In nearly 40% of heart failure patients, left ventricular ejection fraction is not impaired. Majority of them develop heart failure due to impaired left ventricular diastolic function. This disease has some clinical characteristics including elderly people, female dominancy, and quick response to diuretic therapy. Hypertension, diabetes, and obesity are more closely associated with diastolic heart failure. Recent investigation shows that prognosis of this kind of heart failure is as worse as heart failure with systolic dysfunction. Since treatment for this condition has not been established, conventional treatments for systolic heart failure are applied. The incidence of diastolic heart failure is increasing according to the increment of elderly population. Further investigation is needed to elucidate the pathophysiology and clinical management of diastolic heart failure.

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Unmethylated CpG motifs frequently appear in bacterial DNA and induce immune responses through Toll-like receptor 9 (TLR9) pathway. Noble class of suppressive oligodeoxynucleotide (suppressive ODN) inhibits the immune activation by CpG DNAs. Interleukin-12 (IL-12) has several biological activities and modulates inflammatory responses in the lungs. Objectives: The objective of this study was to show that bacterial DNA induces IL-12 expression through TLR9 pathway in vivo. Methods: To test IL-12 production by bacterial DNA in the lungs, bacterial DNA (E. coli DNA) or mammalian DNA (calf thymus DNA) was intratracheally instilled into the murine lungs. 16 hours after instillation, bronchoalveolar lavage (BAL) was performed. Recovered BAL fluid were stored and examined for IL-12 concentration by ELISA. Results: E. coli DNA but not calf thymus DNA induced IL-12 production. Oligodeoxynucleotide containing unmethylated CpG motifs (CpG ODN) also induced IL-12 production. Neutral ODN which does not contain CpG motif did not induce IL-12 production. Suppressive ODN significantly inhibited IL-12 production by E. coli DNA and CpG ODN. Conclusions: This in vivo study demonstrated that bacterial DNA induces IL-12 production through TLR9-dependent pathway.

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Background: The diagnostic criteria of acute-phase disseminated intravascular coagulation (DIC) were reported by the Japanese Association for Acute Medicine (JAAM) in 2005. The effectiveness of antithrombin III (AT-III) supplementation in septic shock patients diagnosed to have acute-phase DIC on the basis of the JAAM diagnostic criteria has not yet been reported. Objective: We examined the effectiveness of AT-III supplementation in septic shock cases with reference to the diagnosis of acute-phase DIC made on the basis of the JAAM criteria. Material and Methods: A retrospective analysis was performed of 32 septic shock patients who were admitted to our intensive care unit between July 2005 and February 2007 and were diagnosed to have DIC on the basis of the JAMM DIC criteria. The patients were divided into two groups for the analysis: the AT-III group (21 cases), in which the patients were treated with AT-III within 24 hours of the diagnosis of DIC, and the non AT-III group (11 cases), in which no AT-III treatment was administered. Results: There were no significant differences in the average Acute Physiology and Chronic Health Evaluation (APACHE) II score on admission or average Sepsis-related Organ Failure Assessment (SOFA) score at the time of a shock diagnosis between the two groups. The AT-III group tended to show a better survival rate (not significant difference; P = 0.0595), with significant improvement of the plasminogen activator inhibitor-1 (PAI-1) and protein C levels being observed. Conclusion: Early AT-III treatment after confirmation of DIC diagnosis by the JAAM DIC criteria would appear to be a useful strategy for the management of DIC-complicating septic shock.

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This study was conducted to clarify the factors influencing the necessity for re-intubation. We compared the clinical factors between re-intubated and non-re-intubated patients among 344 patients admitted to our ICU. We collected data from the clinical and nursing records, and the Mann-Whitney and χ² tests were performed to examine the statistical significance of the associations. Thirty-three (9.6%) of the 344 patients needed re-intubation within 72 hours of extubation. The Acute Physiology and Chronic Health Evaluation (APACHE) II score, intubated duration, pneumonia, renal failure, and continuous hemodiafiltration (CHDF) were identified as significant contributors to the risk of re-intubation (P<0.05). Factors related to coughing up phlegm, such as the force of cough, and the use of a transdermic transtracheal needle, also contributed significantly to the risk of re-intubation (P<0.01).

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The validity of albumin use in critically ill patients has been lately reevaluated. Although clinical guidelines for blood products in Japan have stated that albumin use to maintain serum albumin values is appropriate, there is a tendency to administer albumin products indiscriminately to patients after major surgery. In April 2006, we developed and started a restrictive albumin use protocol with an upper limit of 3.0 g·dl⁻¹ in patients undergoing an esophagectomy. We then compared the clinical courses and complications which occurred in these patients with a group of patients from before application of our restrictive protocol as retrospective controls. The amount of albumin use and the recorded serum albumin values reduced significantly after the restriction. However, the duration of mechanical ventilation, ICU stay and in-hospital mortality did not differ. In conclusion, the restriction of albumin use with an upper limit of 3.0 g·dl⁻¹ in post-esophagectomy patients did not appear to have any harmful influence on the clinical course of the study subjects.

