Atsuto Yoshino

A comparison of Ringer's lactate and acetate solutions and resuscitative effects on splanchnic dysoxia in patients with extensive burns

We compared the effects of Ringers lactate (RL) and acetate (RA) solutions on parameters of splanchnic dysoxia such as PgCO(2) (PCO(2) of gastric mucosa) and pH(i) (pH of gastric mucosa) using a gastric tonometer, in addition to blood markers such as the serum arterial level of lactate, base excess, ketone body ratio, and antithrombin during the first 72h of the resuscitation period in patients with burns covering 30% or more of their body surface. A prospective study was conducted in the university tertiary referral centers. There were no significant differences in the average age, TBSA (total burn surface area), and resuscitative fluid volume during the first and second 24h between the two groups. In the RA group, PCO(2) gap values calculated employing the formula: PgCO(2)-PaCO(2) (arterial PCO(2)), and pH gap calculated by: pH(a) (arterial pH)-pH(i), improved to the normal ranges at 24 h postburn, which was significantly faster than in the RL group. On the other hand, there were no significant differences in blood parameters between the two groups over the course. These results suggest that fluid resuscitation with RA may more rapidly ameliorate splanchnic dysoxia, as evidenced by gastric tonometry, compared to that with RL.

Enhanced secretion of tissue plasminogen activator by simultaneous use of retinoic acid and ascorbic acid from tissue cultured gastroepiploic artery

Tissue-type plasminogen activator (tPA) is a key enzyme in the fibrinolysis system and the regulation of its expression has been extensively studied in cultured vascular endothelial cells. Many kinds of supplements including growth factors are needed, however, to keep endothelial cells viable, which leads the culture condition far from the physiological milieu. Using a new device of amorphous calcium phosphate coated culture plate, we succeeded in culturing ring-cut gastroepiploic artery in a basic medium of RPMI 1640 containing 10% fetal calf serum. The overall normal vessel architecture and the antigenicity of von Willebrand factor, tPA and plasminogen activator inhibitor type 1 (PAI-1) were retained for at least 9 days. tPA was constantly secreted into the conditioned medium at least up to day 12. Employing this organ culture technique, we analyzed the effects of two well-known profibrinolytic vitamins of retinoic acid (Vit. A) and ascorbic acid (Vit. C) on the release of tPA and PAI-1. The cultured artery responded well and the tPA secretion was enhanced by factors of 1.5 fold by Vit. A, 1.7 fold by Vit C and 3.2 fold by their combination, whereas none of these stimuli increased PAI-1 secretion. These results suggested that the cultured ring-cut artery retained functional endothelial cells for at least 9 days and was suitable in analyzing the regulatory mechanism of protein synthesis and secretion from the vascular wall. Using this method, vitamins A and C were shown to lead the intravascular condition to a profibrinolytic state.

Severe heat stroke associated with high plasma levels of plasminogen activator inhibitor 1

In a 38-year-old man, severe heat stroke caused disseminated intravascular coagulation (DIC) associated with significantly elevated plasma plasminogen activator inhibitor 1 levels. Investigation of the effects of hyperthermia on coagulation and fibrinolysis showed, in apparent conflict with previous reports, a time lag between the initial hypercoagulable and hyperfibrinolytic response (within 24 hr) and hypofibrinolysis shown by a disproportionate increase of PAI-1 (after 24 h), which possibly occurs in correspondence with the recovery of vascular endothelial integrity. The patient was discharged without sequelae although computed tomography (CT) scans indicated the likelihood of venous infarction or posterior inferior cerebellar artery area infarction secondary to DIC.

