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Background: A team approach is essential for effective trauma management. Close collaboration between interventional radiologists and surgeons during the initial management of trauma patients is important for prompt and accurate trauma care. This study aimed to determine whether trauma patients benefit from close collaboration between interventional radiology (IR) and surgical teams during the primary trauma survey., Methods: A retrospective observational study was conducted between 2014 and 2021 at a single institution. Patients were assigned to an embolization group (EG), a surgery group (SG), or a combination group (CG) according to their treatment. The primary and secondary outcomes were survival at hospital discharge compared with the probability of survival (Ps) and the time course of treatment., Results: The analysis included 197 patients, consisting of 135 men and 62 women, with a median age of 56 [IQR, 38-72] years and an injury severity score of 20 [10-29]. The EG, SG, and CG included 114, 48, and 35 patients, respectively. Differences in organ injury patterns were observed between the three groups. In-hospital survival rates in all three groups were higher than the Ps. In particular, the survival rate in the CG was 15.5% higher than the Ps (95% CI: 7.5-23.6%; p < 0.001). In the CG, the median time for starting the initial procedure was 53 [37-79] min and the procedure times for IR and surgery were 48 [29-72] min and 63 [35-94] min, respectively. Those times were significantly shorter among three groups., Conclusion: Close collaboration between IR and surgical teams, including the primary survey, improves the survival of severe trauma patients who require both IR procedures and surgeries by improving appropriate treatment selection and reducing the time process., (© 2024. The Author(s).)

Introduction Blast injuries in modern society often occur owing to terrorist attacks in confined spaces, particularly in urban settings, indoors, and in vehicles, leading to significant damage. Therefore, it is important to focus on blast injuries in confined spaces rather than in conventional open-field experiments. Materials and methods We used an air-driven shock wave generator (blast tube) established indoors in 2017 and conducted basic research to potentially save the lives of patients with blast injuries. Under general anesthesia, pigs were divided into with body armor (BA) and without BA groups. The pigs were fixed in the measurement chamber with their dorsal chest directly exposed to the shock wave. The driving pressure was set at 3.0 MPa to achieve a mortality rate of approximately 50%. A generated shock wave was directly applied to the pigs. Comparisons were made between the groups with respect to cardiac arrest and survival, as well as apnea, bradycardia, and hypotension, which are the triad of blast lung. Autopsies were performed to confirm the extent of the organ damage. Statistical analysis was performed using Fisher's exact test, and statistical significance was set at p <0.05. The animal experimentation was conducted according to the protocol reviewed and approved by the Animal Ethics Committee of the National Defense Medical College Hospital (approval number 19041). Results Eight pigs were assigned to the BA group and seven pigs to the non-BA group. In the non-BA group, apnea was observed in four of seven cases, three of which resulted in death. None of the eight pigs in the BA group had respiratory arrest; notably, all survived. Hypotension was observed in some pigs in each group; however, there were no cases of bradycardia in either group. Statistical analysis showed that wearing BA significantly reduced the occurrence of respiratory and cardiac arrest ( p =0.026) but not survival ( p =0.077). No significant differences were found in other vital signs. Conclusions Wearing BA with adequate neck and chest protection reduced mortality and it was effective to reduce cardiac and respiratory arrest against shock wave exposure. Mortality from shock wave injury appears to be associated with respiratory arrest, and the avoidance of respiratory arrest may lead to survival., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Kiriu et al.)

Rationale: Cardiac tamponade, a condition in which the heart is compressed by pericardial fluid retention, is easy to diagnose; however, identifying the cause may be challenging since it can be caused by a variety of conditions, including trauma and pericardial disease., Patient Concerns: A 22-year-old man was admitted to the intensive care unit with respiratory failure. He had previously received allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia and developed chronic graft-versus-host disease (cGvHD) that was treated with a corticosteroid. At this time, he developed bilateral femur head necrosis and underwent surgery after discontinuation of the corticosteroid but developed respiratory failure postoperatively. The initial diagnosis was cardiac failure, which temporarily improved with treatment; however, eosinophilia and pericardial effusions became prominent., Diagnoses: Pericardial effusion gradually progressed, resulting in cardiac tamponade., Interventions: Pericardiocentesis was performed. Eosinophilia could be the cause of cardiac tamponade; thus, corticosteroid was administered., Outcomes: Pericardial effusion improved remarkably after corticosteroid administration. The corticosteroid dose was gradually tapered, and the patient was discharged., Lessons: This case presented with cardiac tamponade associated with eosinophilia, probably owing to graft-versus-host disease. This is an unusual condition associated with a history of hematologic neoplasms; although evaluation is challenging, appropriate assessment could help save the patient's life., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Competing Interests: There are no conflicts of interest.

