Patients: This study was performed on 13 patients with severe acute pancreatitis diagnosed according to Japanese severity score between November 2001 and May 2003 who underwent testing to determine procalcitonin (PCT) and interleukin-6 (IL-6) blood levels. Japanese severity score was 9.5 ± 4.7 (range 4-19) and APACHE II score 13.2 ± 6.7 (range 7-29). Four patients had multiple organ failure (MOF) (SOFA score 14.3 ± 3.9, range 10-17) within 7 days after admission, and finally died due to MOF. Measurements: PCT was measured by immunoluminometric assay and IL-6 by ELISA. Measurements of PCT and IL-6 were mainly performed within 48 hours (within 4 days after onset of severe acute pancreatitis), on the 3-4th day, and the 7th day after admission (total 41 measurements). Data analyses were performed using the Mann-Whitney U test and Spearman's rank correlation test. Findings of p<0.05 were considered significant. Results: PCT (ng/ml) and IL-6 (× 10³ pg/ml) blood levels within 48 hours after admission were 2.83 ± 3.92 (range 0.08-12.61) and 5.45 ± 15.08 (range 0.05-54.87), respectively. IL-6 level was slightly correlated with Japanese severity score (rs=0.570, p=0.0495) and PCT level was nearly correlated with it (rs=0.554, p=0.0565). Both PCT and IL-6 levels were strongly correlated with APACHE II score (rs=0.735, p=0.0113 and rs=0.663, p=0.0226, respectively). PCT (ng/ml) and IL-6 (× 10³ pg/ml) levels within 48 hours after admission in the 4 patients who died were significantly higher than those in the 9 patients who survived (7.63 ± 4.01 and 17.20 ± 25.36 vs. 0.70 ± 0.61 and 0.23 ± 0.12, p=0.0055 and p=0.0055, respectively). The results were similar on the 3-4th and the 7th days. Both sensitivity and specificity for the prediction of death were 100% when the cut off levels were 2.0 ng/ml for PCT and 1.0 × 10³ pg/ml for IL-6 within 48 hours after admission. A good correlation was found between PCT and IL-6 levels at all times of measurement (rs=0.741, p=0.0079). Conclusions: Both PCT and IL-6 levels measured within 4 days after onset of severe acute pancreatitis were useful for predicting outcome.

View full abstract

Autopsy of individuals in whom the cause of death was unknown is recommended, but the autopsy rate varies regionally, and it cannot be always performed. No guidelines for its promotion have been complied from the viewpoint of medicine yet. For accurate determination of causes of deaths, establishment of databases using the Utstein style and evaluating by postmortem examination system are performed in Kobe. In this study, we evaluated the findings obtained by medical examination or autopsy of CPA patients, in whom determination of the cause of death was clinically difficult, and attempted to produce a chart for the clinical estimation of causes of deaths in regions in which evaluation by autopsy is difficult. Subjects and methods: Among 2,606 individuals recorded using the Utstein style between January 1, 2001 and December 31, 2003, the subjects were 226 CPA patients who had undergone postmortem examination or autopsy because the cause of death was considered endogenous but uncertain. We evaluated the clinical findings and results of postmortem examination or autopsy. Results: Of the 226 patients, postmortem examination alone was performed in 76, and autopsy in 150, respectively. The confirmed causes of deaths were ischemic cardiac disorders in 31% of the patients, cerebrovascular disorders in 7.1%, cardiac or great vascular disorders in 7.1%, aspiration or asphyxiation in 8.4%, and other cardiac disorders in 11.1%. Prodromes before the occurrence of out-of-hospital CPA were noted only in 20 patients. Discussion: It is difficult to determine causes in individuals who died of certain disorders, such as great vascular disorders, gastrointestinal perforation, chemical poisoning, and dysbolism, by postmortem examination alone, therefore autopsy is often required. Physical findings and postmortem examination are insufficient for identifying the causes of deaths in CPA patients, and results of clinical examinations are often meaningless because they are affected by various factors. Prodromes in out-of-hospital CPA provide important information, but they cannot be generally obtained. We produced a flowchart for the estimation of the cause of death in decreasing order: (1) ischemic cardiac disorders, (2) great vascular disorders, (3) cerebrovascular disorders, and (4) aspiration or asphyxiation, which showed high incidences in this study, so that it can be applied to out-of-hospital CPA in which identifying the cause of death is difficult in regions where autopsy examination is difficult.

