Bilateral Eyelid Edema in a Pediatric Patient With COVID-19: A Case Report and Literature Review

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is primarily transmitted through the eyes, nose, or mouth. Ophthalmic complications, such as conjunctivitis and dacryoadenitis, have been reported in patients with coronavirus disease 19 (COVID-19). We report the case of an early adolescent girl who presented with bilateral urticarial rashes, eyelid edema, fever, and cough. She was diagnosed with acute dacryoadenitis with SARS-CoV-2 infection confirmed by a nasopharyngeal polymerase chain reaction and clinical investigations. The patient was treated with dexamethasone (3 mg daily) for three days, which resulted in the resolution of fever and urticarial rash, and improvement of eyelid edema. While bilateral upper eyelid edema and acute dacryoadenitis commonly occur in pediatric patients due to Epstein-Barr virus (EBV) infection and Kawasaki disease, they are rarely associated with other diseases. However, ocular symptoms have been reported in 11.4% of patients with COVID-19. In addition, eyelid edema and acute dacryoadenitis have also been reported after COVID-19 messenger RNA (mRNA) vaccination. The underlying mechanisms of these complications are not yet completely understood. Our case highlights the possibility of bilateral eyelid edema in children with COVID-19, which can occur in addition to other viral infections such as EBV.

CDK actively contributes to establishment of the stationary phase state in fission yeast

Upon exhaustion of essential environmental nutrients, unicellular organisms cease cell division and enter stationary phase, a metabolically repressed state essential for cell survival in stressful environments. In yeast, cell size is reduced by cell division before entry into stationary phase; thus cyclin-dependent kinase (CDK) must actively contribute to stationary phase establishment. However, the contribution of CDK to stationary phase remains largely uncharacterized. Here, we examine the role of CDK in the establishment of stationary phase in fission yeast. We show that in stationary phase, nuclear and chromosomal volumes and the nucleus-to-cell volume ratio are reduced, and sister chromatid separation and chromosome fluctuation are repressed. Furthermore, CDK accumulates in the nucleolus. Most of these changes are induced by glucose depletion. Reduction in CDK activity before and upon stationary phase entry alleviates the changes and shortens the survival time of stationary phase cells, while CDK inhibition represses nucleolar CDK accumulation and glucose depletion-induced nuclear volume reduction. These results demonstrate that CDK actively regulates stationary phase, both before and upon stationary phase entry.

Detection of Histidine-Tagged Protein in Escherichia coli by Single-Cell Inductively Coupled Plasma-Mass Spectrometry

We have developed a rapid and precise quantification method for a histidine (His)-tagged recombinant protein produced in Escherichia coli (E. coli) by single-cell inductively coupled plasma-mass spectrometry (SC-ICP-MS). Plasmid vector containing enhanced green fluorescent protein (EGFP) or red fluorescent protein (mCherry) gene fused with His-tag was transformed into E. coli. The transformed E. coli was exposed to nickel (Ni) chloride or cobalt (Co) chloride for labeling His-tag with the Ni or Co ion. Then, E. coli was analyzed by SC-ICP-MS to determine the amount of EGFP or mCherry protein on the basis of the signal of Ni or Co bound to His-tag. By comparing Ni and Co contents in E. coli expressing His-tagged mCherry with those in nontagged mCherry, the specific binding of Co to His-tag was more clearly detected than that of Ni. The Co contents were increased until 6 h after the protein induction, and this observation was coincident with the increases in fluorescence intensity of EGFP or mCherry measured by a flow cytometer. However, the Co contents were decreased for EGFP and kept at a constant level for mCherry from 6 to 24 h despite the continuous increase in the fluorescence intensity through incubation. The fluorescent proteins were mainly recovered in the insoluble fraction 24 h after the induction. This can be explained by the fact that the overexpressed fluorescent proteins with His-tag are transferred into inclusion bodies, which hampers the binding of the fluorescent proteins to the Co ion. SC-ICP-MS can be a useful technique to precisely quantify soluble recombinant proteins in E. coli without the extraction and purification process.

Elevation of serum fibroblast growth factor 23 level in a pediatric patient with lupus nephritis

Fibroblast growth factor 23 (FGF-23), a hormone mainly secreted by osteocytes and osteoblasts, regulates phosphate and vitamin D levels. However, the in vivo significance of FGF-23 is not fully elucidated. This case report describes a 12-year-old girl with systemic lupus erythematosus (SLE), lupus nephritis, and an elevated serum FGF-23 level. The patient was treated with active vitamin D and oral sodium phosphate medications to manage low serum phosphate levels (2.2 mg/dL). Magnetic resonance imaging (MRI) revealed a high-intensity area in the left femur, but somatostatin receptor scintigraphy images did not indicate tumor-induced osteomalacia. SLE treatment using mycophenolate mofetil (1500 mg/day) was initiated, and serum complements levels increased as FGF-23 level increased. Serum FGF-23 level gradually decreased as urinary protein levels decreased after treatment with steroids; however, there was no change in the high-intensity area on MRI. Recent studies have reported that serum FGF-23 level is associated with iron deficiency and inflammation; yet, the mechanism related to these associations is not fully elucidated. The findings from this case suggest that elevated serum FGF-23 levels noted in our patient were related to silent lupus nephritis and lupus nephritis activity.

Acute kidney injury caused by ammonium acid urate crystals in diabetic ketoacidosis at the onset of type 1 diabetes mellitus

SUMMARY

Ammonium acid urate (AAU) crystals are rare in industrialized countries. Furthermore, the number of children with diabetic ketoacidosis (DKA) who develop severe acute kidney injury (AKI) after hospitalization is small. We encountered two patients with AKI caused by AAU crystals during the recovery phase of DKA upon admission. They were diagnosed with severe DKA and hyperuricemia. Their urine volume decreased and AKI developed several days after hospitalization; however, acidosis improved in both patients. Urine sediment analysis revealed AAU crystals. They were treated with urine alkalization and diuretics. Excretion of ammonia in the urine and urine pH levels increased after treatment of DKA, which resulted in the formation of AAU crystals. In patients with severe DKA, the urine and urine sediment should be carefully examined as AAU can form in the recovery phase of DKA.

LEARNING POINTS

Ammonium acid urate crystals could be formed in the recovery phase of diabetic ketoacidosis. Diabetic ketoacidosis patients may develop acute kidney injury caused by ammonium acid urate crystals. Urine and urine sediment should be carefully checked in patients with severe DKA who present with hyperuricemia and volume depletion.

