Transarterial embolization to treat a massive hemothorax during mechanical circulatory support via puncturing of the extracorporeal membrane oxygenation circuit

BACKGROUND

Current guidelines recommend the use of mechanical circulatory support (MCS) for patients with cardiogenic shock that is refractory to medical therapy. Bleeding is the most common complication of MCS. Transarterial embolization (TAE) is often performed to treat this complication, because it is a less invasive hemostatic procedure. However, the TAE option needs to be carefully considered during MCS, as the access route may be limited during MCS.

CASE PRESENTATION

A man in his 70 s was diagnosed with acute myocardial infarction and underwent percutaneous coronary intervention via venoarterial extracorporeal membrane oxygenation (VA-ECMO) and Impella. During treatment in the intensive care unit, he suffered damage to a branch of the internal thoracic artery during a cardiac drainage procedure, which was subsequently treated via emergency TAE. An ECMO return cannula and an Impella sheath were inserted into the patient's right and left femoral arteries, respectively. An approach from the left brachial artery was selected, and the left internal thoracic artery was embolized. Subsequently, the patient required re-intervention to treat re-bleeding from another artery. Because it was difficult to target the target artery from the brachial one, owing to interference from the Impella catheter, the ECMO circuit near the return cannula was punctured and a guiding sheath was inserted. The ECMO flow and the patient's blood pressure decreased following placement of this guiding sheath. We were thus able to maintain the patient's blood pressure by increasing the infusion fluids and Impella flow, and embolize the target artery using a gelatin sponge to achieve hemostasis.

CONCLUSION

When TAE is difficult to perform during MCS using an approach from the upper extremities, a lower extremity approach with a sheath inserted into the ECMO circuit may represent a viable alternative.

In vitro comparison of the leakage of carbon dioxide and iodine contrast media in a bleeding model

BACKGROUND

We aimed to compare the hydrodynamic values of carbon dioxide (CO2) and iodine contrast media for bleeding detection using an in vitro model.

MATERIALS AND METHODS

We created a bleeding model with large and small wounds in simulated blood vessels. We connected a syringe to the bleeding model and the blood pressure transducer, filling the circuit with CO2 and iodine contrast media. The syringe's piston was pressed, and the flow rate and intravascular pressure of the CO2 and iodine contrast media leaking from the bleeding model were measured. We compared each leaked contrast medium's volume, sphere-equivalent diameter, and sphere-equivalent area. These values were analyzed to compare the visibility of the leakage objectively.

RESULTS

At a constant flow rate, the intravascular pressure required for the model to leak was lower for the CO2 than that for the iodine contrast medium. The CO2 contrast medium leakage volume, equivalent circle diameter, and equivalent circle area were greater than those of the iodine one. These values indicate higher CO2 visibility during fluoroscopy.

CONCLUSIONS

In the bleeding model, a CO2 contrast medium may be more prone to leakage than the iodine one in large and small wounds. Regarding visibility, a CO2 contrast medium may be more likely to detect leakage than an iodine one.

Combination of neuroendoscopic hematoma evacuation and endovascular coil embolization for a ruptured anterior choroidal artery aneurysm in patients with moyamoya disease: illustrative cases

BACKGROUND

The treatment strategy for hemorrhagic moyamoya disease (MMD) due to a ruptured aneurysm at the distal portion of the anterior choroidal artery remains controversial. The authors successfully treated the ruptured aneurysm with neuroendoscopic hematoma evacuation, followed by endovascular coil embolization.

OBSERVATIONS

The authors encountered two patients with massive hemorrhagic MMD whose MMD had already been diagnosed and who had a periventricular anastomosis due to a ruptured aneurysm of the distal portion of the anterior choroidal artery involving the periventricular anastomosis. In both cases, neuroendoscopic hematoma evacuation was performed for hemorrhagic MMD in the acute phase, followed by endovascular coil embolization of the ruptured aneurysm in the chronic phase. In both endovascular treatments, the patient's condition was stabilized by hematoma evacuation, allowing a detailed preoperative evaluation of the anatomical findings of the vessel and functional findings of intraoperative neurophysiological monitoring using continuous monitoring of motor evoked potentials to preserve motor function.

LESSONS

Combination therapy can be useful for hemorrhagic MMD in patients with diagnosed MMD with a periventricular anastomosis. Additionally, a preoperative understanding of the vascular construction and intraoperative neurophysiological monitoring will aid in the successful coil embolization of aneurysms at the distal portion of the anterior choroidal artery with hemorrhagic MMD.

Elevated Plasma Tryptophan in Patients with Anorexia Nervosa Compared with Hypotrophic Controls

Introduction

We hypothesized that anorexia nervosa (AN) is associated with pathological amino acid metabolism. This study aimed to identify amino acids exhibiting abnormal metabolism in patients with AN compared with those in low-nutrient controls.

Methods

This was a single-center, retrospective, observational study that compared patients with AN with a low-nutrient control group. All participants were admitted to the Kitasato University Hospital Emergency Center between January 1, 2018, and January 31, 2021. Both the AN and low-nutrient control groups had five patients each. Plasma amino acid category testing was conducted at the same institution for both groups. Patient sex, age, height, weight, and comorbidities were retrospectively extracted. Plasma amino acid fractions, total amino acids, total essential amino acids, total nonessential amino acids, branched-chain amino acids (sum of valine, isoleucine, and leucine), and amino acid concentrations and ratios were compared between the two groups. Data were analyzed using the Mann-Whitney U test.

Results

Body mass index was lower in the AN group (p = 0.00794). Tryptophan levels were significantly higher in the AN group (p = 0.00794). Other amino acid values, the sum of amino acid values, and amino acid ratios were not significantly different between both groups.

Conclusions

Serum tryptophan levels were higher in the AN group than in the low-nutrient group, and AN may be associated with abnormal amino acid metabolism.

Carnitine Deficiency in Intensive Care Unit Patients Undergoing Continuous Renal Replacement Therapy: A Single-center Retrospective Study

Introduction

Carnitine deficiency is common in patients undergoing intermittent hemodialysis and may also occur during continuous renal replacement therapy (CRRT). We evaluated intensive care unit (ICU) patients undergoing CRRT for carnitine deficiency and its associated risk factors.

Methods

This was a single-center, retrospective, observational study performed between June 2019 and March 2020. The primary outcome was the incidence of carnitine deficiency in ICU patients undergoing CRRT.

