A case of delayed encephalopathy after carbon monoxide poisoning longitudinally monitored by diffusion tensor imaging.

A woman with DE after CO poisoning was longitudinally evaluated by DTI, performed during the following periods: at the phase of acute CO poisoning, the lucid interval, neurologic deterioration due to DE, and neurologic recovery. The present case revealed the long-term course of DTI parameters after CO poisoning and the usefulness of DTI for quantifying neurologic damage after CO poisoning.

Improvement in the results of surgical treatment of advanced squamous esophageal carcinoma during 15 consecutive years.

OBJECTIVE: To document the clinicopathologic characteristics and survival of patients undergoing esophagectomy for squamous carcinoma of the thoracic esophagus, and to examine the factors contributing to improvements in outcome noted in patients with advanced carcinoma. SUMMARY BACKGROUND DATA: Japanese and some Western surgeons recently have reported that radical esophagectomy with extensive lymphadenectomy conferred a survival advantage to patients with esophageal carcinoma. The factors contributing to this improvement in results have not been well defined. METHODS: From 1981 to 1995, 419 patients with carcinoma of the thoracic esophagus underwent esophagectomy at the Keio University Hospital. The clinicopathologic characteristics and survival of patients treated between 1981 and 1987 were compared with those of patients treated between 1988 and 1995. Multivariate analysis using the Cox regression model was carried out to evaluate the impact of 15 variables on survival of patients with p stage IIa to IV disease. Several variables related to prognosis were examined to identify differences between the two time periods. RESULTS: The 5-year survival rate for all patients was 40.0%. The 5-year survival rate was 17.7% for p stage IIa to IV patients treated during the earlier period and 37.6% for those treated during the latter period. The Cox regression model revealed seven variables to be important prognostic factors. Of these seven, three (severity of postoperative complications, degree of residual tumor, and number of dissected mediastinal nodes) were found to be significantly different between the earlier and latter periods. CONCLUSIONS: The survival of patients undergoing surgery for advanced carcinoma (p stage IIa to IV) of the thoracic esophagus has improved during the past 15 years. The authors' data suggest that this improvement is due mainly to advances in surgical technique and perioperative management.

[Pulmonary thromboembolism accompanied by abnormal plasminogen].

A 38-year-old man was admitted to our hospital because of sudden chest pain and bloody sputum. Lung perfusion scintigraphy disclosed segmental defects in both lungs. An enhanced thin-section computed tomographic scan of the chest showed a low-density area in the right main pulmonary artery. These findings yielded a diagnosis of pulmonary thromboembolism. Serum plasminogen activity was low, not only in the patient but in his elder brother and daughter. Gene analysis revealed a point mutation at exon 15 of the plasminogen gene, suggesting abnormal plasminogen. Abnormal plasminogen is more prevalent in Japan than in the USA or Europe, and is usually asymptomatic. Thromboembolism in patients with abnormal plasminogen is very rare. Further studies are needed to elucidate the relationship between plasminogen abnormalities and pulmonary thromboembolism.

A case of traumatic shock complicated by methamphetamine intoxication.

A case of a 38-year-old male with traumatic shock complicated by methamphetamine intoxication is presented. The patient was involved in an assault which resulted in cardiac tamponade and right ventricular outflow laceration. Pericardiocentesis was immediately performed. However, profound metabolic acidosis greatly in excess of that expected from the short duration of the shock was revealed by arterial blood gas analysis. Another cause of the metabolic acidosis was suspected. The patient subsequently admitted to intravenous use of methamphetamine. Following hemodynamic and metabolic stabilization by continuous pericardial drainage and intravenous administration of sodium bicarbonate, the patient underwent cardiac surgery. His postoperative course was uneventful. There is a substantial association between methamphetamine users and traumatic accidents. In such cases, early identification of drug use is important. Marked metabolic acidosis, which conflicts with the diagnosed cause of shock, may be a clinical clue to methamphetamine intoxication.

