An early feature of acute respiratory distress syndrome and multiple organ dysfunction syndrome is vascular endothelial cell injury and subsequent increase in generalized microvascular permeability. It has recently been postulated that the level of microalbuminuria represents generalized microvascular permeability in the clinical setting. The purpose of this study was to ascertain whether the extent of microalbuminuria correlates with the level of endothelial cell injury, the severity of illness, and the magnitude of impaired respiratory function and multiple organ dysfunction in patients who required therapeutic interventions. Methods: Fourteen consecutive ICU patients who required emergent operation or non-invasive interventions were studied. Urine albumin/creatinine ratio (ACR) and the circulating markers of endothelial cell injury, i.e., serum thrombomodulin (TM) and plasma von Willebrand factor antigen (vWF), were measured within 24 hours after intervention. The data of Acute Physiology and Chronic Health Evaluation II score (APACHE II), simplified acute physiology score (SAPS), multiple organ dysfunction score (MODs), sequential organ failure assessment (SOFA), PaO₂/FiO₂ ratio, lunginjury score (LIS), white blood cell count (WBC) in the blood, and serum C-reactive protein (CRP) were obtained daily during the first 7 days. The relationships between ACR and other variables were assessed. Results: During the first 24 hours after intervention, there was an increase in ACR (280±86mg/g) above normal value (<10mg/g). Log ACR showed a significant correlation with serum TM, but not with plasma vWF. When the levels of Log ACR were compared to other clinical variables obtained within the first 24 hours, the increase in Log ACR correlated positively with APACHE II, SAPS, MODs, SOFA and LIS. Log ACR correlated negatively with PaO₂/FiO₂ ratio. Log ACR did not correlate with WBC, or CRP. When the levels of Log ACR were compared to the worst data of those variables measured during the first week, Log ACR correlated positively with the worst data of APACHE II, SAPS, MODs, SOFA, and LIS. Log ACR correlated negatively with the worst data of PaO₂/FiO₂ ratio. Log ACR did not show any relation with WBC, or CRP. Conclusion: The extent of urinary ACR measured during the first 24 hours after intervention correlated with the level of endothelial cell injury, the severity of illness, and the magnitude of impaired respiratory function and multiple organ dysfunction. These findings appear to support the hypothesis that microalbuminuria represents the magnitude of generalized microvascular permeability.

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To clarify the pathophysiological mechanism of crush syndrome, we analyzed histological muscle preparations taken from patients with crush syndrome. Muscle tissue was taken by biopsy from 6 patients injured in the Hanshin-Awaji Earthquake which occurred 1995, 40∼50 days after the injury. The samples were analyzed using HE and other histochemical stains. In 4 of the 6 patients, typical myopathic changes such as muscle cell necrosis, regeneration, and inflammatory cell infiltration were commonly observed. Neurogenic muscular changes was observed in 3 of the 6 patients. Regenerating fiber was seen in 4 of the 6 patients, and ATPase stain revealed the presence of type 2c fibers in some of these cases. These findings show that muscle injury caused by crush syndrome is not a simple injury triggered by one episode, but is a sustained and complicated injury, in which a secondary injury mechanism might be engaged.

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A 3-year-old girl was injured in a traffic accident. She suffered traumatic subarachnoid hemorrhage, pneumocephalus and multiple skull fractures including the skull base. Polyuria appeared 8 hours after injury. Urinalysis revealed that osmolarity was 122 mOsmol. The diagnosis of post-traumatic diabetes insipidus was determined, and continuous intravenous infusion of ADH (antidiuretic hormone) was started. Because interruption of ADH infusion resulted in polyuria, administration of ADH continued until the 77th hospital day. She was discharged on the 336th hospital day in a persistent vegetative state. T₂-weighted magnetic resonance imaging revealed high intensity with contrast enhancement at the hypothalamus. Endocrine findings revealed hypopituitarism due to insufficient hypothalamus function. With these findings, we concluded that direct injury to hypothalamus resulted in diabetes insipidus.

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A case of Anderson type III odontoid fracture was reported. A 56-year-old woman suffered severe trauma from a traffic accident. She reported a short period of unconsciousness, at the time of impact but in the emergency room of our hospital, she was alert, oriented, and cooperative. There was no evidence of any neurological deficit, but she complained of pain in the back of the neck. No fracture or subluxation was identified by cervical X-ray films (standard anteroposterior, lateral, and odontoid views), but cervical computerized tomography (CT) and magnetic resonance imaging (MRI) revealed an Anderson type III odontoid fracture. Fortunately, no intrathecal lesion was found by MRI. Because of minimal signs traceable to the neck, and no cervical dislocation, we chose conservative therapy for this patient. She was doing well, with no neurological deficit, 18 weeks after cervial brace fixation. Odontoid fracture should be considered as a possible complication in traffic trauma patients. We should pay particularly attention to patients with period of unconsciousness or memory disturbance, or with complaint of neck pain. We emphasize the importance of early diagnosis and following appropriate treatment of odontoid fracture to avoid a delayed disability.

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A 27-year-old male with rectal gangrene as a result of a hemorrhoid infection complicated by pelvic cellulitis is described. Management initially included an exploratory laparotomy and perirectal space drainage. The patient deteriorated acutely on the 2nd postoperative day and required emergency abdomino-perineal resection. Reviewing the medical literatures, rectal gangrene can occur as a result of variety of etiologies such as occlusion of small arteries, toxication, infection, or trauma, although most of them occur after the abdominal aortic operations. Because clinical deterioration occurs in a matter of hours, a high index of suspicion should be maintained and the emergency operation is always required to save patient's life.

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