Tomoatsu Tsuji

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.

Lactate as a prognostic factor in carbon monoxide poisoning: a case report

Carbon monoxide (CO) poisoning results in various neuropsychological impairments, including delayed encephalopathy (DE) and death. However, factors related to these outcomes are unknown. A group suicide was attempted by 3 young people--a 31-year-old man (patient 1), a 21-year-old woman (patient 2), and a 20-year-old man (patient 3)--by burning charcoal in a closed car. At the emergency department, hypotension and hyperthermia were severe in patient 1, moderate in patient 2, and absent in patient 3, although all the patients were comatose. The initial serum lactate levels were 75.1 mg/dL in patient 1, 41.9 mg/dL in patient 2, and 26.3 mg/dL in patient 3, although the carboxyhemoglobin levels were approximately equal in all the patients. Hyperbaric oxygen therapy (HBOT) was immediately initiated and continued for 10 days in all the cases; however, the outcomes of these patients varied considerably. Patient 1 remained comatose and died on day 31 because of central diabetes insipidus after shock. Patient 2 recovered from coma and was discharged; however, she was rehospitalized for DE on day 45 and recovered completely after another 10-day HBOT. Patient 3 gained consciousness and recovered completely with no sequelae during the 1-year follow-up. From these cases, we can consider that the initial blood lactate may correlate with the patient outcomes and prove to be a useful prognostic factor. Thus, we should particularly consider elevated lactate levels in CO poisoning.

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.

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.

Determination of glyphosate and glufosinate in human serum by MonoSpin TiO extraction and liquid chromatography–tandem mass spectrometry

We developed and validated an assay for determination of glyphosate (GLYP) and glufosinate (GLUF) in human serum. Serum samples were extracted by using a MonoSpin® TiO column and analyzed by liquid chromatography–tandem mass spectrometry (LC–MS/MS). MonoSpin® TiO tends to specifically bind to phosphate groups. The assay was linear over a concentration range of 1–250 μg/mL. The recoveries for the 2 compounds were 1.6%–2.3%. The intra- and inter-day variations were <15%. Precision and accuracy were 5.6%–12.7% and 97.0%–103.9%, respectively. The validated method was applied to quantify the GLYP and GLUF content in the serum of GLYP and GLUF-poisoned patients. In conclusion, the method was successfully applied for accurate determination of GLYP and GLUF in serum obtained from patients with GLYP and GLUF poisoning.

Tension Hemothorax following Blunt Abdominal Aortic Injury: CT Imaging

Blunt abdominal aortic injury is an extremely rare and fatal condition. Hemothorax with bleeding from an extrathoracic organ is also an extremely rare condition. Studies have reported abdominal aortic aneurysm and renal trauma but not hemothorax following blunt abdominal aortic injury.