Tetsuya Takakuwa

Plasma endotoxin and cytokine concentrations in patients with hemorrhagic shock

ObjectivesThe roles of cytokines and endotoxin in hemorrhagic shock, particularly the translocation of endotoxin and bacteria during hemorrhagic shock, were investigated. DesignProspective study. SettingCritical care and emergency center of a university hospital. PatientsTwenty-nine patients with hemorrhagic shock and 20 healthy controls. InterventionsSerial blood samples were collected from both study and control patients. Standard resuscitation techniques were used. Measurements and Main ResultsPlasma levels of endotoxin and various cytokines were determined repeatedly during hemorrhagic shock. Endotoxin was measured using an endo-toxin-specific assay in addition to a new perchloric acid method for pretreatment of plasma. Cytokines were measured by commercial enzyme-linked immunosorbent assays. Plasma endotoxin concentrations remained within the normal range for 7 days after admission. Although levels of tumor necrosis factor-α and several interleukins increased slightly in some patients, these cytokines did not reach the levels seen in septic shock. ConclusionTranslocation of bacteria or endotoxin from the gastrointestinal tract into the bloodstream has been noted in animal experiments; however, translocation was not detected in our patients with hemorrhagic shock. (Crit Care Med 1994; 22:949–955)

Plasma tumour necrosis factor-α (TNF-α) levels in patients with burns

Abstract Levels of plasma tumour necrosis factor-α (TNF-α) were determined consecutively in 42 patients with burns > 20 per cent of the total body surface area using an enzyme-linked immunosorbent assay. In the early period after injury (including the period of burn shock), 24 patients had detectable TNF-α levels in their plasma. However, the plasma TNF-α levels at the time of admission were very low and did not correlate with the extent of the burn or the prognosis. In contrast, the maximum plasma TNF-α level over the whole clinical course was significantly correlated with the area of the burn and the prognosis. No correlation was found between the plasma TNF-α and plasma endotoxin levels. TNF-α may be produced locally in infected burns and monitoring of plasma TNF-α levels may be a useful prognostic indicator for burns patients.

Plasma concentrations of type II phospholipase A2, cytokines and eicosanoids in patients with burns

The plasma concentrations of type II phospholipase A2 (type II PLA2) and eicosanoids, such as leukotriene B4 (LTB4), 6-keto-prostaglandin F1 alpha (6-keto-PGF1 alpha), and thromboxane B2 (TXB2), were determined by radioimmunoassay in 23 patients with burns covering at least 20 per cent of their body surface. Cytokines such as tumour necrosis factor-alpha (TNF-alpha), interleukin 6 (IL-6) and interleukin 8 (IL-8) were determined by enzyme-immunosorbent assay. There was no increase in type II PLA2 concentration in the early stage of burns, but an increase in type II PLA2 concentration was triggered by infection (P < 0.0001). The level of type II PLA2 was significantly higher in the non-surviving group than in the surviving group (P = 0.0006), suggesting that it reflects the severity of the disease. There was a significant correlation between the maximum level of type II PLA2 and TNF-alpha (r = 0.6346, P = 0.0011). There was a significant correlation between the maximum level of type II PLA2 and the accompanying plasma concentrations of LTB4, 6-keto-PGF1 alpha, and TXB2 throughout the observation period (r = 0.4814, P = 0.0200; r = 0.5943, P = 0.0028; r = 0.4368, P = 0.0372 respectively). Plasma levels of LTB4, and TXB2 were significantly higher in the burn patients who died than in those who survived (P = 0.0493; P = 0.0493 respectively).

Os odontoideum with vertebral artery occlusion.

A 21-year-old man developed signs of brainstem damage after being injured while playing rugby. Cervical x-ray films showed os odontoideum, and angiography revealed persistent occlusion of the right vertebral artery at the level of the second cervical spine. These findings indicated that atlantoaxial dislocation caused by os odontoideum may have induced vertebral artery occlusion, leading to brainstem infarction.

Cervical spinal cord injury associated with ossification of the posterior longitudinal ligament

Among 231 patients with cervical injuries treated over 12 years, 15 had cervical spinal cord injury associated with ossification of the posterior longitudinal ligament. All of them were male and most had injuries due to a relatively weak external force. Four of them underwent surgery. There was little difference in improvement of paralysis between the conservatively and the surgically treated group.

Evaluation of recombinant human granulocyte colony-stimulating factor (rhG-CSF) therapy in granulopoetic patients complicated with sepsis.