Factors predicting endocrine late effects in childhood cancer survivors from a Japanese hospital

We retrospectively analyzed endocrine late effects in 81 childhood cancer survivor (CCS) patients who had been referred to our endocrinology department in Chiba Children's Hospital between January 1, 2008 and December 31, 2016. Among 69 eligible patients (33 male, 36 female), endocrine late effects were identified in 56 patients (81.1%). The median age at the last visit to our endocrinology department was 17.4 years (range: 7.1-35.3 years). The most common primary cancer was acute lymphoblastic leukemia (22 patients, 31.8%). Forty-four patients (64%) were treated using radiation therapy. A primary brain tumor and high doses (≥6 g/m²) of cyclophosphamide were significantly associated with growth hormone deficiency (GHD). Our present study suggests that high doses of cyclophosphamide is a risk factor for GHD. Adult heights and pubertal growth spurts of patients treated with radiation therapy were significantly lower than patients not treated with radiation therapy. Our retrospective study reconfirmed that hematopoietic stem cell transplantation and chronic graft versus host disease (GVHD) were associated with elevated risks of primary hypothyroidism. However, it is unclear whether GVHD induces thyroid dysfunction. Gonadal radiation and busulfan were associated with primary hypogonadism as reported in previous studies. We found high doses of cyclophosphamide to be involved in pituitary disorders. We suggest that pediatric endocrinologists should discuss the potential effects of radiation therapy on adult height and pubertal growth spurt in CCS patients. Moreover, patients who have been treated with high doses of cyclophosphamide or have chronic GVHD require long-term follow-up for endocrine late effects.

Seasonal occurrence and development of three closely related Oligonychus species (Acari: Tetranychidae) and their associated natural enemies on fagaceous trees

We compared the life cycles and diapause attributes among three closely related spider mites, Oligonychus castaneae on Castanea crenata, and O. gotohi and O. amiensis on Lithocarpus edulis. The lower thermal thresholds from egg to egg were 10.5, 8.5 and 8.9 °C, respectively, and the thermal constants were 177.8, 229.5 and 232.5 degree-days, respectively. The cumulative hatching rates of diapause eggs of O. castaneae and O. gotohi increased as the season progressed in and after early-to-mid January, which indicates diapause termination. In contrast, O. amiensis showed higher hatching rates in December and January, but hatchability gradually decreased in and after February because some of the eggs died from the cold. Oligonychus castaneae and O. gotohi females produced diapause eggs in response to the short photoperiod in late September to early October and in early-to-late October, respectively, which corresponded to the times predicted by the critical photoperiods (at 15 °C) of 12 h 15 min and 11 h 15 min for the respective species. Oligonychus castaneae showed at least a single population peak over the 3-year observation period, but the time of peak population varied from mid-July to mid-September. The population of O. gotohi was higher between November and May when diapause eggs were present on host plants in early winter and the first-generation females laid eggs on leaves in spring. The population of O. amiensis, which is a non-diapause species, was only high between September and December, because eggs were laid on leaves in autumn to winter and then gradually disappeared and/or died during winter. Natural enemies were observed as the number of spider mites declined, and the density suppression effect by natural enemies was confirmed in the field.

Thyroid nodules and long-term follow-up among childhood cancer survivors who underwent hematopoietic stem cell transplantation

Thyroid nodules have been observed in childhood cancer survivors (CCS) treated with chemotherapy and radiotherapy. We report four patients with thyroid nodules identified during the long-term follow-up of children who underwent hematopoietic stem cell transplantation (HSCT). The thyroid nodules were diagnosed as adenomatous goiter in all four patients. The interval between the primary cancer diagnosis and the occurrence of the thyroid nodules was more than 10 yr. Furthermore, all four patients underwent HSCT in conditioning with total body irradiation (TBI) before the age of 10 yr. Two of four patients commenced treatment with levothyroxine due to elevated TSH levels. Only two patients showed elevated thyroglobulin levels (> 70 µg/L). In conclusion, we suggest that CCS who have undergone HSCT in conditioning with TBI more than 10 yr previously should be followed up carefully for thyroid nodules using ultrasound.

Nuclear resonant scattering measurements on (57)Fe by multichannel scaling with a 64-pixel silicon avalanche photodiode linear-array detector

We developed a silicon avalanche photodiode (Si-APD) linear-array detector for use in nuclear resonant scattering experiments using synchrotron X-rays. The Si-APD linear array consists of 64 pixels (pixel size: 100 × 200 μm(2)) with a pixel pitch of 150 μm and depletion depth of 10 μm. An ultrafast frontend circuit allows the X-ray detector to obtain a high output rate of >10(7) cps per pixel. High-performance integrated circuits achieve multichannel scaling over 1024 continuous time bins with a 1 ns resolution for each pixel without dead time. The multichannel scaling method enabled us to record a time spectrum of the 14.4 keV nuclear radiation at each pixel with a time resolution of 1.4 ns (FWHM). This method was successfully applied to nuclear forward scattering and nuclear small-angle scattering on (57)Fe.

Efficacy and safety of recombinant human soluble thrombomodulin (ART-123) in disseminated intravascular coagulation: results of a phase III, randomized, double-blind clinical trial

BACKGROUND

Soluble thrombomodulin is a promising therapeutic natural anticoagulant that is comparable to antithrombin, tissue factor pathway inhibitor and activated protein C.

OBJECTIVES

We conducted a multicenter, double-blind, randomized, parallel-group trial to compare the efficacy and safety of recombinant human soluble thrombomodulin (ART-123) to those of low-dose heparin for the treatment of disseminated intravascular coagulation (DIC) associated with hematologic malignancy or infection.

METHODS

DIC patients (n = 234) were assigned to receive ART-123 (0.06 mg kg(-1) for 30 min, once daily) or heparin sodium (8 U kg(-1) h(-1) for 24 h) for 6 days, using a double-dummy method. The primary efficacy endpoint was DIC resolution rate. The secondary endpoints included clinical course of bleeding symptoms and mortality rate at 28 days.

RESULTS

DIC was resolved in 66.1% of the ART-123 group, as compared with 49.9% of the heparin group [difference 16.2%; 95% confidence interval (CI) 3.3-29.1]. Patients in the ART-123 group also showed more marked improvement in clinical course of bleeding symptoms (P = 0.0271). The incidence of bleeding-related adverse events up to 7 days after the start of infusion was lower in the ART-123 group than in the heparin group (43.1% vs. 56.5%, P = 0.0487).

CONCLUSIONS

When compared with heparin therapy, ART-123 therapy more significantly improves DIC and alleviates bleeding symptoms in DIC patients.

Classification of Clostridium butyricum based on sodium dodecyl sulfate-polyacrylamide gel electrophoresis and pulsed-field gel electrophoresis

Eleven strains of Clostridium butyricum collected from different sources were analysed by both sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and pulsed-field gel electrophoresis (PFGE). The strains could be classified into four groups based on their banding profiles of the proteins extracted from the cells on SDS-PAGE. Group I consisted of seven strains, and these strains were further divided into five subgroups by PFGE. The strains belonging to groups II, III, and IV on SDS-PAGE were also classified into the same II to IV groups by PFGE. These data indicate that grouping of the strains of C. butyricum can be performed by employing both SDS-PAGE and PFGE.