Air embolism is generally considered the most common cause of death within 1 h of a blast injury. Shock lung, respiratory arrest, and circulatory failure caused by vagal reflexes contribute to fatal injuries that lead to immediate death; however, informative mechanistic data are insufficient. Here we used a laser-induced shock wave (LISW) to determine the mechanism of acute fatalities associated with blast injuries. We applied the LISW to the forehead, upper neck, and thoracic dorsum of mice and examined their vital signs. Moreover, the LISW method is well suited for creating site-specific damage. Here we show that only mice with upper neck exposure, without damage elsewhere, died more frequently compared with the other injured groups. The peripheral oxygen saturation (SpO 2 ) of the former mice significantly decreased for < 1 min [p < 0.05] but improved within 3 min. The LISW exposure to the upper neck region was the most lethal factor, affecting the respiratory function. Protecting the upper neck region may reduce fatalities that are related to blast injuries., (© 2022. The Author(s).)

Purpose: The purpose of this study was to examine the survival benefits of a workflow in which an interventional radiology (IR) team participates in a primary trauma survey on patients with hemodynamically unstable trauma., Materials and Methods: A retrospective observational study was conducted between 2012 and 2019 at a single institution. Patients who underwent an IR procedure as the initial hemostasis were assigned to the hemodynamically stable group (HSG) or hemodynamically unstable group (HUG). The primary and secondary outcomes were survival at hospital discharge compared with the probability of survival (Ps) and the time course., Results: A total of 160 patients (100 men, 60 women; median age, 57.5 years [interquartile range (IQR): 31.5-72 years]) with an injury severity score of 24 (IQR: 13.75-34) were included. A total of 125 patients were included in the HSG group and 35 patients in the HUG group. The observational survival rate was significantly greater than the Ps rate by 4.9% (95% confidence interval [CI]: 1.6-8.4%; P = 0.005) in HSG and by 24.6% in HUG (95% CI: 16.9-32.3%; P < 0.001). The observational survival rate was significantly greater than Ps in HUG than in HSG (P < 0.001). The median time to initiate IR procedures and the median procedure time in HUG were 54 min [IQR: 45-66 min] and 48 min [IQR: 30-85 min], respectively; both were significantly shorter than those in the HSG., Conclusion: A trauma workflow utilizing an IR team in a primary survey is associated with improved survival of patients with hemodynamically unstable trauma when compared with Ps with a shorter time course., Competing Interests: Disclosure of interest The authors declare that they have no competing interest., (Copyright © 2021 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

Aim: The mortality rates among elderly patients with open abdomen (OA) are high, and pre-existing comorbidities could affect the outcomes. However, long-term prognosis remains uncertain. We examined long-term outcomes in elderly patients with OA, focusing on physical functional status., Methods: We undertook a retrospective cohort study between 2007 and 2017 at a single institution. Patients with OA who were aged ≥65 years were categorized into two groups: "good preoperative functional status" group (GFG) and "poor preoperative functional status" group (PFG). The GFG was defined as Eastern Cooperative Oncology Group/World Health Organization performance status (PS) 0-1, whereas PFG was defined as PS 2-4. The primary outcomes were survival and PS 2 years following the initial surgery., Results: Of the 53 participants, 38 and 15 were assigned to the GFG and PFG, respectively. The PFG (median age, 81 years) was older than the GFG (median age, 75.5 years; P  = 0.040). The 2-year survival rate was 39.5% in GFG and 6.7% in PFG, and Kaplan-Meier analysis showed significant difference ( P  = 0.022). Among all patients, the PS at 2 years was worse than that at discharge ( P  = 0.007). Preoperative PS was correlated with 2-year survival ( P  = 0.003), whereas age and pre-existing comorbidities were not., Conclusion: The long-term outcomes of elderly patients with OA are affected by the preoperative physical functional status. Functional status deteriorates in a time-dependent manner. Therefore, surgery requiring OA must be carefully considered for elderly patients with PS 2 or higher., Competing Interests: Approval of the research protocol: This study was approved by the ethics committee of the National Health Organization Disaster Medical Center and it conforms to the provisions of the Declaration of Helsinki. Approval No. 2020‐8. Informed consent: The ethics committee did not require informed consent from patients for observational studies using anonymous data such as those used in this study. Registry and the registration no. of the study/trial: N/A. Animal studies: N/A. Conflict of interest: None., (© 2020 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Background: Renal artery stenting is performed for renal artery injuries to preserve renal function and prevent renovascular hypertension. However, its indications are controversial and its long-term prognosis remains unknown. Here, we evaluate the characteristics and long-term outcomes of renal artery stenting for blunt renal artery injuries at our institution., Methods: We retrospectively reviewed patients with blunt renal artery injuries who had been treated with stenting over a 12-year period at our institution. Five patients (three men and two women) were included., Results: Trauma resulted from falls in three patients and motor vehicle accidents in two. All patients had experienced multiple injuries (median injury severity score, 24 [range, 16-48]; median revised trauma score, 5.9672 [4.0936-7.8408]; and median probability of survival, 0.689 [0.533-0.980]). All renal artery injuries involved stenosis because of traumatic arterial dissection or intimal tear; no cases of total occlusion were observed. No complications due to the intervention itself were observed. Although two patients developed reversible acute renal failure, none required long-term hemodialysis. One patient with renovascular hypertension was treated with antihypertensive agents for a month and subsequently became normotensive without further medication. All patients underwent postoperative computed tomography, which revealed no stent occlusion or renal atrophy. Renal scintigraphy for three patients demonstrated preserved differential renal function. All five patients survived., Conclusions: Renal artery stenting for hemodynamically stable blunt renal artery injuries with stenosis is suggested to be safe and helps in avoiding long-term hemodialysis and renovascular hypertension.