Results

Eighty-eight patients underwent 103 blood carnitine concentration measurements. The median age was 68 years (interquartile range: 55-80), Acute Physiology and Chronic Health Evaluation II score was 28 (24-33), Sequential Organ Failure score was 8.5 (5-11), Nutrition Risk in Critically Ill score was 6 (5-7), and blood carnitine concentration was 66.1 μmol/L (51.8-83.3). In total, 34 of 88 patients (38.6%) were found to have carnitine deficiency; however, there was no significant difference in the proportions of patients with carnitine deficiency characterized by disease. CRRT was performed in 44 (50%) patients, and the median blood total carnitine concentration measured after 24 h of CRRT without changing the settings was 65.5 μmol/L (48.6-83.3). The purification volume of CRRT and blood carnitine concentration were negatively correlated (R = -0.63; P = 0.02).

Conclusions

Carnitine deficiency is seen in patients receiving CRRT and may increase in incidence as the purification volume increases, requiring regular monitoring.

Efficacy of the bleeding risk scoring system for optimal prophylactic anticoagulation therapy of venous thromboembolism in trauma patients: a single-center, retrospective, observational cohort study

BACKGROUND

We developed a bleeding risk scoring system (BRSS) using prophylactic anticoagulation therapy to comprehensively assess the risk of venous thromboembolism (VTE) in trauma patients. This study evaluated the usefulness of this system in trauma patients, with a focus on minimizing the rate of bleeding events associated with prophylactic anticoagulation therapy.

METHODS

We retrospectively evaluated the efficacy of BRSS in trauma patients who received prophylactic anticoagulation therapy for VTE at the Kitasato University Hospital Emergency and Critical Care Center between April 1, 2015, and August 31, 2020. To compare the incidence of bleeding events, patients were divided into two groups: one group using the BRSS (BRSS group) and another group not using the BRSS (non-BRSS group).

RESULTS

A total of 94 patients were enrolled in this study, with 70 and 24 patients assigned to the non-BRSS and BRSS groups, respectively. The major bleeding event rates were not significantly different between the two groups (BRSS group, 4.2%; non-BRSS group, 5.7%; p = 1.000). However, minor bleeding events were significantly reduced in the BRSS group (4.2% vs.27.1%; p = 0.020). Multivariate logistic regression analysis showed that BRSS was not an independent influencing factor of major bleeding events (odds ratio, 0.660; 95% confidence interval: 0.067-6.47; p = 0.721). Multivariate logistic regression analysis showed that BRSS was an independent influencing factor of minor bleeding events (odds ratio, 0.119; 95% confidence interval: 0.015-0.97; p = 0.047). The incidence of VTE did not differ significantly between groups (BRSS group, 4.2%; non-BRSS group, 8.6%; p = 0.674).

CONCLUSIONS

BRSS may be a useful tool for reducing the incidence of minor bleeding events during the initial prophylactic anticoagulation therapy in trauma patients. There are several limitations of this study that need to be addressed in future research.

Distal radial approach for arterial pressure monitoring with a long catheter provides safe and stable monitoring in the intensive care unit: A single-center retrospective study

BACKGROUND

To compare the distal radial artery approach (DRA) with a longer catheter to DRA with a shorter catheter in arterial catheter (AC) placement in the intensive care unit (ICU).

METHODS

This was a single-center retrospective cohort study of DRA with a long catheter (60 mm) for arterial catheterization in the ICU. DRA with a short catheter (25-30 mm) was used in the control group, and the groups were compared using multivariate regression analysis. The primary study endpoint was the incidence of unplanned AC removal. The secondary endpoint was the incidence of other inappropriate events, namely loss of arterial pressure waveforms, bleeding, catheter-related infection, pressure ulcer, and other complications associated with the AC.

RESULTS

In this study, the DRA with a long catheter was used in 50 patients. No unplanned AC removals or other inappropriate events occurred, and there were no complications associated with the DRA. The DRA procedural success rate was 100%. There was no significant difference in hemostasis times between the groups. Loss of arterial waveforms was an early predictor of unplanned AC removal.

CONCLUSIONS

The DRA with a long catheter provided stable monitoring and was associated with a low unplanned removal rate. This method has the advantages of fewer complications and shorter hemostasis time compared with the DRA with a short catheter, and may become a new AC option in the ICU.

Multiple trauma complicated by traumatic vertebral artery injury without cervical vertebral injury: A case report

Background

Blunt traumatic vertebral artery injury is commonly associated with head and cervical spinal trauma. However, those associated with chest or upper extremity injuries without cervical spine-related trauma are rare.

Case presentation

A 94-year-old woman was injured in a motor vehicle crash. She was diagnosed with traumatic subarachnoid hemorrhage, bilateral subdural hematomas, right vertebral artery injury, and right clavicle fracture. No cervical spine injuries were observed. It was possible that the fracture fragment of the right clavicle may have directly injured the right vertebral artery. Coil embolization was performed for the vertebral artery injury. The patient had a good postoperative course and was transferred to the hospital for rehabilitation on day 65.

Conclusion

Regarding the high-risk injury mechanism, blunt traumatic vertebral artery injuries in the V1-2 segment may occur in cases with clavicle fractures.

Lesser omental hernia through a defect in the posterior layer of the lesser omentum

BACKGROUND

In previously reported cases of lesser omental hernia, a rare clinical presentation, the herniated intestinal tract was passing through both peritoneal layers of the lesser omentum to herniate into the peritoneal cavity or bursa omentalis. Here we present a very rare case of lesser omentum hernia, where the transverse colon entered through only the posterior layer of the lesser omentum to form a hernia between the anterior and posterior layers.

CASE PRESENTATION

A 43-year-old man was admitted to the emergency department with acute abdominal pain. Plain abdominal computed tomography (CT) revealed a change in the caliber of the transverse colon between the stomach and pancreas, forming a closed loop on the cephaloventral side of the stomach. On contrast-enhanced CT images, vessels were observed in the contrast-enhanced lesser omentum surrounding the herniated intestine. The patient was diagnosed with a lesser omental hernia and underwent laparoscopic surgery. Intraoperatively, the transverse colon was covered by the anterior layer of the lesser omentum, and a defect was found in the posterior layer of the lesser omentum on the dorsal side of the stomach. A 2-cm incision was made in the posterior layer of the lesser omentum to widen the small defect. The herniated intestinal section was removed from the hernia sac, and the transverse colon was retained unresected. The postoperative course was uneventful.

CONCLUSIONS

As illustrated in this first case of a lesser omental hernia forming between the anterior and posterior layers, characteristic CT findings may play an active role in the diagnosis of this rare presentation.

Hybrid surgery for blunt aortic injury with rupture: a case report

BACKGROUND

Blunt thoracic aortic injury is one of the most lethal traumatic injuries. Ruptured cases often result in cardiac arrest before arrival at the hospital, and survival is rare.

