Yoshihiro Moriwaki

Outcomes from Prehospital Cardiac Arrest in Blunt Trauma Patients

BackgroundThere are few strategies for treating patients who have suffered cardiopulmonary arrest due to blunt trauma (BT-CPA). The aim of this population-based case series observational study was to clarify the outcome of BT-CPA patients treated with a standardized strategy that included an emergency department thoracotomy (EDT) under an emergency medical service (EMS) system with a rapid transportation system.MethodsThe 477 BT-CPA registry data were augmented by a review of the detailed medical records in our emergency department (ED) and action reports in the prehospital EMS records.ResultsOf those, 76% were witnessed and 20% were CPA after leaving the scene. In all, 18% of the patients went to the intensive care unit (ICU), the transcatheter arterial embolization (TAE) room, or the operating room (OR). Only 3% survived to be discharged. Among the 363 witnessed patients—11 of whom had ventricular fibrillation (VF) as the initial rhythm, 134 exhibiting pulseless electrical activity (PEA), and 221 with asystole—13, 1, and 3%, respectively, survived to discharge. The most common initial rhythm just after collapse was not VF but PEA, and asystole increased over the 7xa0min after collapse. There were no differences in the interval between arrival at the hospital and the return of spontaneous circulation between the patients that survived to discharge and deceased patients in the ED, OR, TAE room, or ICU. The longest interval was 17xa0min.ConclusionsIn BT-CPA patients, a 20-min resuscitation effort and termination of the effort are thought to be relevant. The initial rhythm is not a prognostic indicator. We believe that the decision on whether to undertake aggressive resuscitation efforts should be made on a case-by-case basis.

Gauze packing as damage control for uncontrollable haemorrhage in severe thoracic trauma

Introduction The usefulness of thoracic damage control (DC) for trauma requiring a thoracotomy is not established. The aim of this study was to clarify the usefulness of thoracic packing as DC surgery. Methods This was a retrospective case series study of 12 patients with thoracic trauma suffering uncontrollable intrathoracic haemorrhage and shock who underwent intrathoracic packing. Our thoracic DC technique consisted of ligation and packing over the bleeding point or filling gauze in the bleeding spaces as well as packing for the thoracotomy wound. The success rates of intrathoracic haemostasis, changes in the circulation and the volume of discharge from the thoracic tubes were evaluated. Results Packing was undertaken for the thoracic wall in five patients, for the lung in four patients, for the vertebrae in two patients and for the descending thoracic aorta in one patient. Haemostasis was achieved successfully in seven cases. Of these, the volume of discharge from the thoracic tube exceeded 400ml/hr within three hours after packing in three patients, decreased to less than 200ml/hr within seven hours in six patients and decreased to 100ml/hr within eight hours in six patients. Systolic pressure could be maintained over 70mmHg by seven hours after packing. Conclusions Intrathoracic packing is useful for some patients, particularly in the space around the vertebrae, at the lung apex, and between the diaphragm and the thoracic wall. After packing, it is advisable to wait for three hours to see whether vital signs can be maintained and then to wait further to see if the discharge from the thoracic tube decreases to less than 200ml/hr within five hours.

Changes in the response of neutrophils to endotoxin priming following major abdominal surgery