[Sepsis in extensive burned patients].

The prognosis of extensively burned patients is dependent upon the presence of sepsis. The more extensive the burns, the more likely patients are to become septic. Although recently the frequency of burn wound sepsis has been decreased due to the early excision of necrotic tissue, that of sepsis resulting from respiratory tract infection has increased. Staphylococcus aureus (methicillin-resistant S. aureus) and Pseudomonas aeruginosav are the agents most likely to cause infections. Sepsis syndrome also results from bacterial translocation (BT), in which gut bacteria and/or endotoxins are thought to enter the portal bloodstream and/or lymphosystem. The pathophysiological mechanism of sepsis is the increased release of inflammatory mediators and resulting imbalances between these substances and their antagonists. In cases of severe sepsis, the sequelae of the imbalance between inflammatory mediators and their antagonists can lead to endothelial injury, DIC, and finally MODS. Strategies against the occurrence of sepsis include hospital-wide infection control measures, blockage of infection routes, and administration of antibiotics. The early initiation of nutritional management, preferably by the enteral route, to enhance immune system function and minimize the occurrence of BT is recommended. Several drugs to control inflammatory mediator release are currently under development and are expected to be used clinically in future.

Relationship between pupil size and acetylcholinesterase activity in patients exposed to sarin vapor.

OBJECTIVE: To elucidate the effect of sarin vapor on pupil size and erythrocyte acetylcholinesterase activity (AchE). DESIGN: Retrospective observational survey. SETTING: Emergency department of an urban teaching hospital. PATIENTS: 80 patients who were exposed to sarin in a terrorist attack in Tokyo subways. MEASUREMENTS AND RESULTS: Pupil size and AchE activity on the day of exposure were measured. Among the 80 patients, the pupils were miotic (< 3 mm) in 50 patients (62.5%), while AchE activity was below the normal range (< 1.2 U) in 34 patients (42.5%). AchE was significantly lower in the miotic group than in the group with normal pupils (1.0 +/- 0.5 U vs 1.5 +/- 0.3 U, p < 0.01). In the miotic group, AchE activity was lower than normal in 32 patients (64.0%) but was decreased in only 2 patients in the normal pupil group (6.7%) (p < 0.01). CONCLUSIONS: Miosis is a more sensitive index of exposure to sarin vapor than erythrocyte AchE. Systemic poisoning is apparently less likely to develop if the patient's pupil size is normal on arrival at the hospital.

Superacute phase blood pressure elevation may relate to massive hematoma in hypertensive putaminal hemorrhage.

A restrospective clinical investigation has been performed to elucidate the relationship between hematoma size in putaminal hemorrhage and blood pressure (BP) changes during the immediate post-hemorrhagic phase in the emergency room (ER). Thirty-seven adult patients brought to the emergency department by ambulance within 6 hours after onset of symptoms with a confirmed diagnosis of acute putaminal hemorrhage on CT have been involved. Two BP measurements during the superacute phase in the ER have been studied: immediately after arrival at the ER (BP-I), and immediately prior to CT examination (BP-II). Patients have been divided into 6 categories: 1) those whose BP decreased with treatment (D+), 2) those whose BP decreased without treatment (D-), 3) those whose BP increased in spite of treatment (I+), 4) those whose BP increased without treatment (I-), 5) those whose BP remained unchanged in spite of treatment (U+), and 6) those whose BP remained unchanged without treatment (U-). Hematoma size has been compared among 5 categories (D+, D-, I-, U+, U-) using factorial ANOVA (analysis of variance). The hematoma sizes have been found to be (D+) 54 +/- 44 ml, (D-) 22 +/- 25 ml, (I-) 102 +/- 58 ml, (U+) 11 +/- 5 ml, (U-) 21 +/- 9 ml (mean +/- S.D.), respectively. (I-) has been significantly larger than any of the other categories (p < 0.001 - 0.05). Additional ANOVA has shown that BP-II in category (I-) was significantly higher than that of the other categories. Patients with putaminal hemorrhage whose BP was elevating during the superacute phase in the ER were shown to have massive hematomas.

