Pseudomonas aeruginosa Bacteremia among Immunocompetent and Immunocompromised Patients: Relation to Initial Antibiotic Therapy and Survival

Pseudomonas aeruginosa bacteremia occurs mainly in immunocompromised patients. However, P. aeruginosa bacteremia in immunocompetent patients has also been reported. The aim of this study was to evaluate the clinical characteristics of P. aeruginosa bacteremia in relation to the immune status of the patients. The medical records of 126 adult patients with P. aeruginosa bacteremia in Nagasaki University Hospital were retrospectively reviewed between January 2003 and December 2012. Of 126 patients with P. aeruginosa bacteremia, 60 patients (47.6%) were classified as immunocompetent. Mortality in immunocompetent patients tended to be lower than in immunocompromised patients (7-day mortality, 8% vs. 30%, P < 0.01; 30-day mortality, 23% vs. 39%, P = 0.053). Multivariate analysis showed that a higher sequential organ failure assessment score (hazard ratio [HR]: 1.27, P < 0.01) and underlying malignancies (HR: 3.33, P < 0.01) were independently associated with 30-day mortality. Initial antibiotic therapy (HR: 0.21, P < 0.01) and patients' immune status (HR: 0.29, P = 0.02) also had a significant impact on survival. However, there was a significant interaction between these 2 variables (P = 0.03 for interaction). A subgroup analysis showed that in immunocompromised, but not immunocompetent patients, initial appropriate antibiotic therapy was associated with lower mortality (30-day mortality 20.5% vs. 66.7%, P < 0.01 by log-rank test).

Active Surveillance of Methicillin-Resistant Staphylococcus aureus Using a Fully Automated Molecular Test in an Emergency Medical Center

The prevention and control of methicillin-resistant Staphylococcus aureus (MRSA) are important, particularly in emergency units. The active surveillance of MRSA was prospectively performed at the emergency medical center of Nagasaki University Hospital. After obtaining nasal swab specimens, a fully automated molecular test (FAMT) and a culture-screening method were utilized for MRSA detection. A total of 150 patients were enrolled in the study, and 366 nasal swab specimens were obtained. MRSA was detected by culture in 11 (7.3%) patients including one new acquisition and by the FAMT in 34 (22.7%) patients including 13 new acquisitions. The sensitivity, specificity, positive predictive value, and negative predictive value of the FAMT at the patient level were 86.7, 85.2, 39.4, and 98.3%, respectively, when compared with the culture-based results. An FAMT can effectively detect MRSA colonization, which may remain undetected with the conventional method, and it may be useful in detecting newly acquired MRSAs.

Comparison of recombinant human thrombomodulin and gabexate mesylate for treatment of disseminated intravascular coagulation (DIC) with sepsis following emergent gastrointestinal surgery: a retrospective study

PURPOSE

Recombinant thrombomodulin (rTM) has been available in Japan since 2008, but there is concern about its association with postoperative hemorrhage. The efficacy and safety of rTM were examined in patients with disseminated intravascular coagulation (DIC) caused by a septic condition after gastrointestinal surgery.

METHODS

Forty-two patients were emergently admitted to the intensive care unit after emergent gastrointestinal surgery in Kyushu University Hospital from May 2008 to April 2013. Of these patients, 22 had DIC (defined as an acute DIC score ≥ 4). All but three patients received treatment with gabexate mesylate (GM) (n = 9) or rTM (n = 10). The causes of sepsis were peritonitis with colorectal perforation, anastomotic leakage, and intestinal necrosis. Acute DIC score, sepsis-related organ failure assessment score, platelet count, and a variety of biochemical parameters were compared between rTM and GM recipients after treatment administration.

RESULTS

There were no significant differences between the groups for any parameter except C-reactive protein levels. The CRP level tended to be lower in the rTM group than in the GM group. Acute DIC score in the rTM group resolved significantly earlier than that in the GM group. No patient stopped the administration of rTM because of postoperative bleeding.

CONCLUSION

rTM may be an effective therapeutic drug for the treatment of septic patients with DIC following emergent gastrointestinal surgery.

In vitro and in vivo activities of piperacillin-tazobactam and meropenem at different inoculum sizes of ESBL-producing Klebsiella pneumoniae

The inoculum effect is a laboratory phenomenon in which the minimal inhibitory concentration (MIC) of an antibiotic is increased when a large number of organisms are exposed. Due to the emergence of extended-spectrum β-lactamase-producing Klebsiella pneumoniae (ESBL-Kpn) infections, the inoculum effect of ESBL-Kpn on β-lactams was studied in vitro and in vivo using an experimental model of pneumonia. The in vitro inoculum effect of 45 clinical ESBL-Kpn isolates on β-lactams was evaluated at standard (10(5) CFU/mL) and high (10(7) CFU/mL) organism concentrations. The MIC50 of piperacillin-tazobactam, cefotaxime and cefepime was increased eight-fold or more and that of meropenem was increased two-fold. The in vivo inoculum effect was evaluated in an ESBL-Kpn pneumonia mouse model treated with bacteriostatic effect-adjusted doses of piperacillin-tazobactam (1000 mg/kg four times daily, %T>MIC; 32.60%) or meropenem (100 mg/kg twice daily, %T>MIC; 28.65%) at low/standard (10(4) CFU/mouse) and high (10(6) CFU/mouse) inocula. In mice administered a low inoculum, no mice died after treatment with piperacillin-tazobactam or meropenem, whereas all the control mice died. In contrast, in the high inoculum model, all mice in the piperacillin-tazobactam-treated group died, whereas all meropenem-treated mice survived and had a decreased bacterial load in the lungs and no invasion into the blood. In conclusion, meropenem was more resistant to the inoculum effect of ESBL-Kpn than piperacillin-tazobactam both in vitro and in vivo. In the management of severe pneumonia caused by ESBL-Kpn, carbapenems may be the drugs of choice to achieve a successful outcome.