CASE PRESENTATION

A female patient in her 30 s was struck by an automobile while she was walking across an intersection. She was in a state of shock when emergency services arrived and was in cardiac arrest shortly after arriving at the hospital. A left anterolateral thoracotomy revealed a massive hemothorax secondary to thoracic aortic rupture. In addition, the patient had multiple traumas, including maxillary, pelvic, and lumbar burst fractures. We attempted to directly suture the aortic lesion; however, the increasing blood pressure caused the suture to break. We used a thoracic stent graft while ensuring permissive hypotension. Her postoperative prognosis was positive, and she was transferred to another hospital 85 days later.

CONCLUSIONS

We successfully performed a hybrid surgery combining thoracotomy and endovascular repair for this emergency case of blunt thoracic aortic injury with rupture.

Endoscope-integrated indocyanine green video angiography and the detection of the fragile periventricular collaterals associated with moyamoya disease: illustrative cases

BACKGROUND

Hemorrhagic moyamoya disease (MMD) and the fragile periventricular collaterals are known to have a causal relationship. Digital subtraction angiography and magnetic resonance angiography have shown the presence of fragile periventricular moyamoya vessels. However, dynamic fragile periventricular moyamoya vessels have never been observed under direct vision.

OBSERVATIONS

The authors treated two patients with hemorrhagic MMD: a 42-year-old man with intraventricular hemorrhage and a 47-year-old woman with intracerebral hemorrhage. Endoscope-integrated indocyanine green video angiography (EICG angiography) could visualize the dynamic fragile periventricular collaterals. In particular, EICG angiography enabled visualization of invisible moyamoya vessels buried in the subependyma and characterization of the blood flow in the moyamoya vessels located inside the lateral ventricles and hematoma cavity.

LESSONS

EICG angiography can confirm the fragile periventricular collaterals associated with MMD by direct visualization. The high spatial resolution and real-time imaging can help to avoid accidental hemorrhage in and after evacuation of hemorrhage in patients with MMD.

Relationship between subarachnoid hemorrhage and nonocclusive mesenteric ischemia as a fatal complication: patient series

BACKGROUND

Nonocclusive mesenteric ischemia (NOMI) causes intestinal necrosis due to irreversible ischemia of the intestinal tract. The authors evaluated the incidence of NOMI in patients with subarachnoid hemorrhage (SAH) due to ruptured aneurysms, and they present the clinical characteristics and describe the outcomes to emphasize the importance of recognizing NOMI.

OBSERVATIONS

Overall, 7 of 276 consecutive patients with SAH developed NOMI. Their average age was 71 years, and 5 patients were men. Hunt and Kosnik grades were as follows: grade II, 2 patients; grade III, 3 patients; grade IV, 1 patient; and grade V, 1 patient. Fisher grades were as follows: grade 1, 1 patient; grade 2, 1 patient; and grade 3, 5 patients. Three patients were treated with endovascular coiling, 3 with microsurgical clipping, and 1 with conservative management. Five patients had abdominal symptoms prior to the confirmed diagnosis of NOMI. Four patients fell into shock. Two patients required emergent laparotomy followed by second-look surgery. Four patients could be managed conservatively. The overall mortality of patients with NOMI complication was 29% (2 of 7 cases).

LESSONS

NOMI had a high mortality rate. Neurosurgeons should recognize that NOMI can occur as a fatal complication after SAH.

The Relationship Between Falling Distance and Trauma Severity Among Fall Injury Survivors Who Were Transported to a Trauma Center

Introduction

Falls from >6 meters have been shown to cause multiple traumas and serious injuries. However, especially among fall survivors who were transported to trauma centers, the relationship between falling distance and trauma severity remains unclear. This study aimed to investigate the relationship between falling distance and trauma severity among fall injury survivors who were transported to a trauma center and clarify the characteristics of trauma among survivors of falls from high places from an orthopedic surgeon’s perspective.

Methods

We retrospectively reviewed the medical records of 65 fall injury survivors who were transported to a trauma center for falling distance; whether the fall was a suicide attempt; abdominal, chest, and head trauma; the numbers of upper-limb, lower-limb, and spinal vertebral fractures; McCormack load-sharing classification score; unstable pelvic fracture; Frankel classification; injury severity score (ISS); and duration of intensive care unit (ICU) and hospital stay. We evaluated the correlations between falling distance and the other factors and compared all factors between those falling <6 meters and those falling >6 meters.

Results

Falling distance was weakly positively correlated with durations of ICU and hospital stay. The percentage of cases that were suicide attempts, the number of lower-limb fractures, the McCormack load-sharing classification score, and the durations of ICU and hospital stay were significantly higher among those falling from >6 meters than among those falling from <6 meters. Conversely, there were no significant differences in abdominal trauma, chest trauma, head trauma, number of upper-limb fractures, number of vertebral fractures, unstable pelvic fracture, or Frankel classification between the two groups.

Conclusion

The findings indicate that falling from a higher distance may increase lower-limb and vertebral fracture severity and may lead to longer ICU and hospital stays among fall injury survivors who are transported to trauma centers.

Psychological stress of emergency medical staff after the largest mass murder incident in post-World War II era

Background

A mass‐casualty incident occurred on July 26, 2016, at Tsukui Yamayuri‐en, which is a welfare facility for people with intellectual disabilities. Nineteen residents with intellectual disabilities were killed, and 26 other residents and staff members were injured. Kitasato University Hospital Emergency and Disaster Medical Center treated many patients in serious condition at the site and in the hospital.

Aims

The authors investigated the symptom severity and distributions of posttraumatic stress disorder (PTSD) among the emergency medical staff in charge.

The subjects of this study were the staff members, mostly working at the Emergency and Disaster Medical Center, who treated the people injured in the incident.

Methods

We conducted a questionnaire survey using Impact of Event Scale‐Revised (IES‐R) on 104 staff members, and 79 responded.

Results

The IES‐R scores of nurses were significantly higher than those of doctors. There was no significant difference in the scores between male and female staff members, and there was no correlation between the score of each IES‐R subscale and age.

Conclusion

Results suggest that mental care should be provided to emergency medical staff, especially nurses who treat trauma patients involved in disasters and heinous crimes.

Mental care should be provided to emergency medical staff, especially nurses who treat trauma patients involved in disasters and heinous crimes.

