Hiromichi Naito

Delftia acidovorans bacteremia caused by bacterial translocation after organophosphorus poisoning in an immunocompetent adult patient

A 46-year-old woman was transferred to our emergency unit because of impaired consciousness and respiratory failure with the history of excessive pesticide intake. The patient was hypersalivative and had bilateral pupillary miosis. Laboratory results showed markedly decreased cholinesterase. She was intubated and treated in the intensive care unit with the diagnosis of organophosphorus poisoning. The patient had persisted diarrhea, with a high fever and stomach tenderness on day 10. Whole-body contrast enhanced computed tomography revealed a swollen, enhanced small intestinal wall, and blood culture identified Delftia acidovorans. She was diagnosed as D. acidovorans bacteremia, probably caused by bacterial translocation based on the clinical presentation and the exclusion of other sources, and treated well with a total of 8xa0days of antibiotic therapy. So far as we know, this is the first case of D. acidovorans bacteremia that was presumably caused by bacterial translocation after organophosphorus poisoning in an immunocompetent adult patient.

Effects of pharyngeal cooling on brain temperature in primates and humans: a study for proof of principle.

Background: Pharyngeal cooling decreases brain temperature by cooling carotid arteries. This study was designed to evaluate the principle of pharyngeal cooling in monkeys and humans. Methods: Monkeys (n = 10) were resuscitated following 12 min of cardiac arrest. Pharyngeal cooling (n = 5), in which cold saline (5°C) was perfused into the cuff at the rate of 500 ml/min, was initiated simultaneously with the onset of resuscitation for 30 min. Patients (n = 3) who were in an intensive care unit were subjected to 30 min of pharyngeal cooling under propofol anesthesia. Results: In the animal study, core brain temperature was significantly decreased compared with that in the control group by 1.9°C (SD = 0.8, P < 0.001) and 3.1°C (SD = 1.0, P < 0.001) at 10 min and 30 min after the onset of cooling, respectively. The cooling effect was more evident in an animal with low postresuscitation blood pressure. Total dose of epinephrine, number of direct current shocks, and recovery of blood pressure were not different between the two groups. The pharyngeal epithelium was microscopically intact on day 5. In the clinical study, insertion of the cuff and start of perfusion did not affect heart rate or blood pressure. Tympanic temperature was decreased by 0.6 ± 0.1°C/30 min without affecting bladder temperature. The pharynx was macroscopically intact for 3 days. Conclusions: Pharyngeal cooling rapidly and selectively decreased brain temperature in primates and tympanic temperature in humans and did not have adverse effects on return of spontaneous circulation, even when initiated during cardiac arrest in primates.

Intraperitoneally administered, hydrogen-rich physiologic solution protects against postoperative ileus and is associated with reduced nitric oxide production

BACKGROUNDnPostoperative ileus, a transient impairment of bowel motility initiated by intestinal inflammation, is common after an abdominal operation and leads to increased hospital stays and costs. Hydrogen has potent anti-inflammatory and antioxidant properties and potential therapeutic value. Solubilized hydrogen may be a portable and practical means of administering therapeutic hydrogen gas. We hypothesized that intraperitoneal administration of hydrogen-rich saline would ameliorate postoperative ileus.nnnMETHODSnIleus was induced via surgical manipulation in mice and rats. The peritoneal cavity was filled with 1.0xa0mL saline or hydrogen-rich saline (≥1.5-2.0xa0ppm) before closure of the abdominal incision. Intestinal transit was assessed 24xa0hours postoperatively. Inflammation was examined by quantitation of neutrophil extravasation and expression of proinflammatory markers. Nitric oxide production was assessed in cultured muscularis propria.nnnRESULTSnSurgical manipulation resulted in a marked delay in intestinal transit and was associated with upregulation of proinflammatory cytokines and increased neutrophil extravasation. Bowel dysmotility, induced by surgical manipulation and inflammatory events, was significantly attenuated by intra-abdominal administration of hydrogen-rich saline. Nitric oxide production in the muscle layers of the bowel was inhibited by hydrogen treatment.nnnCONCLUSIONnA single intraperitoneal dose of hydrogen-rich saline ameliorates postoperative ileus by inhibiting the inflammatory response and suppressing nitric oxide production.

Co-infection with invasive pulmonary aspergillosis and Pneumocystis jirovecii pneumonia after corticosteroid therapy

A 95-year-old man with chronic obstructive pulmonary disease and chronic hepatitis C virus infection was treated for acute lung injury caused by Chlamydophila pneumoniae with antibiotics and high-dose corticosteroids. In total, 7,500xa0mg methylprednisolone and 680xa0mg prednisolone were administered over 21xa0days. However, respiratory failure progressed, and chest computed tomography (CT) scan showed bilateral ground-glass opacity and cavity-forming consolidation in the right upper lobe. Despite intensive therapy, the patient died of multiple organ failure on day 7. CT-guided necropsy was performed, and pathological examination revealed invasive pulmonary aspergillosis and Pneumocystis jirovecii pneumonia. Invasive pulmonary aspergillosis and P. jirovecii pneumonia are both life-threatening opportunistic fungal infections. Co-infection of these organisms is rare but possible if the patient is in an extremely immunocompromised state. Short-term but high-dose systemic corticosteroid therapy was considered to be the risk factor in this case. We should pay more attention to immunocompromised hosts who might be suffering from co-infection of opportunistic infections. Moreover, we need to consider preventive measures in such high-risk cases.

Quantitative evaluation of the neuroprotective effects of a short-acting β-adrenoceptor antagonist at a clinical dose on forebrain ischemia in gerbils: effects of esmolol on ischemic depolarization and histologic outcome of hippocampal CA1.