Influence of antimicrobial regimen on decreased in-hospital mortality of patients with MRSA bacteremia

Methicillin-resistant Staphylococcus aureus (MRSA) is one of the most important causes of bacteremia. Recently, several epidemiological and microbiological changes have become evident in MRSA infections. The purposes of this study were to assess clinical characteristics of patients with MRSA bacteremia and microbiological changes in MRSA. We conducted a retrospective observational study on patients with MRSA bacteremia who were hospitalized between 2008 and 2011. We used univariate and multivariate analysis to evaluate the predictors associated with 30-day mortality. The 7-day and 30-day mortality rates were 12.0% and 25.3%, respectively. According to multivariate analysis, the independent predictors that associated with 30-day mortality were leukopenia, low serum albumin, high sequential organ failure assessment (SOFA) score, and quinolone use within 30 days. Compared to previous data (2003-2007), the SOFA score of the new data set remained unchanged, but in-hospital mortality decreased significantly. In particular, the mortality associated with use of vancomycin (VCM) was significantly lower. Although the minimum inhibitory concentration of VCM required to inhibit the growth of 90% of organisms (MIC90) had not changed, the trough value of VCM changed significantly; a VCM trough value of 10 or greater was significantly higher compared to previous data. Of the staphylococcal cassette chromosome mec (SCCmec) types, SCCmec II values decreased significantly, and SCCmec I and IV values increased significantly. Our results indicate that changes in VCM usage might contribute to decreased in-hospital mortality.

In vivo efficacy of biapenem with ME1071, a novel metallo-β-lactamase (MBL) inhibitor, in a murine model mimicking ventilator-associated pneumonia caused by MBL-producing Pseudomonas aeruginosa

ME1071, a maleic acid derivative, is a novel, specific inhibitor of metallo-β-lactamases (MBLs). In vitro, ME1071 can potentiate the activity of carbapenems against MBL-producing Pseudomonas aeruginosa. To confirm the clinical efficacy of ME1071 in ventilator-associated pneumonia (VAP) caused by MBL-producing P. aeruginosa, a mouse model that mimics VAP by placement of a plastic tube in the bronchus was used. Biapenem (100 mg/kg) or ME1071 plus biapenem (each 100 mg/kg) was administered intraperitoneally every 12 h beginning at 12 h after inoculation. Survival was evaluated over 7 days. At 30 h post infection, mice were sacrificed and the numbers of viable bacteria in the lungs and bronchoalveolar lavage fluid (BALF) were compared. Histopathological analysis of lung specimens was also performed. The pharmacokinetics of ME1071 was analysed after initial treatment. The ME1071 plus biapenem combination group displayed significantly longer survival compared with the control and biapenem monotherapy groups (P<0.05). Furthermore, the number of viable bacteria in the lungs was significantly lower in the combination group (P<0.05). Histopathological examination of lung specimens indicated that progression of lung inflammation was prevented in the combination group. Furthermore, total cell and neutrophil counts, as well as cytokine levels, in BALF were significantly decreased (P<0.05) in the combination group. The percentage time above the MIC (%T>MIC) for biapenem without ME1071 was 0% in plasma; however, this value was elevated to 10.8% with ME1071. These results suggest that ME1071 is potent and effective for treatment of VAP caused by MBL-producing P. aeruginosa.

A case of intravascular large B-cell lymphoma (IVLBCL) with no abnormal findings on chest computed tomography diagnosed by random transbronchial lung biopsy

A 58-year-old woman was admitted with refractory fever despite receiving broad-spectrum antibiotics. She had hypoxemia, severe anemia, elevated levels of serum lactic dehydrogenase and soluble interleukin-2 receptor, and a positive direct Coombs test, which suggested an underlying autoimmune hemolytic anemia (AIHA). Chest computed tomography (CT) showed no abnormal findings, but she had hypoxia, and her alveolar-arterial oxygen difference (A-aDO2) was increased. A random transbronchial lung biopsy (TBLB) was performed, and pathological analysis showed massive proliferation of tumor cells in the lumina of the small vessels. Intravascular large B-cell lymphoma (IVLBCL) was diagnosed, and her general status improved after chemotherapy.

[Case of pulmonary adenocarcinoma with co-existing pulmonary actinomycosis in one region of the lung]

A 64-year-old man presented with chronic cough. Chest CT revealed a nodular shadow with cavitation in the right S6. Seven months after his first examination, the nodular shadow had gradually increased, so flexible fiberoptic bronchoscopy was performed. The results of bronchial brushing and aspiration cytology were negative, however, gram-stained smear of the bronchial aspirate revealed many gram-positive rods with branching filamentous hyphae and culture of the bronchial aspirate was positive for the Actinomyces species. On a diagnosis of pulmonary actinomycosis, 1500 mg of oral amoxicillin was initiated. After 4 months of treatment, the right S6 nodule size was unchanged and the level of CYFRA in serum was elevated. Therefore, video-assisted thoracic surgery (VATS) was performed. A histological examination of the resected tumor showed papillary and acinar adenocarcinoma. The common radiological features in patients with pulmonary actinomycosis are nodules, mass formation and cavitation. Pulmonary actinomycosis requires differentiation from lung cancer. Although lung cancer with coexisting pulmonary actinomycosis is rare, clinicians should take into consideration the fact that lung cancer and pulmonary actinomycosis can co-exist in the same patient.

