Hiromichi Aoki

The Comparison of Characteristic and Clinical Features of Self-inflicted Abdominal Stab Wound Patients in Japan: Simple Stab Wounds Versus Hara-kiri Wounds

BACKGROUND The proportion of suicide attempts by infliction of abdominal stab wounds (ASWs) is higher in Japan than in other counties. There are few clinical reports on these wounds, especially hara-kiri wounds, which involve transversely cutting the abdomen. This study aimed to investigate Japanese patients with self-inflicted hara-kiri wounds and determine their characteristics and clinical features. METHODS We investigated 84 patients with self-inflicted ASWs who had been transferred to our hospital between April 1994 and March 2004. We recorded their characteristics and clinical features. They were then divided into two groups depending on their wound type, namely, simple stab wounds (SSWs) and hara-kiri wounds. The characteristics and clinical features of each group were then compared. RESULTS SSWs were frequently observed in the periumbilical and epigastric regions, whereas most hara-kiri wounds were observed in the middle abdomen. The rate of organ injury was 58.7% (44 of 75) for SSWs and 66.7% (6 of 9) for hara-kiri wounds; no significant difference was observed in this regard. SSWs resulted in injury to various organs, whereas hara-kiri wounds typically caused small bowel, mesenterium, omentum, and major vascular injuries. Small bowel and major vascular injuries had a significantly high incidence in hara-kiri wounds. The mortality rate caused by hara-kiri wounds was significantly higher than that caused by SSWs (1.3% vs. 22.2%). CONCLUSION The mortality rate caused by ASWs is relatively low. However, hara-kiri wounds might be a risk factor for death. Further, because hara-kiri wounds transversely cut the abdomen, they might be a risk factor for major vascular injury.

Clinical characteristics of α-pyrrolidinovalerophenone (α-PVP) poisoning

Abstract Context: α-Pyrrolidinovalerophenone (α-PVP) is a synthetic cathinone that has been abused in recent years. The clinical presentation of acute α-PVP poisoning has not been well characterized. Objective: To elucidate the clinical features of acute α-PVP poisoning. Materials and methods: This retrospective case series included eight subjects that visited our hospital emergency department (ED) between March 2012 and November 2014 and had analytically confirmed blood α-PVP levels. Data related to subject demographics, clinical history, laboratory findings, blood drug levels, and outcome were collected. Results: The median age of the eight study subjects was 27 (range; 21–63) years, and six were male. Drug preparations had been administered by rectal insertion (three subjects) or inhalation (five subjects). The time between drug exposure and presentation at the ED was 8.5 (1–24) h and blood α-PVP concentrations ranged from 1.0 to 52.5 ng/ml. Although psychiatric and neurological findings were reported before arrival at the ED in 5/8 and 7/8 subjects, respectively, these were only observed in 1/8 and 2/8 subjects, respectively, at the ED. Symptoms of high body temperature (3/8), tachycardia (5/8), hypertension (3/8), acid-base balance disorder (5/8), coagulopathy (4/6), blood creatinine phosphokinase >190 U/l (6/8), and a blood lactate level > 1.7 mmol/l (5/7) were observed. All subjects survived and were discharged. Conclusions: This retrospective case series showed that after acute exposure to α-PVP, transient neuropsychiatric findings were accompanied by more persistent sympathomimetic physical findings, disorders of acid-base balance and blood coagulation, high blood creatinine phosphokinase, and hyperlactacidemia.

Sudden Asphyxia Caused by Retropharyngeal Hematoma after Blunt Thyrocervical Artery Injury