[Cytokine-mediated biological response to severe infections in surgical patients].

Cytokines serve to initiate the acute inflammatory response and to integrate nonspecific and specific immunological responses to infections occurring in perioperative patients. Microbial substances induce macrophages to produce pivotal cytokines (TNF-alpha and IL-1 beta). This results in an activation of other cytokine productions including IL-2, IL-3, IL-4, IL-6, chemokines, and IL-10. Also, other host-originated humoral mediators are released from macrophages, neutrophils, platelets, and endothelial cells Various cytokines are also produced by helper-T (Th) cells, and the Th1/Th2 balance is regulated by cytokines and stress hormones. This nonspecific inflammatory response and specific immunological response which are mediated by cytokines are crucial for the host defense against invading pathogens. On the other hand, the blood levels of TNF-alpha, IL-6, IL-8, and MIP-1 alpha were correlated with the severity and mortality in patients with sepsis. Also we found that in patients with inhalation injury the high IL-8 levels in bronchoalveolar lavage fluid on admission predicted the development of respiratory insufficiency. In severe infection, a systemic release of various cytokines is not properly regulated, and the high blood levels of the proinflammatory cytokines cause an autodestructive systemic inflammatory response syndrome (SIRS). This condition is termed "Cytokine Storm" by the author. In cytokine storm, not only proinflamamtory cytokines, but also anti-inflammatory cytokines appear in circulating blood, leading to septic shock, multiple organ dysfunction, and immunosuppression. With further understanding of the roles of cytokines in sepsis, modulation of cytokine responses could be a new modality of the treatment.

Serum MIP-1 alpha and IL-8 in septic patients.

UNLABELLED: We studied blood MIP-1 alpha and IL-8 in 38 septic patients and 5 healthy volunteers. Both chemokines were undetectable in the healthy volunteers. In sepsis, serum MIP-1 alpha was detected in 45% of the patients and Il-8 in 84%. The levels of MIP-1 alpha, but not of IL-8, correlated with CRP, IL-6 and TNF alpha levels. Complications, including various organ failures and mortality, showed no correlation with serum MIP-1 alpha levels. In contrast, we found increased levels of serum IL-8 in septic patients with disseminated intravascular coagulation, central nervous system (CNS) dysfunction or renal failure, and the mortality rate was higher in the IL-8 detectable group than in the IL-8 undetectable group (50% vs 0%, p < 0.05). In conclusion, the production of both MIP-1 alpha and IL-8 was increased and initially detectable levels of circulating IL-8 predicted high mortality in sepsis. OBJECTIVE: To determine the significance of the C-C chemokine MIP-1 alpha and the C-X-C chemokine IL-8 in sepsis. DESIGN: Prospective study. SETTING: Clinical investigation, emergency department and general intensive care unit of university hospital. PATIENTS AND PARTICIPANTS: 38 septic patients and 5 healthy volunteers were studied. Sepsis was diagnosed following the criteria formulated by ACCP/SCCM. INTERVENTIONS: 10-20 ml of blood was drawn from each patient at the time of initial diagnosis of sepsis. MEASUREMENTS AND RESULTS: MIP-1 alpha and IL-8 were determined by sandwich ELISA. Both chemokines were undetectable in the healthy volunteers. In sepsis, serum MIP-1 alpha was detected in 45% of the patients and IL-8 was detected in 84%. The levels of MIP-1 alpha, but not of IL-8, correlated with CRP, IL-6 and TNF alpha levels. Complications, including various organ failures and mortality, showed no correlation with serum MIP-1 alpha levels. In contrast, we found increased levels of serum IL-8 in patients with disseminated intravascular coagulation (DIC) (p < 0.05), central nervous system (CNS) dysfunction (p < 0.05), renal failure (p < 0.01) and the mortality rates were higher in the IL-8 detectable group than in the IL-8 undetectable group (50% vs 0%, p < 0.05). CONCLUSIONS: The production of MIP-1 alpha and IL-8 was increased in sepsis. Furthermore, an initially detectable level of circulating IL-8, but not MIP-1 alpha, predicted a high mortality in sepsis diagnosed according to the ACCP/SCCM criteria.