Epidemiological and outcome characteristics of major burns in Tokyo

The Tokyo Burn Unit Association (TBUA) was established in 1983 funded by the Tokyo Metropolitan Government, and is organized by 13 burn units in Tokyo. TBUA covers more than 90% of severe burn patients occurring in Tokyo, and all of the cases are registered according to the burn injury registration format. The purpose of this study is to analyze the registered data and to elucidate epidemiological and outcome characteristics of major burn injuries in Tokyo. The total of 6988 hospitalized patients had data for epidemiological analysis, and 6401 patients had complete data for outcome analysis as well, and were included in this study. The characteristic profiles for the analysis included age, sex, cause of burns, inhalation injury, %BSA, burn index (BI), length of burn unit stay, and outcome, and were analyzed by age groups. The mean age of the patients was 40.4 years, and 63% of them were male. It was noteworthy that 25% of the total patients were elderly patients over 60 years of age. Flame was the most common cause making up 45.6% followed by scalding (32.0%). The overall mortality rate was 15.4%. Inhalation injury was accompanied in 27.3% of burn patients. The mortality rate was 34.6% with inhalation injury, and 8.2% without inhalation injury. Causes of death showed that multiple organ failure made up 36.9% of total mortality, followed by sepsis 25.2 and shock 19.0%. The burn size (%BSA and BI) and inhalation injury were the factors for high mortality rate in all age groups whereas age was a predictor for high mortality in the patients older than 16 years of age. Gender was not a factor for high mortality in any age group. The mortality rate showed mildly decreasing tendency since 1995 for which implementation of skin bank was thought to be responsible.

Diffraction peak profiles from spherical crystallites with lognormal size distribution

An efficient and accurate method to evaluate the theoretical diffraction peak profiles from spherical crystallites with lognormal size distribution (SLN profile) is presented. Precise results can be obtained typically by an eight-term numerical integral for any values of the parameters, by applying an appropriate substitution of the variable to the integral formula. The calculated SLN profiles have been verified by comparison with those calculated by inverse Fourier transform from the exact analytical solution of the Fourier-transformed SLN profile. It has been found that the shape of the SLN profile strongly depends on the variance of size distribution. When the logarithmic standard deviation ω of the size distribution is close to 0.76, the SLN profile becomes close to a Lorentzian profile, and `super-Lorentzian' profiles are predicted for larger values of ω, as has been concluded by Popa & Balzar [J. Appl. Cryst.(2002),35, 338–346]. The intrinsic diffraction peak profiles of an SiC powder sample obtained by deconvolution of the instrumental function have certainly shown `super-Lorentzian' line profiles, and they are well reproduced by the SLN profile for the value ω = 0.93.

Efficacy of endoscopic hemoclipping for GI bleeding in relation to severity of shock

BACKGROUND/AIMS

To examine the efficacy of prospectively performing endoscopic hemoclipping in patients with severe gastrointestinal bleeding by assessing in relation to the severity of the case.

METHODOLOGY

Endoscopic hemoclipping was performed in 44 patients in shock caused by severe gastrointestinal bleeding. The level of severity was categorized using two factors. One factor was the presence or absence of severe shock, and the other was the presence or absence of active bleeding at endoscopy. Age, blood transfusion volume, APACHE III score, coagulopathy, initial hemostatic, rebleeding and mortality rate were recorded in relation to those four subsets. If rebleeding occurred, the systolic blood pressure, heart rate and serum hemoglobin concentration were compared between the initial time of bleeding and rebleeding.

RESULTS

Initial hemostasis was successfully achieved in all cases. The severe shock group required significantly more blood transfusions. The most severe subset had the highest APACHE III score, and coagulopathy. Rebleeding occurred in seven cases in the severe shock group only. In the rebleeding group, the systolic body pressure was lower, heart rate was higher, and serum hemoglobin concentration was lower than the non-rebleeding group. Four patients, all in subset 1, died, but no patient died due to gastrointestinal bleeding.

CONCLUSIONS

The endoscopic hemoclipping method is very effective for severe gastrointestinal bleeding in shock. The severity of shock was a more important risk factor than the presence of active bleeding. Our category of severity is simple, it reflects the patients' clinical condition accurately, and is very useful for patients with gastrointestinal bleeding.

Spontaneous rupture of the pancreaticoduodenal artery possibly related to prior occlusion of the common hepatic artery: report of a case

We report herein a case of spontaneous rupture of the pancreaticoduodenal artery (PDA) associated with obstruction of the common hepatic artery. A 68-year-old man was admitted to our hospital following the sudden onset of severe upper abdominal pain. Computed tomography revealed a large mass formation in the peritoneal cavity. Hemorrhagic shock rapidly developed during the initial evaluation, necessitating an exploratory laparotomy to be performed in the emergency room. This revealed a large hematoma in the retroperitoneal space, and a ruptured PDA was sutured. Postoperative angiography showed obstruction of the common hepatic artery and also suggested that the source of the bleeding was the PDA. Thus, a diagnosis of spontaneous rupture of a PDA aneurysm associated with occlusion of the common hepatic artery was made. Following this case report, we discuss the development of true aneurysms of the PDA and the treatment of ruptured true PDA aneurysms resulting in shock.

Transient hematopoietic stem cell rescue using umbilical cord blood for a lethally irradiated nuclear accident victim

We performed stem cell rescue and allogeneic skin transplantation on a lethally neutron-irradiated nuclear accident victim. HLA-DRB1 mismatched unrelated umbilical cord blood cells (2.08 x 10(7)/kg recipient body weight) were transplanted to an 8-10 Gy equivalent neutron-irradiated patient because of a lack of a suitable bone marrow or peripheral blood donor. Pre-transplant conditioning consisted of anti-thymocyte gamma-globulin alone, and GVHD prophylaxis was a combination of cyclosporine (CYA) and methylprednisolone (mPSL). Granulocyte colony-stimulating factor (G-CSF), erythropoietin (EPO), and thrombopoietin (TPO) were concurrently administered after transplantation. The absolute neutrophil count reached 0.5 x 10(9)/l on day 15, the reticulocyte count rose above 1% on day 23, and the platelet count was over 50 x 10(9)/l on day 27, respectively. Cytogenetic studies of blood and marrow showed donor/recipient mixed chimerism. Rapid autologous hematopoietic recovery was recognized after withdrawal of CYA and mPSL. Repeated pathological examinations of the skin revealed no evidence of acute GVHD. Eighty-two days after the irradiation, skin transplantation was performed to treat radiation burns. Almost 90% of the transplanted skin engrafted. Immunological examination after autologous hematopoietic recovery revealed an almost normal T cell count. However, immune functions were severely impaired. The patient died from infectious complication 210 days after the accident.

