Yuichi Koido

Change in the ratio of interleukin-6 to interleukin-10 predicts a poor outcome in patients with systemic inflammatory response syndrome.

OBJECTIVE To examine whether changes in interleukin (IL)-6 and IL-10 concentrations in patients with systemic inflammatory response syndrome (SIRS) can predict a poor outcome. DESIGN Prospective study. SETTING Emergency and intensive care unit of a medical school hospital. PATIENTS Twenty-five patients who fulfilled the criteria for SIRS. INTERVENTIONS Blood samples were collected for cytokine determinations. MEASUREMENTS AND MAIN RESULTS IL-6 and IL-10 concentrations were measured by enzyme-linked immunosorbent assay in plasma samples. Blood samples were obtained at 0, 1, 2, and 4 days from patients who fulfilled the criteria for SIRS. Of 25 patients, 19 survived and the other six patients died of multiple organ failure. Although IL-6 and IL-10 concentrations in survivors decreased gradually from 186.1 +/- 34.4 to 93.6 +/- 18.9 (SEM) pg/mL (p < .05) and from 77.4 +/- 21.2 to 32.0 +/- 11.8 pg/mL (p < .05), IL-6 concentrations in nonsurvivors did not. Although the ratio of IL-6 to IL-10 in survivors was almost stable, the ratio in nonsurvivors increased from 5.5 +/- 3.1 to 18.7 +/- 2.8 (p < .05). Multivariate analysis showed that when heart rate, mean arterial pressure, IL-6, IL-10, and the ratio of IL-6 to IL-10 were taken into account, there only remained a relationship between the ratio of IL-6 to IL-10 and outcome. CONCLUSIONS In nonsurvivors, IL-6 concentrations did not decrease, IL-10 concentration decreased, and the ratio of IL-6 to IL-10 increased. An increase in the ratio of IL-6 to IL-10 indicated a correlation with a poor outcome.

Post-flood — Infectious Diseases in Mozambique

INTRODUCTION The types of medical care required during a disaster are determined by variables such as the cycle and nature of the disaster. Following a flood, there exists the potential for transmission of water-borne diseases and for increased levels of endemic illnesses such as vector-borne diseases. Therefore, consideration of the situation of infectious diseases must be addressed when providing relief. The Japan Disaster Relief (JDR) Medical Team was sent to Mozambique where a flood disaster occurred during January to March 2000. The team operated in the Hokwe area of the State of Gaza, in the mid-south of Mozambique where damage was the greatest. METHODS An epidemiological study was conducted. Information was collected from medical records by abstracting data at local medical facilities, interviewing in habitants and evacuees, and conducting analyses of water. RESULTS A total of 2,611 patients received medical care during the nine days. Infectious diseases were detected in 85% of all of patients, predominantly malaria, respiratory infectious diseases, and diarrhea. There was no outbreak of cholera or dysentery. Self-reports of the level of health decreased among the flood victims after the event. The incidence of malaria increased by four to five times over non-disaster periods, and the quality of drinking water deteriorated after the event. CONCLUSIONS Both the number of patients and the incidence of endemic infectious diseases, such as malaria and diarrhea, increased following the flood. Also, there was a heightening of risk factors for infectious diseases such as an increase in population, deterioration of physical strength due to the shortage of food and the temporary living conditions for safety purposes, and turbid degeneration of drinking water. These findings support the hypotheses that there exists the potential for the increased transmission of water borne diseases and that there occurs increased levels of endemic illnesses during the post-flood period.

The ratio of interleukin-6 to interleukin-10 correlates with severity in patients with chest and abdominal trauma

To evaluate the relation between proinflammatory cytokines and antiinflammatory cytokines after major trauma, we measured pro-inflammatory cytokine (interleukin [IL]-6) and antiinflammatory cytokine (IL-10) concentrations after trauma, and evaluated the relationship between the ratio of IL-6 to IL-10 and injury severity. In 20 patients who sustained chest and abdominal trauma, IL-10, IL-6, and lactate concentrations were measured at 0, 1, 2, and 4 days. The Injury Severity Score (ISS), Acute Physiology and Chronic Health Evaluation (APACHE) II score, and the ratio of IL-6 to IL-10 were calculated. IL-6, IL-10, and lactate concentrations were 197.2+/-28.4 (mean +/- SEM), 71.1+/-10.1 pg/mL, and 46.7+/-9.4 mg/dL at entry. These concentrations were significantly decreased at day 4. The ratio of IL-6 to IL-10 was 3.11+/-0.47 at entry and was significantly correlated with ISS (r=.872, P<.01), APACHE II score (r=.887, P<.01). The IL-10, IL-6, and lactate concentrations were elevated immediately after major trauma, and the ratio of IL-6 to IL-10 was correlated with injury severity. This suggests that the ratio of IL-6 to IL-10 may be used to predict the injury severity after trauma.

Usefulness of the bilateral anterior rectus abdominis sheath turnover flap method for early fascial closure in patients requiring open abdominal management.