Objectives: The inferior vena cava (IVC) diameter is associated with shock and increased mortality in trauma patients. However, there are no reports examining the association between the IVC diameter and massive transfusion (MT) requirements in trauma patients. The aim of this study was to evaluate the association between IVC diameter and MT requirements in patients with blunt trauma., Methods: We retrospectively reviewed all patients who were consecutively hospitalized with blunt trauma (Injury Severity Score [ISS] ≥16) between from November 1, 2011 to March 30, 2016. Univariate and multivariate analyzes were performed to identify the independent predictors of MT (defined as >10units of red cell concentrate transfusions within 24h of admission). Receiver operating characteristic curve and the area under the curve (AUC) were estimated., Results: Of the 222 patients included in this study, MT occurred in 22.5% patients. On multiple regression analysis, IVC diameter [Odds ratio (OR), 0.88; 95% confidence interval (CI), 0.80-0.96; p<0.01], fibrin degradation product (FDP; OR, 1.01; 95% CI, 1.00-1.01; p<0.01), and fibrinogen level (OR, 0.99; 95% CI, 0.98-1.00; p<0.01) were strong predictors of MT. IVC diameter demonstrated moderate accuracy (AUC, 0.74; cutoff level, 13.0mm; sensitivity, 67%; specificity, 73%). Combined cutoff levels of FDP <80.5μg/ml, fibrinogen ≥165mg/dl, and IVC diameter ≥13mm could also determine how unnecessary a MT was with 100% accuracy., Conclusions: Initial IVC diameter is a predictor of MT in blunt trauma patients., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: Several reports have compared the efficacy of linezolid (LZD) in Methicillin-resistant Staphylococcus aureus (MRSA) infections with that of vancomycin (VCM); however, these two antibiotics for the treatment of nosocomial MRSA pneumonia in elderly patients has not been well evaluated. The purpose of this study is to evaluate the efficacy and safety of LZD compared with VCM for the treatment of elderly patients with nosocomial MRSA pneumonia in a retrospective chart review of a cohort., Methods: We included 28 consecutive patients aged ≥65years hospitalized with a confirmed diagnosis of MRSA pneumonia and treated with LZD (n=11) or VCM (n=17) between November 2010 and May 2015. We collected patient, disease, and laboratory data. The primary outcome was 30-day mortality. The secondary outcomes were the sequential organ failure assessment (SOFA) total, respiratory, renal, coagulation, hepatic, cardiovascular, and central nervous system scores on days 1, 3, 7, and 14., Results: There were no significant differences between the two groups with regard to baseline characteristics. The 30-day mortality rate was significantly lower in the LZD group than in the VCM group (0% vs. 41%, P=.02). The SOFA total score on days 3, 7, and 14 were significantly lower those at baseline in the LZD group (P<.05). The SOFA respiratory score on days 14 was also significantly lower than baseline in the LZD group (P<.05)., Conclusion: LZD may be more efficacious than VCM for treating elderly patients with nosocomial MRSA pneumonia., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: This study aimed to determine whether severe acidemia (pH <7.2) on arrival at the emergency department (ED) is a predictive factor for neurologic outcomes of post-cardiac arrest patients treated with targeted temperature management (TTM)., Materials and Methods: Data in the National Disaster Medical Center, a tertiary care hospital, were used to perform a case-control study on post-cardiac arrest patients treated with TTM from January 2013 to April 2015. The case group comprised patients with good neurologic outcomes (cerebral performance categories 1 and 2), whereas the control group comprised patients with poor neurologic outcomes (cerebral performance categories 3-5). Exposure was defined as arterial pH less than 7.2 on arrival at the ED., Results: We identified 32 patients matching our criteria, of which 13 had good outcomes and 19 poor outcomes. Arterial pH on arrival was not significantly associated with neurologic outcomes (P = .47; odds ratio, 0.5; 95% confidence interval, 0.09-2.61). In 24 patients with cardiogenic causes of cardiac arrest, pH on arrival was not significantly associated with neurologic outcomes (P = .68; odds ratio, 0.5; 95% confidence interval, 0.09-2.73) after matched-pair analysis by age, sex, and presence of light reflex., Conclusion: Severe acidemia on arrival at the ED is not a significant predictive factor for neurologic outcomes in post-cardiac arrest patients treated with TTM, particularly in patients with cardiogenic causes of cardiac arrest. These results suggest that treatment should not be withheld in post-cardiac arrest patients with severe acidemia., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objectives: The mortality of severe sepsis has markedly decreased since the implementation of the Surviving Sepsis Campaign guidelines. The next logical step is to examine the necessity of individualized management guidelines for targeted therapy against specific bacteria. Streptococcus pneumoniae is the leading cause of community-acquired severe sepsis; however, little is known regarding the prognostic factors in adult patients with S pneumoniae sepsis. We aimed to identify prognostic factors in patients with S pneumoniae sepsis and to explore a subgroup of patients at high risk for death with detailed Sequential Organ Failure Assessment (SOFA) score analysis., Methods: We retrospectively reviewed the records of patients with S pneumoniae infection treated between 1st January 2006 and 31st July 2012. We identified prognostic factors for 28-day mortality using univariate and multivariate logistic regression models., Results: Of 171 patients (median age, 72 years) with S pneumoniae infection who were included in this study, the 28-day mortality was 17% (29/171). The SOFA score (odds ratio, 2.25; 95% confidence interval, 1.60-3.18; P < .001) and bacteremia (odds ratio, 19.0; 95% confidence interval, 4.06-90.20; P < .001) were identified as prognostic factors for the 28-day mortality. In a subgroup analysis with a cutoff value of the SOFA score determined by receiver operating characteristic analysis, patients with bacteremia and a SOFA score of at least 7 had a significantly higher mortality than did patients without bacteremia and a SOFA score lower than 7 (84% vs 0%, respectively)., Conclusions: Bacteremia and a SOFA score at least 7 were independent prognostic factors of poor outcome in S pneumoniae sepsis., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Snake bites are life-threatening injuries that can require intensive care. The diagnosis and treatment of venomous snake bites is sometimes difficult for clinicians because sufficient information has not been provided in clinical practice. Here we review the literature to present the proper management of bites by mamushi, habu, and yamakagashi snakes, which widely inhabit Japan and other Asian countries. No definite diagnostic markers or kits are available for clinical practice; therefore, definitive diagnosis of snake-venom poisoning requires positive identification of the snake and observation of the clinical manifestations of envenomation. Mamushi (Gloydius blomhoffii) bites cause swelling and pain that spreads gradually from the bite site. The platelet count gradually decreases due to the platelet aggregation activity of the venom and can decrease to <100,000/mm(3). If the venom gets directly injected into the blood vessel, the platelet count rapidly decreases to <10,000/mm(3) within 1 h after the bite. Habu (Protobothrops flavoviridis) bites result in swelling within 30 min. Severe cases manifest not only local signs but also general symptoms such as vomiting, cyanosis, loss of consciousness, and hypotension. Yamakagashi (Rhabdophis tigrinus) bites induce life-threatening hemorrhagic symptoms and severe disseminated intravascular coagulation with a fibrinolytic phenotype, resulting in hypofibrinogenemia and increased levels of fibrinogen degradation products. Previously recommended first-aid measures such as tourniquets, incision, and suction are strongly discouraged. Once airway, breathing, and circulation have been established, a rapid, detailed history should be obtained. If a snake bite is suspected, hospital admission should be considered for further follow-up. All venomous snake bites can be effectively treated with antivenom. Side effects of antivenom should be prevented by sufficient preparation. Approved antivenoms for mamushi and habu are available. Yamakagashi antivenom is used as an off-label drug in Japan, requiring clinicians to join a clinical research group for its use in clinical practice.

