Soichi Maekawa

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.

Differences in antithrombin III activities by administration method in critical patients with disseminated intravascular coagulation: a pharmacokinetic study.

Pharmacokinetic (PK) data for antithrombin III (AT) are limited in the critical patients. We therefore performed PK analysis using a two-compartment model and also examined whether plasma AT activity would change depending on two administration methods, AT agent at 500 U/8 h (divided group) or 1,500 U/24 h (combined group) for 3 days, a regulated dosage for disseminated intravascular coagulation (DIC) treatment in Japan, in critical patients with DIC. Clinical prospective randomized study. A high care unit in a university hospital. Twenty-four consecutive critical patients with DIC. Ages ranged from 34 to 91 years. Acute physiology age and chronic health evaluation II scores were 25 to 35. Antithrombin III activities in the combined group caused remarkable transient increases but returned to near the preadministration level 24 h after the infusion. Antithrombin III level in the divided group showed small elevations on each session; therefore, steady increases were found after serial administrations of the agent. On the third day, AT trough activities in the divided group were significantly higher than those in the combined group (P = 0.005). However, peak AT activities in the combined group after AT administration were higher than those in the divided group throughout the study (P = 0.024). Aggravation of bleeding tendency occurred more frequently in the combined group (P = 0.03). Half-life times on the distribution phase in both groups were remarkably shorter than those of previously reported control in congenital AT deficiency. This suggests an increased vascular permeability in the critical patients in this study. Distribution volume in the patients here increased significantly as compared with the previous controls. This is the first PK report using a two-compartment model to demonstrate that remarkable increases in vascular permeability and distribution volume occur in critical patients with DIC, and if the same dose is administered intermittently in such PK situation, AT administration in divided manner can maintain plasma AT trough activity higher than that in the combined method.

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.