Endotoxin (ETX) primes polymorphonuclear cells (PMNs) for the subsequent release of reactive oxygen species (ROS) in response to various stimulants such as phorbol myristate acetate (PMA). Although PMNs contribute to oxidative stress after stimulation by standard stimulants and after priming by many humoral factors, it is unknown whether the PMNs from patients at different postoperative times exhibit the same response to the same standard stimulant. We examined the response of PMA—induced production of ROS from PMNs at various intervals after major abdominal surgery in response to ETX priming. This study was a prospective clinical and laboratory study conducted over a 7-day period that involved 25 patients who were referred for elective major abdominal surgery (8 for gastric cancer, 9 for colonic cancer, 8 for rectal cancer). Blood was sampled on the day before operation and on postoperative days (PODs) 1, 3, and 7. For each sample we measured luminol-dependent chemiluminescence (CL), the time to peak counts (Tmax) of PMNs stimulated by PMA, and the serum ETX level. We studied the correlation between CL and ETX in samples from PODs 1 and 3. We also studied the CL of PMNs on PODs 1 and 3 preincubated (primed) with various concentrations of ETX (0, 20, 40, 60, and 100 pg/ml). We found that CL decreased on POD 1 compared with the preoperative level (p<0.05) because of the decreased Tmax. The level of CL per 1 µl of whole blood, however, was higher on PODs 1 and 3 than preoperatively. During this time, leukocytosis should compensate for the impaired production of ROS by an individual PMN. The serum ETX level was increased on POD 1 (p<0.05). There was a negative correlation between CL and ETX on POD 1 (correlation coefficient −0.62, p<0.01) and a positive correlation on POD 3 (0.61, p<0.01). CL on POD 3 was accelerated by ETX priming, but the CL on POD 1 was depressed by the priming using a low concentration of ETX. The mode of the response of PMNs to ETX priming differed between PODs 1 and 3. On POD 1 the responses of PMNs to environmental stimulants is suppressed, but by POD 3 these responses had increased.RésuméL’endotoxine (ETX) potentialise les leucocytes polvmorphes (LP) pour le largage ultérieur des types oxygène réactifs (TOR) en réponse à différents stimulants tels que l’acétate de phorbol mvristate (APM). Bien que l’APM contribue à une agression d’oxvdation après stimulation par des stimulants standards et après une potentialisation par plusieurs facteurs humoraux, on ne sait pas si les LP des patients à des moments différents de leur évolution ont les mêmes réponses aux mêmes stimulants. Nous avons examiné la réponse de la production des TOR à partir des LP à des moments différents après chirurgie abdominale majeure en réponse à la stimulation par des ETX. Cette étude prospective, clinique et paraclinique, sur une période de sept jours, comprenait 25 patients ayant besoin de chirurgie majeure (huit pour un cancer gastrique, neuf pour un cancer du côlon et huit un cancer rectal). On a prélevé du sang le jour avant l’intervention et aux jours postopératoires 1, 3 et 7. Pour chaque échantillon, nous avons mesuré le chimioluminescence luminol-dépendante (CL) ainsi que le temps pour atteindre un nombre maximal (TNmax) de LP stimulés par l’APM et les taux sériques d’ETX. Pour les échantillons des jours postopératoires 1 et 3, nous avons étudié la corrélation entre la CL et i’ETX. Nous avons également étudié la CL des LP des jours postopératoires 1 et 3, préincubés (potentialisés) avec différentes concentrations d’ETX (0, 20, 40, 60, et 100 pg/ml). La CL a diminué au Jl comparée au taux du jour préopératoire (p<0.05), provoquant une diminution du TNmax. Le taux de CL par 1 µL de sang entier, cependant, était plus élevé aux jours postopératoires 1 et 3 par rapport aux taux préopératoires. Pendant cette période, l’hyperleucocytose doit pouvoir compenser la mauvaise production de TOR par chaque LP. Les taux sériques d’ETX ont augmenté au jour postopératoire 1 (p<0.05). Il y avait une corrélation négative entre la CL et l’ETX au jour postopératoire 1 (coefficient de corrélation=−0.62, p<0.01) et une corrélation positive au jour postopératoire 3 (0.61 p<0.01). A partir du jour postopératoire 3, la CL a été accéléré