Background: Neuroprotective effects of esmolol in laboratory and clinical settings have been reported. The present study was designed to quantitatively evaluate the neuroprotective effects of esmolol using logistic regression curves and extracellular potentials. Materials and Methods: In 42 gerbils, bilateral occlusion of common carotid arteries was performed for 3, 5, or 7 minutes (n=7 in each group). In treated animals, esmolol (200 µg/kg/min) was administered for 90 minutes, 30 minutes before the onset of ischemia. Direct current potentials were measured in the bilateral CA1 regions, in which histologic evaluation was performed 5 days later. Relations of neuronal damage with ischemic duration and duration of ischemic depolarization were determined using logistic regression curves. Results: There was no significant difference in onset time between the 2 groups (the control group vs. the esmolol group: 1.65±0.46 vs. 1.68±0.45 min, P=0.76), and significant differences in durations of ischemic depolarization were not observed with any ischemic duration. However, logistic regression curves indicated that esmolol has a neuroprotective effect from 2.95 to 7.66 minutes of ischemic depolarization (P<0.05), and esmolol prolonged the duration of ischemic depolarization causing 50% neuronal damage from 4.97 to 6.34 minutes (P<0.05). Logistic regression curves also indicated that esmolol has a neuroprotective effect from 3.77 to 7.74 minutes of ischemic duration (P<0.05), and esmolol prolonged the ischemic duration causing 50% neuronal damage from 4.26 to 4.91 minutes (P<0.05). Conclusions: Esmolol has neuroprotective effects in the acute phase of ischemia by a mechanism other than shortening the duration of ischemic depolarization.

A successfully treated case of criminal thallium poisoning

Thallium was once commonly used as a household rodent or ant killer, but many countries have banned such use due to unintentional or criminal poisonings of humans. A common initial clinical manifestation of thallium poisoning is gastrointestinal symptoms followed by delayed onset of neurological symptoms and alopecia. These clinical characteristics can provide important diagnostic clues regarding thallium poisoning. Here, we report a 23-year-old woman who was poisoned by a business colleague when she unknowingly drank tea containing the toxic substance several times. The patient was treated with multi-dose activated charcoal with airway protection and Prussian blue.

Successfully-treated asymptomatic celiac artery aneurysm: A case report

Highlights • Although rare, celiac artery aneurysm may carry a definite risk for rupture and other complications.• Because of its rarity, no strong consensus concerning indications for intervention of asymptomatic celiac artery aneurysm exists in the literature.• Clinicians awareness regarding this rare entity and efforts to discover before rupturing are imperative.

Venous thromboembolism in major trauma patients: a single-center retrospective cohort study of the epidemiology and utility of D-dimer for screening

Venous thromboembolism (VTE) can be a life‐threatening complication after major trauma. The aim of this study was to investigate the epidemiology of VTE and to assess the usefulness of D‐dimer for screening for VTE in major trauma cases among the Japanese population.

Impact of Cushing’s sign in the prehospital setting on predicting the need for immediate neurosurgical intervention in trauma patients: a nationwide retrospective observational study

BackgroundCushing’s reflex usually results from intracranial hypertension. Although Cushing’s sign can implicate severe traumatic brain injury (TBI) in injured patients, no major investigations have been made. The purpose of this study was to assess the predictability of life-threatening brain injury requiring immediate neurosurgical intervention (LT-BI) among trauma patients with Cushing’s sign in the prehospital setting.MethodsThis was a retrospective study using data from the Japan Trauma Data Bank from the period of 2010 to 2014. Patients 16xa0years old or older with blunt mechanisms of injury who were transported directly from the scene and Glasgow Coma Scale for eye opening of one in the prehospital setting were included. LT-BI was defined as patients requiring burr hole evacuation or craniotomy within 24xa0h of hospital arrival and patients who were non-survivors due to isolated severe TBI. Prehospital systolic blood pressure (pSBP) and heart rate (pHR) were assessed using area under the receiver operating characteristic curve (AUROC) and multiple logistic regression analysis to predict LT-BI.ResultsOf 6332 eligible patients, 1859 (29%) exhibited LT-BI. AUROC of LT-BI using pSBP and pHR was 0.666 (95% confidence interval (CI); 0.652–0.681, Pu2009<u20090.001), and 0.578 (95% CI; 0.563–0.594, Pu2009<u20090.001), respectively. AUROC of pSBP was the highest among the 60u2009≤u2009pHRu2009≤u200999 subgroup, of which AUROC was 0.680 (95% CI; 0.662–0.699, Pu2009<u20090.001).Multiple logistic regression analysis showed that the higher the pSBP and the lower the pHR, the more likely that the patients had LT-BI. In a group with pSBPu2009≥u2009180xa0mmHg and pHRu2009≤u200959 beats/min, the odds ratio and 95% CI of LT-BI after adjusting for age, sex, and severity of injuries to other body regions was 4.77 (2.85–7.97), Pu2009<u20090.001 was compared with the reference group, which was defined as patients with normal vital signs.DiscussionOur study has found that the combination of hypertension and bradycardia, which are the components of Cushings sign without eye opening in the prehospital setting was a weak but a significant predictor of LT-BI, or death due to possible isolated severe TBI.ConclusionsPrehospital Cushing’s sign with disturbed level of consciousness in trauma patients was a weak but significant predictor of the need for immediate neurosurgical intervention.

Soft tissue hematoma of the neck due to thyroid rupture with unusual mechanism.

Highlights • Massive bleeding from the thyroid without direct neck trauma rarely causes airway compromise.• Physicians should regard possible thyroid gland rupture in patients with swelling of the neck or acute respiratory failure after direct/indirect trauma to the neck.• Airway management is the most important consideration in such patients with thyroid injury.