Yoshinori Murao

Increased plasma concentrations of adrenomedullin correlate with relaxation of vascular tone in patients with septic shock

OBJECTIVE To investigate plasma concentrations of adrenomedullin in patients with septic shock and the potential association of these concentrations with relaxation of vascular tone. DESIGN Prospective, case series. SETTING Department of Emergency and Critical Care Medicine, Nara Medical University. PATIENTS Twelve patients who fulfilled the clinical criteria for severe sepsis or septic shock (as defined by the Members of the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference Committee) and 13 healthy volunteers. INTERVENTIONS Arterial blood samples were obtained via a 20-gauge cannula inserted into each patients radial artery. MEASUREMENTS AND MAIN RESULTS After extraction and purification, plasma adrenomedullin was measured by radioimmunoassay. Systemic vascular resistance index, pulmonary vascular resistance, cardiac index, and stroke volume index were determined with a thermodilution catheter. The mean plasma concentration of adrenomedullin was markedly higher in patients than in controls (226.1 +/- 66.4 [SEM] vs. 5.05 +/- 0.21 fmol/mL, p < .01). Moreover, these concentrations correlated significantly with cardiac index, stroke volume index, and heart rate values, and correlated significantly with decreases in diastolic blood pressure, systemic vascular resistance index, and pulmonary vascular resistance index values. CONCLUSIONS Enhanced production of adrenomedullin in patients with septic shock may contribute to reduced vascular tone, hypotension, or both. More data are needed to clarify the role of adrenomedullin in the regulation of vascular tone in this patient population.

Spinal cord injury treatment with intrathecal autologous bone marrow stromal cell transplantation: the first clinical trial case report.

Spinal cord injury often results in devastating dysfunction and disability. When a spinal cord is injured, various symptoms are presented depending on the segments of the damage and the degree. If cervical spinal damage is severe, tetraplegia results. If damage occurs at levels higher than C4, diaphragmatic movement will be impaired, and the patient has to live being connected with the ventilator on the bed. Patients will suffer from acute hyperesthesia or severe chronic pain, urinary and rectal dysfunction, and autonomic dystonia as well as motor and sensory deficits. In Japan, there are more than 100,000 victims suffering from spinal injury, and a new 5,000 to 6,000 patients are added every year. In the Unites States, about 250,000 to 400,000 people are living with spinal cord injury, and there are about 11,000 to 13,000 new injuries every year. The number of incidence is increasing. The majority of them result from motor vehicle or sports injuries, violence, or falls. An injured central nervous system never regenerates. This has long been thought as a medical common sense terms. Therefore, the principal object for the treatment of spinal injury was mainly purposed how to minimize the progression of secondary injuries and maintain the remnant function of the spine. For the purpose of preventing secondary spinal cord injury, spine stabilization for the fracture or dislocation and rehabilitation were the main strategy in the treatment. There has been no successful treatment for the severe spinal cord injury to recover the function satisfactorily. However, if spinal cord damage is functionally improved even at the minimum, it will affect not only the physical, mental, and economic status of patients and their families, but also the medical resources of society. Recently, regenerative treatments with stem cells are in the limelight. However, there are some serious problems such as ethical ones to be solved for the study with stem cells. We reported significant recovery of motor function in rats with experimental spinal cord injury treated by transplanting bone marrow stromal cells (BMSCs) in the cerebrospinal fluid (CSF). Based on that study, we aimed at the clinical application of this treatment, and actually planned a clinical trial of spinal cord injury treatment by transplanting patient’s autologous BMSCs into CSF in the acute phase after spinal cord injury, at Kansai Medical University Hospital. We have developed a detailed protocol for the clinical trial. The medical ethics committees of the institutions have approved the protocol officially. This clinical trial aims to treat a damaged spinal cord by a novel method of injecting BMSCs into CSF through the lumbar puncture, and assess the safety and efficacy of the procedure. Although we have experienced only a single case, a committee that monitors the data to assess the efficacy and safety of the trial with members independent of this study team has evaluated the safety of the trial in this case, approved to continue the study, and agreed to submit a report of the first case. In addition, Japan Spinal Cord Foundation strongly requested to disclose the course of the first case. Therefore, we would like to publish the report of the first case to enhance research work on the new strategy for the difficult treatment of spinal cord injury. Submitted for publication July 6, 2007. Accepted for publication September 18, 2007. Copyright

Hypertonic saline resuscitation reduces apoptosis and tissue damage of the small intestine in a mouse model of hemorrhagic shock.

