Objective: To test the hypothesis that the diagnostic criteria for disseminated intravascular coagulation (DIC) developed by the Japanese Association for Acute Medicine (JAAM DIC criteria) can also be applied to an obstetrical DIC diagnosis.
Patients and Methods: The JAAM DIC criteria were retrospectively applied for the DIC diagnosis in 19 obstetrical emergency patients. The obstetrical DIC diagnostic criteria (Obstetrical DIC criteria) score of 8 points or more was used as a gold standard for the DIC diagnosis.
Results: Nine patients fulfilled the Obstetrical DIC criteria. The JAAM DIC criteria could diagnose obstetrical DIC early with a high sensitivity (94.7%) and a moderate specificity (75.0%). The area under the receiver operating characteristic curve for the obstetrical DIC by the JAAM DIC criteria was 0.847 (Standard error, 0.06) and its 95% confidence interval ranged from 0.740-0.955 (p=0.0001). In addition, a significant correlation in the scores was observed between the JAAM DIC criteria and the Obstetrical DIC criteria (r=0.601, p=0.0001). Considering clinical conditions of the patients and the conditions that should be ruled out, high specificity (88.6%) with unchanged sensitivity were observed.
Conclusion: The JAAM DIC criteria are therefore considered to have an acceptable ability for the diagnosis of obstetrical DIC. The scoring system identified most of the patients diagnosed by the Obstetrical DIC criteria at an early stage of the disease.

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The occurrence of cerebral infarction in children is relatively rare. Therapy with intravenous recombinant tissue plasminogen activator (rt-PA) for acute cerebral infarction has been widely used since October 2005 in Japan. However, this therapy must be initiated within 3 hours from onset, because the risk of intracranial hemorrhage increases dramatically after this period. We herein report the successful use of intravenous rt-PA for the treatment of acute cerebral infarction with the occlusion of the internal carotid artery in a child. The patient recovered with no neurological deficits. In selected cases, the cautious use of intravenous rt-PA in children with cerebral infarction is therefore considered to be useful.

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Recombinant factor VIIa (rFVIIa) is administered to treat bleeding tendency in patients with hemophilia. Recently, several reports have shown that the administration of rFVIIa inhibited massive bleeding due to severe trauma or surgery. However, there are few reports investigating whether the administration of rFVIIa can inhibit massive postoperative bleeding. We report two cases in which the administration of rFVIIa was a safe and effective treatment for massive postoperative bleeding. The first case, a 36-year-old female, underwent caesarean section due to premature separation of the placenta. Because massive bleeding and hypotension persisted after surgery, hysterectomy was performed. However, bleeding remained uncontrolled after hysterectomy. Therefore, rFVIIa was administered, and the bleeding gradually stopped. The second case, a 14-year-old male, underwent thoracotomy for removal of Ewing sarcoma involving the rib. Because massive bleeding and hypotension persisted after surgery, he fell into cardiac arrest. Therefore, 2 times of thoracotomy was performed. However, bleeding remained uncontrolled after the second surgery. Therefore, rFVIIa was administered, and the bleeding gradually stopped. For these two patients, rFVIIa was very effective and there were no adverse events attributable to rFVIIa.

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A 76-year-old man who enjoyed sport shooting was resting on the front seat of his car. A companion's shotgun located in the back of the car discharged accidentally, and all of the pellets hit the patient in his right back. An abdominal x-ray and a CT scan showed that about 170 pellets were lodged in his right lower back. Operative findings revealed two intestinal penetrations, and ascending colon perforation was also suspected. We performed primary closures of the small intestine, an ileocecal resection, and extraction of 70 pellets from the circumference of the right ilium. Due to concern about lead poisoning from remnant pellets, the patient's blood lead concentration (BLC) was measured, and was determined to be 19 μg/dl. A lead-chelating agent was administered intravenously for 5 days. At post-operative day 50, the BLC was increasing, so oral administration of the chelating agent was initiated and was continued until 1 year after the injury. Measurement of the BLC at 2 and 4 months after the chelating agent was stopped revealed that it was no longer increasing. We conclude that in cases of remnant shotgun pellets, the BLC needs to be followed up carefully for several years after the injury.

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We report a case of traumatic right diaphragmatic hernia accurately diagnosed by multislice CT (MSCT). A 37-year-old man was injured in a traffic accident. On arrival, he was in shock. The initial chest X-ray and axial views of the trunk on MSCT demonstrated multiple right rib fractures, right lung contusion, right pneumo-hemothorax, peritoneal fluid collection, liver contusion, and pelvic fractures. Diaphragmatic hernia was not detected at that time. After placing a right chest tube, repeat chest X-ray demonstrated an abnormal oval contour of the right diaphragm. Multiplanar reformation views of the initial MSCT were reviewed. We accurately diagnosed right diaphragmatic hernia with characteristic “hump sign” and “band sign” configurations. Following hepatic and pelvic angiography with transcatheter arterial embolization of liver contusion, emergent laparotomy was performed. An 11 cm right diaphragmatic disruption was repaired. The patient was discharged with no complications on post operative day 30. Transient shock immediately following application of negative pressure thoracostomy tube suction to right hemithorthorax was suspected to reflect obstructive shock due to liver and diaphragm herniation compressing the right atrium. MSCT is quite useful for accurate diagnosis of traumatic right diaphragmatic hernia at an early stage.

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Cholesterol embolization (CE) is well known as a multi-systemic disorder that frequently occurs after cardiac catheterization or cardiovascular surgery. CE after carotid stenting has been rarely reported. We describe a case in which carotid stenting triggered rapid progression to CE. Carotid stenting was performed in a 73-year-old man with severe stenosis of the left carotid artery. Peri-procedural magnetic resonance images revealed multi-focal acute brain infarctions. Ten days after the procedure, the patient developed hypertension, bilateral livedo reticularis of the toes, and renal dysfunction with eosinophilia. A skin biopsy showed evidence of cholesterol emboli in the arterioles. CE after carotid stenting was diagnosed. The patient received corticosteroid therapy including pulse therapy which was effective in diminishing further deterioration of renal function. CE should be suspected in patients who present with signs of ischemia following carotid stenting. Corticosteroids may prove beneficial in cases of CE-induced renal dysfunction.

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