Strategic neuronavigation-guided emergent endoscopic evacuation of the hematoma caused by ruptured brain arteriovenous malformation: Technical note and retrospective case series

The treatment strategy for ruptured brain arteriovenous malformations (bAVMs) in the acute phase is still controversial. We describe five consecutive cases of successful emergent endoscopic evacuation (EEE) of intracerebral hematoma (ICH) caused by ruptured bAVMs with the electromagnetic (EM)-neuronavigation system to avoid damage to the bAVMs intended to save valuable time in the emergent phase. A single-institution retrospective analysis was performed in patients with ruptured bAVMs treated by the EM-navigated EEE as part of the strategic multimodality therapy. EM-navigated EEE was performed as follows: 1) obtaining three-dimensional computed tomography to identify the location of the nidus, large draining vein, feeding artery, and hematoma; 2) using a supine position without rigid head fixation for both supra- and infratentorial hematoma; 3) planning the entry point and trajectory of the endoscope as far as possible from the location of the nidus using the EM-navigation system; 4) designing a linear skin incision line suitable for the endoscopic surgery as well as possible decompressive craniectomy; and 5) performing EM-navigated endoscopic partial evacuation of ICH. EM-navigated EEE of ICH was successfully performed for all 5 patients, resulting in partial removal of the ICH without rebleeding from bAVMs. The mean surgical time was 37 min. Subsequent strategic endovascular embolization and curative resection of bAVMs could be performed for all patients, achieving Glasgow Coma Scale score of 15. EM-navigated EEE of partial ICH may be valuable in the emergent phase of ruptured bAVMs with massive life-threatening ICH to reduce the intracranial pressure and to obtain better prognosis.

Efficacy of median sacral artery embolization for treating severe pelvic fractures: a retrospective study

Objective

Transcatheter arterial embolization (TAE) of bilateral internal iliac arteries (IIAs) in patients with a hemodynamically unstable pelvic fracture is associated with a low mortality rate. The persistence of unstable hemodynamics after IIA embolization indicates the involvement of other arteries, such as the median sacral artery (MSA). This study aimed to evaluate the efficacy of MSA embolization.

Methods

In this single-center, retrospective, observational study, medical records of patients who underwent MSA angiography or embolization for pelvic fractures (n = 21) between January 2007 and August 2019 were reviewed. The percentage of patients achieving hemodynamic stabilization by MSA embolization was calculated.

Results

Fifteen patients underwent MSA embolization, and the remaining six underwent MSA angiography. The shock index value was significantly higher after MSA embolization than that before MSA embolization in hemodynamically unstable patients who underwent this procedure. The success rate of MSA selection was 100%. One patient presented with urinary retention because of bladder and rectal disorders after MSA embolization. The 30-day survival rate was 85.7%.

Conclusions

Severe pelvic fractures, such as a Dennis Zone III fracture and suicidal jumper’s fracture due to trauma from a fall, may require MSA embolization.

Advanced do-not-attempt-resuscitation directives and emergency medical services for out-of-hospital cardiopulmonary arrest patients in Japan: a pilot study

Aims

We investigated how do‐not‐attempt‐resuscitation (DNAR) orders are currently used, and we examined the emergency medical team responses for out‐of‐hospital cardiac arrest (OHCA) cases in Japan.

Methods

The sample for this prospective study comprised all OHCA cases attended to by the Sagamihara Municipal Fire Department emergency medical services between May 30, 2019 and February 15, 2020. Data were recorded by the responding emergency medical team.

Results

There were 396 OHCA cases. The mean age was 75 ± 18 years, and individuals aged 65 years or older accounted for 80.6%. Approximately 70% of the patients had an underlying disease. A DNAR order was available in only 45 (11.4%) of the cases, of which 12 (26.7%) were written, 27 (60%) were verbally confirmed, and six (13.3%) were confirmed in some other way or both. The home physician was present and able to confirm the patient’s death in only one of the DNAR cases. In 43 (95.6%) of the cases, the emergency medical team carried out cardiopulmonary resuscitation despite a DNAR order; of them, a total of 17 (37.8%) patients were transported to a tertiary emergency hospital.

Conclusions

Our analyses indicate the under‐utilization of DNAR advance directives and advance care planning (which are important for better end‐of‐life care) in Japan. Currently, an emergency medical team could be required to attempt resuscitation against an individuals’ clear DNAR order. In the future, legal arrangements regarding the handling of DNAR directives on site may be required to respect patients’ wishes.

Transcatheter arterial embolization for severe blunt liver injury in hemodynamically unstable patients: a 15-year retrospective study

Background

Transcatheter arterial embolization (TAE) is the first-line nonsurgical treatment for severe blunt liver injury in patients, whereas operative management (OM) is recommended for hemodynamically unstable patients. This study investigated the comparative efficacy of TAE in hemodynamically unstable patients who responded to initial infusion therapy.

Methods

This retrospective study enrolled patients with severe blunt liver injuries, which were of grades III–V according to the American Association for the Surgery of Trauma Organ Injury Scale (OIS). Patients who responded to initial infusion therapy underwent computed tomography to determine the treatment plan. A shock index > 1, despite undergoing initial infusion therapy, was defined as hemodynamic instability. We compared the clinical outcomes and mortality rates between patients who received OM and those who underwent TAE.

Results

Sixty-two patients were included (eight and 54 who underwent OM and TAE, respectively; mean injury severity score, 26.6). The overall in-hospital mortality rate was 6% (13% OM vs. 6% TAE, p = 0.50), and the hemodynamic instability was 35% (88% OM vs. 28% TAE, p < 0.01). Hemodynamically unstable patients who underwent TAE had 7% in-hospital mortality and 7% clinical failure. Logistic regression analysis showed that the treatment choice was not a predictor of outcome, whereas hemodynamic instability was an independent predictor of intensive care unit stay ≥7 days (odds ratio [OR], 3.80; p = 0.05) and massive blood transfusion (OR, 7.25; p = 0.01); OIS grades IV–V were predictors of complications (OR, 6.61; p < 0.01).

Conclusions

TAE in hemodynamically unstable patients who responded to initial infusion therapy to some extent has acceptable in-hospital mortality and clinical failure rates. Hemodynamic instability and OIS, but not treatment choice, affected the clinical outcomes.

Usefulness of lavage and drainage using video-assisted thoracoscopic surgery for Boerhaave's syndrome: a retrospective analysis

Background

Boerhaave’s syndrome has a high mortality rate due to respiratory failure, septic shock, and multiple organ failure. We had previously carried out primary repair with laparotomy and postoperative computed tomography-guided drainage for mediastinal abscess and empyema. However, this treatment prolonged mechanical ventilator days and length of intensive care unit stay. Therefore, we decided to carry out primary repair with laparotomy and add lavage and drainage using video-assisted thoracoscopic surgery.

Methods

From April 2004 to September 2018, 18 patients with Boerhaave’s syndrome were treated; 6 patients treated conservatively were excluded. Thus, 12 patients who underwent surgical treatment were divided into the computed tomography-guided drainage group (D group) (6 patients) and the lavage and drainage using video-assisted thoracoscopic surgery group (VATS group) (6 patients), and the two groups were retrospectively compared.

Results

The VATS group had significantly longer operation time than the D group {359 [328, 387] vs. 220 [155, 235] min, P=0.004}, but the ventilator-free days (VFDs) were significantly extended {24 [21, 24] vs. 10 [0, 17] days, P=0.02}, and the length of intensive care unit stay was significantly shortened {14 [8, 14] vs. 35 [29, 55] days, P=0.01}.

