INTRODUCTION: There are only a few reports about the effect of the neutrophil elastase (NE) inhibitor, sivelestat, on the pulmonary vascular permeability in patients with sepsis induced acute lung injury and/or acute respiratory distress syndrome (ALI/ARDS). The objective of this study was to investigate whether or not the NE inhibitor could improve the pulmonary vascular permeability of patients with ALI/ARDS and sepsis.
METHODS: We examined survived 22 pts with sepsis induced ALI/ARDS. All patients were mechanically ventilated. They were divided into two groups (the sivelestat 11 pts and non-sivelestat group 11 pts). Upon admission, the pulse contour cardiac output (PiCCO) monitoring system (Pulsion Medical Systems, Munich, Germany) was set up to provide an estimate of extravascular lung water (EVLW) index and pulmonary vascular permeability index (PVPI). PVPI is the ratio of EVLW to pulmonary blood volume. These measurements were taken immediately and subsequently every 24 h for 2 days. At the same time the PaO₂/FiO₂ ratio, sequential organ failure assessment (SOFA) score, peak end-expiratory pressure (PEEP), fluid balance, lactate and base excess were recorded. Statistical analyses: χ² test, the Mann-Whitney U-test, analysis of variance (ANOVA) and liner regression analysis were used. P < 0.05 was regarded as statistically significant.
RESULTS: There was no statistically significant difference in age, gender, source of infection, SOFA score and PaO₂/FiO₂ ratio on the baseline between the sivelestat group and the non-sivelestat group. Fluid balance of the second 24 h was significantly lower in the sivelestat group than in the non-sivelestat group (-6.9 ± 18.0, 14.4 ± 28.7 ml/kg, p<0.05). PVPI, SOFA score, PaO₂/FiO₂ ratio, PEEP and base excess in the sivelestat group improved significantly (p<0.05 or 0.01) during 48 h, while those values in the non-sivelestat group did not change significantly. In the sivelestat group, the change of EVLWI and PVPI were related to the change of PaO₂/FiO₂ ratio during 48 h (r = -0.78, -0.6, p<0.005, 0.05).
CONCLUSIONS: 1) The NE inhibitor, sivelestat, seems to provide good efficacy for reducing the pulmonary vascular permeability that plays an important role in improving oxygenation in sepsis induced ALI/ARDS. 2) The analysis of the difference in the fluid balance between two groups shows that sivelestat seems to have the effect of reducing also the vascular permeability of other organs.

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Spontaneous rupture of an abdominal aortic aneurysm into the vena cava is rare and, in most cases, the symptoms are presented over an interval of several days or even months. Herein, we describe successful treatment of a patient with cardiopulmonary arrest due to an iliac arteriovenous fistula. A 65-year old man with no past history complained of acute chest and back pain, and was transferred to our hospital under a diagnosis of acute myocardial infarction. Soon after arrival, the patient fell into shock and cardio-pulmonary arrest. Following cardiopulmonary resuscitation, recovery of spontaneous circulation was immediately obtained and an abdominal aortic aneurysm was detected by echocardiogram findings. Further, an iliac arteriovenous fistula was detected by enhanced CT imaging and an emergency operation was commenced. Venous bleeding was controlled by insertion of a urinary balloon catheter and the fistula was closed from within the aneurysm with interrupted sutures. The patients was discharged 31 days after surgery without disability. In the present patient, the fistula was relatively wide and enlarged much quicker than that reported in other cases, as blood flow from the arterial circulation was suddenly diverted by it into the venous circulation, leading to so-called distributive shock.

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A 74-year-old male fell down while driving a motor-cycle and suffered trauma to his abdomen. After examining him for persistent abdominal pain, an abdominal CT showed a thoraco-abdominal aortic dissection (Stanford B). However, since his pain subsided the next day and he did not demonstrate any signs of ischemic organs, he was discharged. However, he suddenly exhibited intractable abdominal pain on at 81 days after the initial accident and abdominal CT depicted a compression of true lumen of the aorta by a pseudolumen at a level of arising from the celiac and supramesenteric artery. As a result, he underwent left iliac - supramesenteric artery bypass surgery. After the operation, his symptoms subsided and discharged on foot 17 days after surgery. The occurrence of blunt abdominal dissecting aortic injury is rare, however, it has the potential to be fatal due to a rupture or organ ischemia, and therefore physicians should be very careful not to overlook it in patients presenting with pain due to trauma to the abdomen.