A study was carried out to investigate the efficacy of therapy with recombinant human granulocyte colony-stimulating factor (rhG-CSF) in 24 patients with granulocytopenia and sepsis who had failed to respond to antibiotics. The mean leukocyte count at the start of the study was 911 +/- 334/microliter. Patients were injected subcutaneously with 75 micrograms rhG-CSF once daily for a mean of 5.2 days. The plasma G-CSF concentration was measured by ELISA. The leukocyte count increased approximately 9-fold after 1 week in 19 patients and the percentage of granulocytes rose from 46.2% to 78.9%. These 19 patients survived, while the 5 patients with no leukocyte response to rhG-CSF died. High plasma G-CSF levels were found in patients with granulocytopenia. Plasma G-CSF levels decreased as levels of granulocyte increased in survivors. A high plasma G-CSF concentration persisted in the 5 non-responding patients resulting in a fatal outcome. This study suggests that rhG-CSF both increased the leukocyte count and was a useful therapeutic manoeuvre for sepsis.

Plasma levels of endothelin-1 and thrombomodulin in burn patients

Plasma concentrations of endothelin-1 (ET-1) and thrombomodulin (TM) were determined in patients with burns to examine their relation to the severity of illness. Tumor necrosis factor-alpha (TNF-alpha) was also measured, and its relationship to ET-1 and TM determined. Twenty-three burn patients were evaluated, who had a total burn surface area (TBSA) of at least 20 per cent. ET-1 was measured by radioimmunoassay (RIA). TM and TNF-alpha were measured by enzyme-linked immunosorbent assay (ELISA). Both the ET-1 and TM concentrations were significantly higher in the patients who developed sepsis than in those who did not and in the patients who eventually died than in those who survived. Maximum plasma concentrations of ET-1 and TM were significantly correlated with the acute physiological and chronic health evaluation II score. There was also a significant correlation between the plasma levels of TNF-alpha and both ET-1 and TM. ET-1 and TM closely reflect the severity of illness in patients with burns in the infectious stage; TNF-alpha may be involved in the production of ET-1 and TM.

Bilateral traumatic hip dislocation in a child

SummaryTraumatic dislocation of in children occurs less frequently than in adults, and bilateral dislocation is extremely rare. Manual reduction was performed in a 3-year-old girl with bilateral traumatic hip dislocation. The recovery course has been favorable for about 1 year.

Factors determining the severity of ski injuries

We investigated the relationship between the severity of ski injuries (n=895) classified according to the abbreviated injury score (AIS; based on objective criteria for judging the severity of injuries) and the following factors: sex, site and mode of injury, skill level, speed at the time of injury, binding release, gradient, type of snow, surface conditions, weather, visibility, and the month and day of the week on which the injury was sustained. Age, sex, mode and site of injury, speed at the time of injury, binding release, visibility, and the month and day of the week on which the injury was sustained were associated with the severity of injuries, but the skill level, gradient, type of snow, surface conditions, and weather were not. Injuries with an AIS of 4 or higher accounted for only 4.6% of injuries (AIS scores range from 1; e.g., mild sprains, to a maximum of 6; injuries with scores of 4 and above are regarded as life-threatening). Given that patients with very severe injuries tend to be taken to our facility, the actual incidence of severe ski injuries may be even lower. However, measures to protect against severe injuries are needed to ensure greater safety for skiers.

Snowboarding injuries: Comparison of injuries in snowboarders and skiers

To clarify the characteristics of injuries occurring in snowboarding accidents, we compared, injuries in 138 snowboarders and 128 skiers (aged 15–35 years), injured at the “H” Ski Resort. In the snowboarder group, injuries to the upper extremities, particularly the wrist joint, were more frequent, whereas injuries to the lower extremities, particularly the knee joint, were less frequent. As for the type of injury, fractures were more frequent in snowboarders, while sprains and ligament injuries were less frequent. Fractures, sprains of the wrist joint, and contusions of the shoulder were more frequent in snowboarders, with sprains of the knee joint and the thumb were being less frequent. The duration of sporting activity was significantly longer in snowboarders. Injuries to snowboarders occurred more often while they were traveling at “reckless speed” on moderate slopes. There were no significant differences in skill levels between the two groups. Differences between the snow boarders and skiers boots and differences in sliding on boards and on skis are believed to have contributed to the differences in their injuries. Our analysis indicates that it is necessary to create slopes that are safe and enjoyable for board riders as well as skiers. Lessons are also recommended so that snowboarders learn the proper technique, and understand the general principles of slope safety; the potential for injury would thus be reduced.