Conclusions

Lavage and drainage using video-assisted thoracoscopic surgery is an effective surgical method for Boerhaave’s syndrome.

Diagnosis of skin and soft tissue infections using near-infrared spectroscopy

Aim

Skin and soft tissue infections are classified into cellulitis and necrotizing fasciitis, which are difficult to distinguish. Necrotizing fasciitis has a poor prognosis and requires immediate intensive care. The diagnostic gold standard is to incise the lesion to determine whether necrosis has reached the fascia. We aimed to show that these infections can be differentiated using near-infrared spectroscopy.

Methods

We describe two cases in an observational study about the utility of near-infrared spectroscopy. Case 1 involved a 77-year-old man with a chief complaint of pain, redness, and swelling in the right lower leg for 1 week. Computed tomography of his legs showed no gas formation. Case 2 involved an 82-year-old man. He visited another hospital because of pain, redness, and swelling in the right thigh. Based on the X-ray examination, necrotizing fasciitis was suspected, and he was transferred to our hospital.

Results

In Case 1, the regional oxygen saturation value was lower on the lesion side (41%) than on the healthy side (55%). We confirmed the depth of invasion by incision, leading to a diagnosis of necrotizing fasciitis. In Case 2, the thigh's regional oxygen saturation was higher on the affected side (76%) than on the healthy side (61%). An incision was made for diagnosis, but the fascia was not necrotized. Thus, we diagnosed cellulitis and provided conservative treatment using antibiotics.

Conclusion

Near-infrared spectroscopy can be utilized to measure tissue blood flow, and it could be useful as a non-invasive diagnostic tool for skin and soft tissue infections.

Safety of arterial catheterization using the distal radial approach in intensive care unit management: A pilot study

BACKGROUND

Arterial catheter (A-line) is essential for managing severely ill patients, and the radial artery is the most common insertion site in the intensive care unit (ICU). However, many accidental removals occur because the insertion site of A-line in the traditional radial approach (TRA) overlaps with the joint flexion. Recent reports have shown no significant difference in the complication rates between coronarography using the distal radial approach (DRA) and that using TRA. However, to date, no report has examined accidental removals of DRA in the ICU. This study aimed to retrospectively evaluate the safety of the DRA A-line in ICU management.

METHODS

This retrospective, descriptive, and observational study enrolled patients who underwent A-line insertion using the DRA at the authors' facility, which is a university hospital with approximately 1100 beds, from January 1, 2019 to August 31, 2019. The participants' clinical data were extracted from their medical records. The primary outcome was the number of accidental removals.

RESULTS

The study included 20 patients with a median age of 70 (interquartile range (IQR): 58.5-77) years: 10 patients with traumas, 6 with cerebral hemorrhages, 2 with gastrointestinal perforations, and 2 with other diagnoses. The number of punctures was 1 in 15 patients, 2 in 4 patients, and 3 in 1 patient. Only 1 patient required ultrasound guidance, whereas 12 patients required the use of guidewires. The median duration after insertion was 3 (IQR 2.5-5.5) days. Accidental removal was noted in only one patient. No other complications were observed during the period from insertion to removal.

CONCLUSIONS

DRA may be a safe option for insertion of a new A-line in the ICU.

Tracheal Tube Obstruction Due to Hemoptysis Associated With Pulmonary Infarction in a Patient With Severe COVID-19 Pneumonia

The incidence of thrombotic complications is extremely high among severe coronavirus disease 2019 (COVID-19) patients in the intensive care unit. Various factors such as a cytokine storm due to an excessive immune response to inflammation, hypoxemia, and disseminated intravascular coagulation are considered predisposing factors for thrombotic complications. A 55-year-old Japanese man intubated eight days previously was referred to our hospital because of a severe COVID-19 pneumonia diagnosis after his pharyngeal swab tested positive for severe acute respiratory syndrome coronavirus 2 using reverse transcription-polymerase chain reaction. The patient continued to remain hypoxic (PaO2/FiO2 ratio <100 mmHg) at the referring hospital. On admission, we initiated veno-venous extracorporeal membrane oxygenation (VV-ECMO). Unfractionated heparin and nafamostat mesylate were used as anticoagulants during VV-ECMO. Despite adequate anticoagulant therapy, he developed pulmonary infarction due to pulmonary embolism followed by hemoptysis. On day 10 following admission, his oxygen saturation dropped from 95% to 88%, with a marked decrease in his ventilator tidal volume, accompanied by an inability to ventilate the patient. Thereafter, we increased the VV-ECMO flow and exchanged his endotracheal tube. The lumen of the removed tracheal tube was found to be occluded by a large-sized blood coagulum. There was no further episode of tube occlusion. The patient was discharged in a walkable state on day 39 following admission. Endotracheal tube obstruction secondary to hemoptysis should be suggested in patients with COVID-19 requiring ventilator support, as they are unable to perform frequent endotracheal tube suctions owing to the risk of infection.

Life-threatening traumatic epistaxis due to massive bleeding into the maxillary sinus

A 77-year-old woman with no medical history fell, and her face was strongly impacted on the ground. On arrival at our hospital, her initial vital signs were stable. She underwent an endoscopy to stop the bleeding. However, identification of the origin of the bleeding failed, and her injury resulted in hemorrhagic shock during the procedure. Head to face contrast computed tomography showed extravasation of contrast media into the maxillary sinus. Transcatheter arterial embolization was performed for the ruptured infraorbital artery branching from the maxillary artery. She recovered from the "shock" state after transcatheter arterial embolization and was admitted to the intensive care unit. There were no complications associated with transcatheter arterial embolization during hospitalization. For this case, early recognition of an active hemorrhage was challenging because the hemorrhage was pooled in the sinuses. Although epistaxis is sometimes fatal, transcatheter arterial embolization can be the first choice for the treatment of life-threatening epistaxis, owing to its safety and effectiveness.

Pancreatitis in a Patient with Severe Coronavirus Disease Pneumonia Treated with Veno-venous Extracorporeal Membrane Oxygenation

Severe coronavirus disease (COVID-19) can induce serious complications, including acute respiratory distress syndrome, septic shock, and acute kidney injury. However, few reports have associated COVID-19 with pancreatitis. We herein report the case of a 55-year-old patient who developed acute pancreatitis associated with severe COVID-19 pneumonia and was successfully treated with veno-venous extracorporeal membrane oxygenation (ECMO). Elevated pancreatic enzymes levels and computed tomography findings led to the diagnosis of acute pancreatitis due to COVID-19. Although we found that severe COVID-19 pneumonia can lead to pancreatitis, the underlying pathophysiology remains unknown.