BackgroundMany patients requiring conventional open abdominal management need a postoperative intermediate period with a large ventral hernia. This situation, in which the granulated abdominal contents are covered only with a skin graft, carry with it a high risk of enterocutaneous fistula, and the patients ultimately require late-stage abdominal wall reconstruction. Early abdominal wall reconstruction in noncandidates for standard fascial closure has received little attention. In this study we used bilateral anterior rectus abdominis sheath turnover flaps for early fascial closure which, to date, has not been evaluated as a technique for early fascial closure.MethodsEleven trauma and 18 nontrauma cases requiring open abdominal management over a 7-year period were reviewed. Bilateral anterior rectus abdominis sheath turnover flaps were created by longitudinal incisions along the lateral edge of the anterior rectus sheath, which were mobilized medially and approximated. The skin was closed primarily.ResultsTwelve nontrauma and eight trauma patients survived. No enteric fistula or abdominal abscess occurred. Anterior rectus sheath turnover flaps were used in nine of the 18 nontrauma and two of the 11 trauma patients, all of whom were unsuitable for standard fascial closure of prolonged visceral edema; the respective mean intervals from initial laparotomy to fascial closure were 9.4 and 18 days. Of the 11 patients with flaps, ten survived without fascial dehiscence or herniation (maximum follow-up: 65 months).ConclusionsEarly fascial closure using the anterior rectus abdominis sheath turnover flap may reduce the need for skin grafting and subsequent abdominal wall reconstruction. This approach can be considered as an alternative technique in the early management of patients with open abdomen.

NEW DIAGNOSTIC PERITONEAL LAVAGE CRITERIA FOR DIAGNOSIS OF INTESTINAL INJURY

BACKGROUND Although diagnostic peritoneal lavage (DPL) is a well-established, reliably objective method of diagnosis of intraperitoneal injury, it is too sensitive to be used as an indicator for emergency celiotomy. Therefore, since the development of ultrasonography and advanced computed tomographic scanners, the role of DPL has been markedly reduced. Despite such remarkable advances, however, radiologic diagnosis of intestinal injury cannot always provide definitive results, and DPL may still be valuable in such instances. We have developed a new DPL criteria specifically designed to aid in the diagnosis of intestinal injury and have evaluated its effectiveness. METHODS From August 1988 to December 1995, we performed DPL in 250 patients with blunt abdominal trauma and analyzed the diagnostic accuracy of our new criteria. We used the standard quantitative white blood cell (WBC) criterion for detection of intestinal injury supplemented by a positive-negative borderline adjusted to WBC > or = red blood cell (RBC)/150, where RBC > or = 10 x 10(4)/mm3. RESULTS Our criteria had a diagnostic sensitivity of 96.6% and a specificity of 99.4% for intestinal injury after exclusion of 57 patients in whom DPL was performed within 3 hours or after 18 hours from the time of injury. In 133 patients with hemoperitoneum, emergency celiotomy was performed in only 48; the remaining 85 patients with negative DPL based on the WBC criterion avoided surgery, and conservative management resulted in no complications. CONCLUSION With the proposed criteria, DPL can be used to diagnose or exclude intestinal injury even in the presence of hemoperitoneum.

Analysis of patient load data from the 2002 FIFA World Cup Korea/Japan.

INTRODUCTION Past history of mass casualties related to international football games brought the importance of practical planning, preparedness, simulation training, and analysis of potential patient presentations to the forefront of emergency research. METHODS The Japanese Ministry of Health, Labor, and Welfare established the Health Research Team (HRT-MHLW) for the 2002 FIFA World Cup game (FIFAWC). The HRT-MHLW collected patient data related to the games and analyzed the related factors regarding patient presentations. RESULTS A total of 1661 patients presented for evaluation and care from all 32 games in Japan. The patient presentation rate per 1000 spectators per game was 1.21 and the transport-to-hospital rate was 0.05. The step-wise regression analysis identified that the patient presentations rate increased where access was difficult. As the number of total spectators increased, the patient presentation rate decreased. (p < 0.0001, r = 0.823, r2 = 0.677). CONCLUSION In order to develop mass-gathering medical-care plans in accordance with the types and sizes of mass gatherings, it is necessary to collect data and examine risk factors for patient presentations for a variety of events.

Implications of Excessive Fibrinolysis and α2-Plasmin Inhibitor Deficiency in Patients with Severe Head Injury