View full abstract

We report the case of a 17-year-old female first presenting as circadian rhythm sleep disorder, then later diagnosed as insulinoma. The patient demonstrated severe deterioration of academic performance in high school classes six months prior to examination. She also had disordered dietary habits, including copious late-night consumption progressing to reversal of daytime and nighttime activities. The patient was examined by a psychiatrist and diagnosed with circadian rhythm sleep disorder. Somnolence developed and worsened thereafter, and the patient was transported by ambulance to our facility. The patient was silent and almost non-verbal at admission, suggesting a mental disorder. However, hypoglycemia persisted despite the opportunity for adequate food intake after admission. Additional investigation and extensive test results showed an insulin/glucose ratio of 0.64 (17.8 μU/ml/28 mg/dl). Abdominal magnetic resonance imaging (MRI) demonstrated a 15 × 10 mm tumor at the border of the pancreatic head and body. Insulinoma was diagnosed, and the tumor was excised. Hypoglycemia and circadian rhythm sleep disorder disappeared completely after surgery, and the patient was discharged. The Japanese literature shows that approximately 10% of insulinomas present various mental symptoms. Chronic hypoglycemia symptoms are also sometimes difficult to differentiate from mental disorders, and careful observation is required in emergency room settings.

View full abstract

Generally, the number of patients who recover from cardiac standstill is very low. In addition to that, cases where patients have been discharged from the hospital after cardiac standstill are rare. Here, we report the case of an 89-year-old male's successful discharge from the hospital after a cardiac standstill. He felt chest pain first and his family called the ambulance. After the arrival of the ambulance team, the man was examined by the team. The AED monitor showed asystole and that electric shock was not required. Since his breathing was weak, the ambulance team judged that this case was a cardiac arrest and started CPR. But on the way to the hospital, the monitor showed asystole only. On arrival at the hospital, he still was not breathing normally and his electrocardiogram showed cardiac standstill. We continued CPR and gave 1mg epinephrine injections repeatedly. After the 3rd injection of epinephrine, around 24 minutes after confirmation of cardiac standstill, spontaneous circulation was restored. Since his laboratory data showed hyperkalemia and renal dysfunction, after admission, we gave the patient additional treatment of insulin and glucose in order to decrease the level of plasma potassium. As the concetration of plasma potassium decreased, his heart rate became stable over time. The next day he regained consciousness, and his breathing improved the day after that. On the 34th day, he was discharged. This case showed, even though the patients was over 80 and experienced a cardiac standstill, as long as the cause of the cardiac standstill is hyperkalemia and we treat the patient with adequate BLS & ACLS, we may be able to resuscitate and discharge the patient successfully.

View full abstract

A previously healthy 60-yaer-old man was transported to our hospital suffering from pain in the left arm and right leg. His arm and leg exhibited purpura. His blood pressure was 138/100 mmHg and body temperature was 35.5°C. Laboratory test showed CRP and CK levels of 16.5 mg/dl and 4,268 U/l, respectively. Right leg angiogram indicated severe arterial spasm of the popliteal artery. Hemodynamics evaluation with a Swan-Ganz catheter demonstrated a low cardiac output and high peripheral vascular resistance. Prostaglandin E1 and antibiotics were administrated and continuous hemodiafiltration was performed, but these approaches were not effective. The purpura and rhabdomyolysis became progressively worse, and the patient died after 18 hrs after admission. Vibrio vulnificus was detected from blood culture. This case was diagnosed as infection with V. vulnificus. The angiogram and hemodynamics suggest that insufficiency of peripheral arterial circulation due to severe vasospasm has a significant connection with the rapid worsening in clinical course.

View full abstract