Background and Purpose: The efficacy of early enteral feeding using an immuno-enhancing diet (IED) in patients with stroke is indeterminate. The purpose of this study is to elucidate the immune modifying effect of early enteral nutrition using an IED in patients with severe stroke. Method: Eighteen severe stroke patients having a Glasgow Coma Scale (GCS) score of 8 or less were randomly divided into two groups: an IED group of 8 patients, who were given an IED in the early enteral nutrition, and a control group of ten patients, who were given no IED. Both groups were tested as follows. Resting energy expenditures were measured by indirect calorimetry and target levels for nutritional administration were determined. Early enteral nutrition was administered until the nutritional target levels were reached, at which point in time was designated “day 1.” Enteral nutrition levels were then maintained for 14 days (the final day being day 14). Lymphocyte counts, natural killer (NK) cell activity (percentage cytotoxicity; cytotoxicity test), cluster of differentiation (CD) 4 values, CD8 values, and serum eicosapentaenoic acid (EPA) and serum arachidonic acid (AA) concentrations were measured from blood samples taken on admission and on day 14. Results: Scores for acute physiology, chronic health evaluation II and GCS revealed no significant difference in severity between the two groups at the initial stage. In the IED group, lymphocyte counts (p<0.05), NK cell activity (p<0.05) and CD4 values (p<0.01) were significantly increased on day 14 compared to the admission day. The group also showed significantly increased EPA (p<0.01) concentrations and decreased AA (p<0.05) concentrations on day 14 compared with admission day. There were no significant differences over time in the control group. Conclusions: Considering that lymphocyte counts, NK cell activity, CD4 values and EPA increased while AA decreased after early enteral IED feeding when compared to the pre-feeding period (admission day). We conclude that early enteral IED feeding in patients with severe stroke improves cellular immunity, although clinical validity remains unsubstantiated.

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Objective: To clarify the relationship between EMS transportation time and 30-day survival and discharge rates from hospital to home, we evaluated 1, 057 patients (consisting of acute myocardial infarction: 201 cases, unstable angina pectoris: 49 cases, subarachnoid hemorrhage: 217 cases, cerebral infarction: 405 cases, cerebral hemorrhage: 114 cases and gastrointestinal bleeding: 45 cases, aortic dissection: 26 cases) transported directly from the scene to 6 hospitals in Kyushu. In the most severe cases of AMI (Forrester classification grade IV), there was a significant correlation between the EMS transportation time and the 30-day discharge rates but not between the time and 30-day survival rate. There was an exponential relationship between the transportation time and hospital discharge after 30 days as y=2.9619e^-0.07x (R²=0.9962). In the cases of cerebrovascular attack (CVA) resulting in unconsciousness, mild to moderate cases of AMI and so on, it is possible there were many cases in which the onset time was unclear or the 119 call was delayed. Further investigation is needed. To shorten the transportation time from the island to the mainland hospital, we need to consider again the construction of a bridge link or the use of a helicopter. Conclusion: The shorter the length of time from the telephone call 119 to arrival at the hospital, the higher the 30-day discharge rate from hospital to home in severe cases of AMI.

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A case of conversion disorder caused by traffic accident mimicking cervical cord injury is reported. The patient was a 42-year-old male. He was transferred to our emergency center by ambulance after a traffic accident while riding a 400cc motorcycle. He exhibited abdominal breathing, and motor and sensory function of the bilateral upper and lower extremities hadbeen completely lost. There was no anal reflex, though other neurological reflexes were normal. Severe lower cervical injury was suspected, but cervical vertebral radiographs, head CT, and cervical, thoracic, and lumbar magnetic resonance imaging revealed no abnormalities. Finally, it became clear that he had suffered an episode of acute transient psychological disorder 6 years previously, and was therefore admitted to our hospital with the diagnosis of conversion disorder. His symptoms gradually improved, and on the 13th hospital day he was transferred to another hospital for rehabilitation. Psychological disorder should be considered in the differential diagnosis when detailed physical examination indicates the presence of dissociative symptoms.

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A 6 year-old girl suffered an occipital hit with loss of consciousness at that time and vomiting. She was admitted to our hospital one day after injury for repeated vomiting. The patient was alert and indicated no obvious neurological deficits. Laboratory findings showed no anemia and hypoproteinemia. However, coagulation studies were not performed. The CT scan one day after injury showed an extra-axial biconvex isodense mass in the right posterior fossa. Repeated CT scan five days after injury showed no enlarged isodense mass, and MRI 12 days after injury revealed epidural hematoma without intraaxial pathology. Acute isodense epidural hematoma is very rare in the acute phase after injury. The mechanism of different densities is still unknown and possible causes include coexistence of fresh blood and clotted blood, decrease in hemoglobin and hematocrit, extravasated blood consisting of low attenuating protein, and mixture of blood with cerebrospinal fluid due to dural tears. We suggest that the acute isodense epidural hematoma in our case may be caused by blood with cerebrospinal fluid.

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A 67-year-old man with primary macroglobulinemia had noticed the swelling of his lower extremities 3 weeks before the admission to our hospital. As he started to feel pain in his left leg and right flank and ecchymosis started to appear, he consulted a local clinic. On examination, his general condition was so severe that he was transferred to our hospital for the treatment of cellulitis. At the time of admission, blood examinations revealed leukocytopenia and metabolic acidosis. He was considered to be in hypotensive state and was intubated for mechanical ventilation. As the inflammation had already extended to his trunk, we did not conduct a surgery and instead started antibiotics and immunoglobulin therapy. 30 hours after the admission, his condition gradually worsened and he died of septic shock. Histological findings showed massive neutrophilic infiltration in the mediastinum. Penicillin-resistant Streptococcus pneumoniae (PRSP) was isolated from the culture of wound aspirates. Necrotizing fasciitis due to PRSP is quite uncommon. This report discusses necrotizing fasciitis due to penicillin-resistant Streptococcus pneumoniae with reference to primary macroglobulinemia.

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A pseudoaneurysm arising in the superficial temporal artery (STA) is rare, but can occur after a blunt trauma. We report a case of a rapidly enlarged giant pseudoaneurysm, caused by focal infection after head injury. A 46-year old man had a suture of the left fronto-parietal skin wound after a traffic accident. Three weeks later a swelling was noted in the temporal region. Due to increasing pain and its enlarged size, he visited the hospital. Investigational cerebral angiogram revealed an approx. 5cm. giant aneurysm on the frontal branch of the STA, which was ligated and resected. Under histological examination, the aneurismal wall was formed by fibrous tissue with perivascular inflammatory cells and the micro abscess. Therefore, we concluded that this pseudoaneurysm was caused by a blunt injury and its enlargement was because of focal infection. After the operation, additional medication was given to treat the infection and the patient was discharged with no further complication. It is very important that the complete debridement and care of the primary wound should be done to prevent wound infection, and possible further complications of pseudoaneurysm, as we report here.

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