&NA; The effect of hypertonic saline resuscitation on intestinal damage and the incidence of apoptosis after hemorrhagic shock were investigated. After anesthesia, male BALB/c mice weighing 24‐34 g were hemorrhaged to the mean arterial pressure of 40 ± 5 mmHg for 90 min. Animals were randomly assigned to four groups: 1) resuscitation with 4 mL/kg of 7.5% NaCl (hypertonic saline; HS) + shed blood (SB); 2) resuscitation with two times the volume of shed blood of lactated Ringers solution (2LR) + SB; 3) sham (catheter only); or 4) control (no treatment). Intestinal damage was graded based on the extent of the vacuolation at the basal area of the intestinal villi. Apoptosis of the small intestines was examined with the terminal deoxynucleotidyl transferase‐mediated deoxyuridine 5‐triphosphate nick‐end labeling method and with DNA laddering. Caspase‐3 activation, heat shock protein (HSP) 70, and HSP40 were assessed by western blotting. Apoptosis of the small intestine and intestinal damage were significantly lower (P < 0.01) in the HS+SB group compared with the 2LR+SB group 2 h and 6 h after hemorrhagic shock and resuscitation, respectively. This corresponded with more DNA fragmentation in the small intestine of the 2LR+SB group compared with the HS+SB group 2 h after hemorrhage and resuscitation. In addition, we observed less caspase‐3 activation in the small intestine of the HS+SB group compared with the 2LR+SB group at 2 h after resuscitation. The content of HSP40 and HSP70 in the HS+SB group was similar to that in controls, but slightly decreased in the 2LR+SB group. HS resuscitation reduced intestinal damage and apoptosis after hemorrhagic shock, suggesting that HS resuscitation may improve the outcome after hemorrhagic shock by reducing apoptosis and damage to the small intestine.

Effect of dose of hypertonic saline on its potential to prevent lung tissue damage in a mouse model of hemorrhagic shock

&NA; Recent studies have shown that hypertonic saline (HS) resuscitation can reduce hemorrhage‐induced lung damage by preventing neutrophil activation. In this study, we examined whether this protective effect can be improved by increasing the HS dose used for resuscitation. The protective effect of two HS doses was tested in a mouse model of hemorrhagic shock. BALB/c mice were bled to a mean arterial blood pressure of 35 ± 5 mmHg for 1 h. Then the animals were resuscitated with lactated Ringers (LR) or with HS (7.5% NaCl) at doses of 4 mL/kg or 6 mL/kg body weight, sacrificed after 24 h, and lung tissue samples were collected. Evidence of lung injury was evaluated morphologically by scoring histology specimens in a blinded fashion. In a separate set of mice, plasma Na+ and osmolarity were determined 15 min after resuscitation. Resuscitation of hemorrhaged mice with 4 and 6 mL/kg HS increased plasma Na+ concentrations by 5 and 11 mM, respectively. LR treatment reduced plasma Na+ concentrations by 6 mM and resulted in a lung injury score of 6.1 ± 0.8, accompanied by focal thickening of alveolar membranes, congestion, pulmonary edema, and interstitial and intra‐alveolar neutrophil infiltration. HS at 4 mL/kg decreased focal thickening, congestion, pulmonary edema, and neutrophil infiltration, and the injury score to 3.8 ± 0.9, which was not significantly different from controls (3.6 ± 0.8), and lung damage was lowest in animals that received 6 mL/kg HS (2.5 ± 0.2, P < 0.005 vs. LR). Lung damage scores inversely correlated with plasma Na+ concentrations (r > 0.9999). Our data suggest that the protective effect of HS may be a function of the plasma Na+ concentration and that HS at 6 mL/kg is at least equally effective in reducing hemorrhage‐induced lung damage compared to the more commonly used HS dose of 4 mL/kg.

Does the timing of hypertonic saline resuscitation affect its potential to prevent lung damage

