Y. Shinozawa

Improvement in the Results of Surgical Treatment of Advanced Squamous Esophageal Carcinoma During 15 Consecutive Years

ObjectiveTo document the clinicopathologic characteristics and survival of patients undergoing esophagectomy for squamous carcinoma of the thoracic esophagus, and to examine the factors contributing to improvements in outcome noted in patients with advanced carcinoma. Summary Background DataJapanese and some Western surgeons recently have reported that radical esophagectomy with extensive lymphadenectomy conferred a survival advantage to patients with esophageal carcinoma. The factors contributing to this improvement in results have not been well defined. MethodsFrom 1981 to 1995, 419 patients with carcinoma of the thoracic esophagus underwent esophagectomy at the Keio University Hospital. The clinicopathologic characteristics and survival of patients treated between 1981 and 1987 were compared with those of patients treated between 1988 and 1995. Multivariate analysis using the Cox regression model was carried out to evaluate the impact of 15 variables on survival of patients with p stage IIa to IV disease. Several variables related to prognosis were examined to identify differences between the two time periods. ResultsThe 5-year survival rate for all patients was 40.0%. The 5-year survival rate was 17.7% for p stage IIa to IV patients treated during the earlier period and 37.6% for those treated during the latter period. The Cox regression model revealed seven variables to be important prognostic factors. Of these seven, three (severity of postoperative complications, degree of residual tumor, and number of dissected mediastinal nodes) were found to be significantly different between the earlier and latter periods. ConclusionsThe survival of patients undergoing surgery for advanced carcinoma (p stage IIa to IV) of the thoracic esophagus has improved during the past 15 years. The authors’ data suggest that this improvement is due mainly to advances in surgical technique and perioperative management.

Secondary exposure of medical staff to sarin vapor in the emergency room.

ObjectiveTo clarify the risk of secondary exposure of medical staff to sarin vapor in the emergency room, and to warn emergency room staffs of the hazard.DesignRetrospective observational survery.SettingEmergency department of a university hospital in a metropolitan area of Japan.ParticipantsFifteen doctors treating victims of a terrorist attack with sarin in the Tokyo subways on the day of the attack.Measurements and resultsOf the 15 doctors who worked in the emergency room treating the victims, 13 became simultaneously aware of symptoms during the resuscitation of two victims who were exposed to sarin. Among 11 doctors (73%) who complained of dim vision, the pupils were severely miotic (<2 mm) in 8 (73%). Other symptoms included rhinorrhea in eight (53%), dyspnea or tightness of the chest in four (27%), and cough in two (13%). Atropine sulfate was given to six, and pralidoxime was given to one of these six doctors. To decontaminate the emergency room of sarin vapor, ventilation was facilitated and all belongings of the patients were sealed up. None of the doctors noticed worsening of their symptoms thereffter.ConclusionsCareful attention to the risks of secondary exposure to toxic gas in the emergency room and prompt decontamination if such exposure should occur are necessary in the case of large-scale disasters caused by sarin.

Clinical analysis of multiple organ failure in burned patients

Severely burned patients often show various degrees of organ failures, and when several vital organs are involved mortality becomes extremely high. A study was undertaken to elucidate the aetiology and clinical significance of multiple organ failure (MOF) in burned patients. One hundred and fifty-eight burned patients were analysed for organ failures in five vital organs or systems, the heart, lung, liver, kidney and blood clotting system. There were 91 organ failures observed in 34 patients, of which 26 had MOF. The most frequently affected organ was the lung, followed by the heart, kidney, liver and the blood clotting system. The mortality rate was 76.9 per cent in MOF and 1.5 per cent in non-MOF patients. Septicaemia was closely associated with the development of MOF. Also, inhalation injury and shock were contributing factors to the morbidity. Five extensively burned patients had an early development of MOF without infectious foci and this type of early MOF was attributed to endotoxaemia possibly originating from the patients own intestinal flora.

Serum MIP-1α and IL-8 in septic patients

We studied blood MIP-1α and IL-8 in 38 septic patients and 5 healthy volunteers. Both chemokines were undetectable in the healthy volunteers. In sepsis, serum MIP-1α was detected in 45% of the patients and IL-8 in 84%. The levels of MIP-1α, but not of IL-8, correlated with CRP, IL-6 and TNFα levels. Complication, including various organ failures and mortality, showed no correlation with serum MIP-1α levels. In contrast, we found increased levels of serum IL-8 in septic patients with disseminated intravascular coagulation, central nervous system (CNS) dysfunction or renal failure, and the mortality rate was higher in the IL-8-detectable group than in the IL-8 undetectable group (50% vs 0%,p<0.05). In conclusion, the production of both MIP-1α and IL-8 was increased and initially detectable levels of circulating IL-8 predicted high mortality in sepsis.ObjectiveTo determine the significance of the C-C chemokine MIP-1α and the C-X-C chemokine IL-8 in sepsis.DesignProspective study.SettingClinical investigation, emergency department and general intensive care unit of university hospital.Patients and participants38 septic patients and 5 healthy volunteers were studied. Sepsis was diagnosed following the criteria formulated by ACCP/SCCM.Interventions10–20 ml of blood was drawn from each patient at the time of initial diagnosis of sepsis.Measurements and resultsMIP-1α and IL-8 were determined by sand-wich ELISA. Both chemokines were undetectable in the healthy volunteers. In sepsis, serum MIP-1α was detected in 45% of the patients and IL-8 was detected in 84%. The levels of MIP-1α, but not of IL-8, correlated with CRP, IL-6 and TNFα levels. Complications, including various organ failures and mortality, showed no correlation with serum MIP-1α levels. In contrast, we found increased levels of serum IL-8 in patients with disseminated intravascular coagulation (DIC) (p<0.05), central nervous system (CNS) dysfunction (p<0.05), renal failure (p<0.01) and the mortality rates were higher in the IL-8 detectable group than in the IL-8 undetectable group (50% vs 0%,p<0.05).ConclusionsThe production of MIP-1α and IL-8 was increased in sepsis. Furthermore, an initially detectable level of circulating IL-8, but not MIP-1α, predicted a high mortality in sepsis diagnosed according to the ACCP/SCCM criteria.

