Kensuke Umakoshi

Time related changes in reversible MRI findings after prolonged hypoglycemia

Diffusion weighted magnetic resonance images (DWI) in hypoglycemic coma show more definite and earlier findings than do T1-weighted images, or even fluid-attenuated inversion recovery (FLAIR). However, there has been limited information on the time related changes of such MRI images. We report here the time related changes of MRI findings after prolonged hypoglycemia in a diabetic 62-year-old man without hypoxia. We found in the patient that hyperintensities in DWI, T2-weighted and FLAIR images disappeared on the 14th day along with normalization of the apparent diffusion coefficient (ADC). Single photon emission computed tomography (SPECT) showed no low perfusion findings throughout the course. Since the day when the hyperintensities disappeared, the patient became to open his eyes in response to verbal command. This paper demonstrates serial alterations in reversible DWI findings after prolonged hypoglycemia and we need to define its mechanisms in the future.

Serum albumin levels anticipate antithrombin III activities before and after antithrombin III agent in critical patients with disseminated intravascular coagulation.

Elevated thrombin-antithrombin complex (TAT) or decreased serum albumin levels suggest heightened vascular permeability in disseminated intravascular coagulation (DIC). In such a situation, plasma antithrombin III (AT-III) may decrease because of the leakage. We thus examined whether AT-III activity before and after administration of an AT-III agent changed depending on plasma TAT and/or serum albumin levels in 20 consecutive patients with DIC. We also analyzed the pharmacokinetics for AT-III using a two-compartment model. Serum albumin levels before AT-III administration correlated with preadministered and postadministered AT-III activity, but TAT levels did not. Regardless of TAT levels, AT-III trough activity on the third day increased significantly. In patients with albumin levels of 2.5 g/dL or less, AT-III trough levels on the third day were significantly lower than those with higher levels of albumin. The half-life of the distribution phase for AT-III agent in the patients was shortened to less than one third the value reported in congenital AT-III deficiency, suggesting increased vascular permeability in the acute state patients here. The distribution volume of the agent increased remarkably compared with the previous control. We report here for the first time that in critical patients with DIC, plasma AT-III levels before and after AT-III administration could be predicted by preadministered serum albumin levels, but not by TAT. These findings could be explained by the pharmacokinetic profile, increased vascular permeability and distribution volume, observed in critical patients.

Antithrombin Supplementation and Mortality in Sepsis-induced Disseminated Intravascular Coagulation: A Multicenter Retrospective Observational Study

ABSTRACT Supplemental doses of antithrombin (AT) are widely used to treat sepsis-induced disseminated intravascular coagulation (DIC) in Japan. However, evidence on the benefits of AT supplementation for DIC is insufficient. This multicenter retrospective observational study aimed to clarify the effect of AT supplementation on sepsis-induced DIC using propensity score analyses. Data from 3,195 consecutive adult patients admitted to 42 intensive care units for severe sepsis treatment were retrospectively analyzed; 1,784 patients were diagnosed with DIC (n = 715, AT group; n = 1,069, control group). Inverse probability of treatment-weighted propensity score analysis indicated a statistically significant association between AT supplementation and lower in-hospital all-cause mortality (n = 1,784, odds ratio [95% confidence intervals]: 0.748 [0.572–0.978], P = 0.034). However, quintile-stratified propensity score analysis (n = 1,784, odds ratio: 0.823 [0.646–1.050], P = 0.117) and propensity score matching analysis (461 matching pairs, odds ratio: 0.855 [0.649–1.125], P = 0.263) did not show this association. In the early days after intensive care unit admission, the survival rate was statistically higher in the propensity score-matched AT group than in the propensity score-matched control group (P = 0.007). In DIC patients without concomitant heparin administration, similar results were observed. In conclusion, AT supplementation may be associated with reduced in-hospital all-cause mortality in patients with sepsis-induced DIC. However, the statistical robustness of this connection was not strong. In addition, although the number of transfusions needed in patients with AT supplementation increased, severe bleeding complications did not.

