Heart transplantation is now an established thearpeutic modality for end-stage heart failure abroad. The world registry indicates that the annual number of patients who receive heart transplantation is now over 3, 500 per year, with survival rates of 82.0% at 1 year and 74.2% at 3 years. The main indications are idiopathic (45.6%) and ischemic (45.6%) cardiomyopathy. Quality of life is well maintained after transplantation, with 90% of patients free of symptoms and fully enjoying ordinary life. The main problems currently facing us are; keeping the safe ischemic time at transplantation at 4 hours, the need for lifetime immunosuppression, development of coronary artery obstruction with chronic rejection that accounts for 20% of late mortality, and severe donor shortage leading to a long waiting period. In Japan, after a decade of national attempts to establish a legal background for organ donation under brain death, the first registration was established in 1997 and the first heart and liver transplantation were achieved this year. Social acknowledgment and support have increased, but the social and legal requirements are still very strict and organ donation has been very limited. The discussions on revision of the current registration have particularly focused the very strict regulation for donation which requires a written living will and the issue of transplantation for children which is currently in practical terms illegal. The current practical procedures and surgical methods of heart procurement and transplantation are described.

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Neutrophil leukocytes (NLs) are able to migrate and accumulate the damaged regions in the initial stage of inflammation. They are not only involved in phagocytosis of bacteria and degenerated cell debris, but, by releasing of various cytokines and enzymes, in the developmentof sepsis and MOF Recently, reports dealing with the expression and upregulation of epitopes of NLs in the acute stage of traumatic injury have been published by several investigators. However, little is known about the details of the morphological changes in NLs in this stage. In the present study, the authors collected blood from trauma patients and prepared smears at 30min, and 12, 24, and 48 hours after the injury. Smears were stained with Wright-Giemsa solution and by the PAS (periodic acid Schiff) method, for light microscopic observation. For electron microscopic examinatio, NLs were separated from heparinized blood as soon as possible striving to prevent morphological artifacts at the same interval. Immediately after separation by centrifugation at 800G to remove the plasma, the leukocyte layer was directly fixed with a mixture of 2.5% para and 2% glutaraldehyde solution and refixed with 1% osmic solution. After dehydration, the specimens were embedded in Epon812 and examined with a JEM2000EX electron microscope. The findings in the PAS-stained specimens and electron micrographs were analyzed with an image processing system. At the light microscopy level, the PAS stainability of NL was shown to decrease between 30min and 12 hours after the injury and to recovers at 48 hours. At the electron-microscopic level, cytosol opacity increased, glycogen granule opacity decreased, from 30min to 12 hours, and recovered at 48 hours. Thus, the contrast of NLs in electron micrographs decreases markedly in the initial stage and recovers at 48 hours. The mitochondria of NLs stand out at 12 and 24 hours, and the Golgi apparatus-especially its lamellar structure-increases in size and in electron opacity, and becomes discernible at 24 hours. Although there was some discrepancy between the observations and the results of image analysis, the sequential changes occurring NL progress in almost in the same pattern. The findings concerning the short life span of NLs reported here, seem to be closely associated with the milieu in peripheral blood, in which NLs circulate for several hours. Possibly, the milieu is affected by the concentration of endotoxin, cytokines, catecholamines, and hormones (endogenous and exogenous) in blood.

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A retrospective survey of 669 cases of acute benzodiazepine poisoning admitted between January and December 1996 to 59 critical care departments was carried out. A review and retrospective analysis of the records of 95 deceased persons who had ingested benzodiazepines in 27 police prefectural jurisdictions in Japan during the same period, was performed to compare these cases and postmortem medicolegal cases of acute benzodiazepine poisoning. The majority of cases in both groups were deliberate self-poisoning (82.7% and 83.2%, respectively). Efforts to decrease morbidity and mortality from acute drug poisoning should target drugs taken frequently in serious and lethal overdoses. This study confirmed that flunitrazepam, triazolam, etizolam, and nitrazepam were the main agents ingested in cases of acute benzodiazepine poisoning in both the critical care and postmortem groups. More specifically flunitrazepam was the derivative most commonly used in the postmortem group. The statistically significant difference was thought to be attributable to the characteristics of the pharmacokinetic parameters of flunitrazepam, which has a short time to peak interval and a relatively long elimination half-life. In other words, rapid onset and prolonged coma contribute to successful suicide. The majority of patients in the critical care group (82.8%) and in the postmortem group (76.8%) had not undergone plasma or urinary drug screening tests. The lack of drug identification may result in serious diagnostic errors or wrong estimates of severity as well as interfere with scientific progress in the study of acute drug poisoning. Six deaths (0.9% of total) were recorded in the critical care departments as a result of poisoning following ingestion of benzodiazepines in combination with other drugs. Five of them were cases of cardiopulmonary arrest on arrival at the hospital. Therefore, most deaths related to benzodiazepines have occurred outside the hospital as a result of prolonged comatose periods in persons who were not discovered. The fact that acute benzodiazepine poisoning is a kind of the iatrogenic disease in Japan should be taken into consideration, since in most of the cases of poisoning the benzodiazepines were prescribed by a physician and given to the patient by a pharmacist. We regard careless prescriptions and routine dispensation of benzodiazepines as being among the reasons why the number of cases of acute poisoning fails to decrease. Accordingly, to prevent acute benzodiazepine poisoning, it is important to control the clinical use of benzodiazepines (especially flunitrazepam, triazolam, etizolam, nitrazepam) more appropriately by monitoring medication use and carefully counseling patients.