Intravascular treatment for ruptured facial artery aneurysm via percutaneous cardiopulmonary support device: A case report

Even in cases of cardiac arrest caused by hemorrhagic shock, when reliable control of the bleeding source is possible, ECPR may be an effective treatment option if anticoagulant therapy is well-managed and is withdrawn early.

Novel transcatheter arterial embolization method for hemodynamically unstable pelvic fractures to prevent complications of gluteal necrosis

Purpose

To validate our previously designed transcatheter arterial embolization (TAE) technique for bilateral iliac arteries in unstable pelvic fractures, which is designed to also prevent gluteal necrosis and avoid vasopressors.

Methods

We retrospectively analyzed the data of patients with pelvic fractures who underwent our new TAE procedure to determine the incidence of subsequent gluteal necrosis. We also compared certain variables between patients who underwent TAE before 2005 using a different technique and developed gluteal necrosis and patients who underwent TAE in 2005 and onward using our technique. Gluteal necrosis was confirmed by a radiologist based on imaging findings.

Results

Seventy patients with pelvic fractures who underwent our TAE technique met the inclusion criteria (bilateral iliac arterial embolization and no embolic agent other than a gelatin sponge). Patients’ median age was 47.5 years, 33 were male, and 92.9% (65/70) had unstable fractures. Sixty-eight patients had severe multiple trauma. No patients developed gluteal necrosis following our TAE procedure and the overall survival rate was 82.9% (58/70). We found no statistically significant difference in procedure time between the previous and new technique, although the new procedure tended to be shorter. Furthermore, overall survival did not significantly differ between the groups. Multiple regression analysis revealed that TAE procedure time and external pelvic fracture fixation were independently related to gluteal necrosis.

Conclusions

Our non-selective bilateral iliac arterial embolization procedure involves arresting shock quickly, resulting in no post-procedure gluteal necrosis. The procedure involves cutting the gelatin sponge rather than “pumping” and avoids the use of vasopressors.

Creating a new index to evaluate imbalance in medical demand and supply when disasters occur

Aim

This study examines the use of the medical risk/resource ratio (RRR) and need for medical resources (NMR) as new indicators of the imbalance in medical demand and supply in disasters. These indicators are used to quantify the medical demand–supply imbalance per disaster base hospital, examine the demand–supply imbalance in the region, and verify the need for medical support.

Methods

We calculated the RRR of each disaster base hospital by dividing the revised estimate of the number of patients with the number of empty beds. We calculated the required number of hospital beds as the NMR to restore the RRR of each disaster base hospital to two. The RRR and NMR were combined, and prioritization for medical support was classified into three levels.

Results

The median RRR was 23 (range, 1–101), and the median NMR was 943 (range, 0–2,124). Fifteen hospitals had a medical support priority of 1, five hospitals had a priority of 2, and 13 hospitals had a priority of 3.

Conclusion

The medical demand–supply imbalance and amount of medical support needed can be quantified using RRR and NMR, which allows examination of the priority level for medical support.

A case of intestinal obstruction due to inflammatory changes in the small intestine from alkaline ingestion

Case

Alkaline ingestion frequently causes corrosive esophagitis but rarely causes lower digestive tract injury. In this case, a 79‐year‐old man accidentally drank kitchen detergent. After 3 h, lower abdominal pain occurred and gradually worsened. He was taking a proton pump inhibitor after proximal gastrectomy for gastric cancer. He had local tenderness in the left lower abdomen. Abdominal computed tomography showed expansion of the small intestine, thickening of the intestinal wall, and inflammatory changes. Upper gastrointestinal endoscopy showed no obvious injury to the esophagus or stomach.

Outcome

Conservative treatment with an ileus tube was undertaken for intestinal obstruction caused by alkaline ingestion. There were no complications, such as gastrointestinal perforation, and he was discharged on day 17.

Conclusion

Alkaline ingestion may cause injuries not only to the upper but also to the lower digestive tract in patients who are taking proton pump inhibitors or have had gastrectomy.

Resuscitative endovascular balloon occlusion of the aorta may increase the bleeding of minor thoracic injury in severe multiple trauma patients: a case report

Background

The resuscitative endovascular balloon occlusion of the aorta, because of its efficacy and feasibility, has been widely used in treating patients with severe torso trauma. However, complications developing around the site proximal to the occlusion by resuscitative endovascular balloon occlusion of the aorta have almost never been studied.

Case presentation

A 50-year-old Japanese woman fell from a height of approximately 10 m. At initial arrival, her respiratory rate was 24 breaths/minute, her blood oxygen saturation was 95% under 10 L/minute oxygenation, her pulse rate was 90 beats per minute, and her blood pressure was 180/120 mmHg. Mild lung contusion, hemopneumothorax, unstable pelvic fracture, and retroperitoneal bleeding with extravasation of contrast media were observed in initial computed tomography. As her vital signs had deteriorated during computed tomography, a 7-French aortic occlusion catheter (RESCUE BALLOON®, Tokai Medical Products, Aichi, Japan) was inserted and inflated for aortic occlusion at the first lumbar vertebra level and transcatheter arterial embolization was performed for the pelvic fracture. Her bilateral internal iliac arteries were embolized with a gelatin sponge; however, the embolized sites presented recanalization as coagulopathy appeared. Her bilateral internal iliac arteries were re-embolized by n-butyl-2-cyanoacrylate. The balloon was deflated 18 minutes later. After embolization, repeat computed tomography was performed and a massive hemothorax, which had not been captured on arrival, had appeared in her left pleural cavity. Thoracotomy hemostasis was performed and a hemothorax of approximately 2500 ml was aspirated to search for the source of bleeding. However, clear active bleeding was not captured; resuscitative endovascular balloon occlusion of the aorta may have been the cause of the increased bleeding of the thoracic injury at the proximal site of the aorta occlusion.

Conclusions

It is necessary to note that the use of resuscitative endovascular balloon occlusion of the aorta may increase bleeding in sites proximal to occlusions, even in the case of minor injuries without active bleeding at the initial diagnosis.

Relationship between Stroke Events during Pachinko Play and Prognosis

BACKGROUND

This study investigated whether pachinko play influences the outcome of stroke events, and identified the significant variables affecting outcomes.

METHODS

We reviewed the medical and imaging records of 2075 consecutive patients with stroke from January 2003 through June 2012. The remaining patients were divided into 2 groups, the pachinko players group (PP) and the non-pachinko players group (NPP). Background factors were recorded on admission. Multivariate logistic regression analysis was used to identify the factors significantly correlated with Glasgow Outcome Scale (GOS) score and risk of death at the time of discharge.