Fewer REBOA complications with smaller devices and partial occlusion: evidence from a multicentre registry in Japan

Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) performed by emergency physicians has been gaining acceptance as a less invasive technique than resuscitative thoracotomy. Objective To evaluate access-related complications and duration of occlusions during REBOA. Methods Patients with haemorrhagic shock requiring REBOA, from 18 hospitals in Japan, included in the DIRECT-IABO Registry were studied. REBOA-related characteristics were compared between non-survivors and survivors at 24 hours. 24-Hour survivors were categorised into groups with small (≤8 Fr), large (≥9 Fr) or unusual sheaths (oversized or multiple) to assess the relationship between the sheath size and complications. Haemodynamic response, occlusion duration and outcomes were compared between groups with partial and complete REBOA. Results Between August 2011 and December 2015, 142 adults undergoing REBOA were analysed. REBOA procedures were predominantly (94%) performed by emergency medicine (EM) physicians. The median duration of the small sheath (n=53) was 19 hours compared with 7.5 hours for the larger sheaths (P=0.025). Smaller sheaths were more likely to be removed using external manual compression (96% vs 45%, P<0.001). One case of a common femoral artery thrombus (large group) and two cases of amputation (unusual group) were identified. Partial REBOA was carried out in more cases (n=78) and resulted in a better haemodynamic response than complete REBOA (improvement in haemodynamics, 92% vs 70%, P=0.004; achievement of stability, 78% vs 51%, P=0.007) and allowed longer occlusion duration (median 58 vs 33 min, P=0.041). No statistically significant difference in 24-hour or 30-day survival was found between partial and complete REBOA. Conclusion In Japan, EM physicians undertake the majority of REBOA procedures. Smaller sheaths appear to have fewer complications despite relatively prolonged placement and require external compression on removal. Although REBOA is a rarely performed procedure, partial REBOA, which may extend the occlusion duration without a reduction in survival, is used more commonly in Japan.

Short-term clinical results of arthroscopic osteochondral fixation for elbow osteochondritis dissecans in teenaged baseball players.

BACKGROUND Reports regarding arthroscopic fixation of the osteochondral fragments for elbow osteochondritis dissecans (OCD) are few. This study assessed the clinical outcomes of arthroscopic fixation of unstable osteochondral fragments by using absorbable pins over a postoperative period of at least 1 year. METHODS The patients were 13 adolescent baseball players with a mean age of 14 years (range, 12-16 years) who underwent OCD of primary lesions at International Cartilage Repair Society grades III and IV. The patients were evaluated by using validated outcome measures at a mean follow-up period of 24 months (range, 12-50 months). RESULTS The mean (standard deviation) score in the disability/symptom section of the Disabilities of the Arm, Shoulder, and Hand improved from 12.4 (6.0) before the surgery to 0.5 (1.2) after the surgery, and the sports section improved from 74.5 (25.4) to 1.4 (5.2). The mean (standard deviation) extension improved from -11° (10.8) to -2° (3.9; P < .001). The mean (SD) flexion improved from 129° (11.6) to 137° (5.6; P = .040). All patients were able to resume playing baseball, and 9 (69%) resumed playing at the same position as before their injuries. CONCLUSIONS The clinical results of arthroscopic osteochondral fragment fixation in the teenaged baseball players with elbow OCD, albeit obtained over only a short period, were favorable. This arthroscopic treatment enables repair of lesions and is considered appropriate for unstable OCD during the adolescent growth spurt.

Full Recovery Case After 82 Minutes Out-of-Hospital Cardiac Arrest: Importance of Chain of Survival and Predicting Outcome

A middle age man underwent immediate cardiopulmonary resuscitation (CPR) for ventricular fibrillation (VF) occurred in an ambulance. After arrival in a regional hospital, return of spontaneous circulation (ROSC) was achieved 82 minutes after the collapse. He was in coma even three hours after ROSC. So, he was transferred to our university hospital to receive therapeutic hypothermia (TH). An initial bispectral index (BIS) value suggested a favorable outcome. Thus we decided to aggressive therapies including TH of 34°C for 48 hours, followed by a very slow rewarming at the rate of 1°C per day. Eventually he was discharged from the hospital with good neurological state. This case shows us two points: 1) the importance of the chain of survival: CPR done immediately after the collapse, persistent CPR for refractory VF, followed by coronary interventions after ROSC, continuing care to the university hospital, 2) decision making for TH using BIS monitoring.

