pre-operative craniotomy planning and combination with intra-operative SEP is essential to reduce the MEP failure.

Pancreatographic classification of pancreatic ductal injuries caused by blunt injury to the pancreas.

BACKGROUND: In the treatment of patients with pancreatic injury, the focus of attention is usually on main ductal injuries. METHODS: To develop a classification system for pancreatic ductal injuries, we retrospectively analyzed blunt pancreatic injuries in 40 patients. We assessed the relationships between findings on pancreatography (36 endoscopic retrograde procedures and 4 transduodenal procedures), the treatment modality, and the clinical course. RESULTS: Patients with class 1 injuries (radiographically normal ducts, n = 13) could be treated nonsurgically without major complications. Patients with class 2 injuries (branch injuries, n = 7), in whom contrast medium from ductal branches did not leak from the pancreatic parenchyma (class 2a, n = 3), could be treated nonsurgically. Patients with leaks into the retroperitoneal space (class 2b, n = 4) required at least a drainage laparotomy. Patients with class 3 injuries (main duct injuries, n = 20), including two patients in whom conservative treatment resulted in severe complications, required laparotomy. CONCLUSION: This classification system for pancreatic ductal injuries may facilitate the selection of appropriate therapeutic modalities for patients with blunt pancreatic injury.

Pulse steroid therapy in adult respiratory distress syndrome following petroleum naphtha ingestion.

CASE REPORT: A suicide attempt by a 23-year-old woman involved ingestion of 1000 mL of petroleum naphtha. Early chemical pneumonitis was complicated by life-threatening, diffuse interstitial lung consolidation with pneumatoceles. Pulse steroid therapy beginning on day 17 was associated with remarkable resolution of interstitial consolidation, although an enlarging secondarily infected pneumatocele ruptured to produce a bronchopleural fistula. Thoracic surgery and antibiotic therapy resulted in improvement of the patient's respiratory condition, and she was discharged with no residual respiratory symptoms. High-dose corticosteroid therapy appears to be a useful addition to aggressive supportive treatment in late adult respiratory distress syndrome following hydrocarbon ingestion.

Analysis of medical needs on day 7 after the tsunami disaster in Papua New Guinea.

INTRODUCTION: Because of great intervening distances, international medical relief activities in catastrophic, sudden-onset disasters often do not begin until days 5-7 after the precipitating event. The medical needs of those affected and what public health problems exist in the community in the week after the tsunami disaster in Papua New Guinea(PNG) were investigated. METHODS: The Japan Medical Team for Disaster Relief (JMTDR) conducted investigative hearings at the District Office responsible for the management of the disaster, the Care Center, and the Hospitals in Aitape, Vanimo, and Wewak in PNG. RESULTS: The numbers of in-patients in the Aitape, Vanimo, and Wewak Hospitals, and in the Care Center in Aitape were 291, > 300, 68, and 104, respectively. The exact number of people affected was unknown at the Aitape District Office. There was no lack of medical supplies and drugs in the hospital, but the Care Center in Aitape did not have sufficient quantities of antibiotics. No outbreak of communicable disease occurred, despite the presence of risk factors such as the dense concentration of affected people and the constant prevalence of malaria and diarrhea. The water at Wewak General Hospital contained chlorine and was suitable for drinking, but that elsewhere contained bacteria. CONCLUSIONS: On about the 7th day after the event, the available information still was incomplete, and it was a time to shift from initial emergency activities to specialized medical care. Although no outbreak of communicable disease actually occurred, there was much anxiety about it because of the risk factors present. For effective medical care at this stage, it is essential to conduct a survey of actual medical needs that also include epidemiological factors.

Severe rhabdomyolysis following massive ingestion of oolong tea: caffeine intoxication with coexisting hyponatremia.