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Objective: To determine the efficacy of prehospital use of military anti-shock trousers (MAST) on the mortality of trauma patients. Data Sources: MEDLINE was used to search the literature related to the above topic from 1966 to 1997 by using the terms “G Suits”, “military antishock trousers” and “shock garment” in MeSH (explode) and key words. Japana Centra Revuo Medicina (Japanese Collection of medical articles) CD was also used to search Japanese publications from 1987 to 1997 by using the terms“shock pants” and “hemorrhagic shock”. Study Selection: Non-randomized controlled trials (non-RCTs), randomized controlled trials (RCTs), and case reports on the effect of MAST on mortality in adult trauma patients were included. The studies were further subgrouped according to methodologic quality (case reports, non-RCT, and RCT). Meta-analysis was performed on 2 RCTs reported. Main Results: More than 20 case reports suggested improvement in survival as a rusult of using MAST in trauma patients. Four non-RCTs that evaluated 1, 570 patients and 2 RCTs that evaluated 1, 032 patients met the respective inclusion criteria. Among the non-RCT studies, MAST reduced mortality in one study and increased it in another study, but it did not change it in the other of 2 studies. MAST was not associated with any significant changes in mortality in either RCT. Meta-analysis of the 2 RCTs showed that MAST did not reduce mortality in the overall or subgroup analysis based on injury sites, blunt or stab wounds, or transport time. It revealed no significant difference in length of ICU or hospital stay between the treated and controll groups. Conclusion: Prehospital use of MAST in trauma patients was not demonstrated to be effective in reducing mortality or length of ICU or hospital stay.

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A case of epidural abscess after sepsis caused by infectious enteritis in a 74-year-old woman is reported. Her first symptoms were watery diarrhea and high fever. Two days later, she developed sepsis, DIC, and complained intolerable low-back pain. With antibiotics administration and intensive care, she recovered from sepsis and DIC in a few days. However, she had a daily spiked fever of 39°C, continuous elevation of C-reactive protein (CRP), and severe low-back pain for more than 4 weeks. Gallium scintigram and MRI revealed an epidural abscess in the lumbar region. The abscess was thought to be due to hematogeneous infection during sepsis, because closed inflammatory lesions were not defined. After treatment with antibiotics and total bed rest for 8 weeks, and rehabilitation for 4 weeks, she recovered completely without neurological disorder.

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Endovascular covered stent placements have been recently utilized as nonurgent treatment for aneurysms in large vessels. However, the effects of covered stent placements for urgent hemostasis has not been clarified. We experienced a case in whom an endovascular covered stent was successfully used for urgent hemostasis of a ruptured external iliac aneurysm. A 72-year-old male was admitted to the Osaka University hospital 2 hours after awakening with severe right lumbago. He developed to severe shock due to the right retroperitoneal hemorrhage. A diagnostic aortogram revealed a rupture of an aneurysm of the isolated right external iliac artery. Medical history disclosed that he had been suffering from cardiomyopathy for 10 years, so he was subject to heart failure. Because of this underlying heart disease endovascular management was applied. We placed the biliary covered stent, which is the only commercially available covered stent in Japan, and thus, provided urgent hemostasis of the aneurysm. He recovered from hemorrhagic shock, and was transferred to another hospital without further complication after 11 days of hospitalization. Our experience suggest that the urgent placement of covered stent should be considered for uncontrollable hemorrhage of large vessels. The commercial supply of covered stents should include different types in Japan.

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Toxic epidermal necrolysis (TEN) is a severe dermatologiocal disorder characterized by extended epidermal necrosis. Intestinal involvement in toxic epidermal necrolysis has been identified only rarely. We report a case of TEN with mucosal erosions of the gastrointestinal and respiratory tracts. A 38-year-old woman was hospitalized with high fever, severe diarrhea and skin eruption. Bloody stool appeared on the day of admission. Skin eruptions extended over 38% of the body surface area by the 4th hospital day. Histological examination of a cutaneous biopsy confirmed the diagnosis of TEN. Sudden cardiac arrest occurred after tachypnea on the 6th hospital day. After heart beat was restored, bronchoscopy revealed bronchial obstruction due to respiratory mucosal sloughing. Despite intensive care, she died from sepsis on the 45th hospital day. Bacterial translocation might have occurred from the gastrointestinal lesions. Autopsy revealed extensive intestinal erosion and ulcer with respiratory tract erosions. We concluded that gastrointestinal and bronchial involvements might contribute to the increased mortality of TEN patients.

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Severe pulmonary thromboembolism (PE) during pregnancy occurred in 2 young patients. One patient died from PE recurrence without placement of an inferior vena cava (IVC) filter, but the other survived with emergent filter placement before cesarean section. A 31-year-old woman presented with sudden dyspnea at 34 weeks of pregnancy. On examination, she was cyanotic and echocardiography revealed marked right heart dilatation and pulmonary hypertension. An emergent cesarean section was performed, but soon after the delivery, she fell into circulatory arrest. PE recurrence was suggested as cause, and t-PA was administered into the pulmonary artery. She was resuscitated but she died from another PE recurrence 4 days later. A 25-year-old woman, 35 weeks pregnant was admitted because of threatened abortion. She felt sudden dyspnea 3 days after admission and was diagnosed with severe PE by echocardiography and pulmonary catheterization. A Vena-Tech IVC filter^™ was inserted at the suprarenal position to prevent PE relapse. Emergent cesarean section was then carried out uneventfully. Heparin and urokinase were administered postoperatively, and her pulmonary arterial pressure decreased. She was extubated 7 days later, and is now doing well 10 months later. Once severe PE has occurred, its relapse may be lethal. The IVC filter is effective in preventing recurrence. Even if the patient is young, emergent IVC filter placement to avoid fatal PE relapse is essential.

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