RESULTS

The PP group exhibited higher prevalence of hypertension and current smoking compared with the NPP group. However, no difference was found in outcomes between the PP and NPP groups. Multivariate analysis identified the dependent predictive variables for GOS as age (adjusted β = -.18, 95% confidence interval [CI]: -.22 to -.14, P <.001), Glasgow Coma Scale (GCS) score on admission (adjusted β = .64, 95% CI: .60 to .68, P <.001), and history of hypertension (adjusted β = -.06, 95% CI: -.10 to -.02, P = .007). Logistic regression analysis showed that age (odds ratio = 1.02, 95% CI: 1.01 to 1.04, P <.001) and GCS score on admission (odds ratio = .72, 95% CI: .69 to .75, P <.001) were significantly associated with death at the time of discharge.

CONCLUSIONS

Patients with stroke during playing pachinko have higher prevalence of hypertension and higher smoking rate, but pachinko play itself was not a critical factor determining the outcome of patients with stroke in our emergency center.

Complications after implantation of subcutaneous central venous ports (PowerPortⓇ)

BACKGROUND

The aim of our study was revised as follows: to clarify the postoperative complications of multifunctional central venous ports and the risk factors for such complications to promote the safe use of the PowerPort system in the hospital.

METHODS

The study group comprised 132 patients in whom implantable central venous access ports (PowerPort^Ⓡ) were placed in our hospital from March 2014 through December 2015. The approach used for port placement was the subclavian vein in 43 patients (33%), the internal jugular vein in 87 patients (66%), and the femoral vein in 2 patients (1%).

RESULTS

Postoperative complications occurred in 8 patients (6%). The catheter was removed because of infection in 4 patients and catheter kinking in 1 patient. Port extravasation occurred in 3 patients. No patient had catheter pinch-off. The mean operation time was 74 min (range, 32 to 171). No patients had intraoperative bleeding or pneumothorax. Benign disease was a risk factor for postoperative complications (p = 0.009).

CONCLUSION

PowerPort is a multifunctional port. Benign disease was a risk factor for postoperative complications. Because many types of subcutaneously implanted ports are used in our hospital, we had to inform the hospital staff about the functions of PowerPort.

Hybrid treatment combining emergency surgery and intraoperative interventional radiology for severe trauma

OBJECT

To evaluate the efficacy of hybrid treatment combining emergency surgery and intraoperative interventional radiology (IVR) for severe trauma.

PATIENTS AND METHODS

The records of 63 severely injured patients who underwent concurrent emergency surgery and IVR at our emergency centre from 1999 through 2013 were retrospectively reviewed. Mobile digital subtraction angiography device was used in the operating room when performing IVR. Patients undergoing hybrid treatment combining intraoperative IVR and emergency surgery (intraoperative IVR group) were compared with those undergoing IVR in the angiography suite before or after emergency surgery (control group).

RESULTS

Thirteen patients underwent hybrid treatment (intraoperative IVR group). Of these 13 patients, 7 underwent treatment for abdominal organ injuries, and 6 for multiregional injuries. Emergency operations were laparotomy (n=12), thoracotomy (n=1), craniotomy (n=1), and haemostasis of the lower extremities (n=1). Five patients underwent damage control surgery. IVR included transarterial embolisation (n=12), endovascular stent or stent-graft placement (n=2), and embolisation of a portal vein by laparotomy (n=2). The mean ISS was 40. The actual overall survival rate was 85%, and the probability of survival (Ps) was 62%. The control group included 45 patients. Five patients who met exclusion criteria were not included in the control group. Age, ISS, RTS, Ps, pH and base excess on arrival, and blood transfusion volume during operation and IVR did not differ significantly between the groups. Total time during operation and IVR was significantly shorter in the intraoperative IVR group than in the control group (229 [SD 72]min vs. 355 [SD 169]min; p=0.007). The mortality were 15 (95% CI 2-45) % in the intraoperative IVR group vs. 36 (95% CI 22-51) % in the control group.

CONCLUSION

Hybrid treatment combining emergency surgery and intraoperative IVR can be a novel treatment strategy for severe trauma, and it will improve patient outcomes due to reduction of the time for resuscitation.

[FAST for abdominal trauma]

Japanese Association for Acute Medicine and Japanese Association for The Surgery of Trauma developed JATEC (Japan Advanced Trauma Evaluation and Care) course as an off-the-job training to improve trauma care in Japan. In this course, the trauma patients undergo primary survey and secondary survey. FAST (focused assessment with sonography for trauma) is performed to detect hemoperitoneum during primary survey. In this article, we describe FAST in the evaluation and care for abdominal trauma. If the patient becomes hemodynamically unstable during the survey or the intraoperative period, we have to repeat primary survey and FAST.

Thyroid ultrasound findings in children from three Japanese prefectures: Aomori, Yamanashi and Nagasaki

Due to the likelihood of physical and mental health impacts following the unprecedented accident at the Fukushima Dai-ichi Nuclear Power Plant, the Fukushima prefectural government decided to conduct the Fukushima Health Management Survey to assist in the long-term health management of residents. This included thyroid ultrasound examination for all children in Fukushima. For appropriate evaluation of ultrasound screening of the thyroid, it is important to understand its reference data of thyroid findings in children in general. In order to analyze the frequencies of specific thyroid findings, we conducted ultrasound screening of the thyroid by the same procedures as used in Fukushima in 4,365 children, aged 3 to 18 years, from three Japanese prefectures. Overall, thyroid cysts were identified in 56.88% and thyroid nodules in 1.65% of the participants. Thyroid cysts and nodules with a maximum diameter of more than 5 mm were identified in 4.58% and 1.01%, respectively, and age-adjusted prevalences were 3.82% and 0.99%, respectively. Although the prevalence of cysts and nodules varied among the examination areas, no significant differences were observed among the three examination areas in the prevalence of cysts and nodules with a maximum diameter of more than 5 mm. Also, the prevalence of thyroid cysts and nodules, especially those with a maximum diameter of more than 5 mm, significantly increased with age, and showed a female predominance. We also identified ectopic thymus (1.95%), diffuse goiter (1.40%), ultimobranchial body (0.73%), lymph node swelling (0.21%) and thyroid agenesis (0.05%). This is the first ultrasound description of the age-adjusted prevalence of thyroid cysts and nodules, or of the prevalence of abnormalities other than cysts and nodules, such as ectopic thymus, in relation to age, in the general Japanese child population. We contend that this can provide relevant information for the Fukushima Health Management Survey and future population studies.

Ultrasonographic thyroid nodular findings in Japanese children

PURPOSE

The Fukushima Health Management Survey conducted after the accident at the Fukushima Nuclear Power Plant included thyroid ultrasound examinations for children aged ≤18 years at the time of the accident. The purpose of this study was to investigate the frequency of thyroid nodular lesions detected using high-quality ultrasonography in a general population of Japanese children, in whom such data have not been previously characterized.