Crowned dens syndrome

Dear Editor, A 90-year-old man visited our emergency department owing to neck pain and occipital headache. The pain occurred suddenly a few days previous, and had become gradually worse. He had a history of cerebral infarction, dementia, and cholelithiasis, but was not on any medication. The patient’s vital signs were stable excluding a body temperature of 37.5°C. Physical examination showed the reduction of passive cervical spine movements with posterior neck pain and occipital headache. Rotation, extension, and flexion in the neck were all limited. However, there was no tenderness in the nape of the neck. In terms of neurological findings, overall cranial nerve, motor, and sensory nervous systems were intact. In laboratory data, the value of the C-responsive protein was 4.34 mg/dL (normal range, 0.0–0.1 mg/dL); all other findings were unremarkable. Computed tomography (CT) of the neck showed crown-shaped calcium deposits surrounding the odontoid process (Fig. 1A, arrows), and dotted calcifications of the transverse ligament of the atlas (Fig. 1B, arrows).There were no other lesions causative of pain in brain or spine. By integrating the results, we diagnosed crowned dens syndrome (CDS). The chief complaint of patients of CDS is neck pain, due to calcification deposition around the odontoid process. The cause of CDS is thought to be the microcrystalline deposition, most often calcium pyrophosphate dihydrate crystals and/or hydroxyapatite crystals, in the transverse ligament of the atlas around the odontoid process. However, the pathophysiologic process has not been completely proven. Clinicians could confuse the differential diagnosis and misdiagnose CDS as meningitis, polymyalgia rheumatica, or dissecting aneurysm of the vertebral and basilar artery. In particular, meningitis must be considered first in the differential diagnosis because the triad of fever, headache, and neck stiffness due to meningitis are very similar to the symptoms of CDS. Using CT scans, CDS is identified in up to 5% of the patients over the age of 70 years who present to hospital with the chief symptom of neck pain. Therefore, it is not a rare entity but becoming unclear using plain radiography for the diagnosis because of improper images. Computed tomography is the gold standard for detecting calcification in transverse, apical, and alar ligaments. However, when the CT scan is carried out a long time after the onset of symptoms, calcification around the odontoid process may not be detected as it may have been absorbed. Non-steroidal anti-inflammatory drugs (NSAIDs) have been commonly used as first-line therapy for CDS. In cases without improvement using NSAIDs alone, treatment with moderate dosage of corticosteroids is recommended. In our case, NSAID therapy alleviated the patient’s symptoms completely. Taiki Yamada, Takeji Saitoh, Hironao Hozumi, Yoshiaki Takahashi, Masashi Nozawa, Toshiaki Mochizuki, and Atsuto Yoshino Department of Emergency and Disaster Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan

The potential of leg-foot chest compression as an alternative to conventional hands-on compression during cardiopulmonary resuscitation:

Background: Conventional hands-on chest compression, in cardiopulmonary resuscitation, is often inadequate, especially when the rescuers are weak or have a small physique. Objectives: This study aimed to investigate the potential of leg-foot chest compression, with and without a footstool, during cardiopulmonary resuscitation. Methods and Results: We prospectively enrolled 21 medical workers competent in basic life support. They performed cardiopulmonary resuscitation on a manikin for 2 min using conventional hands-on compression (HO), leg-foot compression (LF), and leg-foot compression with a footstool (LF + FS). We analyzed the compression depths, changes in the rescuers’ vital signs, and the modified Borg scale scores after the trials. The compression depth did not differ between the cases using HO and LF. In the case of LF + FS, compression depths ⩾5 cm were more frequently observed (median, inter-quartile range: 93%, 81%–100%) than in HO (9%, 0%–57%, p < 0.01) and LF (28%, 11%–47%, p < 0.01). The increase in the heart rate or modified Borg scale scores, after the trials, did not differ between the HO and LF group; however, the values were the lowest in the case of LF + FS (49 ± 18 beats/min and 5 (4–7) in HO, 46 ± 18 and 6 (5–7) in LF, and 32 ± 11 and 2 (1–3) in LF + FS, respectively, p < 0.01). However, the increase in blood pressure, SpO2, and respiratory rate were not different among each group. The increases in the heart rate and modified Borg scale scores negatively were correlated with the rescuers’ body size, in the case of HO and LF, but not LF + FS. Conclusion: LF can be used as an alternative to HO, when adequate HO is difficult. LF + FS could be used when rescuers are weak or have a small physique and when the victims are bigger than the rescuers.