A 36-y-o patient with schizophrenia, who had consumed gradually increasing quantities of oolong tea that eventually reached 15 L each day, became delirious and was admitted to a psychiatric hospital. After abstinence from oolong tea his delirium resolved. He was transferred to our hospital when he was discovered to have acute renal failure with hyponatremia (118 mEq/L) and severe rhabdomyolysis (creatine phosphokinase, 227,200 IU/L). On admission rhabdomyolysis had begun to improve despite a worsening of the hyponatremia (113 mEq/L). With aggressive supportive therapy, including hypertonic saline administration and hemodialysis, the patient fully recovered without detectable sequelae. The clinical course suggests that caffeine, which is present in oolong tea, was mainly responsible for the rhabdomyolysis as well as the delirium, although severe hyponatremia has been reported to cause rhabdomyolysis on rare occasions. We hypothesize that caffeine toxicity injured the muscle cells, which were fragile due to the potassium depletion induced by the coexisting hyponatremia, to result in unusually severe rhabdomyolysis. The possibility of severe rhabdomyolysis should be considered in a patient with water intoxication due to massive ingestion of caffeine-containing beverages.

A case of serious organophosphate poisoning treated by percutaneus cardiopulmonary support.

We report a case of respiratory arrest, refractory circulatory collapse, and severe hypothermia following ingestion of an organophosphate insecticide. In addition to conventional management, including mechanical ventilation, administration of vasopressors, enteral lavage, charcoal hemoperfusion and administration of antidotes, extracorporeal cardiopulmonary support in the form of percutaneous cardiopulmonary support was successfully employed. Percutaneous cardiopulmonary support may be used for severe but potentially reversible pulmonary or cardiovascular toxicity induced by organophosphates as well as complicated severe hypothermia.

Rabbit syndrome following phenol ingestion.

CASE REPORT: An elderly Japanese woman ingested a massive quantity of phenol in a suicide attempt. She was admitted to the Emergency Department in respiratory arrest and deep coma. Duodenogastritis was evident endoscopically. With the return of spontaneous respiration and consciousness, fine, rapid rhythmic perioral movements developed together with Parkinsonian findings. The abnormal movements were aggravated by administration of a neuroleptic and ameliorated by discontinuing the drug; they disappeared completely by hospital day 15. In addition to neuroleptic drugs, phenol intoxication may cause the rabbit syndrome by inducing cholinergic dominance with relative dopamine hypofunction in the central nervous system.

The diagnostic problem associated with blunt traumatic azygous vein injury: delayed appearance of right haemothorax after blunt chest trauma.

Azygous vein injury (AVI) associated with blunt chest trauma is rare, but it can become a very serious problem if diagnosis and treatment are delayed. However, in 13 reported cases of AVI, including the present case, right hemothorax was not found on the initial chest X-ray film, even though its delayed appearance was confirmed in 3 out of 13 patients (23.1%). Thus, the diagnosis of AVI can be hampered because of delayed right hemothorax (DRH).

Survival after massive arsenic poisoning self-treated by high fluid intake.

CASE REPORT: A 23-year-old male pharmacist ingested 1040 mg arsenic trioxide (788 mg trivalent arsenic, 13 mg/kg). After 7 asymptomatic hours, frequent vomiting and diarrhea occurred. Fearing death from shock, he drank 5 L of water over 5 hours. When he was brought to our hospital with chief complaint of constricted vision about 20 hours after ingestion, the major abdominal symptoms had already subsided. Despite a lethal plasma arsenic on admission, all toxic symptoms including hepatic dysfunction, erythematous dermal eruption, and peripheral neuropathy improved during his hospital stay with no treatment except for dimercaptopropanol.

Serum amylase level on admission in the diagnosis of blunt injury to the pancreas: its significance and limitations.

OBJECTIVE: The objective of this study was to elucidate the significance and limitations of serum amylase levels in the diagnosis of blunt injury to the pancreas. SUMMARY BACKGROUND DATA: Several recently published reports of analyses of patients with blunt abdominal trauma have indicated that determination of the serum amylase level on admission seemed to be of little value in the diagnosis of acute injury to the pancreas. Few previous reports have described clearly the significance and the limitations of the serum amylase level in diagnosing injury to the pancreas. METHODS: Retrospective analysis of 73 patients with blunt injury to the pancreas during 16-year period from February 1980 to January 1996 was performed. The factors analyzed in the current study included age, gender, time elapsed from injury to admission, hypotension on admission, type of injury to the pancreas, intra-abdominal- and intracranial-associated injuries, and death. RESULTS: The serum amylase level was found to be abnormal in all patients admitted more than 3 hours after trauma. Various comparisons between patients with elevated (n = 61, 83.6%) and nonelevated (n = 12, 16.4%) serum amylase levels showed the statistical significance solely of the time elapsed from injury to admission (7 +/- 1.5 hours vs. 1.3 +/- 0.2 hour, p < 0.001). The major factor that influences the serum amylase level on admission appeared to be the time elapsed from injury to admission. Determination of the serum amylase level is not diagnostic within 3 hours or fewer after trauma, irrespective of the type of injury. CONCLUSIONS: To avoid failure in the detection of pancreatic injury, the authors advocate determination of serum amylase levels more than 3 hours after trauma.