The role of interventional radiology in the management of blunt renal injury: a practical protocol

OBJECTIVE

The purpose of this study was to evaluate the efficacy of a protocol designed to minimize the need for surgery in the management of severe blunt renal injury.

METHODS

Forty-six of 752 trauma patients had evidence of renal injury on computed tomographic (CT) scan. Two patients required emergency laparotomy, and the remaining 44 patients were classified by CT scan grade using the American Association for the Surgery of Trauma classification system. Patients with CT scan grade 3 or over underwent renal angiography.

RESULTS

Twenty-one patients had a high-grade injury on CT scan (> or =3). Eight had angiographic evidence of extravasation from renal arterial branches and underwent transarterial embolization. One patient with a grade 5 injury had extravasation from a main renal vein and underwent immediate laparotomy. This was the only patient who required surgery for renal injury.

CONCLUSION

Surgery can be avoided in most cases of blunt renal injury. Hemodynamic instability and injury to main renal veins remain indications for surgical exploration.

[A patient with facioscapulohumeral muscular dystrophy accompanied by myasthenia gravis]

A patient was a fifty-year-old man, who had a 35 year-history of facioscapulohumeral muscular dystrophy (FSHD). He was admitted to our hospital because of acute progressive weakness involving his lower extremities without any fluctuation in the recent 3 weeks. We clinically followed him for 30 years and he was able to do all daily activities, walked alone, drove a car and climbed stairs with a handrail. His 76-year-old mother had about 60 year-history of FSHD and could walk with support. On admission, neurological examination revealed moderate to marked muscle weakness and atrophy of the face, limb-girdle and all extremities, predominantly in the upper proximal limbs. He could hardly stand and needed a stick for walking. He had no blepharoptosis or ocular movement disturbance, and did not complain of difficulties in swallowing and chewing. CK values and other laboratory data were normal, and serum anti-Jo-1 antibody, anti-SSA/Ro antibody and anticardiolipin IgG antibody were negative. Because EMG examination revealed myopathic changes and an X-ray examination of the lumbar spine was normal. Thus, polymyositis and neurologenic disorders were ruled out. Disturbance in chewing and swallowing, that were uncommon in FSHD, appeared about a month after admission. Repetitive stimulation test revealed typical waning pattern. Edrophonium chloride injection was effective for decreased waning and the clinical symptoms. The titer of serum anti-ACh receptor antibody was 97 nmol/l, confirming the diagnosis of myasthenia gravis. Because of fluctuated dyspnea, thymectomy was done and his condition gradually relieved after administration of corticosteroid and choline esterase inhibitor. From this experience, we learned that we have to consider other neuromuscular disorders, even rare ones, if there existed unusual weakness of underlying muscular dystrophy.

[Role of level-1 trauma and critical care centers in treatment of acute poisoning]

In the summer of 1998, the so-called Wakayama currty poisoning case occurred, and subsequently additional murders took place in which the accusred used sodium aziede and thallium to posison their victims. When the poison victims were admitted to hospital, food poisoning was mistakenly diagnosed. Due to serious concerns that such misdiagnoses might recur, the Japanese Ministry of Health and Welfare equipped 10 level-1 trauma and critical care centers and 66 critical care centers nationwide with high-performance liquid chromotographs, ion chromatographs, gas chromatographs, fluorescence X-ray analyzers, and high-frequency plasma mass spectrometers. This equipment will allow the detection of most types of industial and other chemicals as well as most therapeutic drugs. This report describes the current status of poison analysis systems and the role of level-1 trauma and critical care centers in cases of poisoning.

Cupric sulfate intoxication with rhabdomyolysis, treated with chelating agents and blood purification

We report a case of cupric sulfate intoxication complicated by hemolytic anemia, hepato-renal damage and acute rhabdomyolysis. The patient was successfully treated with dimercaprol, penicillamine, direct hemoperfusion and hemodiafiltration. We discuss the pathophysiology of cupric intoxication, and propose a treatment combined with chelating agents and blood purification.

Reduction of resuscitation fluid volumes in severely burned patients using ascorbic acid administration: a randomized, prospective study

HYPOTHESIS

High-dose ascorbic acid (vitamin C) therapy (66 mg/kg per hour) attenuates postburn lipid peroxidation, resuscitation fluid volume requirements, and edema generation in severely burned patients.

STUDY DESIGN AND SETTING

A prospective, randomized study at a university trauma and critical care center in Japan.

SUBJECTS AND METHODS

Thirty-seven patients with burns over more than 30% of their total body surface area (TBSA) hospitalized within 2 hours after injury were randomly divided into ascorbic acid and control groups. Fluid resuscitation was performed using Ringer lactate solution to maintain stable hemodynamic measurements and adequate urine output (0.5-1.0 ml/kg per hour). In the ascorbic acid group (n = 19; mean burn size, 63% +/- 26% TBSA; mean burn index, 57 +/- 26; inhalation injury, 15/ 19), ascorbic acid was infused during the initial 24-hour study period. In the control group (n = 18; mean burn size, 53% +/- 17% TBSA; mean burn index, 47 +/- 13; inhalation injury, 12/18), no ascorbic acid was infused. We compared hemodynamic and respiratory measurements, lipid peroxidation, and fluid balance for 96 hours after injury. Two-way analysis of variance and Tukey test were used to analyze the data.

RESULTS

Heart rate, mean arterial pressure, central venous pressure, arterial pH, base deficit, and urine outputs were equivalent in both groups. The 24-hour total fluid infusion volumes in the control and ascorbic acid groups were 5.5 +/- 3.1 and 3.0 +/- 1.7 mL/kg per percentage of burn area, respectively (P<.01). In the first 24 hours, the ascorbic acid group gained 9.2% +/- 8.2% of pretreatment weight; controls, 17.8% +/- 6.9%. Burned tissue water content was 6.1 +/- 1.8 vs 2.6 +/- 1.7 mL/g of dry weight in the control and ascorbic acid groups, respectively (P<.01). Fluid retention in the second 24 hours was also significantly reduced in the ascorbic acid group. In the control group, the ratio of PaO2 to fraction of inspired oxygen at 18, 24, 36, 48, and 72 hours after injury was less than that of the ascorbic acid group (P<.01). The length of mechanical ventilation in the control and ascorbic acid groups was 21.3 +/- 15.6 and 12.1 +/- 8.8 days, respectively (P<.05). Serum malondialdehyde levels were lower in the ascorbic acid group at 18, 24, and 36 hours after injury (P<.05).

