Takeshi Yamagiwa

Reduction of Immunocompetent T Cells Followed by Prolonged Lymphopenia in Severe Sepsis in the Elderly.

Objective:To investigate the immunological changes caused by severe sepsis in elderly patients. Design:One-year, prospective observational study. Setting:Emergency department and intensive care unit of a single university hospital. Patients:Seventy-three patients with severe sepsis and 72 healthy donors. Measurements and Main Results:In elderly septic patients (aged 65 yr and over), 3-month survival was significantly reduced compared with that for adult patients (18–64 yr) (60% vs. 89%, p < 0.01). We found that lymphopenia was prolonged for at least 21 days in elderly nonsurvivors of sepsis, while the number of lymphocytes recovered in both adult and elderly survivors of sepsis. In order to examine the immunological status of septic patients, blood samples were collected within 48 hrs of diagnosis of severe sepsis, and peripheral blood mononuclear cells were purified for flow cytometric analysis. T cell levels were significantly reduced in both adult and elderly septic patients, compared with those in healthy donors (56% and 57% reduction, respectively). Interestingly, the immunocompetent CD28+ subset of CD4+ T cells decreased, whereas the immunosuppressive PD-1+ T cells and the percentage of regulatory T cells (CD4+ T cells that are both Foxp3+ and CD25+) increased in elderly patients, especially nonsurvivors, presumably reflecting the initial signs of immunosuppression. Conclusion:Reduction of immunocompetent T cells followed by prolonged lymphopenia may be associated with poor prognosis in elderly septic patients.

Determination of the appropriate catheter length for needle thoracostomy by using computed tomography scans of trauma patients in Japan

BACKGROUND Previous studies reported a high failure rate in relieving tension pneumothorax by needle thoracostomy, because the catheter was not sufficiently long to access the pleural space. The Advanced Trauma Life Support guideline recommends needle thoracostomy at the second intercostal space in the middle clavicular line using a 5.0-cm catheter, whereas the corresponding guideline in Japan does not mention a catheter length. It is necessary to measure the chest wall thickness (CWT) and determine the appropriate catheter length taking the differences of habitus in race and region into consideration. This study was designed to analyse CWT in Japanese trauma patients by computed tomography and to determine the percentage of patients whose pleural space would be accessible using a 5.0-cm catheter. PATIENTS AND METHODS We performed a retrospective review of chest computed tomography of 256 adult Japanese trauma patients who were admitted to the level 1 trauma centre of Tokai University Hospital in Kanagawa, Japan between January and July 2008. In 256 patients, the CWT at 512 sites (left and right sides) was measured by chest computed tomography at the second intercostal space in the middle clavicular line. The frequency of measurement sites <5.0 cm was calculated simultaneously. The samples were divided according to gender, side (left and right), abbreviated injury scale (<3, ≧3), arm position during examination (up/down), and the existence or non-existence of associated injuries (pneumothorax, subcutaneous emphysema, and fracture of the sternum and ribs); the CWT of each group was compared. RESULTS The mean CWT measured in 192 males and 64 females was 3.06±1.02 cm. The CWT values at 483 sites (94.3%) were less than 5.0 cm. The CWT of females was significantly greater than that of males (3.66 cm vs. 2.85 cm, p<0.0001), and patients with subcutaneous emphysema had greater CWTs than those without it (4.16 cm vs. 3.01 cm, p<0.0001). CONCLUSION The mean CWT at the second intercostal space in the middle clavicular line was 3.06 cm. It is likely that over 94% of Japanese trauma patients could be treated with a 5.0-cm catheter.

Arterial embolization in patients with grade-4 blunt renal trauma: evaluation of the glomerular filtration rates by dynamic scintigraphy with 99mTechnetium-diethylene triamine pentacetic acid

