We clarified the cause of death in 108 of 1437 patients examined for cardiopulmonary arrest (CPA) or neardeath based on autopsies in the last 8 years at our critical care medical center. Of the 108, 69 (64%) were classified with cardiac disease and 65 diagnosed clinopathologically as sudden cardiac death (SCD), i.e., death due to cardiac disease within 24 hours of symptom onset. Causes of SCD were classified into, (1) acute myocardial infarction (AMI) (28%) and (2) all other disorders (72%). Of these without AMI, 40 (85%) had a specific clinicopathological cardiac disorder, as indicated by greater myocardial fiber eosinophilic staining compared to normal fibers with hematoxylin-eosin (HE) staining. This finding was diffuse in the myocardium of both ventricles. Eosinophilic fibers were negative or only weakly positive to myoglobin immunohistochemical staining using antimyoglobin antibody. Most of the cases showed no coronary obstruction or severe narrowing. Clinically, this specific cardiac disorder occurs frequently than AMI in men at a ratio of 4:1 vs. women and in younger patients. Of the 40 with this specific disorder, 28 died within 30 minutes of symptom onset and 12 within 30 minutes to 24 hours. We suspect that acute myocardial ischemia induced by coronary vasospasm may have caused the myocardial eosinophilic change in these cases. We propose calling this specific clinicopathological cardiac disorder “superacute myocardial eosinophilic change (SMEC)”.

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We studied neurological outcome to determine the clinical significance of early decompression in cervical cord injury. We treated 35 patients with cervical cord injury by dislocation reduction or removal of bone fragments in the spinal canal. Of these, 20 had incomplete paralysis (Frankel grade B 8, C 10, D 2) at injury (Group IC), and none had neurological aggravation and 17 improved with one or two grades 1 year after injury. Recovery (Yale Scale Score) was 44.1±30.0%. Correlating significantly and negatively with time until decompression (R=-0.727, p=0.0003). In 11 patients, decompression was achieved within 6 hours of injury. In 9, decompression was conducted ten hours after injury or later. Recovery in early decompression (64.0±20.4%) was higher than that in late decompression (19.8±20.4%) (p=0.0004). Some 15 patients were completely paralyzed at injury (Group C). In final follow-up, 8 rated Frankel A, 5 B, 1 C, and 1 D. Their recovery was 11±20%, independent of time until decompression (R=-0.390, p=0.151). In these 15, bulbocavernous reflex (BCR) was positive in 8 and negative in 7 at decompression. Neurological improvement was observed in 2 with positive BCR and in 5 with negative BCR. In these 5, neurological improvement may be merely recovery from spinal shock. Our results suggest that when the patient has incomplete paralysis at injury, early decompression, especially within 6 hours, provides the chance for neurological recovery. Most patients scoring Frankel A at injury, however, had poor results with early decompression. These may include those with incomplete spinal cord injury (i.e., potential recovery) in spinal shock as our BCR study indicated. All spinal cord injury patients should therefore be treated clinically as incomplete paralysis even if they score Frankel A in the acute stage.

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We evaluated the efficacy of chest compression ventilation (CCV) during cardiopulmonary resuscitation (CPR) and determined whether it could be substituted for mouth-to-mouth ventilation (MMV). Anesthetized and endotracheally intubated patients were ventilated with CCV, with the anesthesiologist squeezing the chest bilaterally with both hands. The ventilation volume (VV) was measured with a respiratory monitor attached to the proximal end of the endotracheal tube. We first studied the influence of gender, age, and degree of obesity for VV by using a multiple regression analysis (n=61). We then measured VV in CCV and in CCV+simultaneous pressure on the epigastrium (n=16), and when lifting the patient's pelvis in a prone position (n=5). VV was 165±57ml (mean±SD) in the first study. VV was influenced by both age and the degree of obesity but not gender. VV in young people was greater than that in older people, and VV in obesity was less than that in patients of normal weight. VV in CCV was 106ml, VV in CCV+simultaneous pressure on the epigastrium 109ml, and VV at lifting the patient's pelvis in a prone position 210ml. We found that CCV cannot be substituted for MMV because VV by CCV is under 200ml, but should be attempted in young patients who are not obese.

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Toxic-shock syndrome is an acute-onset, multiorgan illness that resembles severe scarlet fever. Superantigen activates a huge number of T-cells by linkage to a particular V βelement of the T-cell receptor, which directly associates with major histocompatibility complex (MHC) class II molecules. We report a 64-year-old man with superantigen toxic shock syndrome toxin-1 (TSST-1), who had severe hypoxemia caused by airway stenosis and septic shock due to a cervical abscess. He underwent emergency tracheostomy and cervical incision to remove the abscess. Septic ARDS developed despite intensive care. Here, septic ARDS refers to the respiratory index (R-index: A-aDO₂/PaO₂) increasing to 5.57 on day 10 in the ICU. Changes in TSST-1 were similar to the R-index. No correlation was seen between IL-6 and serum TSST-1 antigen during the ICU period, but a statistically significant correlation (r=0.813, p<0.05) between serum TSST-1 antigen and R-index was found in this case. These results suggest that serum TSST-1 antigen is a possible cause of ARDS.

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Since Japan's organ transplantaion law went into effect in 1997, more than a dozen donations have been made from braindead donors. We discuss 2 problems with organ procurement in Japan, based on 14 cases, including our own, for which we obtained information on the donation time line. The first problem is the need to diagnose clinical brain death before Japanese criteria for brain death are met. The second problem is inputting data on newly available organs to the Japan Organ Transplantation Network computer system. An organ may be input for shipping only after brain death is diagnosed. Beause of these 2 problems, organ donations take much time and place a heavy burden on donor hospitals. The organ procurement procedure is strictly regulated by legal guidelines, and we propose that the procedure is redesigned within the existing legal framework.

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