CONCLUSIONS

Adjuvant administration of high-dose ascorbic acid during the first 24 hours after thermal injury significantly reduces resuscitation fluid volume requirements, body weight gain, and wound edema. A reduction in the severity of respiratory dysfunction was also apparent in these patients.

Molecular epidemiological investigation using a randomly amplified polymorphic DNA assay of Burkholderia cepacia isolates from nosocomial outbreaks

We experienced two Burkholderia cepacia outbreaks over a 1-year period. During this period, 28 B. cepacia isolates were obtained from clinical specimens, and 2 were obtained from environmental specimens (i.e., from a nebulizer solution and a nebulizer tube). These 30 isolates were subjected to the PCR-based randomly amplified polymorphic DNA (RAPD) assay as well as to pulsed-field gel electrophoresis (PFGE). In the first outbreak, in which eight patients hospitalized in the Trauma and Critical Care Center were involved, the RAPD assay revealed that all 20 isolates obtained from clinical specimens and the 2 isolates from environmental specimens had identical DNA profiles. These RAPD data enabled us to pinpoint a possible source and to take countermeasures to prevent further spread of the epidemic-causing strain. In the second outbreak, two consecutive B. cepacia infection/colonization cases were seen in the surgery ward. The RAPD profiles of four isolates obtained were again identical, but they were distinct from those seen in the first outbreak, clearly indicating that the second outbreak was not related to the first. Thus, our experience demonstrated that the RAPD assay is a useful and reliable tool for epidemiological studies of B. cepacia isolates from nosocomial outbreaks. Since the RAPD assay could provide discriminatory potential and reproducibility comparable to those of the widely used PFGE assay with less complexity and in a shorter time, the introduction of the RAPD assay into hospital microbiology laboratories as a routine technique may help prevent nosocomial outbreaks.

High dose vitamin C counteracts the negative interstitial fluid hydrostatic pressure and early edema generation in thermally injured rats

BACKGROUND AND OBJECTIVE

edema formation after thermal injury is rapid and fulminant within the first hour after injury and increased microvascular permeability has been claimed to be the main responsible mechanism. An acute decrease in interstitial fluid hydrostatic pressure (P(if)) down to -150 mm Hg has recently been reported in dermal burns. This strong negative tissue pressure creates a 'suction' on the fluid in the capillaries. Furthermore, high dose vitamin C (VC) has been shown to reduce postburn edema and fluid requirements following major burn injuries. This led to the present study, aimed at investigating whether VC administered after thermal injury in rats, could attenuate the strongly negative P(if). Edema volume was measured by total tissue water content (TTW) and extravasation of albumin (Ealb).

STUDY DESIGN

a prospective, open experimental study.

MATERIALS AND METHODS

pentobarbital-anesthetized rats received either a full-thickness burn injury covering 10% of total body surface area, or a sham burn. The rats were given VC or equal volumes normal saline (NS) either before the burn, 5 or 30 min after the injury. VC (25 mg/ml in NS, osmolality 272 mOsm/l) was administered as a bolus (66 mg/kg) followed by infusion (33 mg/kg/h). The animals were divided into 7 groups (6 animals in each) according to the timing of VC/NS administration: (1) VC-preburn, (2) VC-5 min postburn, (3) VC-30 min postburn, (4) NS-preburn, (5) NS-5 min postburn, (6) NS-30 min postburn and (7) VC-pre sham burn group. All groups were duplicated for series I and II.

MEASUREMENTS

in series I; P(if) was measured using a sharpened glass micropipette connected to a servo-controlled counter pressure system. Measurements were averaged in the following time periods: preburn, 5-20, 21-40, 41-60 and 61-90 min postburn. In series II; Ealb and TTW were measured in burned and non-burned skin by radio-labelled albumin and wet-dry weights, respectively.

RESULTS

in the sham control group (VC-pre-sham burn), P(if) ranged between -1 and -2 mm Hg and did not change throughout the experimental period. In the NS group (placebo), P(if) fell to -46.8 +/- 10.1 (1 S.D.) mm Hg at 5-20 min after the injury and were -23.1 +/- 13.4 and -11.6 +/- 4.1 mm Hg at 21-40 and 41-60 min postburn. P(if) returned to preburn values at 61-90 min post injury. In the VC groups, there was a marked attenuation of the negative P(if) to average -10.1 +/- 11.8 mm Hg at 5-20 min, -2 +/- 1.7 and -0.6 +/- 1.2 mm Hg at 21-40 and 41-60 min after injury, respectively (all p < 0.01 compared to NS). TTW in burned skin of the NS-5 min groups was 3.12 +/- 0.28, VC5-min group was 2.57+/-0.69 and VC sham was 1.77+/-0.19 ml/g DW, respectively (p < 0.01 compared to sham control for all values). In all the VC-groups TTW values were higher than sham control and lower than in the corresponding NS-groups (p > 0.05 both ways). No statistical significant differences were found between Ealb-values in the VC- and NS-groups.

CONCLUSION

high-dose vitamin C attenuates the development of strongly negative P(if) in burned dermis and reduces the edema as measured by TTW. No significant change in Ealb was found. Vitamin C was thus found to have potential beneficial effects on the acute postburn edema generation.

[Shock and acute organ dysfunction]

Multiple trauma, hemorrhage, and sepsis may produce various kinds of shock, and such a host as shock could not be controlled and may easily fall into multiple organ dysfunction. Although those mechanisms on the pathogenesis of these sequential inflammatory responses have been clarified recently, the clinical outcome of such patients suffering from severe sepsis and multiple organ dysfunction is still very low. This inflammatory response against the insult shows a sequential manner; cardiovascular system failure, renal system failure, respiratory system failure, central nervous system failure, and finally, hepatic failure. However, the host response to the insult is a kind of defense against the invasion, and the clinical goal might be to stabilize hemodynamic system, metabolic system, and immunologic system. To achieve hemodynamic homeostasis, we use catecholamines and blood transfusion to improve the oxygen supply to important organs and enhance tissue repair. For metabolic homeostasis, early administration of hyperalimentation may be needed, either parenterally or enterally. Enteral feeding may also provided a route for bacterial translocation. To achieve immunologic homeostasis, prophylactic antibiotic administration and metabolic support may be required and should also protect against infection as a secondary invasion. This review explains these mechanisms in terms of the relationship between shock and organ dysfunction and the general features of clinical management.

Vascular tone in patients with hemorrhagic shock

BACKGROUND

In hemorrhagic shock, the alterations in arterial vascular tone, which are primarily regulated by adrenosympathetic influences are compensatory responses to bleeding.

OBJECTIVE

The aim of this study was to evaluate vascular tone expressed by the volume elastic modulus (Ev) as a clinical monitor to detect the hypovolemic state.

