Youichi Yanagawa

Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest

The effects of mild hypothermia (MH) were investigated. From 1995 to 1996, 28 adult patients with out-of-hospital cardiopulmonary arrest (CPA) had return of spontaneous circulation and survived for more than two days. Thirteen patients were in the MH group. In the MH group, core temperature was maintained between 33 and 34 degrees C for 48 h, and then re-warmed to a temperature of 37 degrees C, at a rate of no greater than 1 degrees C per day. Fifteen patients, admitted before the MH protocol was instituted, were in the control group. Despite the fact that the number of witnessed arrests in the control group were greater than in the MH group, there were both more survivors (7/13 vs. 5/15) and more fully recovered patients (3/13 vs. 1/15) in the MH vs Control groups. Eleven of 13 MH patients, as compared to 6/15 controls developed pneumonia. Our study, although preliminary, suggests that MH might confer improved outcome, as has been shown in animal models, after CPA. This treatment is associated with an increase in pneumonic complications.

A quantitative analysis of head injury using T2*-weighted gradient-echo imaging.

BACKGROUND T2*-weighted gradient-echo imaging (T2*-GE) is useful for detecting small hemorrhages. METHODS Thirty-four patients were prospectively examined, first by magnetic resonance imaging (1.5 T) and then by T2-weighted fast spin echo (T2-FSE) and T2*-GE. Thereafter, the correlations between the T2-FSE or T2*-GE findings and the clinical or computed tomography findings were analyzed. RESULTS The number of lesions detected by T2*-GE was 14.5 +/- 16.3 (mean +/- SD, n = 34), which was significantly (p < 0.001) greater than that detected by T2-FSE (5.6 +/- 5.6, n = 34). The findings of T2*-GE correlated positively with both the duration of unconsciousness (R2 = 0.74,p < 0.0001) and with Glasgow Outcome Scale (R2 = 0.81, p < 0.0001), whereas those of T2-FSE did not show any significant correlation. T2*-GE imaging could also detect all areas responsible for focal neurologic signs 1 month after in. jury, whereas T2-FSE imaging detected only 22 of 33 such signs. CONCLUSION T2*-GE was found to be useful for evaluating the clinical symptoms of head injury.

Hypovolemic shock evaluated by sonographic measurement of the inferior vena cava during resuscitation in trauma patients.

BACKGROUND Inferior vena cava (IVC) diameter immediately after fluid resuscitation has not yet been investigated in trauma patients with shock on arrival. METHODS Between June 2004 and May 2005, 30 trauma patients with hemorrhagic shock were prospectively investigated. Using ultrasound, we measured maximum anterior-posterior diameter of the IVC just below the diaphragm in the hepatic segment, in the expiratory phase. This was performed on arrival and when systolic blood pressure had been raised to over 90 mm Hg by fluid resuscitation in the emergency room. Subjects were divided into two groups: a transient responder group (n = 17) in which shock recurred after leaving the emergency room and a responder group (n = 13) in which blood pressure remained stable. RESULTS There were no significant differences between the two groups regarding age or gender, or regarding vital signs or IVC diameter on arrival. Average injury severity score in the transient responder group was significantly greater than that in the responder group. After fluid resuscitation, no significant intergroup differences were observed regarding vital signs. However, IVC diameter was significantly smaller in the transient responder group than in the responder group (6.5 +/- 0.5 mm; mean +/- SE vs. 10.7 +/- 0.7 mm, p < 0.05). CONCLUSION In trauma patients, inadequate dilatation of the IVC by fluid resuscitation, might indicate insufficient circulating blood volume despite normalization of blood pressure. In this small study, IVC diameter appeared a better predictor of recurrence of shock than blood pressure, heart rate, or arterial base excess. A larger prospective study is called for to clearly establish the sensitivity and specificity of this method.