Hypertonic saline (HS) resuscitation has been reported to prevent lung damage by suppressing neutrophil activation in animal models. Data on the effectiveness of HS to prevent organ damage in the clinical setting are inconsistent. We investigated whether the timing of HS administration relative to neutrophil activation could affect its potential to block neutrophil responses. Different likely clinical circumstances were simulated in vitro by exposing human neutrophils to HS at different time points before and after activation with N-formyl-methionyl-leucyl-phenylalanine (fMLP). The in vivo effect of using HS as a secondary resuscitation fluid was determined with a mouse model of hemorrhage. BALB/c mice were hemorrhaged (40 +/- 5 mmHg) for 1 h and partially resuscitated with HS or Lactated Ringers (LR) 20 min before completing resuscitation with LR or HS, respectively. Neutrophil activation parameters were determined 2 h after complete resuscitation and lung damage was assessed after 24 h. The length of exposure to physiologically relevant HS levels (20 mM) determined the suppressive effect on in vitro neutrophil superoxide formation. HS treatment caused a transient state of suppression during which neutrophil activation was suppressed; however, HS was unable to suppress cells that were stimulated with fMLP before HS was added. Accordingly, in vivo lung damage was greater in animals that received HS after they had been partially resuscitated with LR compared to mice that received HS before LR (P < 0.05). We conclude that timing of exposure to HS affects neutrophil responses in vitro and may reduce the potential of HS resuscitation to prevent lung injury in vivo.

Administration of cultured autologous bone marrow stromal cells into cerebrospinal fluid in spinal injury patients: A pilot study

PURPOSE To determine whether intrathecal administration of cultured autologous bone marrow stromal cells (BMSCs) is safe and feasible for treatment of subacute spinal injury. METHODS Five patients with complete tetraplegia due to cervical spinal injury on admission were included. A small amount of bone marrow was obtained during surgery for spinal fusion. BMSCs were cultured, reaching 107-108 cells. The properties and functional efficacy of the BMSCs were verified with surface marker analysis and a neurite extension test. BMSCs were administered by lumbar puncture. The patients were closely observed for 6 months, and the Committee on Effectiveness and Safety of Clinical Treatment (CESCT) evaluated safety. RESULTS No adverse responses were observed in biochemical and radiographic examinations. The CESCT did not recognize any harmful effects of the transplantation, and concluded it was safe for treatment. The patients were further followed up for 1 to 4 years with no adverse responses. The recovery of American Spinal Injury Association Impairment Scale (AIS) B and C patients at transplantation was rapid and remarkable, but gradual or limited in AIS A patients. CONCLUSION This study demonstrated that intrathecal administration of cultured autologous BMSCs is safe and feasible for treatment of spinal cord injury.

Continuous arterial infusion therapy for severe acute pancreatitis: correlation between CT arteriography and therapeutic effect.

PURPOSE This study evaluates the relationship between the therapeutic effect of arterial infusion therapy for severe acute pancreatitis and drug distribution on CT-arteriography (CTA). MATERIALS AND METHODS Eleven patients with severe acute pancreatitis were treated by arterial infusion with use of protease inhibitor and antibiotics. Ten patients had an inflammation of the entire pancreas, while one had pancreatitis localized to the body and tail of the pancreas. The arterial infusion drugs were infused into the celiac artery, splenic artery, inferior pancreaticoduodenal artery, and common hepatic artery. The drug distributions were evaluated by CTA in 10 patients. The duration of arterial infusion ranged from 3 to 39 days. The relationship between the distribution on the CTA and the change in clinical grading of pancreatitis as evaluated by an APACHE II score was studied. RESULTS Of the nine patients with inflammation of the entire pancreas, six showed the distribution of contrast material to the entire area of pancreatic inflammation (a good distribution) on the CTA, and the remaining three did not show the distribution of contrast material to cover the entire area of pancreatic inflammation (a poor distribution). One patient with localized pancreatitis showed a good distribution. In seven patients with a good distribution, the APACHE II score was decreased from 11.7 points to 4.3 points during follow-up. In the remaining three patients with a poor distribution, the APACHE II score was decreased from 12.3 points to nine points, but was decreased to five points after the additional interventions. One patient without CTA showed a marked improvement in the APACHE II score. No clinically important complications were observed. CONCLUSION The present study findings suggest that arterial infusion is effective in the treatment of severe acute pancreatitis. A good drug distribution to the area of inflammation is needed to ensure a proper therapeutic effect.