METHODS

Thirteen patients with hemorrhagic shock were studied. The initial Ev measurement was performed at arrival, and subsequent measurements were obtained 4 and 12 hours after arrival. Patients were divided into two groups by cluster analysis by using the Ev values at arrival and 4 hours after arrival. Circulatory parameters, the clinical course, and fluid were compared.

RESULTS

The Ev values were identical at admission (cluster I vs. II: 456.4+/-197.1 vs 566.1+/-234.1 mm Hg, mean +/- SD). After 4 hours of fluid resuscitation, all patients were recovered from shock. In cluster I, the Ev remained high at 4 hours (523.4+/-75.1 mm Hg) and invasive treatments for hemostasis were required. In cluster II, the Ev significantly decreased at 4 hours (182.8+/-70.7 mm Hg, p < 0.01) and clinical courses were eventless thereafter. During 4 to 12 hours, more fluid was given in cluster I (p < 0.05). At 12 hours after arrival, the Ev values were identical in both clusters.

CONCLUSION

These data demonstrate that the Ev increases in hemorrhagic shock. Furthermore, normotensive hypovolemic conditions generated by persistent bleeding can be detected by measuring the Ev.

[Fungal infection in patients with serious disease. Risk analysis of fungal infection]

BACKGROUND

Candidemia is still a major source of high morbidity and mortality in severely disease patients. However, the etiology and risk factor is still unknown.

PURPOSE

To evaluate the risk factor of fungal infection in intensive care patients.

SUBJECTS AND METHOD

505 patients who stayed in the intensive care unit of the Critical Care Center, Kyorin University more than 10 days between May 1, 1997 to June 31, 1998 were studied. They were divided into 7 groups: 1) trauma (injury severity score<10), 2) burn (burn index<10), 3) cerebro-vascular disease (unconsciousness<JCS 10), 4) GI tract disease, 5) acute poisoning, 6) cardiac dysfunction, 7) sepsis and others. Background factors, such as ISS, AIS scores for various trauma sites, length of stay in ICU and length of ventilatory days, as well as the fungal culture derived from blood, sputum, urine and pharyngeal smear, and the serological diagnosis were compared for the seven groups.

RESULTS

Higher fungal detection was found in upper airways (oral and sputum culture), but little was detected in urine or blood samples. Groups in trauma, burn, GI tract disease and CVA disease showed a higher detection rate of fungal species and diagnosed fungal infection, while patients with association of severe chest injury, inhalation injury and coma were significantly higher in the fungal infection group, than those in the non-fungal infection (p<0.01). Length of stay in ICU and the length of respiratory days were significantly longer in the fungal infection group (p<0.001).

CONCLUSION

The frequency of fungal infection onset was higher in patients with severe ISS of 16 or higher, those who used the ventilator, had inhalation injury, severe burns (BI>15), were in a coma, and had severe injury of lung parenchyme with chest AIS 3 or higher. In these serious patients, it is necessary to make a rapid diagnosis and treatment based on the surveillance culture and serological examination of sputum and urine for occult fungal infection.

[Cytokine imbalance in critically ill patients: SIRS and CARS]

It remains difficult to treat severely ill patients, especially those who have sepsis and subsequent multiple organ dysfunction syndrome. We propose the hypothesis that the pathophysiology in the sequential sepsis and multiple organ dysfunction syndrome may be strongly related to the imbalance between inflammatory cytokines and antiinflammatory cytokines induced for the host defense to active neutrophils and endothelial cells. Thus we attempted to develop cytokine modulation therapy to normalize the cytokine balance in the host defense system. In this review, we elucidate the relationship between cytokine imbalance and SIRS/CARS in patients with severe burn injury. Furthermore, we examine the possible usage of G-CSF to amplify neutrophil function, and clarify the reasons why various innovative therapies against sepsis have failed.

Enzyme-free method for cultured skin grafting

Cultured skin autografting has promise to improve the prognosis of severe burn injury. Established methods for cultured epithelial cell autografting need enzymatic proteolytic reaction that have potential risks of losing cell surface structures and causing allergic reactions in the recipients. Therefore, we have developed an enzyme-free method of cultured skin autografting. Donor skin was obtained in 0.2-0.3 mm thickness during an operation of debriding burned eschar. The skin was cut into pieces and spread on removable soft culture surface membrane in culture plates. Modified MCDB 153 medium with 10 microg/L epidermal growth factor and 150 mg/L bovine pituitary extract was used. The tissues were incubated at 37 degrees C in a water-saturated atmosphere of 5% CO2 in air. After 3 weeks, the cultured tissue on the membrane was removed mechanically from the bottom of the plates and implanted on granulated recipient sites in upside down manner. The cultured auto-skin grafting was successfully performed in two patients with severe burn. The recipient sites were partially epithelized in 2 weeks and maintained thereafter. Our method is performed easily using partial thickness donor skin without enzymatic processes.

Laparoscopic drainage of an intramural duodenal hematoma

A 21-year-old man was admitted with vomiting and abdominal pain 3 days after sustaining blunt abdominal trauma by being tackled in a game of American football. A diagnosis of intramural hematoma of the duodenum was made using computed tomography and upper gastrointestinal tract contrast radiography. The hematoma caused obstructive jaundice by compressing the common bile duct. The contents of the hematoma were laparoscopically drained. A small perforation was then found in the duodenal wall. The patient underwent laparotomy and repair of the injury. Laparoscopic surgery can be used as definitive therapy in this type of abdominal trauma.

Sensory afferent properties of immobilised or inflamed rat knees during continuous passive movement

We studied the sensory afferent properties of normal, immobilised and inflamed rat knees by recording the activity of the medial articular nerve (MAN).

When the knee was inflamed by kaolin-carrageenan or immobilised for six weeks, MAN activity significantly increased during rest and continuous passive motion (CPM). The maximal discharge rate tended to increase depending on the angular velocity of the CPM. When the knees were then rested for one hour before again starting CPM, activity was further increased at the initial CPM cycle, the ‘post-rest effect’. Analysis of the conduction velocity showed that 94% and 66% of spike units on the recorded discharge of the immobilised and inflamed knees, respectively, belonged to fine nerve fibres.

Our findings show that the sensory receptors in the knee are sensitised in a similar manner by immobilisation and by inflammation, suggesting a relationship to pain. The post-rest effect may be related to a characteristic symptom of osteoarthritis called ‘starting pain’.