Objectives: There is no consensus on whether mechanical ventilation should be initiated for advanced age with community-acquired pneumonia (CAP). This study investigated the effects of age on the outcomes of mechanical ventilation in the emergency department (ED) for advanced age with CAP., Methods: We retrospectively investigated the medical records of advanced age (age, ≥65 years) with CAP who required mechanical ventilation in the ED of our hospital between January 2006 and December 2012. The patients were divided into 65 to 74, 75 to 84, and 85 years or older age groups. The following outcomes were measured: number of patients weaned from mechanical ventilation, in-hospital mortality, ventilator-free days, and intensive care unit days. Multiple logistic regression analysis was used to identify risk factors associated with mortality and weaning from mechanical ventilation., Results: Seventy-one patients (mean age, 79.5 years) were included. The overall in-hospital mortality rate was 43.7%. No significant differences were observed among the 3 groups with regard to weaning from mechanical ventilation (P=.59), in-hospital mortality (P=.90), ventilator-free days (P=.83), or intensive care unit days (P=.12). Age was not significantly associated with weaning from mechanical ventilation or in-hospital mortality among advanced age. Diabetes mellitus was an independent factor for weaning from mechanical ventilation (P=.048) and was relatively associated with mortality (P=.051)., Conclusions: Age, in itself, may not be a factor limiting the initiation of mechanical ventilation in the ED in advanced age with CAP. Further studies should determine appropriate indications for mechanical ventilation in the ED for these patients., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Redback spiders (Latrodectus hasselti) (RBSs) are venomous spiders that have recently spread to Asia from Australia. Since the first case report in 1997 (Osaka), RBS bites have been a clinical and administrative issue in Japan; however, the clinical characteristics and effective treatment of RBS bites, particularly outside Australia remains unclear. This study aimed to elucidate the clinical characteristics of RBS bites and to clarify the effectiveness of the administration of antivenom for treatment., Methods: We performed a retrospective questionnaire survey from January 2009 to December 2013 to determine the following: patient characteristics, effect of antivenom treatment, and outcomes. To clarify the characteristics of patients who develop systemic symptoms, we compared patients with localized symptoms and those with systemic symptoms. We also examined the efficacy and adverse effects in cases administered antivenom., Results: Over the 5-year study period, 28 patients were identified from 10 hospitals. Of these, 39.3% were male and the median age was 32 years. Bites most commonly occurred on the hand, followed by the forearm. Over 80% of patients developed local pain and erythema, and 35.7% (10 patients) developed systemic symptoms. Baseline characteristics, vital signs, laboratory data, treatment-related factors, and outcome were not significantly different between the localized and systemic symptoms groups. Six patients with systemic symptoms received antivenom, of whom four experienced symptom relief following antivenom administration. Premedication with an antihistamine or epinephrine to prevent the adverse effects of antivenom was administered in four patients, which resulted in no anaphylaxis. One out of two patients who did not receive premedication developed a mild allergic reaction after antivenom administration that subsided without treatment., Conclusions: Approximately one third of cases developed systemic symptoms, and antivenom was administered effectively and safely in severe cases. Further research is required to identify clinically applicable indications for antivenom use.