Steroid receptor signalling in the brain--lessons learned from molecular imaging

Studies with green fluorescent protein (GFP) have revealed the subcellular distribution of many steroid hormone receptors to be much more dynamic than previously thought. Fluorescence resonance energy transfer (FRET) and fluorescence recovery after photobleaching (FRAP) are powerful techniques with which to examine protein-protein interaction and the mobility of tagged proteins, respectively. FRET analysis revealed that steroid treatment (with corticosterone or testosterone) induces direct interaction of the glucocorticoid receptor (GR) and importin alpha in the cytoplasm and that, shortly after nuclear entry, the GR detaches from importin alpha. The mineralocorticoid receptor (MR) and androgen receptor (AR) show the same trafficking. Upon oestradiol treatment, ERalpha and ERbeta in the same cell are relocalised to form a discrete pattern and are localised in the same discrete cluster (subnuclear foci). FRAP analysis showed that nuclear ERalpha and ERbeta are most dynamic and mobile in the absence of the ligand, and that mobility decreases slightly after ligand treatment. Genomic as well as non-genomic actions of steroid hormones influence the cellular function of target tissues spacio-temporally.

Carcinosarcoma of the parotid gland: an unusual case with large-cell neuroendocrine carcinoma and rhabdomyosarcoma. Case report

We report a case of carcinosarcoma of the parotid gland in a 72-year-old Japanese man. The patient noticed a rapidly enlarging hard mass in the right parotid gland. He underwent radical parotidectomy with cervical lymph node dissection. The resected tumor measured 3.5 x 4.5 cm and histopathologically showed carcinomatous and sarcomatous components. The carcinomatous component consisted of large-cell neuroendocrine carcinoma (LCNEC), squamous cell carcinoma and adenocarcinoma not otherwise specified, while the sarcomatous component included spindle cell sarcoma not otherwise specified, so-called myxosarcoma and rhabdomyosarcoma. The LCNEC component was predominant within the whole tumor. The diagnoses of LCNEC and rhabdomyosarcoma were also confirmed immunohistochemically. With regard to histopathogenesis, based on the lack of histopathological evidence and antecedent history of pleomorphic adenoma, we considered the present case to be de novo, not expleomorphic adenoma.

Does the self-centering mechanism of bipolar hip endoprosthesis really work in vivo?

PURPOSES

To examine radiographically the component motion in a bipolar prosthesis and to determine whether the self-centering mechanism really works in vivo.

METHODS

38 patients with 41 bipolar hip endoprostheses (30 for coxarthrosis and 11 for osteonecrosis of femoral head) were included in this study. Two radiographs of each case were taken to evaluate the self-centering mechanism. The first anteroposterior radiograph of both hip joints was taken at the maximum abduction while the patient standing on the endoprosthetic leg. The second radiograph was taken after the patient returned to neutral position while standing on 2 legs. In the present study, the order in which the radiographs were taken differed from previously reported studies. The radiographs were analysed using the method similar to that of Drinker and Murray. The adductive motion from abduction to a neutral position is within the range of inner bearing oscillation.

RESULTS

The outer head alignment changed from 23 degrees to 12 degrees in the patients with osteonecrosis. However, the valgus position of the outer head (36 degrees) remained unchanged in the patients with coxarthrosis standing on 2 legs in the neutral position.

CONCLUSION

The self-centering mechanism of the bipolar endoprosthesis functioned in the patients with osteonecrosis, but did not work in the coxarthrosis group.

Expression of beta-catenin, E-cadherin and cyclin D1 in adenoid cystic carcinoma of the salivary gland

We evaluated the expression of beta-catenin, E-cadherin, and cyclin-D1 in 23 cases of adenoid cystic carcinoma (ACC) of the salivary gland. We detected beta-catenin on the cell membranes in all ACCs, but its distribution was irregular, as compared to that on normal structures. In three out of the 23 cases, beta-catenin was detected in the nuclei, as well as on cell membranes. Polymerase chain reaction (PCR) and direct sequencing revealed a missense mutation in one case in which beta-catenin had been detected in the nuclei of tumor cells. We also detected E-cadherin on cell membranes with a similar irregular distribution to that of beta-catenin. In 11 cases (almost 48%) of ACC, cyclin D1 was localized in cell nuclei but there was no correlation with the nuclear staining of the beta-catenin. Our results suggest that disturbances in the distribution of beta-catenin and E-cadherin might affect the morphology ofACC and that a small fraction of cases of ACC are characterized by a mutation in the beta-catenin gene, which is associated with the nuclear accumulation of the product of this gene but does not affect the transcription of the gene for cyclin-D1.

Biomechanical properties of heat-treated bone grafts

INTRODUCTION

A possible critical complication associated with banking bone is human immunodeficiency virus (HIV) infection. Recently, since the report of HIV infection in bone allografts from an HIV-seronegative donor, a more reliable method of sterilization for preserved bone graft has become necessary. Heat treatment of banking bone is one of the simple sterilization methods. This method is especially safe and practical for the prevention of HIV infection.