OBJECTIVETo evaluate the involvement of the fibrinolytic system, especially focused on &agr;2-plasmin inhibitor, in patients with head injury. METHODSThis study consisted of 47 patients with isolated blunt head trauma in whom blood sampling could be initiated within 3 hours after injury. Patients were divided into two groups according to Glasgow Outcome Scale score status at 3 months after injury. In Group 1 patients (n = 26), the outcome was characterized as good recovery or moderate disability; in Group 2 patients (n = 21), the outcome was characterized as severe disability, vegetative state, or death. RESULTSConcentrations of thrombin-antithrombin III complex were greater than 100 &mgr;g/L in 39 of 47 patients, and concentrations in Group 2 patients were elevated significantly beyond the concentrations in Group 1 patients. Activities of &agr;2-plasmin inhibitor in Group 2 were significantly lower than in Group 1 (P < 0.0001). In Group 1 patients, &agr;2-plasmin inhibitor activity was greater than 60%, while in all but four Group 2 patients, the inhibitor was reduced to less than 60% of normal activity within 3 hours of injury. All patients with &agr;2-plasmin inhibitor activity less than 60% showed a marked bleeding tendency and/or severe brain edema. Using sandwich enzyme-linked immunosorbent assay, fibrinogen degradation product and fibrin degradation product were measured separately. A significant correlation was apparent between thrombin-antithrombin III complex and fibrinogen degradation product, as well as between the complex and fibrin degradation product. Marked decreases in &agr;2-plasmin inhibitor were noted only in patients with thrombin-antithrombin III complex concentrations exceeding 500 &mgr;g/L. CONCLUSIONFibrinolysis and fibrinogenolysis may be involved according to the degree of coagulation activation in the pathophysiology of severe head injury. Decreased activity of &agr;2-plasmin inhibitor indicated poor prognosis and may be an exacerbating factor in the acute phase of head trauma.

Analysis of medical needs on day 7 after the tsunami disaster in Papua New Guinea.

INTRODUCTION Because of great intervening distances, international medical relief activities in catastrophic, sudden-onset disasters often do not begin until days 5-7 after the precipitating event. The medical needs of those affected and what public health problems exist in the community in the week after the tsunami disaster in Papua New Guinea(PNG) were investigated. METHODS The Japan Medical Team for Disaster Relief (JMTDR) conducted investigative hearings at the District Office responsible for the management of the disaster, the Care Center, and the Hospitals in Aitape, Vanimo, and Wewak in PNG. RESULTS The numbers of in-patients in the Aitape, Vanimo, and Wewak Hospitals, and in the Care Center in Aitape were 291, > 300, 68, and 104, respectively. The exact number of people affected was unknown at the Aitape District Office. There was no lack of medical supplies and drugs in the hospital, but the Care Center in Aitape did not have sufficient quantities of antibiotics. No outbreak of communicable disease occurred, despite the presence of risk factors such as the dense concentration of affected people and the constant prevalence of malaria and diarrhea. The water at Wewak General Hospital contained chlorine and was suitable for drinking, but that elsewhere contained bacteria. CONCLUSIONS On about the 7th day after the event, the available information still was incomplete, and it was a time to shift from initial emergency activities to specialized medical care. Although no outbreak of communicable disease actually occurred, there was much anxiety about it because of the risk factors present. For effective medical care at this stage, it is essential to conduct a survey of actual medical needs that also include epidemiological factors.

Resources for business continuity in disaster-based hospitals in the great East Japan earthquake: survey of Miyagi Prefecture disaster base hospitals and the prefectural disaster medicine headquarters.

OBJECTIVE To clarify advance measures for business continuity taken by disaster base hospitals involved in the Great East Japan Earthquake. METHODS The predisaster situation regarding stockpiles was abstracted from a 2010 survey. Timing of electricity and water restoration and sufficiency of supplies to continue operations were investigated through materials from Miyagi Prefecture disaster medicine headquarters (prefectural medical headquarters) and disaster base hospitals (14 hospitals) in Miyagi Prefecture after the East Japan earthquake. RESULTS The number of hospitals with less than 1 day of stockpiles in reserve before the disaster was 7 (50%) for electricity supplies, 8 (57.1%) for water, 6 (42.9%) for medical goods, and 6 (42.9%) for food. After the disaster, restoration of electricity and water did not occur until the second day or later at 8 of 13 (61.5%) hospitals, respectively. By the fourth postdisaster day, 14 hospitals had requested supplies from the prefectural medical headquarters: 9 (64.3%) for electricity supplies, 2 (14.3%) for water trucks, 9 (64.3%) for medical goods, and 6 (42.9%) for food. CONCLUSIONS The lack of supplies needed to continue operations in disaster base hospitals following the disaster clearly indicated that current business continuity plans require revision.

Experience from the Great East Japan Earthquake Response as the Basis for Revising the Japanese Disaster Medical Assistance Team (DMAT) Training Program

OBJECTIVE The objective of this study was to draft a new Japanese Disaster Medical Assistance Team (DMAT) training program based on the responses to the Great East Japan Earthquake. METHODS Working group members of the Japan DMAT Investigative Commission, Ministry of Health, Labour and Welfare, reviewed reports and academic papers on DMAT activities after the disaster and identified items in the current Japanese DMAT training program that should be changed. A new program was proposed that incorporates these changes. RESULTS New topics that were identified to be added to the DMAT training program were hospital evacuation, preparations to receive DMATs at damaged hospitals, coordination when DMAT activities are prolonged, and safety management and communication when on board small helicopters. The use of wide-area transport was reviewed and changes were made to cover selection of various transport means including helicopter ambulances. Content related to confined space medicine was removed. The time spent on emergency medical information system (EMIS) practical training was increased. Redundant or similar content was combined and reorganized, and a revised DMAT training program that did not increase the overall training time was designed. CONCLUSION The revised DMAT training program will provide practical training better suited to the present circumstances in Japan.