Elevation of Neutrophil Elastase Activity in Intra-Operative Recovered ShedBlood

Background and Aim: Neutrophil elastase releasing from activated polymorphonuclear neutrophils (PMN) may have a central role in acute lung injury. Thus, we examined whether neutrophil elastase activity (NEA), a crucial parameter for organ damages from stresses, may increase in intra-operative recovered blood and also whether the storage duration of the bank bloods may affect such changes in NEA. Methods: In thirty-two packed red cells of bank bloods, NEAs were measured by ELISA on several day points after the storage. Intra-operative salvaged red cell concentrates (RCCs) were obtained from thirteen patients undergoing spinal surgery. The salvaged bloods from the patients were divided into two groups: NE activities in autologous RCCs obtained from eight patients were examined soon after the preparation (Group A); such activities in RCCs from five subjects were determined post-operatively (Group B). Results: In the bank bloods, NEAs gradually increased after the storage, showing a plateau at the day 10 if not specifically filtered leukocytes before the preparation. In Group B, NEA levels in RCCs were significantly higher than those in Group A. In Group B (RCCs stored for four hours), NEAs were nearly two times higher than those of the peak NEA values of the bank blood at the day 21. Conclusion: Thus, we need to pay attention the occurrence of lung injury even after the transfusion of autologous bloods collecting by the intra-operative shed blood recovered system.

Effects of Dexamethasone on Pulmonary Oxygenation Impairments inTherapeutic Hypothermia for Patients with Traumatic Brain Injury

Objectives: We studied retrospectively to examine differences in the occurrence rate of pneumonia and the time-course changes in pulmonary oxygenation between hypothermic and normothermic therapies with or without dexamethasone (D) administration in patients with traumatic brain injury (TBI). Design: A retrospective observational study. Setting: Two university hospitals. Subjects and Methods: In consecutive TBI patients (GCS ≤ 8) treated with hypothermic (N=23, 32-33°C) or normothermic (N=16, 36-37.5°C) therapy, the occurrence rate of pneumonia, PaO2/FIO2 (P/F) ratios and C-reactive protein (CRP) levels were examined. The comparisons were made among hypothermic and normothermic groups with or without D administration. In several patients in both groups, neutrophil functions were examined. Data were analyzed with ANOVA followed by Sheffe’s F-test, Mann-Whitney U-test, Kruskal-Wallis tests or chi-squared test (p<0.05) as appropriate. Results: The occurrence rate of pneumonia in a hypothermic group with D administration was significantly lower than in a hypothermic group without D. In the hypothermic group without D treatment, CRP elevation during the rewarming phase occurred, which was followed by more severe P/F ratio deteriorations as compared to the hypothermic group given D. Neutrophil phagocytic functions in hypothermic patients without D were activated around 35°C, which were followed by marked decreases in pulmonary oxygen. In contrast, phagocytic function in a hypothermic patient receiving D was depressed, but without P/F ratios below 280. Conclusion: This study poses hypotheses that neutrophils play a role in the pulmonary oxygenation impairment in hypothermic therapy for TBI patients, and that dexamethasone improves the pulmonary complications in therapeutic hypothermia.

Sudden cerebral depression detected by bispectral index monitoring in cryptococcal meningitis with elevated near-fatal cerebrospinal fluid pressure

An increase in cerebrospinal fluid pressure (CSFP) is usually prominent in cryptococcal meningitis, which has a high mortality rate, so aggressive management to control CSFP is crucial. In this case, a 40‐year‐old‐man survived cryptococcal meningitis treated with continuous spinal drainage under bispectral index (BIS) monitoring. He unexpectedly showed hypertension, went into a coma, and even loss his light reflexes due to CSFP elevation. His BIS values had abruptly dropped before developing these symptoms, but dramatically recovered after lumbar puncture drainage, suggesting that BIS monitoring could reflect cerebral function changes due to CSFP alternations.

Minimally invasive necrosectomy using resectoscope for intractable necrotic abscess after severe acute pancreatitis: report of a case

Case reportA 43-year-old male was admitted to a regional hospital after being diagnosed with severe acute pancreatitis. The patient developed a pancreatic abscess with multiple organ failure. He was transferred to our hospital in critical condition. Computed tomography scans revealed enormous pancreatic abscesses expanding from the pancreatic body to the pelvic area. Pigtail catheters were inserted for percutaneous drainage. Even after the drainage, the abscesses did not improve. Percutaneous necrosectomy was performed using a resectoscope through a fistulous tract. After two necrosectomies, the CT scans showed remarkable decreases in the size of the cystic abscesses, and finally, no abscesses were detectable on the 117th hospital day.ConclusionWe herein present the first description of a minimally invasive technique, using resectoscopy, for treating intractable pancreatic abscesses. Future studies are warranted to examine the efficacy and safety of this procedure for difficult cases, as presented in this report.