MATERIALS AND METHODS

We previously reported a biological study on heat-treated bone graft. In that study, we showed that revascularization and new bone formation of bone graft after heat treatment at 60 degrees C was nearly the same as that of non-heat-treated bone graft, while at 100 degrees C, revascularization and new bone formation showed a significant delay. This time, we examined the change of mechanical strength of heat-treated bone grafts after transplantation in an experiment. To eliminate the problem of antigenicity of grafted bone, we used autografts, not allografts. Two types of heat-treated autografts were employed: heat-treated at 60 degrees C for 30 min and heat-treated at 100 degrees C for 5 min; as a control, fresh autografts were replaced in the left femur of rabbits. A strength test was performed for both the transplanted bone and the untreated intact right femur with time after transplantation. The strength test consisted of a compression test and torsional test, and the strength was compared between transplanted bone and the untreated intact right femur.

RESULTS

In the compression test, the grafts heat-treated at 60 degrees C showed a strength ratio before transplantation of 97.3%. The strength ratio decreased to 63.5% at 18 weeks after transplantation. Then the strength ratio increased and recovered to 94.5% at 48 weeks after transplantation. However, the grafts heat-treated at 100 degrees C showed unsatisfactory mechanical strength, at 48 weeks the strength ratio was 60.1%, which was significantly lower compared with controls. In the torsional test, the grafts heat-treated at 60 degrees C showed almost the same strength observed in the compression test. However, the grafts heat-treated at 100 degrees C showed unsatisfactory mechanical strength: at 48 weeks, the strength ratio was 57.3%.

CONCLUSION

Therefore, heat treatment at 60 degrees C is a useful sterilization method, not only in biological but also mechanical terms.

3M integral bipolar cup system for dysplastic osteoarthritis. Clinical and radiographic review with five- to seven-year follow-up

Between 1995 and 1997 we undertook 40 bipolar hip arthroplasties in 35 patients with dysplastic osteoarthritis. The steep and shallow acetabulum was excavated and the bipolar socket was placed high with an adjustment of leg-length. At follow-up of between five and seven years, there were 19 excellent, 16 good and five fair results according to the scoring system of Merle d'Aubigné and Postel. The mean radiographic superior migration of the bipolar socket was 2.1 mm (0 to 10). Osteolysis was noted in three hips within three years of the operation. Abduction on weight-bearing was recorded in 24 hips and the bipolar system was found to be functioning predominantly between the inner bearing and the metal femoral head in 20.

3M integral bipolar cup system for dysplastic osteoarthritis

Between 1995 and 1997 we undertook 40 bipolar hip arthroplasties in 35 patients with dysplastic osteoarthritis. The steep and shallow acetabulum was excavated and the bipolar socket was placed high with an adjustment of leg-length. At follow-up of between five and seven years, there were 19 excellent, 16 good and five fair results according to the scoring system of Merle d’Aubigné and Postel. The mean radiographic superior migration of the bipolar socket was 2.1 mm (0 to 10). Osteolysis was noted in three hips within three years of the operation. Abduction on weight-bearing was recorded in 24 hips and the bipolar system was found to be functioning predominantly between the inner bearing and the metal femoral head in 20.

Lipid extracted freeze-dried bank bone sterilized with low temperature plasma

Ethylene oxide gas (EOG) is widely used for sterilization of freeze-dried bone. Recently EOG is regulated for clinical use because of cytotoxicity and environmental pollution concerns. Low Temperature Plasma Sterilization (LTPS) has no toxicity and mutagenicity working with a hydrogen peroxide gas plasma at 45 degrees centigrade. We have now used this method experimentally and clinically to sterilize freeze-dried bone. Cortical bone with a thickness of 5 mm and cancellous bone with a 10 mm cubic size were prepared, washed, defatted, dehydrated by freeze drying and finally sterilized by LTPS. As a Microbiological test, defatted freeze-dried bone was contaminated with B. subtilis, and after then the contaminated bone was treated with LTPS and the bacteria was proven inactive. Mechanical testing on rabbit cortical bone was investigated by compression testing using a mechanical testing machine. No differences between EOG treated and LTPS treated bone were found. From December 1996, 52 patients who had small and middle bone defects were treated with defatted, freeze-dried and LTPS sterilized bone. Clinical result was good. No deep infections, no transmission of virus infections or severe graft absorption were noted. The LTPS bank bone is safe and useful to reconstruction to small bone defects.

Management of severe blunt liver injuries

To assess the effectiveness of non-surgical treatment for severe blunt liver injuries, we retrospectively examined the files of 147 patients (excluding cases with cardiopulmonary arrest on arrival). The patients were divided into three groups according to the date of admission: Group-A (1982-85), B (1986-90) and C (1991-95). The patients were further divided on the basis of the type of injury, according to the classification proposed by the Japanese Association for the Surgery of Trauma (JAST). The types of injuries reported here were of type II, IIIa or IIIb. There was no difference in the patients' background, injury severity score (ISS), amount of intra-peritoneal hemorrhage, and amount of blood transfusion among the three groups, A, B and C. Surgical treatment was carried out in all Group-A patients, in 81.8% of Group-B patients and in 31% of Group-C patients. The hospitalization period was shorter in the Group-C, and the frequency of fatal outcome was also lower in Group-C. Non-surgical treatment has been performed since 1988 in our center, and its frequency has been increasing since then. It was applied to 6 cases (18.2%) of Type II injuries in Group-B. In total, 69% of the cases in Group-C were non-surgically treated, including cases of Type IIIa and Type IIIb injuries. Non-surgical treatment prevented 8 out of 9 cases of severe liver injury from having fatal outcomes in 1995. Moreover, 5 of those cases were of the most serious type (Type IIIb). There were three fatalities in Group-C and none in Group-B. Out of all the non-surgically treated cases, injuries to the head were the cause of fatality. Any treatment of cases showing inferior vena cava damage was generally ineffective due to heavy bleeding, unless the bleeding was stopped by surgical intervention. Non-surgical treatment is suitable for blunt liver injuries, including severe liver injuries, provided that bleeding control and close observation are maintained.

