Yoshihide Nakagawa

RISK FACTORS FOR RHABDOMYOLYSIS IN SELF-INDUCED WATER INTOXICATION (SIWI) PATIENTS

Self-induced water intoxication (SIWI) patients present with various neurological and non-neurological symptoms. However, it is reported that non-neurological manifestations such as rhabdomyolysis are comparatively rare. The mechanism underlying rhabdomyolysis remains controversial. To investigate this further, we evaluated 22 SIWI patients for rhabdomyolysis. We reviewed the records of 22 patients with SIWI and evaluated their clinical characteristics. These patients were divided into the following two groups: Group A with rhabdomyolysis and Group B without it. We compared these groups to study the risk factors underlying the occurrence of rhabdomyolysis. Furthermore, we compared the complications and the duration of hospitalization between the two groups. The maximum serum sodium correction speed per hour, the increase in the serum sodium level in the initial 24 h, and the duration of hospitalization for group A were faster, higher, and longer, respectively, when compared with those in group B. Only group A patients showed complications. The rapid correction of hyponatremia may possibly trigger rhabdomyolysis in SIWI patients.

Painless acute aortic dissection with a left hemiparesis.

BackgroundPatients who present with only neurological symptoms and no pain challenge the recognition of acute aortic dissection.ResultsWe report three patients with completely painless acute aortic dissection who presented with left hemiparesis. All patients presented with a left-sided weakness of sudden onset. We suspected an ischemic stroke but diagnosed acute aortic dissection (DeBakey Type II, Stanford Type A). We suspect that the innominate artery is occluded when the blood flow of the false lumen is dominant. In our cases, surgical and autopsy findings showed dissection of the innominate artery.ConclusionsHighly unusual presentations of aortic dissection with acute ischemic stroke exist. A wide mediastinum on plain chest X-ray was present in all cases.

Correlating the severity of paraquat poisoning with specific hemodynamic and oxygen metabolism variables

Objective To investigate the hemodynamics and oxygen metabolism of patients with varying degrees of severity of paraquat poisoning. Design Prospective, observational, clinical study. Setting Intensive care unit in a university hospital. Patients Forty-three consecutive patients with paraquat and/or diquat poisoning were classified into three groups by the severity index of paraquat poisoning (SIPP; hr/mg/L). Interventions Standard treatments included specific respiratory management, fluid resuscitation, and aggressive circulatory support. Measurements and Main Results Serum paraquat and diquat levels were measured at arrival, and SIPP was calculated. The cardiac index (CI), left ventricular stroke work index (LVSWI), systemic vascular resistance index (SVRI), oxygen delivery index (˙Do2I), oxygen consumption index (&OV0312;o2I), and oxygen extraction ratio (O2ER) were measured at 6, 12, 24, 36, 48, 72, and 96 hrs postadmission. A significant inverse correlation between SIPP and survival time was found in 31 fatal cases (r2 = .85;p < .001). In the SIPP 10–50 group, CI, ˙Do2I, &OV0312;o2I, and O2ER were maintained at higher levels than in the SIPP group of <10 (p < .05), whereas SVRI decreased significantly (p < .05). In the SIPP group of >50, CI, LVSWI, SVRI, ˙Do2I, and &OV0312;o2I decreased, whereas O2ER had a tendency to increase progressively. There was a significant correlation between SVRI and SIPP, O2ER and SIPP, and O2ER and SVRI 24 hrs after admission, respectively (p < .001). Conclusions Paraquat poisoning is characterized by high oxygen consumption with high oxygen extraction, with the degree of derangement based on the severity index. The development of a marked imbalance between increased oxygen demand and decreased oxygen supply because of myocardial depression might be a possible cause of death in circulatory failure.

Characteristics of suicide attempters with depressive disorders

Abstract  Attempted suicide is known to be an important risk factor of committed suicide. Past studies of the relationship of attempted suicide with mental disorders have shown that it is most closely related to depression. The objective of the present study was to clarify characteristics of depression and measures to prevent committed suicide by comparing depression with other mental disorders. The patients with depression were significantly more often aged, males, married, and used methods other than poisoning by solids or liquids compared with patients with other mental disorders. Particularly, the major risk factors of attempted suicide (i.e. a younger age and the female gender), did not apply to our depressed patients. These results suggest that approaches such as intensive psychiatric treatment may lead to the prevention of committed suicide in older male patients with depression who have attempted suicide.

Nifekalant Hydrochloride and Amiodarone Hydrochloride Result in Similar Improvements for 24-Hour Survival in Cardiopulmonary Arrest Patients: The SOS-KANTO 2012 Study.

