Background: To ensure a good prognosis for subarachnoid hemorrhage (SAH), early diagnosis is essential. Although delayed diagnosis is associated with increased morbidity and mortality, it has been reported that 12% of cases of SAH are overlooked at initial assessment. Therefore, accurate prediction at the initial stage is necessary.
Objective: To identify objective predictive factors associated with SAH in patients admitted on an emergency basis with a chief complaint of a headache, and to propose a score for predicting the presence or absence of SAH by combining these factors.
Subjects and Methods: Among emergency patients brought by ambulance with a chief complaint of a headache during the nine-year period from 2001, a total of 573 patients were selected by excluding patients with trauma, drunkenness, or coma, as well as patients whose final outcome was unknown. Among these patients, those for whom data were obtained between January 1, 2001 and December 31, 2006 (356 cases) were used to derive a prediction rule and classified into the SAH group (n=88) and control (non-SAH) group (n=268) based on the diagnosis obtained on brain CT and lumbar puncture. Numerically expressed items such as vital signs and laboratory test values were investigated using univariate and multivariate logistic regression analyses in order to identify predictive factors, and an SAH prediction score (SPS) was created based on these factors. In addition, patient's data obtained between January 1, 2007 and December 31, 2009 (217 cases) were used to validate the SPS.
Results: In consideration of ease of use in clinical settings, the following factors and cutoff values were selected: white blood cell count >8,000/μl, blood glucose >130 mg/dl, serum potassium <3.5 mEq/l, systolic blood pressure >140 mmHg. By assigning points to these predictive factors, SPS was calculated for each group. No patients with an SPS of 0 had SAH. In addition, according to the derived prediction rule, the risk of SAH increased as SPS increased. Moreover, similar results were obtained for SPS in the validation.
Conclusion: The use of SPS may enable reliable prediction of SAH in initial assessment of patients with acute headache at emergency departments.

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Background: Although some case reports have previously demonstrated the neurological sequelae of heatstroke, the clinical findings associated with its pathogenesis have not yet been fully investigated.
Objective: To examine the risk factors for central nervous system damage secondary to heatstroke.
Methods: This study analyzed the medical data of patients with neurological sequelae of heatstroke that were extracted from the Heatstroke STUDY 2006 and Heatstroke STUDY 2008, which were carried out by the Heatstroke Surveillance Committee of the Japanese Association for Acute Medicine. We compared these data with those of patients without neurological sequelae (control group), and their severity of heatstroke was categorized as Class III, except for fatal cases.
Results: Twenty-two of 1,441 cases (1.5%) with heat-related illnesses manifested sequelae in the central nervous system. These findings included cognitive impairment (15 cases), swallowing disturbance (6 cases), cerebellar ataxia (2 cases), aphasia (1 case) and vegetative state (1 case). The mean age and male-female ratio of patients with sequelae of heatstroke was 62.6 years, and 13 to 9, respectively, while those of the 286 patients in a control group was 55.4 years, and 213 to 72 (unknown 1), respectively. The clinical findings on arrival at the hospital, showed that a decrease in systolic arterial blood pressure (90 mmHg or less) and tachycardia (120 beats/minute or more) were observed more frequently in the patients with sequelae than those in a control group, but a comparison of the observed values showed no significant difference between the groups. On the other hand, significant differences were observed in the total scores on the Glasgow coma scale (GCS), body temperature, the value of base excess (BE) in arterial blood gas on arrival, and the cooling time from start to attaining 38 °C in the hospital (p=0.001, p=0.004, p=0.006, p=0.010, respectively).
Conclusion: Heatstroke patients presenting with severe disturbance of consciousness on arrival at the hospital, higher body temperature or low BE values were more likely to experience sequelae in the central nervous system, and they were treated for a longer cooling time to achieve the target temperature. It is important to provide aggressive cooling, intensive care and neuroprotective therapy as soon as possible, in order to avoid the neurological sequelae of heatstroke.

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A 53-year-old male who was being treated for hypertension, diabetes mellitus and alcoholic liver dysfunction at another hospital, was found with his face immersed in a bathtub after drinking alcohol. When he was transferred to our hospital by ambulance, he had disturbance of consciousness and respiratory failure. His condition gradually improved after admission to our hospital. However, he had a fever and his respiratory condition worsened on the 6th day. We diagnosed acute respiratory distress syndrome (ARDS) due to secondary drowning, and treated him with intensive care including the administration of sivelestat sodium hydrate and high-frequency oscillatory ventilation (HFOV). These treatments were effective and he was extubated on the 9th day. He was discharged on the 40th day. Sivelestat sodium hydrate was effective in a patient with ARDS based on drowning, and HFOV improved oxygenation in the patient with ARDS.