BackgroundHigh-grade blunt renal trauma has been treated by arterial embolization (AE). However, it is unknown whether AE preserves renal function, because conventional renal function tests reflect total renal function and not the function of the injured kidney alone. Dynamic scintigraphy can assess differential renal function.MethodsWe performed AE in 17 patients with grade-4 blunt renal trauma and determined their serum creatinine (sCr) level and glomerular filtration rate (GFR; estimated by dynamic scintigraphy) after 3 months. In 4 patients with low GFR of the injured kidney (<20 ml·min-1·1.73 m-2), the GFR and sCr were measured again at 6 months. Data are presented as median and interquartile range (25th, 75th percentile).ResultsThe median GFR of the injured kidney, total GFR, and median sCr at 3 months were 29.3 (23.7, 35.3) and 96.8 (79.1, 102.6) ml·min-1·1.73 m-2 and 0.6 (0.5, 0.7) mg/dl, respectively. In the patients with low GFR (ml·min-1·1.73 m-2), the median GFR of the injured kidney, total GFR, and median sCr (mg/dl) were 16.2 (15.7, 16.3), 68.7 (61.1, 71.6), and 0.7 (0.7, 0.9), respectively, at 3 months and 34.5 (29.2, 37.0), 90.9 (79.1, 98.8), and 0.7 (0.7, 0.8), respectively, at 6 months.ConclusionsThe function of the injured kidney was preserved in all patients, indicating the efficacy of AE for the treatment of grade-4 blunt renal trauma.

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.

Characteristics of elderly Japanese patients with severe burns.

In this study, we report the clinical characteristics of elderly Japanese patients with severe burns. We studied the clinical features of 76 adult patients with severe burns, 35 of whom (46.1%) were ≥65 years old. We evaluated the characteristics of patients with respect to each type of burn. In addition, we studied the rate of death and survival in the elderly and also between the elderly and non-elderly patients. The following parameters were either assessed or compared between the elderly and non-elderly: gender, average age, vital signs (Glasgow Coma Scale, systolic blood pressure, heart rate and respiratory rate) and PaO(2)/FiO(2) (P/F) ratio at admission, cause of burn and a history of physical or psychiatric disease. Further, we investigated whether the burn was caused by attempting suicide and determined the percent total body surface area (%TBSA), second- and third-degree burn area, burn index (BI), prognostic burn index (PBI), presence of tracheal burns, presence of alcohol intoxication and overdose poisoning, presence of tracheal intubation, outcome and cause of death. The male:female ratio of the elderly patients was 17:18 (average age, 78.1 (8.2) years). Burns were mostly caused by flame (26/35), followed by scalding (8/35). Ten patients had attempted suicide. The %TBSA, second-degree burn area, third-degree burn area, BI and PBI, respectively were 46.6% (26.7%), 15.3% (19.0%), 35.6% (26.0%), 41.1 (25.2) and 119.2 (25.9). Of the 35 patients, 23 died. The notable characteristics of the elderly patients who died were flame as the cause of the burns: high %TBSA, BI and PBI, and a high rate of tracheal intubation. Elderly patients constituted approximately 45% of our study population. Most burns were caused by flames. The incidence of accidental bathtub-related burns was higher and that of suicide attempts was lower in the elderly patients, as compared with the non-elderly patients. Severe burns were fatal for elderly patients. Therefore, elderly Japanese people should be educated on how to prevent non-intentional burns.

Arterial embolization of an extrapleural hematoma from a dislocated fracture of the lumbar spine: a case report

BackgroundWe present a report of a blunt-trauma patient who developed an atypical extrapleural hematoma with hemodynamic instability following a dislocation fracture of the first lumbar vertebra. We successfully treated her with arterial embolization (AE) of the lumbar and intercostal arteries.Case reportThe patient, a 74-year-old woman, was injured in a traffic accident. At the scene of the accident, she was found to be alert, and her hemodynamic condition was stable. She arrived at our hospital complaining of lumbago. A thoracoabdominal computed tomography (CT) scan with contrast enhancement showed a dislocation fracture of the first lumbar vertebra along with paravertebral and retroperitoneal hematomas. Therefore, we managed the patient conservatively with bed rest. However, 3 h after admission, her blood pressure suddenly decreased. A repeated thoracoabdominal CT scan showed enlargement of the right retroperitoneal hematoma with extravasation of the contrast medium into the right extrapleural space. Angiography was immediately performed, showing extravasation of the contrast media from the right intercostal (Th12) and lumbar arteries (L1). After arterial embolization (AE) with gelatin-sponge particles, extravasation of the contrast medium ceased, and the patients hemodynamic condition stabilized without massive fluid resuscitation.ConclusionThe extrapleural hematoma reduced in size after AE, and almost disappeared on the 14th day of hospitalization. The lumbar spinal fracture was successfully repaired on day 16, and the patient was kept in the hospital to recuperate. We believe that AE is effective for the management of intractable bleeding following fractures of the spine.

