It has been known that the production of ulinastatin (UTI) increases when the human body is damaged and that the degree of damage correlates well with urinary UTI level. UTI is considered to excrete from blood to urine. An earlier study reported that blood UTI level could serve as a sepsis severity in dicator because it is associated with thenumber of impaired organs in patients with sepsis. In this study, we measured blood UTI level in trauma patients over time to investigate the relationship with the severity of trauma and other inflammation parameters, thereby examining the utility of measuring blood UTI level in trauma patients. Seventeen trauma patients without any history, who did not receive any exogenous UTI for treatment, were the subjects for this study. They were divided into two groups by injury severity score (ISS) of 25 or higher or less than 25. Each group was further divided into two subgroups by improvement or deterioration of their sequential organ failure assessment (SOFA) score in 48 hours from admission, The results showed that six patients had ISS of 25 or higher and worse SOFA score (Group A), five patients had ISS of 25 or higher and improved SOFA score (Group B), and six patients had ISS of less than 25 and improved SOFA score (Group C). No patients had ISS of less than 25 and worse SOFA score. The mortality rates of groups A, B, and C were 33%, 0%, and 0%. Blood UTI level was measured on admission and 1^st, 3^rd, 5^th and 7^th hospital day to examine its change in each group. None of the groups showed any significant differences in blood UTI by ISS on admission. UTI was not associated with anatomical severity when they suffered from trauma. Blood UTI level tended to increase in the group with the SOFA score that deteriorated (Group A): it was significantly higher in Group A than in the other two groups with the improved SOFA score. It appeared that the subjects in Group A were in anatomically and physiologically severe conditions as well as continuously affected by the trauma. Blood UTI level was positively correlated with the SOFA score (R=0.493, p<0.0001), CRP (R=0.388, p=0.0013), and IL-6 (R=0.26, p=0.036). The change in blood URI level was well correlated with physiological severity. It is therefore suggested that the increased blood UTI level over time in trauma patients may serve as an indicator of the development of multiple organ failure after trauma, and that blood UTI level may vary in association with the severity of trauma, therapeutic effects, and outcome.

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Objective: To evaluate whether proper diagnoses were made at an emergency department to elderly patients who presented with abdominal pain, and to identify factors associated with acute surgical condition. Methods: A two-year retrospective review of patients aged 65 years and older complaining of abdominal pain who presented to the emergency department. Results: 189 patients were enrolled. The over all accuracy rate for emergency department diagnoses was 79%. Of the 13 (7.1%) patients with a very different diagnosis from the first diagnosis after admission, six cases were not initially recognized as an acute surgical condition, and surgery was delayed. Factors associated with acute surgical condition by univariate analyses included tachypnea, hypothermia, persistent pain, perspiration, hyperglycemia, hypoalbuminemia, hypocalcemia, and the presence of systemic inflammatory response syndrome. A multivariate, logistic regression analysis indicates that persistent pain is a possible predictive factor indicating an acute surgical condition. In all six cases where such a condition initially went unrecognized, the abdominal CT was a key resource in revealing an acute surgical condition. Conclusions: In the emergency department, diagnosis of abdominal pain in the elderly with less specific symptoms is difficult and less accurate. Persistent pain is a possible predictive factor indicating an acute surgical condition and patients with persistent pain should be evaluated by abdominal CT scan early in the evaluative process.

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We report a successfully treated case of thoracic penetrating injury caused by a kitchen knife. A 52-year-old woman, stabbed in the right thorax by a kitchen knife was transported into our hospital. The kitchen knife was deeply lodged in the right thorax, and the sound of air leaking was heard at the entrance of the wound. However, the patient was hemodynamically stable. Emergency computed tomography (CT) revealed that the kitchen knife had entered the right thorax across the rib and right lung and was lodged near the vertebrae without causing any cardiovascular injury. The patient was immediately transferred to the operating room. On thoracotomy, the knife was found to have penetrated the tenth ribs and right lower lobe, and it had reached the eighth rib. Right lower lobectomy with removal of the kitchen knife was then conducted. The postoperative course was uneventful. Thus, CT was useful to evaluate the presence of injuries in heart and great vessels and to start operation promptly in our present case.

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Various the methods of temporary wound closure are reported. For example, silo closure method was reported, but it takes time and damages the fascia to close abdominal wall. Temporary wound closure by using the zipper system are hardly reported in Japan. We reported 4 cases who were applied the zipper system. One of the cases was 49-year-old man. He was operated for pan-peritonitis caused by perforation of the ileum. We closed his abdominal wall by using the zipper system to prevent the development of ACS (abdominal compartment syndrome) and to make easier abdominal re-explorations through the zipper. After the operation, we could check the bowel every day and performed peritoneal lavage at bedside. Patient could discharge due to earlier definitive closure could be done. Management with zipper system was useful and effective in another 3 cases. Indications for using zipper system in our facility are severe diffuse peritonitis which needs several explorations and daily lavage, necrotizing pancreatitis and ACS. The zipper system is established as one of the temporary wound closures in Europe. There are only few reports in Japan about the zipper system, so we reported the cases and its usefulness.

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A 33-year-male with severe tetanus was first treated with muscle relaxant and dexmedetomidine or propofol. However, due to the occurrence of side effects or the ineffectiveness in preventing muscle spasm of these drugs led us to convert them to continuous infusion of high dose magnesium sulphate for 21 days. This therapy was able to successfully prevent muscle spasm, avoid a sympathetic crisis and also enable the patient to communicate with healthcare providers. The patient was discharged on the 88th hospital day after undergoing rehabilitation. This is the first report of the case with severe tetanus who was treated with the continuous high dose infusion of magnesium sulphate in Japan. This therapy was therefore found to be effective and inexpensive for the treatment of severe tetanus.

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We present here in the case of a patient who died of multiple organ failure after being stung by a swarm of hornets (Vespa xanthoptera). The patient was an 80-year-old man who was attacked and stung in 78 places by hornets in a farm field. He was in shock on admission to our hospital about 1hr after the attack. Infusion and intravenous administration of 0.1mg of epinephrine quickly achieved hemodynamic stability. However, blood testing conducted on admission revealed abnormalities such as hepatic dysfunction, rhabdomyolysis and coagulation disorder. Despite administration of fresh frozen plasma (FFP) and steroid, hematological and systemic status deteriorated. Plasma exchange (PE) and continuous hemodiafiltration (CHDF) were initiated about 13hr after the attack, while using a ventilator. However, the patient died of multiple organ failure at 51hr after the attack. A search of the literature revealed 25 reports of organ injury and failure caused by multiple hornet stings in Japan, with 8 deaths. Organ injury was due to hornet toxin in most cases, not anaphylaxis, and most deceased patients sustained>50 stings. If the patient is stung>50 places and displays poor general condition, PE should be performed promptly, followed by CHF or CHDF.

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