Effects of overexpression of Escherichia coli katE and bet genes on the tolerance for salt stress in a freshwater cyanobacterium Synechococcus sp. PCC 7942

To explore the potential role of catalase and glycine betaine in the protection of cyanobacteria from damage due to salt stress, we transformed a freshwater cyanobacterium Synechococcus sp. PCC 7942 with shuttle vectors that contained the Escherichia coli katE, bet, and katE plus bet (katE/bet) genes. The catalase activity in the cells overexpressing katE and katE/bet genes was about 1.4-1.8-fold higher than that in the control cells. The control and transformant cells had a similar growth rate in the medium with a low salinity. However, under a high-salinity condition, the cells transformed with katE grew faster than the control cells, and the cells expressing katE/bet genes grew faster than those expressing either the katE or bet gene alone. These results indicate that high-salinity caused oxidative stress and the coexpression of katE and bet genes in Synechococcus cells were superior to the expression of either katE or bet alone for the protection of the cells from the damage due to high-salinity.

Molecular characterization of DnaK from the halotolerant cyanobacterium Aphanothece halophytica for ATPase, protein folding, and copper binding under various salinity conditions

Previously, it was found that the dnaK1 gene of the halotolerant cyanobacterium Aphanothece halophytica encodes a polypeptide of 721 amino acids which has a long C-terminal region rich in acidic amino acid residues. To understand whether the A. halophytica DnaK1 possesses chaperone activity at high salinity and to clarify the role of the extra C-terminal amino acids, a comparative study examined three kinds of DnaK molecules for ATPase activity as well as the refolding activity of other urea-denatured proteins under various salinity conditions. DnaK1s from A. halophytica and Synechococcus sp. PCC 7942 and the C-terminal deleted A. halophytica DnaK1 were expressed in Escherichia coli and purified. The ATPase activity of A. halophytica DnaK1 was very high even at high salinity ( 1.0 M NaCl or KCl), whereas this activity in Synechococcus PCC 7942 DnaK1 decreased with increasing concentrations of NaCl or KCl. The salt dependence on the refolding activity of urea-denatured lactate dehydrogenase by DnaK1s was similar to that of ATPase activity of the respective DnaK1s. The deletion of the C-terminal amino acids of A. halophytica DnaK had no effect on the ATPase activity, but caused a significant decrease in the refolding activity of other denatured proteins. These facts indicate that the extra C-terminal region of A. halophytica DnaK1 plays an important role in the refolding of other urea-denatured proteins at high salinity. Furthermore, it was shown that DnaK1 could assist the copper binding of precursor apo-plastocyanin as well as that of mature apo-plastocyanin during the folding of these copper proteins.

Two survival cases of alcoholic lactic acidosis complicated with diabetes mellitus and alcoholic liver disease

We have experienced two patients with alcoholic lactic acidosis complicated with liver disease and diabetes mellitus who were successfully treated. They developed hypoglycemia, dehydration, lactic acidosis, and renal failure after drinking a large volume of alcohol without eating for 1 week before onset. Acidosis was thought to be directly related to excessive alcoholic intake, because it was no associated with severe liver failure and rhabdomyolysis. During monitoring of respiratory and circulatory functions, a rapid infusion of fluids adjusting to water and electrolyte imbalance was performed. A mixture of physiological saline and 5% glucose solution was thought to be effective in these cases. Patients recovered from renal failure and lactic acidosis without hemodialysis. Our experience will hopefully provide a key to successful treatment of fatal alcoholic lactic acidosis.

Morphological and histochemical study of nonhemiplegic muscle in acute stroke patients manifesting respiratory failure

There is little information on skeletal muscle changes in patients with acute stroke. We performed morphological and histochemical examinations of nonhemiplegic sternothyroid muscles biopsied at the time of tracheostomy from 13 patients with acute stroke manifesting acute respiratory failure. Degenerating and regenerating fibers were observed in all 13 specimens. Following characteristic myopathic changes suggestive of mitochondrial abnormalities were also demonstrated in a majority of patients. Namely, ragged-red fibers, focal increase in NADH-TR activity in subsarcolemmal areas and increases in acid phosphate activity were found. The changes were similar but extremely slight in control patients with acute respiratory failure due to causes other than stroke and were absent in the other control patients with adenomatous thyroid tumor. The severity and extent of the histopathological changes in the muscle fibers in patients with acute stroke were closely correlated with the duration of hypoxemia but not with such items as type of stroke, site of cerebral lesion, consciousness level, days of biopsy after the stroke, clinical outcome, levels of serum creatine kinase, myoglobin and PaO2. This acute nonhemiplegic muscle involvement was considered to be a very common complication in severe stroke patients.