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.

A case of torsades de pointes induced by severe QT prolongation after an overdose of eperisone and triazolam in a patient receiving nifedipine.

Introduction. Eperisone hydrochloride is a centrally acting muscle relaxant, and triazolam is a short-acting benzodiazepine. Although commonly prescribed, cardiotoxicity induced by a single overdose of either drug is comparatively rare. A patient receiving nifedipine developed torsades de pointes (TdP) because of prolongation of the corrected QT (QTc) interval after an overdose of eperisone hydrochloride and triazolam. Case report. A 60-year-old man receiving nifedipine was admitted in a comatose condition 3 h after ingesting 5,000 mg of eperisone and 2.5 mg of triazolam. Electrocardiogram showed sinus rhythm with prolongation of the QTc interval (820 ms). The serum electrolyte levels were as follows: potassium, 3.8 mEq/L; magnesium, 2.4 mg/dL. The serum drug concentrations were high: eperisone, 15,360 ng/mL; triazolam, 110.8 ng/mL. A temporary cardiac pacemaker was implanted immediately after the development of TdP, 11 h after the ingestion. The serum triazolam concentration normalized on day 2. The QTc interval and eperisone concentration normalized on day 6. Conclusion. Eperisone and triazolam overdose can cause life-threatening cardiotoxicity. Electrocardiographic monitoring and serial determination of QTc interval are likely the best way to observe these patients and evaluate the risk of cardiotoxicity.

Two Cases in Which Myocardial Injury Could Be Only Evaluated by Nuclear Medicine Studies on Electric Shock Patients Whose Electrocardiogram and Myocardial Enzyme Levels Were Normal

Heart injury due to electric shock is currently diagnosed based on electrocardiogram (ECG) changes or elevated levels of myocardial enzymes or both. However, the rate at which ECG detects abnormalities is very low; thus, the estimated rate of the diagnosis of myocardial damage due to electric shock is lower than the actual rate. The method of nuclear medicine study of the heart is superior with regard to evaluating transient ischemia, such as angina pectoris, in patients whose ECG and myocardial enzyme levels are normal. Therefore, we attempted to diagnose transient myocardial damage in electric shock patients by using nuclear medicine study of the heart.

Supramolecular ferric porphyrins and a cyclodextrin dimer as antidotes for cyanide poisoning.

Objectives: This study aimed to evaluate the antidotal effect of a newly developed supramolecular complex, ferric porphyrins and a cyclodextrin dimer (FeIIIPIm3CD), that possess a higher binding constant and quicker binding rate to cyanide ions than those of hydroxocobalamin (OHCbl) in the presence of serum protein. Methods: First, in vitro cytochrome activity and cell viability were evaluated in murine fibroblast cells cultured with various doses of FeIIIPIm3CD and potassium cyanide (KCN). Next, BALB/c mice were pretreated with intravenous OHCbl (0.23 mmol/kg), FeIIIPIm3CD (0.23 mmol/kg), or saline and then received KCN (lethal dose 100% (LD100): 0.23 mmol/kg) through a stomach tube. Finally, as a resuscitation model, KCN-induced apnea was treated with a bolus injection of an equimolar dose of antidotes followed by a slow infusion of the same reagent. Results: FeIIIPIm3CD showed dose-dependent antidotal effects in vitro. Pretreatment with FeIII PIm3CD prevented KCN-induced apnea significantly better than OHCbl. Resuscitation with FeIIIPIm3CD resulted in an earlier resumption of respiration than that seen with OHCbl. However, 24-h survival was similar among the treatments (FeIIIPIm3CD, nine of nine mice; OHCbl, eight of nine mice). Conclusion: FeIIIPIm3CD exerted significant antidotal effects on cyanide toxicity in vitro and in vivo, with a potency equal in the mortality of cyanide-poisoned mice or superior in the respiratory status during an acute phase to those of OHCbl.