Budd-Chiari syndrome attributed to protein C deficiency.

The protein C anticoagulant pathway is an important downregulating mechanism of the blood coagulation cascade. We report a 47-yr-old male with Budd-Chiari syndrome and occlusion of the inferior vena cava. His plasma protein C antigen level was decreased to 42%, and its activity was 34%. Other coagulable factors were normal. Protein C deficiency should be considered a possible etiological factor of the Budd-Chiari syndrome.

Secondary exposure of medical staff to sarin vapor in the emergency room.

OBJECTIVE: To clarify the risk of secondary exposure of medical staff to sarin vapor in the emergency room, and to warn emergency room staffs of the hazard. DESIGN: Retrospective observational survey. SETTING: Emergency department of a university hospital in a metropolitan area of Japan. PARTICIPANTS: Fifteen doctors treating victims of a terrorist attack with sarin in the Tokyo subways on the day of the attack. MEASUREMENTS AND RESULTS: Of the 15 doctors who worked in the emergency room treating the victims, 13 became simultaneously aware of symptoms during the resuscitation of two victims who were exposed to sarin. Among 11 doctors (73%) who complained of dim vision, the pupils were severely miotic (<2 mm) in 8 (73%). Other symptoms included rhinorrhea in eight (53%), dyspnea or tightness of the chest in four (27%), and cough in two (13%). Atropine sulfate was given to six, and pralidoxime was given to one of these six doctors. To decontaminate the emergency room of sarin vapor, ventilation was facilitated and all belongings of the patients were sealed up. None of the doctors noticed worsening of their symptoms thereafter. CONCLUSIONS: Careful attention to the risks of secondary exposure to toxic gas in the emergency room and prompt decontamination if such exposure should occur are necessary in the case of large-scale disasters caused by sarin.

An alternative limb lead system for electrocardiographs in emergency patients.

It is occasionally difficult to record the standard 12-lead electrocardiograph (ECG) in emergency patients. The aim of this study was to evaluate the influence on electrocardiographic wave form recordings of moving the location of electrodes from the standard limb lead position to the trunk. The participants were 10 normal subjects and 20 patients with heart disease. In the new lead system, the limb electrodes were placed on the anterior acromial region and the anterior superior iliac spine using adhesive electrodes. Conventional 12-lead ECGs were recorded by the standard and the new lead system simultaneously in the supine position. Wave form analysis was done by an automatic analysis program. Motion artifacts in the recordings were less in the new lead system. The R wave amplitude of the new lead system increased in leads II, III and aVF, and decreased in leads I and aVL. However, the amplitudes of each wave obtained by standard electrocardiography and the new lead system correlated well (y = 1.008x + 2.038, r = 0.99, n = 2,880). In 99.6% of all wave forms, the differences in amplitudes were within 5% of the values of standard recordings. The average of differences in the ST-segment was 2.6 +/- 11.4 microV. The frontal plane QRS axis obtained by the new lead system showed a vertical shift of 7.8 +/- 8.5 degrees (y = 0.94911x + 10.346, r = 0.98, n = 30). The recording errors produced by the new lead system were within the permissible range of variation. The new lead system is a reasonable alternative for recording ECGs if application of the standard lead is difficult in an emergency.

[Blood pressure change and syncope during leg phlebography].

