Purpose: In previous study, the author reported that the beginning of diuresis period was significantly delayed in cases that underwent operation 6hrs after traumatic intestinal perforation (JJAAM 1997; 8: 145-60). The purpose of the present study is to explain the mechanism of these delays in diuresis by clarifying the roles of cytokines (IL-1 and IL-6) and antidiuretic hormone (ADH) in postoperative water redistribution. Materials & Methods: Fifteen cases of traumatic perforation of the small intestine were divided into 2 groups. The Early group are cases operated on within 6hrs of injury. The Late group are those operated on 6hrs after injury. Water balances were measured every hour and the time from operation to beginning of diuresis period (T_d) were calculated. Serum levels were measured every 4 to 6hrs after operation ADH (15 cases) and IL-1, IL-6 (9 cases). The time taken for elevated serum ADH to decline to reference range after operation (T_ADH) were estimated. Results: 1) Serum ADH level declined in an exponential curve after operation. There was no significant difference in half-time of serum ADH level between the Early and Late groups. 2) Regression equation between T_d and T_ADH were T_d=0.982 and T_ADH+0.094(r=0.972). 3) Serum ADH level immediately after operation were significantly higher in the Late group compared to the Early group. 4) There was no significant difference in serum IL-1beta level immediately after operation between the Early and Late groups. 5) Serum IL-6 level immediately after operation were significantly higher in the Late group compared to the Early group. Discussions: From the above results, the mechanism for delay of diuresis period in the Late group may be as follows: The beginning of the diuresis period coincides with the time ADH declines to the reference range. In the Late group, long duration of peritonitis stimulates secretion of IL-6, and a high serum IL-6 level stimulates ADH secretion. So, serum ADH levels after operation are higher in the Late group compared to Early group. In Late group, high ADH levels takes longer to decline to the reference range, causing delay in the beginning of the diuresis period.

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Background: The helmet is a well-known from of head protection. In Japan, helmets are classified into three categories (A-, B-and C-type) by the Japanese Industrial Standard (JIS). Types A and C are both widely used, however, many patients are still brought to the hospital with head or facial injuries despite the fact that they were wearing helmets. This paper describes the results of clinical and experimental studies of the protective effectiveness of various types of helmets. Subjects and Methods: The clinical study involved 157 patients who had been treated for injuries sustained in motorcycle accidents in the period between January 1995 and December 1996. In these patients, types of head and facial injuries and their severity were evaluated in relation to the type of helmets worn at the time of accident. The impact management tests were performed using a shock absorption testing apparatus to compare A-and C-type helmets. The test-drop heights were set at 183cm and 376cm, in conformity with the Japanese Industrial Standards and the 1995 Snell Standards. Results: Fifty-six of the clinical subjects were wearing A-type and 101 were wearing C-type helmets at the time of their accidents. Head or facial injury was found in 60.7% of the A-type group, but only 25.7% of the C-type group. Also traumatic intracranial hemorrhage and facial injuries occurred significantly more frequently in the A-type group (p>0.001). Impact management tests of A-type helmets from a drop height of 376cm resulted in average peak accelerations of more than 400G (407.2±11.9; max 419.0; min 387.0; n=6). Tests performed on C-type helmets dropped from the same height yielded an average peak acceleration of less than 300G (278.8±11.5; max 290.0; min 262.0; n=6). Conclusion: The 1995 Snell Standards specifies that the peak acceleration of the head may not exceed 300G for any valid impact test. However, the average peak acceleration of A-type helmets was over 400G. This study clearly indicates that A-type helmets do not provide a sufficient level of head protection, and demonstrates the need for revisions in the Japanese Industrial Standard.

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A 49-year-old woman was found submerged in the bathtub at home. Closed chest compression was performed first by her husband for approximately 10 minutes, and then by ambulance personnel for 37 minutes. She was transported to our hospital's emergency room while cardiopulmonary resuscitation was continued. She received external chest compression for 19 minutes and then open-chest direct cardiac massage for 45 minutes. Major autopsy findings were hemorrhage (approximately 400ml) in the pericardial sac and a large longitudinal 3.5cm laceration of the right ventricle. Histopathological examination of the right ventricle revealed marked fatty infiltrations, which had partially replaced the major cardiac muscle layer. Some of cardiac muscle bundles in the right ventricle were disarrayed with fibrosis and fat. Infiltrations of fat were also seen in the left ventricular wall and septum near the conducting system. These autopsy findings suggest that the major cause of death in this case might have been a lethal arrhythmia due to arrhythmogenic right ventricular cardiomyopathy (ARVC), and that the ruptured right ventricular wall and cardiac tamponade were complications of the vigorous resuscitative efforts. In conclusion, the softened myocardium with massive fatty infiltration in ARVC may be susceptible to CPR-related injuries.

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