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We report a case of toxic shock syndrome (TSS) by methicillin-resistant Staphylococcus aureus (MRSA), developing a rapid necrosis of upper and lower extremities. A 34-year-old man injured left tibia during his work and osteosynthetic surgery of the tibia was performed. On postoperative day (POD) 1, he had a high fever, nausea, vomiting, diarrhea and skin rash. On POD 3, he was admitted to our ICU due to severe hypotension and acute renal failure. At first, we diagnosed his disease as a septic shock even though the origin of infection was unknown. We administered vasopressors and antibiotics, and induced continuous hemodiafiltration. However, the tip of his extremities became necrotic. On POD 5, toxin-producing MRSA was cultured from left knee fluid, and his disease was diagnosed as TSS. After administration of anti-MRSA drug as well as lavage and drainage of the surgical site, TSS seemed to be controlled. However, because the necrotic extremities could be additional focuses of infection, amputations of bilateral legs and fingers were performed. As early diagnosis and adequate treatments are essential for patients suffering from TSS, TSS should be one of the differential diagnoses in patients with septic shock accompanied by skin rash, and we should recognize that most strains of MRSA produce TSS-related toxins.

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During 5-year period between 2000 and 2004, respiratory care was administered to four patients with obesity hypoventilation syndrome (OHS). Cases: The condition was brought under control in two of the patients by applying noninvasive positive pressure ventilation (NPPV). They also suffered from hepato-renal dysfunction due to hypoxia, from which they recovered with improved oxygenation. The remaining two were treated with invasive positive pressure ventilation (IPPV) while under endotracheal intubation. Following weaning from IPPV, respiration was supported by NPPV and the patients were weaned from artificial respiration. Conclusion: Acute respiratory failure caused by OHS could be controlled by NPPV. It is worth trying this aggressive mode of treatment. Repeated intubation may be averted by incorporating NPPV in auxiliary respiratory therapy following weaning from IPPV.

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We report a case of pheochromocytoma that presented with progressive heart failure. The patient was successfully treated with early surgical intervention with percutaneous cardiopulmonary support (PCPS). This patient, a 32-year-old man, was admitted to our ICU for recurrence of hypertensive crisis. Abdominal CT revealed a left adrenal tumor diagnosed as a pheochromocytoma. Although treatment with vasodilators and volume loading was initiated, the patient's condition rapidly progressed to severe congestive heart failure. We thought that eliminating the catecholamine release from the tumor could greatly increase the chances of the patient's survival, and therefore, we performed emergency surgery for tumor removal with PCPS, which facilitated better oxygenation and provided circulatory support. Unexpectedly, the patient was hemodynamically stable during surgery. Examination of the resected tumor revealed massive hemorrhagic necrosis, which suggested that the catecholamine release from the tumor had stopped before surgery. The patient was promptly weaned from PCPS after surgery. Subsequently, his cardiac function recovered favorably, and he was discharged from our hospital 21 days after admission. In the case of patients with pheochromocytoma developing progressive heart failure, physicians should consider the possibility of sudden cessation of catecholamine release following acute tumor necrosis as well as of catecholamine-induced cardiomyopathy.

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Emphysematous pyelonephritis (EPN) is a life-threatening infectious disease that requires surgical intervention. The clinical condition mimics acute pyelonephritis, but EPN is almost exclusively accompanied by diabetes mellitus, especially poorly controlled diabetes. CT is considered to be the most useful diagnostic tool. A 69-year-old man was transferred to our hospital complaining abdominal pain. He presented with septic shock, disseminated intravascular coagulation, acute kidney failure and hyperglycemia. He was diagnosed acute pyelonephritis by a CT examination. Because the hemoglobin A_1c level was found to be 12.6%, we thoroughly reevaluated the CT findings to rule out the possibility of EPN but could not detect any renal gas. Though the patient's septic shock temporarily reversed by intensive care, his abdominal pain and hypoxemia rapidly progressed following paroxysmal atrial fibrillation. We performed a second CT examination to exclude the possibility of a mesenteric artery embolism, and incidentally observed EPN. The patient underwent a left radical nephrectomy and overcame the crisis. In patients with urosepsis and poorly controlled diabetes accompanied by septic shock, an abdominal CT examination is highly recommended, even if the septic shock has been temporarily reversed, to rule out the possibility of EPN.

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