Two cases of acute poisoning with acetamiprid in humans

Introduction. Acetamiprid is a potent and a relatively new neonicotinoid insecticide. Animal studies have indicated that it has a low toxicity to mammals. Despite wide usage, human exposure resulting in toxicity is quite limited, and this is the first report in the English literature about acute acetamiprid poisoning in humans. Case Details. We herein describe two cases of acute poisoning with an insecticide formulation containing acetamiprid for suicidal purposes. Both cases experienced severe nausea and vomiting, muscle weakness, hypothermia, convulsions, and clinical manifestations including tachycardia, hypotension, electrocardiogram changes, hypoxia, and thirst in the case with the higher serum concentration of acetamiprid. The symptoms were partially similar to acute organophosphate intoxication. Supportive treatments for a variety of symptoms were sufficient for recovery, and both individuals were discharged without any complications 2 days after ingestion.

Indications for Transcatheter Arterial Embolization in Persistent Hemothorax caused by Blunt Trauma

BACKGROUND To confirm the usefulness of contrast-enhanced computed tomography (CECT) and the efficacy of transcatheter arterial embolization (TAE) in patients, who undergo tube thoracostomy for hemothorax secondary to blunt chest trauma. MATERIALS CECT was performed at admission in patients, who suffered blunt chest trauma but did not require an emergent thoracotomy. Pulmonary injuries with intrapulmonary hematomas or traumatic pneumatoceles or both on computed tomography images were diagnosed as pulmonary lacerations (PL). The size of the pulmonary injuries with the PL was measured as percent volume (volume of the PL/volume of the lung). Rib fracture displacement was measured on computed tomography images and expressed as parallel and transverse displacement of the fractured ribs (PD and TD, respectively). Patients with an injury to a thoracic great vessel (e.g., aortic injury) were excluded. RESULTS CECT of the chest was performed on 154 of 976 consecutive patients with blunt torso trauma. Thirty-four patients have PL without a great vessel injury. Tube thoracostomy was performed at 38 sites in 29 patients. After the initial bloody drainage, the mean drainage during the first hour was 81.2 mL/h +/- 137 mL/h. The mean percent volume of the PL was 29.0% +/- 15.4%. The mean PD was 12.2 mm +/- 10.4 mm. The PD and the TD correlated with the hourly drainage (p = 0.001, p < 0.001, respectively). No correlation was found between the percent volume of PL and hourly drainage (p = 0.11). Of the 38 thoracostomy sites, 6 had a blood loss of > or =200 mL/h. Contrast extravasation on CECT was observed in five of these six sites, and angiography was performed. All five sites had contrast extravasation from an intercostal artery, and TAE was successfully performed. CONCLUSION Intercostal arterial bleeding should be suspected in patients with persistent hemothorax > or =200 mL/h and large displacement of a fractured rib. In such cases, CECT should be performed and TAE is indicated if contrast extravasation is observed.

Moderate hypothermia alters interleukin-6 and interleukin-1α reactions in ischemic brain in mice

Female C57BL/6 mice were decapitated and their brains were removed and cultured at either 37 or 33 degrees C for 48 h to investigate whether or not moderate hypothermia alters the cytokine reactions in the ischemic brain. The interleukin-6 and interleukin-1alpha levels in the culture media were significantly elevated in a time-dependent manner. The interleukin-6 levels after the incubation at 33 degrees C were significantly lower than those at 37 degrees C. The interleukin-1alpha levels at 33 degrees C were significantly higher than those at 37 degrees C. The interleukin-1alpha levels incubated with interleukin-6 antibody were significantly higher than those without IL-6 antibody. At 37 degrees C, the mRNA expression of interleukin-6 was observed from 2 to 48 h after incubation, but the same expression of interleukin-1alpha was only detected until 12 h. Accordingly, the ischemic brain incubated at 33 degrees C showed a decreased interleukin-6 production in comparison with that at 37 degrees C and the level of interleukin-6 showed negative feedback for the production of interleukin-1alpha. The temperature should, therefore, be carefully considered when evaluating the cytokine reaction for cerebral ischemia.