Effect of Hypertonic Saline Resuscitation on CD4+CD25+ Regulatory T Cells and γδ T Cells After Hemorrhagic Shock and Resuscitation in Relation to Apoptosis and iNOS

BACKGROUND Hemorrhagic shock and resuscitation induce immunosuppression. CD4CD25 regulatory T cells and gammadeltaT cells may affect these immunosuppressive conditions. Hypertonic saline resuscitation reduces damage to organs and apoptosis and also restores immunosuppressive condition. We investigated how hypertonic saline resuscitation affected the induction of CD4CD25 regulatory T cells and gammadeltaT cells, and their apoptosis after hemorrhagic shock and resuscitation, and its relationship to inducible nitric oxide synthase (iNOS) (nitric oxide production). METHODS Male inbred C57BL6/J mice 8-week to 12-week-old as wild type and iNOS gene knock out (iNOS-/-), weighing 20 g to 35 g, were used. Hemorrhagic shock model of +/-40 mm Hg for 60 minutes was setup. Animals were randomly assigned to the following four resuscitation group: (1) wild HS: resuscitation with hypertonic saline (4 mL/Kg of 7.5% NaCl) and shed blood (SB), (2) wild 2LR: resuscitation with lactated Ringers solution (two times the volume of the SB) and SB, (3) iNOS knockout HS, and (4) iNOS knockout 2LR. Untreated groups for wild and iNOS knockout mice were designated as control groups. Samples of thymus and spleen were harvested at 2 hours, 6 hours, 24 hours, and 48 hours after resuscitation. CD4CD25 regulatory T cells and gammadeltaT cells were analyzed using three-color flow cytometry. RESULTS (1) gammadelta T cells increased earlier at 24 hours and CD4CD25 regulatory T cells increased later at 48 hours compared with controls in spleen of wild type (p < 0.01). (2) Hypertonic saline resuscitation suppressed gammadelta T cells compared with 2LR at 24 hours in iNOS knockout mice in spleen (p < 0.05). Hypertonic saline resuscitation increased apoptosis of CD4CD25 regulatory T cells at 48 hours in iNOS knockout mice in spleen (p < 0.01). (3) CD4CD25 regulatory T cells of iNOS knockout both in HS and 2LR groups at 48 hours decreased compared with wild type both in HS and 2LR groups in spleen (p < 0.01). (4) Apoptotic gammadelta T cells both in spleen and thymus in iNOS knockout mice at 48 hours increased compared with those in wild type (p < 0.05, respectively, except gammadelta T cells 2LR in spleen: p = 0.058). CONCLUSION gammadelta T cells increased earlier at 24 hours, whereas CD4CD25 regulatory T cells increased later at 48 hours in spleen of wild type. Hypertonic saline was effective without the presence of iNOS, i.e., decreased gammadelta T cells at 24 hours and increased apoptosis of CD4CD25 regulatory T cells at 48 hours. CD4CD25 regulatory T cells at 48 hours without iNOS decreased compared with those of wild type. gammadelta T cells at 48 hours induced apoptosis under the condition without iNOS in spleen and thymus. iNOS worked as an accelerating factor for immunosuppressive condition, affected apoptosis, and immunoenhancing effect by hypertonic saline.

Posttraumatic Intestinal Stenosis Presenting as a Perforation: Report of a Case

A 78-year-old woman was admitted to the hospital after falling into a ditch approximately 1 m deep and sustaining a blunt abdominal trauma with a left femur fracture. On the tenth day after admission, symptoms of a small bowel obstruction occurred. A nasogastric tube was inserted, and the symptoms thus improved. She sometimes complained of abdominal pain during the 12 months after the fall, but recovered with conservative management. The next year, she was readmitted to the hospital for a pin extraction of the left femur bone. During this admission, 15 months since her admission after her fall, she again complained of abdominal pain. Abdominal pain increased with a muscular defense, and abdominal X-rays revealed free air. She was referred to our hospital with a diagnosis of perforative peritonitis, and emergency surgery was performed. Upon laparotomy, circumferential stenoses of the small bowel were recognized in the proximal segments about 40 cm, 80 cm, and 100 cm from the ileocecal region. In addition, a perforation and prominent dilatation of the bowel segment was observed just proximal to the stenosis about 100 cm from the ileocecal region. She underwent a small intestinal resection at two sites. There were no findings of an intestinal specific ulcer, such as Crohn’s disease, intestinal tuberculosis, or malignancy, based on the results of a histopathological examination.

Primary adenocarcinoma of appendix, colonic type associated with perforating peritonitis in an elderly patient

We report a case of colonic type adenocarcinoma of the appendix with perforating peritonitis in a 92-year-old man. The preoperative diagnosis was localized peritonitis due to acute appendicitis and emergency laparotomy was performed. A gray, hard tumor was palpated at the base of the appendix. Appendiceal cancer was suspected, and right hemicolectomy was performed. The histopathological diagnosis was moderately differentiated adenocarcinoma of the appendix. The tumor obstructed the orifice of the appendix, and this may have caused the perforation of the appendix. The patient had an uneventful postoperative course and there have been no signs of recurrence in the 2 years since the operation.