par l’ETX mais déprimée lorsque la concentration en ETX était basse, et pour ce dernier, à partir du jour postopératoire 1. Le mode de réponse des LP à l’ETX différait entre les jours postopératoires 1 et 3. Au jour postopératoire 1, la réponse aux stimulants environmentaux est supprimée alors qu’au jour 3, ces réponses augmentaient.ResumenLa endotoxina (ETX) prepara las células poîimorfonucleares (PMNs) para la liberación subsiguiente de especies reactivas de oxígeno (ROS) en respuesta a diversos estímulos tales como el acetato de forbol miristato (phorbol myristate acetate, PMA). Aunque los PMNs contribuyen al estrés oxidative luego de ser estimulados por estimulantes estándar y de su preparación por múltiples factores humorales, se desconoce si los PMNs de los pacientes en diferentes periodos postoperatorios exhiben la misma respuesta al mismo estimulante estándar. Estudiamos la respuesta de la producción de ROS inducida por PMA de PMNs en varios intervalos de tiempo luego de cirugía abdominal en respuesta a la preparación por ETX. El presente es un estudio clínico prospectivo realizado durante siete años, que involucró 25 pacientes referidos para cirugía abdominal mayor (8 para cáncer gástrico, 9 para cáncer de colon y 8 para cáncer de recto). Se tomaron muestras de sangre el día preoperatorio y en el primero, tercero y séptimo días postoperatorios. En cada muestra se hizo la determinación de quimioluminiscencia luminol-dependiente (chemiluminescence, CL) así como en el momento de los recuentos máximos (Tmax) de PMNs estimulados por PMA y de los niveles séricos de ETX. En las muestras de los días primero y tercero postoperatorios, se estudió la correlación entre CL y ETX. También estudiamos la CL de los PMNs de los días primero y tercero postoperatorios, preincubado (primed) con varias concentraciones de ETX (0, 20, 40, 60, y 100 pg/ml). La CL disminuyó en el primer día postoperatorio en comparación con el nivel preoperatorio (p<0.05) como resultado de disminución del Tmax. Sin embargo, el nivel de CL por 1 µl de sangre total apareció elevado en los días primero y tercero postoperatorios. Durante este tiempo, la leucocitosis debe compensar la alterada producción de ROS por el PMN. El nivel sérico de ETX apareció aumentado en el primer día postoperatorio (p<0.05). Se demostró una correlación negativa entre CL y ETX en el primer día postoperatorio (coeficiente de correlación −0.62; p<0.01) y correlación positiva en el tercer día postoperatorio (0.61, p<0.01). La CL del tercer día postoperatorio apareció acelerada por la ETX, pero la CL del primer día postoperatorio apareció deprimida utilizando una concentración baja de ETX. El modo de acción preparatoria del PMN a la preparación de ETX fue diferente entre el primer y el tercer día postoperatorios. En el primer día postoperatorio las respuestas de los PMNs a los estimulantes ambientales estuvieron controladas hacia la supresión, y en el tercer día postoperatorio tales respuestas se vieron aumentadas.

Basaloid cell carcinoma of the esophagus with a metastatic neck tumor of unknown origin: report of a case.

A 51-year-old man was admitted to our hospital with a tumor in the right anterior region of his neck. Aspiration biopsy revealed squamous cell carcinoma (SCC). Further investigations, including upper gastro-intestinal series and endoscopy, showed two flush lesions in the middle and lower thoracic esophagus. An endoscopic biopsy was done and the pathological findings indicated poorly differentiated SCC. He underwent esophagectomy with three-field lymph node dissection, including the neck tumor. Histological findings revealed that the tumor in the middle thoracic esophagus was moderately differentiated SCC, and that the other tumor below it was basaloid cell carcinoma (BCC). The depths of invasion were to the lamina propria mucosae for the former and to the submucosal layer for the latter. There was no lymphatic invasion, venous invasion, or lymph node metastasis. A diagnosis of poorly differentiated SCC of unknown origin was made for the neck tumor. Postoperative recombinant chemotherapy with cisplatin and 5-fluorouracil was given for the unknown primary site, which we still have not identified. No recurrence of the esophageal cancer has been detected.