Analysis of Prehospital Care for Cardiac Arrest in an Urban Setting in Japan

BACKGROUND In Japan, the management of prehospital care for cardiopulmonary arrest (CPA) has recently changed. STUDY OBJECTIVES The characteristics of prehospital care for CPA were analyzed to identify predictors of prehospital return of spontaneous circulation (PROSC) and good recovery. METHODS The characteristics of prehospital management of 713 out-of-hospital CPA patients in the First Western District of Saitama Prefecture, Japan, were retrospectively analyzed. RESULTS Overall, PROSC rate was 9.5% (n = 68), and 2.2% of patients (n = 16) made a good recovery. Significant positive predictors of PROSC were: duration from the first call to hospital arrival, witnessed collapse, ventricular fibrillation at scene, and epinephrine administration. Establishment of supraglottic airway was a significant negative predictor of PROSC. Significant positive predictors of good recovery were younger age, ventricular fibrillation at scene, and PROSC. Changes to the life support protocol based on 2005 guidelines did not affect the outcome. CONCLUSIONS Epinephrine was effective in increasing PROSC; however, it did not improve recovery of such patients. The findings also suggest that out-of-hospital care providers should not try to establish a supraglottic airway.

Diffusion-weighted MRI predicts prognosis in severe hypoglycemic encephalopathy.

A 20-year-old woman presented unconscious due to hypoglycemia after a self-administered insulin injection. Diffusion-weighted MRI (DWI), performed 5 days after admission, demonstrated heterogeneous high-intensity signal areas in both the cortex and subcortex but sparing the motor and sensory centers. On the 11th day after admission, she began making incomprehensible verbal sounds, eye opening spontaneously and moving her extremities with pyramidal tract signs. Three months later, she had aphasia, agnosia and apraxia but a normal gait without pyramidal tract signs or ataxia. DWI is thus considered useful to predict the functional outcome of patients with severe hypoglycemia.

Relationship between laboratory findings and the outcome of cardiopulmonary arrest

PURPOSE The aim of this study was to investigate whether laboratory findings on arrival may be useful in predicting the outcome of out-of-hospital cardiopulmonary arrest (CPA). METHODS Between January 2005 and September 2007, a medical chart review was retrospectively performed for CPA. The individual medical records were reviewed for the following data: background of CPA, arterial blood gas, cell blood count, serum biochemical, and cerebral performance category (CPC) 1 month after the CPA. The subjects were divided into patients with a CPC ranging from 3 to 5 (CPC 3-5 group) and from 1 to 2 (CPC 1-2 group). FINDINGS The total protein, platelets, pH, and Po(2) in the CPC 1-2 group tended be higher than those in the CPC 3-5 group. The Pco(2), potassium, phosphorus, and ammonia in the CPC 1-2 group tended be lower than those in the CPC 3-5 group. However, there were no factors independently associated with the outcome by multivariate analysis. CONCLUSION Some of the biochemical-hematologic parameters demonstrate significant changes concerning the outcome. However, initial blood work cannot be used to make clinical decisions because there are no factors independently associated with the outcome.

Cutaneous hemorrhage or necrosis findings after Vespa mandarinia (wasp) stings may predict the occurrence of multiple organ injury: a case report and review of literature.

Data sources. We report one case and analyzed 15 Japanese cases concerning multiple organ failure induced by wasp stings. Data Extraction. Thirteen of 15 cases were associated with skin hemorrhage or necrosis after wasp stings. The mean number of stings (± standard error) in the patients who died (59 ± 12) was significantly greater than that in those who survived (28 ± 4, p=0.01). Conclusion. The occurrence of skin hemorrhage or necrosis after wasp stings is extremely rare and multiple organ injury after wasp stings is also a rare complication. Thus, cutaneous hemorrhaging or necrosis findings after wasp stings may suggest the development of multiple organ injury. In addition, the number of stings may play an important role in predicting outcome.