Prognostic value of electroencephalogram (EEG) in anoxic encephalopathy after cardiopulmonary resuscitation: relationship among anoxic period, EEG grading and outcome

We studied the prognostic applicability of electroencephalograms (EEGs) of seventy-nine patients within 24 hours after successful cardiopulmonary resuscitation. The EEGs were classified into five grades according to a modified Hockaday's scale. The EEGs of grades I and II implied full recovery, while those of grade III gave a varied but generally unfavorable prognosis. Patients with grades IV and V EEGs survived in a vegetative condition or died without awakening. Eighteen patients showed EEG with periodic patterns, all of which led to a fatal or vegetative outcome. One case showed EEGs associated with periodic triphasic waves and repetitive sharp transients in the same record. Several cases showed EEGs with different periodic patterns in consecutive records. We conclude that an EEG is a good indicator of patient prognosis after cardiopulmonary resuscitation. However, the clinical significance of morphological differences of various periodic patterns that can occur during an EEG remains to be established.

Clinical evaluation of severe ischemic limbs by tissue reflection spectrophotometry

The clinical usefulness of tissue reflection spectrophotometry in the prognosis of ischemic limbs was evaluated. The diseased group (n = 12) consisted of 7 cases of femoral artery thrombosis, 4 cases of chronic obstructive arteriosclerosis and 1 case of femoral vein thrombosis. The normal control group consisted of 14 limbs in 7 normal subjects (n = 14). Index of tissue hemoglobin concentration (IHb) was 37.3 +/- 4.5 (n = 14) in the normal control group and 38.5 +/- 16.9 (n = 12) in the diseased group, which was not significantly different. In a subgroup of patients who required amputation or developed necrosis (severe subgroup), the value was 54.2 +/- 1.7 (n = 6). This was significantly higher than the value of 22.8 +/- 8.5 (n = 6) obtained in a subgroup of patients who received the conservative treatment of thrombectomy (mild subgroup) (p < 0.05). Index of tissue oxygen saturation (ISO2) was 28.0 +/- 4.9 (n = 14) in the normal control group, and 9.1 +/- 2.7 (n = 12) in the diseased group (p < 0.05). ISO2 was 7.0 +/- 1.6 (n = 6) in the severe subgroup which was significantly lower than 11.2 +/- 1.9 (n = 6) in the mild subgroup (p < 0.05). Tissue reflection spectrophotometry therefore appears to provide clinically useful information for the prognosis of ischemic limbs.

[A case of spontaneous rupture of the ascending aorta]

We report a rare case of spontaneous rupture of the ascending aorta without any evidence of aneurysm formation or aortic dissection. A woman aged 64 was admitted to our cardiac care unit as an emergency patient with severe chest pain. Her face was pale and systolic blood pressure was 70 mmHg in spite of intravenous administration of dopamine (10 micrograms/kg/min). She had a history of hypertension for two years under good medical control. No trace of the chest trauma was noted before her admission. Physical examination revealed neck vein engorgement and distant heart sounds. Chest X-ray film showed enlargement of the cardiac silhouette. ECG showed no evidence of acute coronary syndrome. Pericardial effusion with a floating hematoma-like mass was detected by 2-dimensional echocardiogram. Pericardiocentesis revealed bloody pericardial fluid (Ht: 26%). Aortagraphy was performed resulting in a clinical diagnosis of acute aortic dissection, but there were no signs of a false lumen, aneurysm formation or extravasation of the contrast medium. Although continuous pericardial drainage was performed, she suddenly lost consciousness, collapsed and died. A longitudinal intimal laceration 5 cm long was observed in the ascending aorta. Pathological examination revealed cystic medial necrosis and irregularity of the elastic fibers in the media. No atheromatous plaque was noted in the intima. Spontaneous rupture of the aorta is a life-threatening condition that requires urgent surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Severe Guillain-Barré syndrome in aged patients: the effect of plasmapheresis

We report two aged patients with Guillain-Barré syndrome (GBS), in whom the rapid progression necessitated the use of a respirator. The first case, a 72-year-old woman, needed a respirator on the 5th day after onset of illness and the second case, a 74-year-old woman, needed a respirator on the 23rd day. We treated the first patient with plasmapheresis; the second patient underwent plasmapheresis as well as a large dose of intravenous methylprednisolone. Both patients showed remarkable recovery and did not need the respirator from the early stages. It was suggested that plasmapheresis is beneficial for treatment of aged patients with severe GBS, who necessitate the support of a respirator, because it prevents the decline in functional status by shortening the period of hospitalization.

[Acute subdural hematoma caused by mild head trauma in the aged]

We encountered 8 cases of acute subdural hematoma caused by mild head trauma in the aged. In this report, these cases were analyzed, taking into consideration clinical symptoms, CT scan, operative findings and outcome. The age ranged from 70 to 92 years (mean age of 79.7 years). 4 patients were male and 4 female. Head trauma was caused by falls in 4 patients, but in the other 4 patients the causes were unknown. Initial symptoms were headache, nausea and vomiting in 5 patients and mild disturbance of consciousness with lucid intervals in 3 patients. Seven patients had more than 100 on JCS and less than 9 on GCS on admission. Small craniotomy (HITT) was performed in 4 patients. Large craniotomy was performed in 2 patients, and decompressive craniectomy was carried out in 2 patients. The bleeding focus came from the cortical artery of the middle cerebral artery in 4 patients, cerebral contusion in 2 patients, and was unknown in 2 patients for HITT. CT scan on admission showed mixed density area of acute subdural hematoma in all of the patients, and intraventricular hemorrhage, intracerebral hemorrhage and subarachnoid hemorrhage in 3 patients. CT scan after operation revealed a new area of cerebral contusion in 3 patients, delayed traumatic intracerebral hematoma (DTICH) in 2 patients, and hypertensive intracerebral hemorrhage in 1 patient. Two patients recovered to good and fair without general complication. But the outcome in 5 patients with general complication was poor for 3 patients and fatal for 2 patients. In conclusion, large craniotomy is recommended because of bleeding from the cortical artery of the middle cerebral artery.(ABSTRACT TRUNCATED AT 250 WORDS)