METHODS

The current study investigated 4,365 free-living children aged between 3 and 18 years in three Japanese prefectures (Aomori, Yamanashi and Nagasaki). The same ultrasonography equipment as that used in the Fukushima Survey was employed to observe thyroid nodular lesions. The following categories of findings were used-'A', further examinations are not necessary; 'B', the presence of thyroid nodules with a diameter of ≥5.1 mm or thyroid cysts with a diameter of ≥20.1 mm; and 'C', immediate further examinations are required. As a sub-category of 'A', 'A1' was defined as the absence of nodules or cysts, and 'A2' was defined as the presence of thyroid nodules with a diameter of ≤5.0 mm or thyroid cysts with a diameter of ≤20.0 mm.

RESULTS

Overall, 4,321 (99 %) of the total participants were classified with a status of 'A' and 44 (1 %) were classified with a status of 'B'. No participants were classified with a status of 'C'. A total of 56.5 % of the total participants was classified with a status of 'A2'. Thyroid nodules were identified in 1.6 % of the total participants and thyroid cysts were identified in 56.9 % of the participants.

CONCLUSION

The current study provides data regarding the actual frequency of ultrasonographically detected thyroid nodular lesions among the Japanese children. These results would be useful for evaluating thyroid findings in Japanese children, although careful interpretation is required.

Emergency/disaster medical support in the restoration project for the Fukushima nuclear power plant accident

The Fukushima Daiichi Nuclear Power Plant (1F) suffered a series of radiation accidents after the Great East Japan Earthquake on 11 March 2011. In a situation where halting or delaying restoration work was thought to translate directly into a very serious risk for the entire country, it was of the utmost importance to strengthen the emergency and disaster medical system in addition to radiation emergency medical care for staff at the frontlines working in an environment that posed a risk of radiation exposure and a large-scale secondary disaster. The Japanese Association for Acute Medicine (JAAM) launched the ‘Emergency Task Force on the Fukushima Nuclear Power Plant Accident’ and sent physicians to the local response headquarters. Thirty-four physicians were dispatched as disaster medical advisors, response guidelines in the event of multitudinous injury victims were created and revised and, along with execution of drills, coordination and advice was given on transport of patients. Forty-nine physicians acted as directing physicians, taking on the tasks of triage, initial treatment and decontamination. A total of 261 patients were attended to by the dispatched physicians. None of the eight patients with external contamination developed acute radiation syndrome. In an environment where the collaboration between organisations in the framework of a vertically bound government and multiple agencies and institutions was certainly not seamless, the participation of the JAAM as the medical academic organisation in the local system presented the opportunity to laterally integrate the physicians affiliated with the respective organisations from the perspective of specialisation.

Individual radiation exposure dose due to support activities at safe shelters in Fukushima Prefecture

Immediately after the accidents in the nuclear power stations in Fukushima on March 11, the Japanese Government ordered the evacuation of the residents within a 20-km radius from the station on March 12, and asked various institutions to monitor the contamination levels of the residents. Hirosaki University, which is located 355 km north of Fukushima City, decided to send support staff to Fukushima. This report summarizes the results of the exposure of 13 individual teams from March 15 to June 20. The support teams surveyed more than 5,000 people during this period. Almost all subjects had external contamination levels of less than 13 kcpm on Geiger-Müller (GM) survey meter, which is categorized as "no contamination level." The 1(st) team showed the highest external exposure dose, but the 4(th) team onward showed no significant change. Subsequently, the internal radiation exposure was measured using a whole body counter that indicated undetectable levels in all staff members. Although the measured external radiation exposure dose cannot have serious biological effects on the health of an individual, a follow-up study of the residents in Fukushima and other regions where the radioactive material has spread will be required for a long time.

Fluorine diffusion assisted by diffusing silicon on the Si(111)-(7x7) surface

The diffusion process of fluorine (F) atoms on the Si(111)-(7x7) surface is investigated using high-temperature scanning tunneling microscopy. The kinetic parameters of F hopping agree well with those of the diffusing silicon (Si) atoms, which implies that of all reaction processes, the Si diffusion serves as the rate-determining one. Deposition of Si on the surface is found to enhance F hopping, which supports the above-mentioned observation. Theory reveals that the replacement of F adsorption sites by diffusing Si atoms is the key process in the diffusion mechanism.

Side-to-side linking of myocardial cells in hypertrophic cardiomyopathy: whole heart microscopic observation with tangential sections

By cross-section or longitudinal section, it is difficult to investigate longitudinal features of myocardial cells in the whole heart. Here, introducing the use of tangential sections to obtain longitudinal aspect of myocardial cells in any part of myocardium, the authors evaluated myocardium in the left ventricle in 10 normal hearts and four hearts with hypertrophic cardiomyopathy (HCM). Tangential sections were obtained by peeling the superficial layer of myocardium. After peeling the whole surface, secondary deep layer was peeled. These procedures were repeated more than five times through the wall. Intercalated discs (ICD) were observed immunohistochemically with anti-N-cadherin and antidesmoplakin. In normal hearts, myocardial cells were cut longitudinally and ran parallel in tangential sections. They linked end-to-end with simple and regular ICD with average lengths of 120-130 microm and average sarcomere numbers of 56-65. In HCM hearts, many myocardial cells were cut almost longitudinally running approximately parallel in tangential sections. Myocardial cells frequently showed side-to-side linking characterized by skewed ICD, indistinct ICD counterparts, and longitudinally arranged ICD. Two young HCM hearts had circle-shaped ICD and vacuole-like structures highlighted by immunostaining for N-cadherin, which were actually extracellular structures comparable with irregular side-to-side linking. It is considered that side-to-side linking of myocardial cells is a characteristic microscopic feature in HCM rather than myocardial disarray.

Changes in the hemodynamic state of patients with acute lethal organophosphate poisoning

The main cause of death due to acute organophosphate poisoning is believed acute respiratory failure caused by peripheral and central cholinergic actions. Today, advances in respiratory management and intensive care make it possible to maintain the respiratory function of patients with organophosphate poisoning, but it is still difficult to maintain their circulation, and some patients with acute organophosphate poisoning die of metabolic acidosis. The present study clarified the hemodynamics of patients with acute lethal organophosphate poisoning. Subjects were patients with severe acute organophosphate poisoning accompanied by hypotension in whom hemodynamics were monitored by pulmonary artery catheterization. In this study, the medical records of these patients were reviewed. Four patients with severe acute organophosphate poisoning accompanied by hypotension and metabolic acidosis died. In 3/4 patients respiration was maintained favorably. In all 4 patients cardiac output was maintained, but systemic vascular resistance index (SVRI) was significantly reduced. Catecholamine administration was ineffective and did not increase SVRI.