Sensory afferent properties of immobilised or inflamed rat knees during continuous passive movement

We studied the sensory afferent properties of normal, immobilised and inflamed rat knees by recording the activity of the medial articular nerve (MAN). When the knee was inflamed by kaolin-carrageenan or immobilised for six weeks, MAN activity significantly increased during rest and continuous passive motion (CPM). The maximal discharge rate tended to increase depending on the angular velocity of the CPM. When the knees were then rested for one hour before again starting CPM, activity was further increased at the initial CPM cycle, the 'post-rest effect'. Analysis of the conduction velocity showed that 94% and 66% of spike units on the recorded discharge of the immobilised and inflamed knees, respectively, belonged to fine nerve fibres. Our findings show that the sensory receptors in the knee are sensitised in a similar manner by immobilisation and by inflammation, suggesting a relationship to pain. The post-rest effect may be related to a characteristic symptom of osteoarthritis called 'starting pain'.

[Analysis of transmission of Burkholderia cepacia isolates in an intrahospital by randomly amplified polymorphic DNA-PCR method]

Strains of Burkholderia cepacia isolated in our hospital from November 1995 to September 1996 were classified with randomly amplified polymorphic DNA-PCR (RAPD-PCR) and conventional biochemical tests (ID test.NF-18, API20NE, and Neg Combo 4J kit), and intrahospital isolates of B. cepacia were analysed. During the period 28 strains from inpatients and 2 from medical apparatus were isolated. Twenty four of 28 (85.7%) were from sputum. In 1996 from January to February, 20 strains were detected from 8 inpatients, and two strains were from the nebulizers at the Trauma and Critical Care Center (TCC). With typing of B. cepacia by conventional methods no epidemiological relations among isolates were found. However, DNA patterns of original isolates from the nebulizers at TCC by RAPD-PCR were identical with those of isolates in sputa from patients in other wards who had stayed at TCC, indicating that TCC was an initial source of transmission and the strain was transmitted with the patients to the wards. These results suggest that RAPD-PCR method might be a useful tool to analyse an epidemiological survey for intrahospital transmission of isolate.

[Current treatment burn wounds: alternative wound coverage methods]

In patients with massive burn injuries and very limited skin donor sites, both acute-phase and long-term problems of skin loss must be solved by the use of alternative wound closure materials. Alternative materials can be used for either temporary wound coverage or for permanent wound closure. Recently, allogenic skin grafts have most commonly been used as alternative wound closure material. However, research is ongoing on many new materials to provide a readily available substitute for skin allografts for permanent wound closure. The best approach to the development of alternative permanent wound closure materials is to incorporate the host's own cellular and structural components. Four general strategies have been devised so far based on the type of matrix structure and cellular content: allografts; cultured epidermal grafts; dermal matrix grafts; and cultured-dermal matrix composite grafts. Several approaches using combined alternative wound closure materials have been used, including transplantation of artificial dermal matrix with thin epidermal autografts, and transplantation of artificial dermal matrix containing human fibroblasts. Ultimately, the best candidate materials for permanent wound closure after extensive burn injury must be determined in prospective, randomized, controlled clinical trials.

Hyperechoic appearance of hepatic parenchyma on ultrasound examination of patients with blunt hepatic injury

OBJECTIVE

To study the significance of a geographic hyperechoic liver parenchyma pattern on ultrasound (US) examination of patients with blunt abdominal injury.

DESIGN

Prospective clinical study with double-blind evaluation of images and clinical data.

METHODS AND MAIN RESULTS

We performed US examinations in 831 consecutive patients admitted to our hospital for blunt abdominal trauma and identified 33 with a geographic hyperechoic pattern in the liver. We correlated the appearance with computed tomographic images and with clinical, angiographic, and scintigraphic data. All patients with a geographic hyperechoic pattern showed mild computed tomographic evidence of hepatic injury (Mirvis grade 2, 69%; Mirvis grade 3, 31%). Excluding patients who required urgent surgery for other reasons and patients in shock, patients with the geographic hyperechoic pattern were managed conservatively with no complications.

CONCLUSION

The geographic hyperechoic pattern of liver parenchyma on US examination of trauma patients is a mild injury that, of itself, does not require surgical therapy.

[Properties of extracellular products produced by group A streptococci isolated from patients with streptococcal toxic shock syndrome]

Extracellular products of group A streptococci isolated from patients with streptococcal toxic shock syndrome (STSS) were examined. The outline of the discussion of the 3 products are as follows; streptolysin O (SLO), proteinase and erythrogenic toxin. SLO and proteinase showed a relatively large amount of products more than erythrogenic toxin. SLO produced by group A streptococci isolated from the patient with STSS had an isoelectric point (pI) of 6.0 and a molecular weight of 64,000 and showed hemolytic activity in the presence of 2-mercaptoethanol (2-ME). Furthermore, the hemolytic activities of all components were inhibited by gamma-globulin and cholesterol. Proteinase had pIs of 8.7 and 8.9, and a molecular weight of 21,000. These data suggest that STSS clinical criteria probably reflects a characteristic of a large amount of products of individual S. pyogenes isolates.

Reduced resuscitation fluid volume for second-degree experimental burns with delayed initiation of vitamin C therapy (beginning 6 h after injury)

We studied the hemodynamic effects of delayed initiation (6 h postburn) of antioxidant therapy with high-dose vitamin C in second-degree thermal injuries. Seventy percent body surface area burns were produced by subxiphoid immersion of 12 guinea pigs into 100 degrees C water for 3 s. The animals were resuscitated with Ringer's lactate solution (R/L) according to the Parkland formula (4 ml/kg/% burn during the first 24 h) from 6 h postburn, after which the resuscitation fluid volume was reduced to 25% of the Parkland formula volume. Animals were divided into two groups. The vitamin C group (n = 6) received R/L to which vitamin C (340 mg/kg/24 h) was added after 6 h postburn. The control group (n = 6) received R/L only. Both groups received identical resuscitation volumes. Heart rates, mean arterial blood pressure, cardiac output, hematocrit level, and water content of burned and unburned tissue were measured before injury and at intervals thereafter. No animals died. There were no significant differences in heart rates or blood pressures between the two groups throughout the 24-h study period. The vitamin C group showed significantly (P < 0.05) lower hematocrits 8 and 24 h postburn, and higher cardiac outputs after 7 h postburn. At 24 h postburn, the burned skin in the vitamin C group had a significantly (P < 0.05) lower water content (73.1 +/- 1.1) than that of the control group (76.0 +/- 0.8). In conclusion, delayed initiation of high-dose vitamin C therapy beginning 6 h postburn with 25% of the Parkland formula volume significantly reduced edema formation in burned tissue, while maintaining stable hemodynamics.

Nonsurgical management of patients with blunt hepatic injury: efficacy of transcatheter arterial embolization

OBJECTIVE

We evaluated the efficacy of transcatheter arterial embolization (TAE) for patients with blunt hepatic injury.