We report a case of absolute vitamin K deficiency (VKD) diagnosed by measuring serum VK levels in an elderly woman undergoing warfarin therapy. A 78-year-old woman was admitted to our hospital because of dyspnea and sore throat diagnosed as pharyngitis 1 week before admission. On admission, the sore throat had exacerbated and dyspnea developed. She had history of atrial fibrillation, for which warfarin 1.5 mg/d was started approximately 10 years prior and her international normalized ratio (INR) had been maintained at an acceptable therapeutic level. Blood results revealed unmeasurable INR and abnormally prolonged activated partial thromboplastin time (APTT). She was diagnosed with adenoiditis and warfarin-related coagulopathy and administered intravenous VK (20 mg) and fresh frozen plasma (FFP; 4 U), which improved INR and APTT. Since the coagulopathy responded to intravenous VK administration, the patient was clinically diagnosed with warfarin-related relative VKD. Approximately 1 month later, she returned with complaints of sore throat. Blood results indicated abnormal INR (7.22) and APTT (N80.0 s). She was diagnosed with recurrent adenoiditis and VK deficient coagulopathy. The patient’s serum VK levels were low (VK1 level, 0.13 ng/mL; VK2 levels, 0.85 ng/mL). Initial treatment of VK (20 mg) and FFP followed by intravenous VK (20 mg/d) for 6 days, her symptoms dissipated. Warfarin was suspected to have caused absolute VKD. Severe coagulopathy in patients undergoing warfarin therapy is primarily caused by, relative VKD. However, the possibility of warfarin-related absolute VKD should be suspected when INRis not sufficiently improved by intravenous VK administration.