Music alexia in a patient with mild pure alexia: disturbed visual perception of nonverbal meaningful figures.

A 26-year-old female pianist suffered from an intracerebral hematoma caused by an arteriovenous malformation of the left occipital parasplenial region, which was operated on seven months after the onset. Incomplete right hemianopsia, mild pure alexia, and partially disturbed naming of visual objects persisted several months after the removal of the malformation. Evaluation of musical ability one and three months after surgery showed that her auditory recognition of music was intact. She could sing and play melodies already learned and could dictate well the notes after hearing tones. However, she had difficulty in reading music, especially the pitch of notes, even for simple sequences of 4 notes. In contrast, her rhythm reading was fairly good. Her visual recognition of other symbolic figures like road signs was also markedly impaired. These results suggest that her visual recognition of written music as well as of other symbolic figures underwent a preliminary verbal decoding in the left hemisphere and that pitch reading was more dependent on verbal processing than rhythm reading.

Characteristics of pancreatic injury in children: a comparison with such injury in adults.

A retrospective study of eight pediatric patients (under 15 years of age) who had pancreatic injuries was undertaken. Comparisons were made with 59 adult patients who sustained pancreatic injuries over the same 15-year period. All the pediatric injuries and 96.6% of the adult resulted from blunt abdominal trauma. Bicycle accidents (children, 75.0%; adults, 0%; P < .001) and automobile accidents (children, 0%; adults, 61.0%; P < .01) were the most common causes of pancreatic injury in the two groups. There was no significant difference in the incidence of abdominal pain or peritoneal irritation between the groups. However, abdominal pain in the adults was poorly localized. Isolated pancreatic injuries were noted in 62.5% of the pediatric patients and in 15.3% of the adult patients (P < .05). Associated intraabdominal injuries were present in 25.0% of the children and in 69.5% of the adults (P < .05). The duodenum was injured in two (25.0%) pediatric patients and in 10 (16.9%) adult patients. Whereas the duodenal injuries in pediatric patients were intramural hematomas without perforation in both cases, all but one of these injuries in adults were perforations or transections (P < .05). There was a significant difference in the type of pancreatic injury between the two groups (P < .05). Surgery was performed in 12.5% of the pediatric cases and in 78.0% of the adult cases (P < .01). There were no deaths among the pediatric patients, but 8.5% of the adults died in the hospital. The difference with respect to clinical course might be related to the differences in cause of injury.

Release site of TNF alpha after intravenous and intraperitoneal injection of LPS from Escherichia coli in rats.

Lipopolysaccharide (LPS) concentrations in the portal vein after intraperitoneal (i.p.) injection were slightly higher than those in the arteries. The tumor necrosis factor (TNF alpha) levels in arterial serum were higher after i.p. injection than after i.v. injection and rose to a peak at 90 min after some delay. Infusion of LPS into the portal vein increased the TNF alpha levels in the arterial serum. Pretreatment with indomethacin further increased the arterial levels of TNF alpha after portal infusion, but did not after them after i.p. injection, because of the reduction by indomethacin of LPS absorption after i.p. Injection of LPS. TNF alpha was also generated in the peritoneal cavity after i.p. injection of LPS. The TNF alpha concentrations in the arterial serum and in the peritoneal cavity were accelerated by mast cell degradation. In conclusion, TNF alpha was generated mainly in the liver, but also in the peritoneal cavity, after i.p. injection of LPS, and was negatively regulated by prostaglandins.

Role of repeat computed tomography after emergency endoscopic retrograde pancreatography in the diagnosis of traumatic injury to pancreatic ducts.