Relationship between pupil size and acetylcholinesterase activity in patients exposed to sarin vapor

Objective: To elucidate the effect of sarin vapor on pupil size and erythrocyte acetylcholinesterase activity (AchE). Design: Retrospective observational survey. Setting: Emergency department of an urban teaching hosp

An alternative limb lead system for electrocardiographs in emergency patients

It is occasionally difficult to record the standard 12-lead electrocardiograph (ECG) in emergency patients. The aim of this study was to evaluate the influence on electrocardiographic wave form recordings of moving the location of electrodes from the standard limb lead position to the trunk. The participants were 10 normal subjects and 20 patients with heart disease. In the new lead system, the limb electrodes were placed on the anterior acromial region and the anterior superior iliac spine using adhesive electrodes. Conventional 12-lead ECGs were recorded by the standard and the new lead system simultaneously in the supine position. Wave form analysis was done by an automatic analysis program. Motion artifacts in the recordings were less in the new lead system. The R wave amplitude of the new lead system increased in leads II, III and aVF, and decreased in leads I and aVL. However, the amplitudes of each wave obtained by standard electrocardiography and the new lead system correlated well (y = 1.008x + 2.038, r = 0.99, n = 2,880). In 99.6% of all wave forms, the differences in amplitudes were within 5% of the values of standard recordings. The average of differences in the ST-segment was 2.6 +/- 11.4 microV. The frontal plane QRS axis obtained by the new lead system showed a vertical shift of 7.8 +/- 8.5 degrees (y = 0.94911x + 10.346, r = 0.98, n = 30). The recording errors produced by the new lead system were within the permissible range of variation. The new lead system is a reasonable alternative for recording ECGs if application of the standard lead is difficult in an emergency.

A case of traumatic shock complicated by methamphetamine intoxication

Abstract A case of a 38-year-old male with traumatic shock complicated by methamphetamine intoxication is presented. The patient was involved in an assault which resulted in cardiac tamponade and right ventricular outflow laceration. Pericardiocentesis was immediately performed. However, profound metabolic acidosis greatly in excess of that expected from the short duration of the shock was revealed by arterial blood gas analysis. Another cause of the metabolic acidosis was suspected. The patient subsequently admitted to intravenous use of methamphetamine. Following hemodynamic and metabolic stabilization by continuous pericardial drainage and intravenous administration of sodium bicarbonate, the patient underwent cardiac surgery. His postoperative course was uneventful. There is a substantial association between methamphetamine users and traumatic accidents. In such cases, early identification of drug use is important. Marked metabolic acidosis, which conflicts with the diagnosed cause of shock, may be a clinical clue to methamphetamine intoxication.

Necessity for Postoperative Artificial Respiration in Esophageal Surgery

Pulmonary complications following esophageal cancer surgery are still important problems, even though much progress has been made recently in perioperative managements. Many institutions perform postoperative artificial respiration, namely mechanical ventilatory support, as the most effective measure against pulmonary complications. The present report describes the necessity, the effect and the new system for prophylactic mechanical ventilation.

The effects of dopamine infusion on the postoperative energy expenditure, metabolism, and catecholamine levels of patients after esophagectomy

Although dopamine is one of the most widely used vasoactive agents, its postoperative thermogenic and metabolic effects have not been studied. In this study, the effects of low-dose dopamine, given at 5 μ/kg/min, on resting energy expenditure (REE), metabolism, and plasma catecholamine levels were examined in eight postsurgical patients. Dopamine infusion increased REE from 1,839 ± 171 kcal/day to 2,071 ±170 kcal/day, and it decreased to 1,867 ± 141 kcal/day after cessation of the infusion. Dopamine also increased the plasma levels of glucagon from 109.4 ± 8.7 pg/ml to 132.5 ±8.0 pg/ml, and it decreased to 102.9 ± 11.1 pg/ml after cessation of the infusion. The plasma levels of dopamine before, during, and after the infusion were 116.1 ± 18.3, 161.1 ±25.6, and 121.4 ± 17.2 ng/ml, respectively. Insulin and glucose were affected by dopamine, but changes in their plasma levels did not parallel the dopamine levels. Epinephrine and norepinephrine were increased by the infusion of dopamine and continued to increase even after its cessation. The results of this study revealed that low-dose dopamine increased REE in postsurgical patients and that this might be associated with the concomitant increase in plasma glucagon.