Intussusception is a rare condition in adults, representing only 1% of all bowel obstructions. In adult cases, operative explorations are recommended to treat the bowel obstruction and to diagnose underlying diseases. The objective of the current case report was to describe the successful treatment of ileocolic intussusception with air enema reduction in an adult patient. A previously healthy 21-year-old woman had a 20-hour history of colicky abdominal pain and vomiting and was diagnosed as having idiopathic ileocolic intussusception by abdominal computed tomography. We treated the patient with air enema reduction under fluoroscopic guidance instead of an operative procedure. She received oxygen and intravenous midazolam to provide some degree of pain relief. Air was carefully pumped manually into the rectum, and the air pressure was monitored with a manometer. Because of air leakage from the rectum through the void to the outside the body, we continued to provide air to maintain the air pressure between 40 and 60 mm Hg. Three minutes after initiation of the air enema, when the patient experienced increasing abdominal pain and vomiting, the pressure was temporarily increased to greater than 100 mm Hg, and the air reached the terminal ileum. We considered the reduction successful and confirmed it with an abdominal ultrasound examination. We believe that air enema reduction is effective for treating idiopathic intussusception within 24 hours of symptom onset in young, previously healthy adult patients.

Background: Although non-thyroidal illness syndrome (NTIS) is considered a negative prognostic factor, the alterations in free triiodothyronine (fT3) levels in trauma patients requiring massive transfusion have not been reported., Methods: A prospective observational study comparing 2 groups of trauma patients was conducted. Group M comprised trauma patients requiring massive transfusions (>10 units of packed red blood cells) within 24 hours of emergency admission. Group C comprised patients with an injury severity score >9 but not requiring massive transfusions. Levels of fT3, free thyroxine (fT4), and thyroid-stimulating hormone (TSH) were evaluated on admission and on days 1, 2, and 7 after admission. The clinical backgrounds and variables measured including total transfusion amounts were compared and the inter-group prognosis was evaluated. Results are presented as mean±standard deviation., Results: Nineteen patients were enrolled in each group. In both groups, 32 were men, and the mean age was 50±24 years. In group C one patient died from respiratory failure. The initial fT3 levels in group M (1.95±0.37 pg/mL) were significantly lower than those in group C (2.49±0.72 pg/mL; P<0.01) and remained low until 1 week after admission. Initial inter-group fT4 and TSH levels were not significantly different. TSH levels at 1 week (1.99±1.64 µIU/mL) were higher than at admission (1.48±0.5 µIU/mL) in group C (P<0.05)., Conclusion: Typical NTIS was observed in trauma patients requiring massive transfusions. When initial resuscitation achieved circulatory stabilization, prognosis was not strongly associated with NTIS.

Background: In approximately 20% of patients, necrotizing pancreatitis is complicated with severe acute pancreatitis, with high morbidity and mortality rates. Minimally invasive step-up approach is both safe and effective, but sometimes requires multiple access sites., Methods: A 62-year-old woman was admitted with diabetic ketoacidosis, and initial computed tomography (CT) revealed no evidence of acute pancreatitis. She was clinically improved with insulin therapy, fluid administration, and electrolyte replacement. However, on the 14(th) day of admission, she developed a high-grade fever, and CT demonstrated evidence of acute necrotizing pancreatitis with a large collection of peripancreatic fluid. Percutaneous transgastric drainage was performed and a 14 French gauge (Fr) pigtail catheter was placed 1 week later, which drained copious pus. Because of persistent high-grade fever and poor clinical improvement, multiple 8 and 10 Fr pigtail catheters were placed via the initial drainage route, allowing the safe and effective drainage of the extensive necrotic tissue that was occupying the bilateral anterior pararenal space., Results: After drainage, the patient recovered well and the last catheter was removed on day 123 of admission., Conclusions: Multiple percutaneous drainage requires both careful judgment and specialist skills. The perforation of the colon and small bowel as well as the injury of the kidney and major vessels can occur. The current technique appears to be safe and minimally invasive compared with other drainage methods in patients with extended, infected necrotic pancreatic pseudocysts.