Endoscopic retrograde pancreatography (ERP) is performed on patients with pancreatic injury after abdominal trauma. To delineate pancreatic ductal injuries more accurately, we performed repeat computed tomography (CT) shortly after completion of ERP. We describe our experiences with six patients to demonstrate the feasibility and utility of this method. In our cases, the diagnosis of pancreatic ductal injury was made with certainty on the basis of the presence of extravasated contrast medium. This protocol is useful for reaffirmation of injuries noted on ERP, for diagnosis of injuries not noted on ERP, and for exclusion of injuries in patients with equivocal results of ERP. Moreover, the protocol is easy to implement because it involves only the transfer of the patient from the endoscopy to the CT suite. The technique can be used to clarify potentially confusing situations.

[The role of emergent endoscopic retrograde pancreatography (ERP): its usefulness in the diagnosis of pancreatic injury].

To determine the therapeutic modalities for pancreatic injury (PI), it is important for the pancreatic ductal injury (DI) to be present or not. We performed ERPs in 36 patients who had positive findings in physical examinations, serum amylase levels and CT within about 13 hours after injury to diagnose the DIs early after injury and to avoid negative laparotomy. In 33 successful ERP patients (intraoperatively in 3), 22 had PIs (14 DIs) and 11 had non-PIs. Of 14 patients with DIs, 12 with main DIs and one with branch injury were treated surgically. Another patient with branch injury, who was treated conservatively, died of the complications of PI. Nineteen patients without DIs, including 8 PIs, were treated conservatively or operated for the associated abdominal injuries, who had no complications on PIs in the hospital days. Three unsuccessful ERP patients, having PIs, were also operated upon. Among 15 patients, including these 3 patients and 12 treated surgically during the era before introducing ERPs, 2 (13.3%) negative laparotomies were noted. Among 16 patients, who underwent both of ERP and operation, no negative laparotomies were noted. No complications of ERPs occurred. In conclusion, ERP is a reliable modality to detect DIs and to determine the therapeutic modalities for PIs.

[The reliability and the significance of serum amylase levels in the diagnosis of the pancreatic injury].

To clarify the diagnostic reliability and significance of serum amylase levels (SAL) in the patients with pancreatic injury (PI), we reviewed 67 PIs. The elapsed time between injury and arrival of the hospital (ETAI) in the patients with normal SAL (1.3 +/- 0.2 hours, mean +/- SE) was significantly shorter than those with hyperamylasemia (5.8 +/- 0.9 hours). SAL on arrival significantly correlated to ETAI in the patients with type I (contusion) and type III injury (ductal injury). Among 45 patients who had arrived over 3 hours after injury, none showed normal SAL. Regardless of severity of PIs, one third of the patients showed normal SAL on arrival within 3 hours after injury. Among 23 patients treated conservatively, SAL in 14 patients (60.9%) normalized within 48 hours after injury, and these patients had no complications related to PIs. Three of remaining 9, who had prolonged hyperamylasemia over 48 hours, had pancreatic ductal branch injury or pseudocysts. This frequency was significantly different compared to that in the patients whose SAL normalized within 48 hours after injury. In conclusion, SAL is unreliable and insignificant to diagnose PIs within 3 hours after injury. Not to overlook the PIs serologically, it is important to determine SAL over 3 hours after injury especially in the patients having stable vital signs and to whom PIs are strongly suspected clinically.

Endoscopic retrograde cholangiography in the nonsurgical management of blunt liver injury.

Injury to the intrahepatic bile duct has not been routinely examined in patients with blunt liver injury, despite the risk of formation of a biloma and hemobilia. In this study we examined the role of endoscopic retrograde cholangiography (ERC) in the evaluation of blunt liver injuries. Sixty-four of 106 (60.3%) patients with blunt hepatic injuries, admitted from April 1986 through March 1992, were managed nonsurgically; ERC was performed in conjunction with computed tomographic (CT) scanning to rule out injury to the bile duct in 28 patients. Injury to the bile duct was detected in six patients (21.4%), five of whom developed a biloma. Patients with hepatic parenchymal injuries that were observed on the CT scans were at greatest risk for injury to the intrahepatic bile duct, and our data suggested that the incidence of injury to the intrahepatic bile duct after blunt hepatic trauma is higher than previously reported. Patients with serious hepatic parenchymal injuries who are candidates for nonsurgical management should be considered for ERC to exclude the possibility of injury to the bile duct.