Shiro Mishima

Spontaneous rupture of the pancreaticoduodenal artery possibly related to prior occlusion of the common hepatic artery: report of a case.

Abstract We report herein a case of spontaneous rupture of the pancreaticoduodenal artery (PDA) associated with obstruction of the common hepatic artery. A 68-year-old man was admitted to our hospital following the sudden onset of severe upper abdominal pain. Computed tomography revealed a large mass formation in the peritoneal cavity. Hemorrhagic shock rapidly developed during the initial evaluation, necessitating an exploratory laparotomy to be performed in the emergency room. This revealed a large hematoma in the retroperitoneal space, and a ruptured PDA was sutured. Postoperative angiography showed obstruction of the common hepatic artery and also suggested that the source of the bleeding was the PDA. Thus, a diagnosis of spontaneous rupture of a PDA aneurysm associated with occlusion of the common hepatic artery was made. Following this case report, we discuss the development of true aneurysms of the PDA and the treatment of ruptured true PDA aneurysms resulting in shock.

Availability of on-site acute vascular interventional radiology techniques performed by trained acute care specialists: a single emergency center experience.

INTRODUCTION Comprehensive treatment of a patient in acute medicine and surgery requires the use of both surgical techniques and other treatment methods. Recently, acute vascular interventional radiology techniques (AVIRTs) have become increasingly popular, enabling adequately trained in-house experts to improve the quality of on-site care. METHODS After obtaining approval from our institutional ethics committee, we conducted a retrospective study of AVIRT procedures performed by acute care specialists trained in acute medicine and surgery over a 1-year period, including those conducted out of hours. Trained acute care specialists were required to be certified by the Japanese Association of Acute Medicine and to have completed at least 1 year of training as a member of the endovascular team in the radiology department of another university hospital. The study was designed to ensure that at least one of the physicians was available to perform AVIRT within 1 h of a request at any time. Femoral sheath insertion was usually performed by the resident physicians under the guidance of trained acute care specialists. RESULTS The study sample comprised 77 endovascular procedures for therapeutic AVIRT (trauma, n = 29, and nontrauma, n = 48) among 62 patients (mean age, 64 years; range, 9–88 years), of which 55% were male. Of the procedures, 47% were performed out of hours (trauma, 52%; and nontrauma, 44%). Three patients underwent resuscitative endovascular balloon occlusion of the aorta in the emergency room. No major device-related complications were encountered, and the overall mortality rate within 60 days was 8%. The recorded causes of death included exsanguination (n = 2), pneumonia (n = 2), sepsis (n = 1), and brain death (n = 1). CONCLUSION When performed by trained acute care specialists, AVIRT seems to be advantageous for acute on-site care and provides good technical success. Therefore, a standard training program should be established for acute care specialists or trauma surgeons to make these techniques a part of the standard regimen. LEVEL OF EVIDENCE Therapy/care management study, level V.

Bifidobacterium longum BB536 and Changes in Septicemia Markers Associated with Antibiotic Use in Critically Ill Patients

Objective: Probiotics exert beneficial effects on gastrointestinal microflora, but these effects may be counteracted by antibiotics, particularly when used in critically ill patients. The aim of this study was to examine the effects of probiotics in association with antibiotics on septicemia markers. Methods: In total, 64 critically ill patients were randomized to receive conventional therapy alone (control group) or with a transluminal preparation containing Bifidobacterium longum BB536 (probiotic group). Patients were retrospectively divided into two subgroups depending on whether they received antibiotic therapy during the study period. Outcome measures included fecal bifidobacteria numbers and serum concentrations of procalcitonin and interleukin 6. Results: After probiotic/control intervention, in the non-antibiotic subgroup, mean fecal bifidobacteria number was significantlyhigher in the probiotic group compared with the control group (8.30 ± 0.84 vs. 6.80 ± 0.90 102 colony-forming units/g, respectively, P<0.01). Mean serum procalcitonin (0.44 ± 0.78 vs. 1.19 ± 1.16 ng/mL, P<0.05) and interleukin 6 (116 ± 131 vs. 230 ± 162 ng/mL, P<0.01) levels were significantly lower in the probiotic group. The outcome measures of patients who received antibiotics were not significantly different between the probiotic and control groups. Conclusion: Our findings suggest that B. longum BB536 suppresses upregulation of procalcitonin and interleukin 6, preventing infectiouscomplications, but the effect was counteracted by antibiotics. This may partly explain why probiotics are not always effective in critically ill patients. Nevertheless, our findings suggest that routine prophylactic use of B. longum BB536 would be beneficial for critically ill patients with non-infectious diseases not receivingtreatment with antibiotics.