Although syncope attacks such as black-out, faint consciousness, and cold sweat are sometimes experienced during leg phlebography, no study of their incidence and mechanism has been reported. We measured blood pressure noninvasively by using a Finapress with ECG monitor during overall examinations (21 cases, 33 limbs; male 8, female 13) following anamnesis. Age, sex, and past history of drug, syncope, leg phlebography, and other diseases were determined. All examinations were done in the upright position. Three cases (14.3%) and four limbs (12.1%) showed syncope attacks during leg phlebography. Syncope occurred after steps taken for the evaluation of venous return in two limbs, during infusion of contrast medium in one, and after infusion in the other. In all cases, the systolic blood pressure measurement during syncope was below 80 mmHg, and the sudden decrease of both systolic blood pressure (-83.0 +/- 22.0 mmHg) and heart rate (-29.5 +/- 5.0/min) suggested vasovagal reaction as a mechanism of syncope. Other causes of syncope including anaphylaxy, hyperventilation syndrome, seizure, and arrhythmia (except for bradycardia) were not found. There were also significant changes in blood pressure and heart rate in the nonsyncope group during leg phlebography that seemed to trigger vasovagal excitation. Premedication, contrast media, and position might be important factors and should be discussed further.

[Intractable bacterial infections in surgical patients].

Although many new antibiotics became available for clinical use, intractable bacterial infections are still major cause of morbidity and mortality in surgical patients. The infections are attributable to multiple factors. Surgical stress such as extensive burns and major surgery results in the depressed host-defense function, which is mediated by cytokine responses. Necrotic tissue, ischemia, hematoma, cholelithiasis, foreign bodies, indwelling catheters, intra-tracheal tubes, and other medical devices are local factors making infection resistant to ordinary chemotherapy. Multi-resistant bacteria such as methicillin resistant Staphylococcus aureus and Pseudomonas, and ampicillin resistant enterococci are the main bacteria causing the infections. 32% of surgical specimens isolated two or more bacteria, making the chemotherapy difficult in clinical setting. Importance of surgical drainage, removal of necrosis and the devices are emphasized.

The effects of dopamine infusion on the postoperative energy expenditure, metabolism, and catecholamine levels of patients after esophagectomy.

Although dopamine is one of the most widely used vasoactive agents, its postoperative thermogenic and metabolic effects have not been studied. In this study, the effects of low-dose dopamine, given at 5 microgram/kg/min, on resting energy expenditure (REE), metabolism, and plasma catecholamine levels were examined in eight postsurgical patients. Dopamine infusion increased REE from 1,839 +/- 171 kcal/day to 2,071 +/- 170 kcal/day, and it decreased to 1,867 +/- 141 kcal/day after cessation of the infusion. Dopamine also increased the plasma levels of glucagon from 109.4 +/- 8.7 pg/ml to 132.5 +/- 8.0 pg/ml, and it decreased to 102.9 +/- 11.1 pg/ml after cessation of the infusion. The plasma levels of dopamine before, during, and after the infusion were 116.1 +/- 18.3, 161.1 +/- 25.6 and 121.4 +/- 17.2 ng/ml, respectively. Insulin and glucose were affected by dopamine, but changes in their plasma levels did not parallel the dopamine levels. Epinephrine and norepinephrine were increased by the infusion of dopamine and continued to increase even after its cessation. The results of this study revealed that low-dose dopamine increased REE in postsurgical patients and that this might be associated with the concomitant increase in plasma glucagon.

[A case of food-dependent exercise-induced anaphylaxis associated with repeated episodes of syncope].

This report describes a patient with food-dependent exercise-induced anaphylaxis (FEA). A 25-year-old female has had three episodes of syncopal attack associated with urticaria in the past two years: the attacks have been developed by exercise after taking meals made of wheat flour. She has an allergic predisposition to metals. No abnormal findings were observed in the routine work up for syncope including, ECG, 24-hour Holter ECG, UCG, tilt table test, and EEG examinations. A provocative test for FEA was performed. It included food (sandwich) intake followed by exercise. The serum histamine concentration was elevated to a three times higher than the control value after the provocation. Accordingly, she was diagnosed as FEA and advised not to take wheat flour prior to physical exercise. No syncopal episode has been observed during the 16 months since the diagnosis.