Two fatal cases of hepatitis B virus carriers after corticosteroid therapy for bronchial asthma

We report two hepatitis B virus (HBV) carriers who had liver failure after withdrawal of corticosteroids (steroids) administered for treatment of serious asthmatic attacks. Liver functions deteriorated 1 to 2 wk after withdrawal of the steroid therapy and liver failure occurred. Steroid readministration and intensive therapy for liver failure did not prevent death. An excessive immune response provoked by steroid withdrawal and decreased reserve capacity due to underlying chronic liver disease were thought to be factors in the liver failure. Caution must be exercised in the administration of steroids to patients with underlying chronic HBV infection to prevent exacerbation of hepatitis. Prompt readministration of steroids is indicated if evidence of liver failure develops.

[Emergency manual aspiration for severe hypertensive cerebellar hemorrhage]

We treated 16 patients with hypertensive cerebellar hemorrhage and coma, or deep coma. Their ages ranged from 44 to 79 years (mean age: 66.3 years). Manual aspiration was performed in 9 patients and suboccipital craniectomy was performed in 7 patients. The difference in outcome between the manual aspiration group and the suboccipital craniectomy group with severe hypertensive cerebellar hemorrhage was then evaluated. Manual aspiration was performed for 4 patients in coma, and 5 in deep coma, with a mean age of 69.0 years. The average size of the hematoma was 48.7mm and the mean volume was 31. 7ml on CT scan. The mean interval from admission to operation was about 60 minutes. The mean aspiration rate was 79.6% and 7 patients (77.8%) had a good response to drainage. The suboccipital craniectomy patients included 5 in coma, and 2 in deep coma, with a mean age of 63.4 years. The average size of the hematoma was 51.1 mm and the mean volume was 33.1 ml on CT scan. The mean interval from admission to operation was about 112 minutes and the mean evacuation rate was 86.4%. The results were as follows: 1) After manual aspiration, 5 patients (55.6%) had a good outcome and 2 patients (40%) with deep coma showed good recovery. In contrast, after suboccipital craniectomy only 2 patients (28.6%) had a good outcome and all of the deep coma patients showed poor recovery. 2) The outcome may be most strongly influenced by the duration from admission to operation. 3) All patients with a hematoma volume of over 30 ml had a poor outcome.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of incidence, mortality and treatment of acute myocardial infarction in hospitals in Japan and China

Acute myocardial infarction (AMI) is one of the most intractable diseases and is increasing rapidly in Japan and China. Two hospitals in Japan and China, the Critical Care Center of Kurume University Hospital and the Chinese Beijing 309 Hospital in China (abbreviated to Beijing 309 Hospital) were compared. The incidence, mortality and treatment of AMI were investigated in both hospitals from 1989 to 1991. The incidence of AMI for all patients admitted during the three years was 5% in Kurume University Hospital and 4.7% in Beijing 309 Hospital, which are similar rates. The average age of the patients in Beijing 309 Hospital was younger (58 +/- 13) than in Kurume University Hospital (64 +/- 11). The mortality rate in Kurume University Hospital was slightly lower than the rate in Beijing 309 Hospital (8.1% vs 8.9%). Thrombolytic therapy was actively performed in both hospitals. In Kurume University Hospital, urokinase (UK: 71.4%) or recombinant tissue plasminogen activator (rt-PA: 28.6%) was administered by intravenous (85.7%) and intracoronary percutaneous transluminal coronary recanalization (PTCR: 14.3%) injection. In Beijing 309 Hospital, UK (32.7%) or snake poison enzyme (SPE: 62.3%) was administered by intravenous (85.8%) or intra-aortic (14.2%) injection. Rt-PA was only used in Japan and SPE was only used in China, but both had very strong fibrinolytic effects and resulted in high success rates of coronary reperfusion. The incidence of direct coronary intervention with percutaneous transluminal coronary angioplasty (PTCA) and intra-aortic balloon pumping (IABP) for cardiogenic shock was much higher at Kurume University Hospital than at Beijing 309 Hospital.(ABSTRACT TRUNCATED AT 250 WORDS)

Spontaneous rupture of the ascending aorta

A case of spontaneous non-traumatic rupture of the thoracic aorta in a hypertensive patient is presented. The clinical findings suggested acute aortic dissection, and a large pericardial effusion was detected by echocardiography. The typical angiographic features of aortic dissection were not found. Autopsy revealed a longitudinal intimal tear and a rupture in the postero-lateral aspect of the ascending aorta. No false lumen was seen in the ascending aorta. When acute intrapericardial or intrapleural bleeding develops with no evidence of aortic aneurysm or dissection, spontaneous aortic rupture should be suspected.