BACKGROUND Retropharyngeal hematomas are often associated with blunt cervical spine injury. Generally, they improve with conservative treatment; however, rarely, airway obstruction occurs due to delayed swelling of retropharyngeal hematoma. OBJECTIVES To report a case of sudden asphyxia due to retropharyngeal hematoma caused by blunt thyrocervical artery injury. CASE REPORT A 30-year-old woman was admitted to the Emergency Department of Tokai University Hospital 4h after injury in a motor vehicle collision. On arrival, she had severe dyspnea and neck swelling; thereafter, a 26-mm-thick retropharyngeal swelling was visualized on lateral cervical plain X-ray study, extending from C1 anterior vertebrae to mediastinum. Emergency intubation was performed for the asphyxia. Because extravasation of contrast agent was observed in the hematoma on emergency contrast-enhanced computed tomography (CT) scan, emergency angiography was performed, from which we diagnosed a hemorrhage from the right thyrocervical artery. CONCLUSION If a patient with a non-displaced cervical spine injury suffers airway obstruction due to retropharyngeal hematoma, vigorous hemorrhage from a thyrocervical artery injury should be considered as the cause, and emergency contrast-enhanced CT scan of the neck should be performed after emergent tracheal intubation.

One-Year Follow-Up and Convalescence Evaluated by Nuclear Medicine Studies and 24-Hour Holter Electrocardiogram in 11 Patients With Myocardial Injury Due to a Blunt Chest Trauma

BACKGROUND There are few reports on long-term convalescence with regard to cardiac injury caused by blunt chest trauma. Nuclear medicine study of the heart (NMSH) in the early stages of injury is reportedly superior to detect the correlation between injury and fatal arrhythmia. Therefore, we prospectively performed NMSH and Holter electrocardiogram (ECG) in the early and chronic stages for a cardiac injury patient, and we longitudinally examined the recovery process and the occurrence of fatal arrhythmia. METHODS AND RESULTS A total of 202 patients with blunt chest trauma were admitted to our hospital between April 2006 and January 2007. Of 65 patients who were diagnosed with cardiac injury by ECG, a myocardial enzyme, or cardiac ultrasonography, 11 were enrolled in this study because they agreed to outpatient visiting for regular examinations for 1 year. NMSH showed positive findings in 6 of the 11 patients in the acute period of <1 month. Twelve months later, five patients improved but still exhibited protracted cardiac damage without complete recovery. Among the six patients in whom NMSH showed positive findings, Holter ECG indicated an abnormal finding in two patients in the acute period and in four patients in the chronic period, and detected one patient with a nonsustained ventricular tachycardia in the chronic period. CONCLUSION Cardiac injuries may exacerbate cardiac functions and lead to fatal arrhythmia during the chronic period. Therefore, evaluating recovery for at least 12 months after myocardial damage is necessary to prevent sudden cardiac death.

Continuous Venovenous Hemodiafiltration for Life-threatening Mitochondrial Myopathy With Lactic Acidosis and Rhabdomyolysis

We report here the clinical course of a 31-year-old male who recovered from a fulminant form of mitochondrial myopathy with lactic acidosis. The patient was transferred to our hospital with acute dyspnea and a convulsive seizure. On admission, he was in a state of shock, and presented with severe high-output heart failure, acute renal failure, and rhabdomyolysis. Treatment with continuous venovenous hemodiafiltration (CVVHDF) resulted in an excellent response, with no signs of hemodynamic instability. This case suggests that CVVHDF with serial hemodynamic monitoring may be effective in treating hypotensive patients with a life-threatening mitochondrial disorder.

Detection of synthetic cannabinoids using GC-EI-MS, positive GC-CI-MS, and negative GC-CI-MS.

Recently, various synthetic cannabinoid (SC) compounds that have been slightly modified at the functional groups have been identified in Japan. However, the structural elucidation of these new compounds using conventional approaches such as gas chromatography–electron impact–mass spectrometry (GC-EI-MS) is difficult. As such, indole and indazole SCs were scanned using GC-MS-EI, positive GC–chemical ionization (CI)–MS, and negative GC–chemical ionization–MS, allowing for efficient structural elucidation of unknown SC compounds. Pure substances have been employed for the study.