Introduction: Impalement injuries with multiple objects are rare and their management is complex. Rapid confirmation of vascular injuries requiring urgent endovascular or surgical management and accurate location of multiple objects are essential for efficient preoperative management. We report the case of a patient with septic shock secondary to a perforated rectum caused by an impalement injury with three reinforced aluminum bars., Case Presentation: A 58-year-old Asian man fell from the roof of a house and received gluteal impalement injuries from three reinforced aluminum bars. A physical examination showed paralysis of his left leg and no active bleeding from the insertion sites of the impaled objects. Multidetector computed tomography angiography confirmed the location of the aluminum bars, which had spared his small bowel, ureter and major vessels. No significant extravasation was observed. Two bars were successfully removed under general anesthesia in the lithotomy position. The third bar, which pierced his rectum, passed through the left side of his vertebrae and extended up to the superior side of his left kidney, was removed following a celiotomy. After removal of this bar, bleeding from the anterior side of the sacral bone was controlled by gauze packing. After surgery, our patient was admitted to our intensive care unit under endotracheal intubation and mechanical ventilation. Dopamine therapy was initiated, followed by direct hemoperfusion with polymyxin B-immobilized fiber (PMX-DHP) for septic shock secondary to a perforated rectum. This treatment was continued for two hours, resulting in stabilization of our patient's hemodynamic condition. Daily peritoneal lavage was performed for several days, along with a colostomy. Although there were motor and sensory disturbances below the L3 level, there were no complications. On day 191 of admission, our patient was discharged with motor and sensory disturbances below the L3 level. He now uses a wheelchair and depends on assistance from others for daily activities., Conclusion: Preoperative multidetector computed tomography angiography confirmed the anatomic location of the aluminum bars and the absence of extravasation; these findings aided in treatment planning. Our patient was successfully managed by colostomy and aggressive surgical and critical care including direct hemoperfusion with polymyxin B-immobilized fiber, and developed no intra-abdominal infection or meningitis.

Invasive pneumococcal disease (IPD) has a high mortality. Although preventive strategies including vaccination have been established for children, less attention has been devoted to pregnant and postnatal women and to mothers caring for their infants. As a significant number of women have either undergone splenectomy or are in a hyposplenic state and have not received adequate pneumococcal vaccinations, they can potentially develop overwhelming postsplenectomy infections. A 34-year-old woman with an 8-month-old baby, who underwent splenectomy at the age of 10 for benign pancreatic tumor, presented with fever and petechial eruption. Despite extensive treatment, she died 17 h after admission. A 40-year-old woman with a 11-month-old baby, who underwent splenectomy at 2 years of age for hemolytic anemia, was admitted for septic shock and disseminated intravascular coagulation. Despite extensive treatment, she died 2 h after admission. Blood cultures from both women were positive for Streptococcus pneumoniae and neither of them had been vaccinated against the bacterium. IPD rapidly progressed and developed to multiple organ dysfunction syndromes in mothers caring for their infants, particularly those who had undergone splenectomy or were in a hyposplenic state. Thus, routine pneumococcal vaccination is recommended for pregnant women. In addition, we suggest a thorough medical interview and checkup for splenectomy or hyposplenism in prenatal women.

Management of cardiac arrest due to severe diabetic ketoacidosis (DKA) using bicarbonate therapy and extracorporeal life support (ECLS) remains controversial. We report a case of a 24-year-old man with insulin-dependent type 1 diabetes mellitus who survived without any neurologic complications after prolonged ECLS (including fluid resuscitation and insulin but no aggressive bicarbonate) for cardiac arrest due to severe DKA. In post-DKA cardiac arrest, insulin and fluid resuscitation is the mainstay of treatment, but ECLS should be considered when prolonged cardiac arrest is expected.