Background: Amiodarone (AMD), nifekalant (NIF), and lidocaine (LID) hydrochlorides are widely used for ventricular tachycardia/fibrillation (VT/VF). This study retrospectively investigated the NIF potency and the differential effects of 2 initial AMD doses (⩽150 mg or 300 mg) in the Japanese SOS-KANTO 2012 study population. Methods and Results: From 16,164 out-of-hospital cardiac arrest cases, 500 adult patients using a single antiarrhythmic drug for shock-resistant VT/VF were enrolled and categorized into 4 groups (73 LID, 47 NIF, 173 AMD-⩽150, and 207 AMD-300). Multivariate analyses evaluated the outcomes of NIF, AMD-⩽150, or AMD-300 groups versus LID group. Odds ratios (ORs) for survival to admission were 3.21 [95% confidence interval (CI): 1.38–7.44, P < 0.01] in NIF and 3.09 (95% CI: 1.55–6.16, P < 0.01) in AMD-⩽150 groups and significantly higher than those of the LID group. However, the OR was 1.78 (95% CI: 0.90–3.51, P = 0.10) in AMD-300 group and was not significant than LID group. ORs for 24-hour survival were 6.68 in NIF, 4.86 in AMD-⩽150, and 2.97 in AMD-300, being significantly higher in these groups. Conclusions: NIF and AMD result in similar improvements for 24-hour survival in cardiopulmonary arrest patients, and this suggest the necessity of a randomized control study.

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.

Continuous Venovenous Hemodiafiltration for Life-threatening Mitochondrial Myopathy With Lactic Acidosis and Rhabdomyolysis

We report here the clinical course of a 31-year-old male who recovered from a fulminant form of mitochondrial myopathy with lactic acidosis. The patient was transferred to our hospital with acute dyspnea and a convulsive seizure. On admission, he was in a state of shock, and presented with severe high-output heart failure, acute renal failure, and rhabdomyolysis. Treatment with continuous venovenous hemodiafiltration (CVVHDF) resulted in an excellent response, with no signs of hemodynamic instability. This case suggests that CVVHDF with serial hemodynamic monitoring may be effective in treating hypotensive patients with a life-threatening mitochondrial disorder.

Does Antiarrhythmic Drug during Cardiopulmonary Resuscitation Improve the One-month Survival: The SOS-KANTO 2012 Study

Background: Antiarrhythmic drugs (AAD) are often used for fatal ventricular arrhythmias during cardiopulmonary resuscitation (CPR). However, the efficacy of initial AAD administration during CPR in improving long-term prognosis remains unknown. This study retrospectively evaluated the effect of AAD administration during CPR on 1-month prognosis in the SOS-KANTO 2012 study population. Methods and Results: Of the 16,164 out-of-hospital cardiac arrest cases, 1350 shock-refractory patients were included: 747 patients not administered AAD and 603 patients administered AAD. Statistical adjustment for potential selection bias was performed using propensity score matching, yielding 1162 patients of whom 792 patients were matched (396 pairs). The primary outcome was 1-month survival. The secondary outcome was the proportion of patients with favorable neurological outcome at 1 month. Logistic regression with propensity scoring demonstrated an odds ratio (OR) for 1-month survival in the AAD group of 1.92 (P < 0.01), whereas the OR for favorable neurological outcome at 1 month was 1.44 (P = 0.26). Conclusions: Significantly greater 1-month survival was observed in the AAD group compared with the non-AAD group. However, the effect of ADD on the likelihood of a favorable neurological outcome remains unclear. The findings of the present study may indicate a requirement for future randomized controlled trials evaluating the effect of ADD administration during CPR on long-term prognosis.

Measurement of blood lactate, D-dimer, and activated prothrombin time improves prediction of in-hospital mortality in adults blunt trauma

Conventional trauma severity indices include the Injury Severity Score, an anatomical index calculated based on the degree of injury to each organ and body part [1], and the Revised Trauma Scale, a physiological index calculated based on the Glasgow Coma Scale score, systolic blood pressure, and respiratory rate [2]. Probability of survival is awidely usedmeasure to estimatemortality due to trauma: it can be calculated using logistic regression models that incorporate these indices and age as explanatory variables [3]. However, Injury Severity Score cannot be accurately determined until diagnoses are ascertained as to the level of injury to each organ and body part. Moreover, Injury Severity Scores can differ depending on the tests performed and between examiners [4]. Problems have been identified with the Revised Trauma Scale as well, including Glasgow Coma Scale measurement errors due to tracheal intubation [4]. Trauma patients in high need of emergency treatment could be more accurately identified if their risk of mortality could be predicted more precisely. This can be achieved by including biomarkers that can be evaluated quickly in emergency department (ED) triage assessments on admission.