Measurement of blood lactate, D-dimer, and activated prothrombin time improves prediction of in-hospital mortality in adults blunt trauma

Conventional trauma severity indices include the Injury Severity Score, an anatomical index calculated based on the degree of injury to each organ and body part [1], and the Revised Trauma Scale, a physiological index calculated based on the Glasgow Coma Scale score, systolic blood pressure, and respiratory rate [2]. Probability of survival is awidely usedmeasure to estimatemortality due to trauma: it can be calculated using logistic regression models that incorporate these indices and age as explanatory variables [3]. However, Injury Severity Score cannot be accurately determined until diagnoses are ascertained as to the level of injury to each organ and body part. Moreover, Injury Severity Scores can differ depending on the tests performed and between examiners [4]. Problems have been identified with the Revised Trauma Scale as well, including Glasgow Coma Scale measurement errors due to tracheal intubation [4]. Trauma patients in high need of emergency treatment could be more accurately identified if their risk of mortality could be predicted more precisely. This can be achieved by including biomarkers that can be evaluated quickly in emergency department (ED) triage assessments on admission.

Optimal management strategy for spontaneous isolated dissection of a visceral artery

Objectives To describe our clinical experiences and recommend a management strategy for spontaneous isolated dissection of a visceral artery. Methods A retrospective study of patients from December 2005 to December 2015 was performed. Thirty-two patients had spontaneous isolated dissection of a visceral artery. Clinical features, computed tomography findings, the treatment method, and follow-up results were evaluated. Results There were 28 men and 4 women (mean age, 54 years). Dissection locations were the celiac artery in 10, superior mesenteric artery in 17, and celiac artery and superior mesenteric artery in 5 patients. Celiac artery stenosis existed with spontaneous isolated dissection of a visceral artery at a high rate. After diagnosis, the blood pressure of all patients was immediately controlled to a lower level. Three patients with arterial rupture and one patient with bowel infarction underwent operations for complications. Overall, the treatment of dissection involved drug therapy alone. The last follow-up computed tomography results of the true lumen residual ratio and the length of the dissected artery improved compared to the values on admission; the maximum diameter of the dissected artery did not enlarge. Eleven patients almost completely improved. No patients had any adverse event. Conclusions Most patients with spontaneous isolated dissection of a visceral artery can be first treated conservatively for dissection with strict blood pressure control and surveillance.

Optimal Treatment for Ruptured Pancreaticoduodenal Artery Aneurysm Caused by Celiac Artery Obstruction Due to Celiac Artery Dissection

A pancreaticoduodenal artery (PDA) aneurysm develops due to increased flow through the pancreaticoduodenal arcade in the setting of celiac or superior mesenteric artery occlusion. Additionally, there is no evidence on the computed tomography scan or angiography images that the dissection process extends to the PDA arcade. Moreover, the optimal treatment protocols for PDA aneurysms with celiac artery obstruction and for celiac artery dissection are controversial. We report 2 cases of ruptured PDA aneurysms caused by celiac artery obstruction due to celiac artery dissection in which the aneurysm was excluded, but celiac artery revascularization was not performed successfully. Our cases indicate that endovascular management for ruptured PDA aneurysms and conservative management for celiac artery obstruction due to celiac artery dissection are feasible as first-line treatment in such cases.

Detection of pathogenic bacteria in the blood from sepsis patients using 16S rRNA gene amplicon sequencing analysis

Prompt identification of causative pathogenic bacteria is imperative for the treatment of patients suffering from infectious diseases, including sepsis and pneumonia. However, current culture-based methodologies have several drawbacks including their limitation of use to culturable bacterial species. To circumvent these problems, we attempted to detect bacterial DNA in blood using next-generation DNA sequencing (NGS) technology. We conducted metagenomic and 16S ribosomal RNA (rRNA) gene amplicon sequencing of DNA extracted from bacteria-spiked blood using an Ion Personal Genome Machine. NGS data was analyzed using our in-house pipeline Genome Search Toolkit and database GenomeSync. The metagenomic sequencing analysis successfully detected three gram-positive and three gram-negative bacteria spiked in the blood, which was associated with a significant portion of non-bacterial reads, even though human blood cells were separated by low-speed centrifugation prior to DNA extraction. Sequencing analysis of seven variable regions of the 16S rRNA gene amplicon also successfully detected all six bacteria spiked in the blood. The methodology using 16S rRNA gene amplicon analysis was verified using DNA from the blood of six patients with sepsis and four healthy volunteers with potential pathogenic bacteria in the blood being identified at the species level. These findings suggest that our system will be a potential platform for practical diagnosis in the future.