SUBJECTS AND METHODS

Of 372 patients with trauma, 60 had evidence on CT of hepatic injury (Mirvis classification). Six of the 60 patients required emergency laparotomy and were excluded. Of the 54 remaining patients, 28 were classified as having high-grade hepatic injury (Mirvis classification of 3 or 4). All 28 underwent arteriography, and TAE was performed in single or multiple hepatic arterial branches when extravasation was seen. Angiography was repeated and cholescintigraphy was performed on patients with continued bleeding or biloma.

RESULTS

Injuries detected were grade 1 (n = 13), grade 2 (n = 13), grade 3 (n = 20), and grade 4 (n = 8). The injury was correlated with the degree of hemoperitoneum seen on CT. Patients with low-grade injuries (Mirvis classification of 1 or 2) were treated conservatively, and no deaths or liver-related morbidity occurred. Of the 28 patients with high-grade injury, 15 also had angiographic evidence of extravasation and underwent TAE. The average fluid resuscitation volume was significantly larger in this group than in the other 13 patients with high-grade injuries who did not undergo TAE. Embolization was successful in all 15 patients, and the shock index was significantly reduced after TAE. All patients survived, with follow-up at 1-8 months (2.5 +/- 1.8 months, mean +/- SD).

CONCLUSION

TAE is an effective alternative to surgery for patients with high-grade liver injury.

[Efficacy of rectal diazepam suppository in the prophylaxis of febrile seizures: comparison with rectal chloral hydrate suppository]

We evaluated the efficacy of diazepam and chloral hydrate given rectally for the prophylaxis of recurrence of febrile seizure. The dose were 0.4 mg/kg for diazepam and 250 mg (for children younger than 3 years old) or 500 mg (for over 3 years old) for chloral hydrate. Another dose was given after an interval of 8 hours if body temperature continued to exceed 38.0 degrees C. Among the 452 patients with febrile seizures who visited our hospital from Jan. 1993 to Jun. 1995, 113 were studied who had at least one febrile episode in the follow-up period that extended over 6 months. These patients were divided into two groups: Group D (72 patients given diazepam) and Group C (41 patients given chloral hydrate). In group D and C, the numbers of febrile episodes were 238 and 167, and those of recurrent seizures 8 (3.8%) and 29 (20.4%), respectively. The recurrences rate was significantly higher in the latter group (p < 0.005). There was no statistical difference as to the mean dosage of diazepam or chloral hydrate between the patients with and without recurrence. The numbers of patients with seizure recurrence were 8 (11.1%) in group D and 12 (29.3%) in group C, being significantly larger in the latter (p < 0.005). Diazepam produced more adverse effects than chloral hydrate did. Thus diazepam suppositories for the prevention of recurrence of febrile seizures were more effective than chloral hydrate suppositories.

Reduced resuscitation fluid volume for second-degree burns with delayed initiation of ascorbic acid therapy

BACKGROUND

Oxygen radicals may play an important role in injury due to thermal burns. High-dose antioxidant ascorbic acid (vitamin C, Cenolete, Abbott Laboratory, Abbott Park, Ill) therapy reduces edema of burned and unburned tissue, lipid peroxidation, and subsequent resuscitation fluid volume requirement in experimental burn models.

OBJECTIVE

To determine the hemodynamic effects of delayed initiation (2 hours after injury) of antioxidant therapy in patients with second-degree burns.

DESIGN

Experimental study. MATERIALS AND INTERVENTION: Burns over 70% of body surface area were produced by subxiphoid immersion of 12 guinea pigs in 100 degrees C water for 3 seconds. The animals were resuscitated with Ringer's lactated solution according to the Parkland formula (4 mL/kg for 1% of burned body surface area during the first 24 hours) from 0.5 to 2 hours following injury, after which the resuscitation fluid volume was reduced to 25% of the Parkland formula. Animals received Ringer's lactated solution to which ascorbic acid (340 mg/kg during the first 24 hours) was added (vitamin C group [n = 6]) or Ringer's lactated solution only (control group [n = 6]).

MEASUREMENTS

Heart rates, mean arterial blood pressure, cardiac output, hematocrit level, and water content in burned and unburned tissue were measured before injury and at intervals thereafter.

RESULTS

There were no significant differences in heart rates (P = .29) and blood pressures (P = .53) between the 2 groups throughout the 24-hour study period. No animal died. The vitamin C group showed significantly lower hematocrit levels (P < .05) and significantly higher cardiac output values (P < .05) at 7 hours following burn injury and at intervals thereafter (P < .001).

CONCLUSION

With delayed initiation of high-dose ascorbic acid therapy, the 24-hour fluid resuscitation volume was reduced to 32.5% of the Parkland formula, while maintaining adequate cardiac output values.

Mild hypotension and body burns synergistically increase bacterial translocation in rats consistent with a "two-hit phenomenon"

Wistar rats were burned over 15% of their total body surface area and suffered hemorrhagic hypotension (mean blood pressure 80 mm Hg) 72 hours after the thermal injury (burn + hypotension group). Rats in other groups were treated in the same way except sham hypotension in burn group, sham burn in hypotension group, and sham hypotension and sham burn in control group. At the end of the study period, the mesenteric lymph nodes (MLN), liver, and spleen were cultured for translocated bacteria. The cecal bacterial burden was not affected by the insults. The number of bacteria translocated to the MLN after the thermal injury was much greater in the burn + hypotension group (156.19 +/- 42.29 colony-forming units [CFUs]/gm tissue) rather than in the other groups (5.24 +/- 8.34, 9.86 +/- 16.56, 40.21 +/- 45.8 in the control, hypotension, and burn groups, respectively). This indicates that bacterial translocation (BT) is the result of a two-hit phenomenon. The gut-MLN BT ratio, obtained by dividing the bacterial CFUs in the MLN by those in the cecum, was higher in the burn + hypotension group than in the other groups (p < 0.01). This ratio allows standardized measurements of BT to the MLN despite differences in the absolute bacterial load in the gut, and the elevated gut mesenteric lymph nodes BT ratio of the burn + hypotension group suggests that the two-hit phenomenon of BT may be the result of alterations in the gut mucosal barrier function.

[Free radicals and surgical stress]

Free radicals have at least one unpaired electron. Some of them have very high reactivity and harmful to cells and tissues. O2-. and HO. are generated during re-perfusion phase of shock. Both induce lipid peroxidation and this attack initiates auto-continuing injury of membrane lipid by lipid peroxide. This may result in damage of membrane function and permeability alteration. NO is an another type of free radical and huge amount of NO is generated by inducible NO synthase with variety of stimulation. NO decreases vascular tonus and may be related with hyperdynamic circulatory status in sepsis. NOx and ONOO- which are NO derivatives, deteriorate mitochondrial function. Free radicals are one of major agents which damages patients under surgical stress, however, they also have important rules in our defense system. In this sense, control rather than suppression may be important to ameliorate injury caused by surgical stress.