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An 84-year-old female had been regularly consuming normal meals, and had not experienced either vomiting or dysphasia. She suddenly complained of dyspnea and respiratory stridor. A chest radiograph revealed an enlargement of the upper mediastinum. The patient was thereafter transported to the ICU at Fukuoka University Hospital for treatment. The patient presented with tachycardia, arrhythmia, tachypnea, respiratory stridor and jugular venous distention at the time of admission. Chest Computed Tomography revealed an abnormal dilation of the esophagus and a large amount of residue, thus leading to a diagnosis of esophageal achalasia. Tracheal intubation was performed because an abnormal dilation due to the esophageal airway obstruction caused by tracheal compression. This induced ventricular fibrillation, which required chest compression. Spontaneous circulation returned approximately 1 minute later, and emergency upper gastrointestinal endoscopy was then performed to release the pressure. The aspiration of aproximately 600 g of food residue from the esophagus caused the cardiac arrhythmia to subside, and the patient thereafter recovered from the shock. Subsequently, her general condition became stabilized. Esophageal achalasia must therefore be recognized as a disease that can sometimes be complicated with cardiac arrest.

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Some reports have shown that pneumococcal infection became fulminant in cases who were splenectomized or showing splenic hypoplasia. In two cases that demonstrated fulminant pneumococcal infection, Howell-Jolly body was confirmed in peripheral erythrocytes and spleen hypoplasia was shown on abdominal CT. One patinet was saved but the other patient died of sepsis and DIC. It is possible that confirmation of Howell-Jolly body and spleen hypoplasia is useful to screen for a high risk group of spleen dysfunction and fulminant pneumococcal infection.

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Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiological entity characterized by headache, encephalopathy, visual disturbances, and seizures associated with reversible vasogenic edema on neuroimaging. We herein present three cases of PRES due to sepsis that developed after liver transplantation. Case 1; A 28-year-old female received a liver transplantation for fulminant hepatitis. She subsequently developed a sudden onset visual disorder about 5 weeks after the operation. She had received an immunosuppressive medication on schedule according to the standard protocol. A brain magnetic resonance imaging (MRI) study revealed high signal intensity areas on T2-weighted images (T2WI), fluid-attenuated inversion recovery (FLAIR) images, and diffusion-weighted images (DWI) at the bilateral occipital lobe, parietal lobe, cerebellum, brainstem, and low signal intensity areas on T1WI at the same areas. Follow-up noncontrast brain CT forty-five days after the operation showed a high density area in the left occipital lobe. A follow-up of brain MRI on FLAIR and T2WI at seventy-six days after the operation showed a residual high intensity area in the left occipital lobe, but no cerebral edema. She recovered following conservative therapy, except for hemianopsia in the right eye field. Case 2; A 5-year-old female liver transplant recipient for liver cirrhosis after congenital biliary atresia experienced a sudden onset seizure within a few seconds recovery about 4 weeks after operation. Brain MRI on T2WI, FLAIR, and DWI showed high signal intensities in the bilateral parieto-occipital regions, and on T1WI, low signal intensities in the same areas. She recovered with no sequelae. Case 3; A 19-old-male liver transplant recipient for fulminant hepatitis had a sudden onset generalized convulsive seizure 5 days after surgery. He experienced a full recovery with no sequelae. MRI is the most sensitive imaging technique for diagnosing PRES. When patients are diagnosed to have PRES, they also tend to have sepsis. Therefore, PRES may have occurred in association with septic conditions in these patients. Attention should therefore be paid by intensivists and emergency medicine teams to ensuring that a patient does not have PRES.

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A 47-year-old woman experienced chest and back pain while working, and an ambulance was called. On admission, the heart rate was 101 beats per minute, blood pressure was 140/95 mmHg and consciousness was alert. Furthermore, she appeared pale, cold and perspired peripherally. ECG on admission showed elevations of ST segment in extensive leads: I, aV_L, and V₂ to V₆. Immediately after the ECG examination, ECG monitoring showed ventricular fibrillation (VF). Following defibrillation, we felt pulsation of the carotid artery. The ECG monitoring record showed polymorphic ventricular tachycardia (PVT) following “R on T”. Urgent coronary angiography demonstrated 90% stenosis in the left anterior descending branch and simultaneous percutaneous coronary intervention was needed. As all ECG records during her clinical course showed a normal QT interval, it was suggested that PVT in this case was the type without prolonged QT interval. PVT with normal QT interval often occurs in the clinical course of coronary artery disease similar to that in this patient. It was also suggested that the PVT had shifted to VF within several tens of seconds. Accordingly, we must start cardio- pulmonary resuscitation in the emergency room. It was also suggested that there was a small residual ischemic lesion since PVT did not recur during her clinical course.

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