To our knowledge, no one has conducted a multi-center trial evaluating the efficacy of antivenom and cepharanthine (CEP) for the treatment of mamushi (Gloydius blomhoffii) bites. Thus, we conducted a large-scale survey among tertiary care centers in Japan from November 2009 to October 2010 to evaluate the efficacy of antivenom and CEP for the treatment of mamushi bites. We divided the therapeutic interventions received by patients into 4 groups: CEP, antivenom, both CEP and antivenom, and neither CEP nor antivenom. We collected data on age, sex, comorbidities, laboratory measurements, length of hospital stay, and grades of mamushi bites (indication of bite severity ranged from I [mild] to V [severe]). We sent questionnaires to 219 tertiary care centers, of which 114 (52.1%) returned completed questionnaires. Two hundred and thirty-four cases of mamushi bites were reported. Among the severe cases (grades of mamushi bites III, IV, and V), patients administered antivenom had a significantly shorter length of hospital stay than those administered CEP (P = 0.024). In contrast, there was no significant difference in the length of hospital stay between mild cases (grades of mamushi bites I and II) (P = 0.77). Our results show that antivenom is effective in reducing the length of hospital stay in patients with severe mamushi bites.

A 51-year-old man was brought to the emergency room because of a sudden onset of severe dysponea. On presentation, his blood pressure was 94/55 mm Hg. Oxygen saturation was 86% while he was receiving 10 l/min oxygen through a non-rebreather mask. On physical examination, no jugular venous distention was noted, but breath sounds over the left lung were diminished. A bedside chest radiograph showed left tension pneumothorax, for which urgent needle decompression followed by chest thoracostomy was performed. Ventricular tachycardia developed, but a biphasic shock at 120 J immediately restored normal sinus rhythm. His vital signs, however, did not improve. A CT scan of the chest showed type A aortic dissection with bullae in the upper lobe of the left lung. He had an emergency operation for distal aortic arch displacement and was discharged on the 37th day of hospitalisation.

We report the results of the first large-scale questionnaire surveillance on the clinical use of pit viper antivenom in tertiary care centers in Japan. The questionnaire surveillance was conducted over a period of 3 years (April 2006 to March 2009). Completed questionnaires were received from the tertiary care centers of 108 (49.3%) medical institutions. In that period, 574 cases of pit viper bites, including 2 severe cases, were reported. Antivenom was administered in 44% of the cases of pit viper bites, and of these cases, 2.4% had adverse reactions but no severe symptoms. Approximately half of the clinicians indicated that antivenom was effective. Antivenom was recognized to be safe; however, the remarkable finding was that although the severity of treated cases was unclear, some clinicians reported using cepharanthine as the first choice of treatment for pit viper bites.

Introduction: There have been few reports of cases where the ingestion of colchicine was utilized as a method of suicide and accordingly, its effect on the human body is not fully understood. It has been reported that all individuals who ingested more than 0.8 mg/kg of colchicine died of shock within 72 hours., Case Report: A 46-year-old man was sent to the hospital after ingesting a lethal amount of colchicine (total dose, 71 mg; body weight, about 70 kg) in a suicide attempt. On admission, his vital signs were stable and physical examination was unremarkable. Laboratory findings were normal. He was admitted to the intensive care unit, and severe diarrhea and vomiting commenced approximately 4 hours after ingestion, accompanied by electrolyte disturbance, coagulopathy and renal dysfunction. Bone marrow suppression, bradycardia, alopecia and myoneuropathy also occurred, these findings being the typical symptoms of colchicine poisoning. The symptoms were almost resolved after about 1 week and he was discharged on the 19th day of admission., Conclusion: Immediate and precise care for colchicine poisoning successfully saved the patient's life.

The severity of alkaline esophagitis due to sodium hypochlorite ingestion is variable and the findings of endoscope within 48 hours of ingestion are reported to be associated with its prognosis. We report a good recovery case of grade 2B of alkaline esophagitis, which was treated with close observation. The patient was 59-year old man. He was found lying on the bed by his wife, after drinking bactericidal agents (Jianok) and kitchen cleaner (Magiclean) for suicide attempt. After his trachea was intubated, he underwent upper gastrointestinal scope, which displayed circumferential ulcers at the lower esophagus. He was diagnosed as having a Grade 2B alkaline esophagitis, which was associated with a higher probability of stricture or perforation. On the 14th day of the admission, the 2nd endoscope was performed and no esophageal strictures were detected. He was extubated and started oral feeding on the 15th day. After that, his hospital course was uneventful and was discharged on the 18th day. 6 months have passed since he left hospital. No esophageal strictures were detected so far.