Clinical significance of traumatic subarachnoid hemorrhage

The clinical significance of traumatic subarachnoid hemorrhage (TSAH) was studied in 20 head-injured patients. They were classified into mild (9) and severe (11) groups by their initial Glasgow Coma Scale (GCS) scores. TSAH detected by computed tomography was localized in the Sylvian fissure in four of the nine mild group patients, but was also found in other basal subarachnoid cisterns in the other five. Except for one patient who developed delayed vasospasm and communicating hydrocephalus, all had favorable outcomes in this group. Massive TSAH was noted in the basal subarachnoid cisterns in 10 severe group patients and only one had a good outcome. Delayed intracerebral hematoma in the frontal or temporal lobe in the vicinity of the Sylvian fissure was found in two mild and two severe group patients with TSAH in the Sylvian fissures. Traumatic parenchymal lesions in the brainstem were minimal in one of the two autopsied patients and no evidence of diffuse axonal injury was found in both cases. Thus, TSAH in the Sylvian fissure is suggestive of focal brain contusion around the fissures. Massive TSAH in the basal subarachnoid cisterns is not necessarily associated with severe parenchymal injury of the brainstem.

[Clinical feature and laboratory findings of multiple organ failure]

The pathology of multiple organ failure consists of tissue-cell damage (disruption of energy metabolism) and severe infections (host exhaustion). The impairment of the TCA cycle was mild in two-organ disease but was nearly arrested in three-organ disease, and the cells are considered to have been in lactic acidosis with a shift of the glycolytic system from pyruvate to lactate. Significant differences were observed also in the number and the function of lymphocytes between two-organ and three-organ diseases. Therefore, in multiple organ failure, infections are considered to worsen as the ability of antigen recognition is impaired and differentiation of B cells into antibody-producing cells is inhibited with a decrease in lymphocytes. The phagocytic activity of neutrophils did not decrease unless leukocytes were reduced.

[Emergency perfusion lung scan for pulmonary embolism]

Six cases of pulmonary embolism were reported. As pulmonary embolism often becomes critical condition, early diagnosis and medical treatment is need. Perfusion lung scan for pulmonary embolism may be useful for a diagnosis and evaluation of the degree of its disease and therapeutic value.

Ornithine transcarbamylase deficiency in male adolescence and adulthood

A discrete deficiency of hepatic ornithine transcarbamylase (OTC) was found in male patients who were 58, 46 and 17 years old. Each had developed hyperammonemic coma. The mother and a sister of the 17-year-old patient exhibited orotic aciduria either spontaneously or after protein loading, thus demonstrating heterozygosity. A sister of one other patient and a daughter of the third patient showed a smaller orotic aciduria after protein loading. These observations indicate that inherited deficiency of OTC should be included in the differential diagnosis of hyperammonemic states in adult male patients.

Tc-99m RBC imaging for demonstrating intermittent intestinal bleeding

A case of intestinal bleeding caused by multiple ulcerations near the terminal ileum is presented. Abdominal scanning with Tc-99m tagged red blood cells (Tc-99m RBC) demonstrated the intermittent bleeding in short intervals. Selective angiography did not demonstrate the bleeding site. Exploratory laparotomy showed 3 ulcers on the ileum at a site near the terminal ileum, with bleeding from one site. Tc-99m RBC abdominal scanning was very useful in this case for localization of the site of gastrointestinal bleeding before laparotomy.

Hemodynamic relationship between renal venous pressure and blood flow regulation during positive end-expiratory pressure

The hemodynamic relationship between renal venous pressure (RVP) and renal blood flow (RBF) during PEEP was investigated using adult mongrel dogs. When continuous mechanical ventilation (CMV) with 10 cm H2O of PEEP was applied to dogs previously on CMV with zero PEEP, RVP increased from 6.6 to 8.7 mm Hg (p less than .01), and left RBF decreased from 66 to 57 ml/min (p less than .05). RBF recovered by 49% of the difference as soon as PEEP was discontinued when the RVP elevation was maintained at the level observed during 10 cm H2O of PEEP. With 20 cm H2O of PEEP, RVP increased further to 10 mm Hg (p less than .01) and left RBF decreased to 48 ml/min (p less than .05). When the left renal vein was occluded and the RVP was maintained at the level seen during 20 cm H2O of PEEP, left RBF recovered only 50% of the difference from the flow during zero PEEP. We conclude that the reduction in RBF with PEEP application is caused by several factors; however, RVP elevation during CMV with PEEP is influential in decreasing RBF.

Short-term and long-term changes in hepatic function in 60 patients with blunt liver injury

We treated 60 patients with blunt liver injury over 14 years. According to Makiya's scale of severity, 22 of these lesions (37%) were of Type I, 23 (38%) of Type II, and 15 (25%) of Type III. The overall mortality rate was 23% (14 patients). Changes in hepatic function were studied in these patients. Transaminase levels showed abnormal elevations immediately after the injury but rapidly decreased to normal levels within about 40 days in both the patients who survived the injury and those who died. The alkaline phosphatase activity showed moderate gradual elevations with time, exceeding 20 K.A. units 10 days after the injury in those who died. The total bilirubin level increased to only about 4 mg/dl in those who survived but exceeded 8 mg/dl 10 days after the injury in about 80% of those who died. The total cholesterol level decreased below 100 mg/dl in those who died. In chloric cobalt reaction, the R-value shifted to the left in those who survived but to the right in those who died. Total plasma protein, which decreased to about 6.0 gm/dl immediately after the injury, gradually recovered in those who survived but further declined in those who died. Percentage of gamma-globulin increased but remained below 20% in those who survived but exceeded 20% within 10 days of injury in many of those who died. Hepatic functions 5 years after the injury were generally within the normal range.