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Polyarteritis nodosa (PN) is a disease marked by necrotizing segmental inflammation of medium to small arteries. The prognosis of untreated PN is very poor. Since symptoms are diverse and there is no specific serologic test, the diagnosis of PN is frequently delayed. We present a patient with hemorrhagic shock due to perirenal hematoma in whom angiography demonstrated typical findings of PN and in whom timely treatment with corticosteroid was tentatively successful. Renal involvement due to aneurysm formation is common, but perirenal hematoma is unusual. A 60-year-old man was admitted to a rural community hospital for temporary paralysis of the left arm and amaurosis fugax. On admission, he presented with idiopathic fever and renal dysfunction. He was referred to our emergency center because of sudden onset of left flank pain and perirenal hematoma formation. Renal angiography showed multiple microaneurysms, therefore, we diagnosed PN and initiated pulse therapy with methylprednisolone. His condition appeared to improve, but then deteriorated due to the development of cerebral hemorrhage and acute myocardial infarction. He died on hospital day 63. PN should be diagnosed early and treated. Moreover, after initiating treatment, we must take precautions to avoid worsening vasculitis.

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There are few young people who suffer a head injury, talk immediately after the injury and then deteriorate later, except in case of epidural hematoma. We present the case of a 16-year-old boy who was able to talk immediately after a traffic accident, but then deteriorated. Upon arrival at our hospital, his consciousness level was E4V4M6 according to the Glasgow Coma Scale (GCS), and brain computed tomography (CT) revealed a traumatic subarachnoid hemorrhage around the left sylvian fissure and a cerebral contusion in the left frontal lobe. Four hours later, anisocoria was observed. Brain CT showed an enlarged hematoma in the cerebral contusion which extended into the subdural space, and craniectomy with evacuation of the hematoma was performed. The patient was discharged on day 42, with a GCS score of E4VTM4. Enhanced CT upon admission yielded a vague image of the right lateral sinus and revealed nonfilling of the right jugular vein, but these structures were clearly depicted on day 14. The right jugular vein was shown to be on the dominant side, suggesting that acute intracranial hypertension might have been associated with the disturbed venous perfusion due to a traumatic dural sinus thrombosis.

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We present a rare case of an impalement injury to the buttocks. As a result of an accidental fall, a 22-year-old man had his right buttock impaled by a round-tipped stainless steel rod (length; 160 cm, diameter; 7 mm). The pole was slippery and accidentally came out when he moved. Because of intense abdominal pain, we rapidly performed radiological examinations but found no abnormality. We could not estimate organ injures according with any remaining foreign body. However, we suspected rectal injury and so performed emergency diagnostic laparotomy. No rectal injury was revealed but there was a penetrative injury of the duodenal bulb, which we directly repaired. Though suffering an impalement injury to the buttocks, this patient had no complicating lower digestive organ injures. The mechanism by which lower digestive organ injury was avoided are thought to be; 1) the steel rod did not damage pelvic organs because of its thin diameter and rounded tip, and 2) the rod was flexible and did not progress in a straight line. The case demonstrates the need to rapidly evaluate for indications of surgical treatment in accordance with the mechanism of injury, radiological examinations, foreign body characteristics and wound condition.

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The patient was an 86-year-old woman who suffered a pelvic fracture in a motor vehicle accident. Dynamic CT performed 12 hours after the injury using a multidetector CT (MDCT) scanner, revealed an aneurysm in the mesentery. CT angiography showed that the aneurysm was located in the peripheral region of the superior mesenteric artery. She was diagnosed as having a traumatic ileal pseudoaneurysm which was gradually increasing in size. At emergency laparotomy the injured intestine and the involved mesenteric artery were resected and anastomosed in an end-to-end fashion. Generally, the treatment of choice for this disorder is either surgery or transcatheter arterial embolization (TAE). We chose surgical treatment because the CT angiography demonstrated that the aneurysm was close to the intestine and thus we considered that TAE could cause intestinal ischemic necrosis. CT angiography using an MDCT scanner is a noninvasive diagnostic tool that allows the localization of an aneurysm and provides morphological information. Therefore, it is very useful to determine the therapeutic strategy.

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