Objective: We investigated the therapeutic effect of recombinant soluble thrombomodulin (rTM) in patients with sepsis who have disseminated intravascular coagulation (DIC).
Methods: The patients with sepsis who met the diagnostic criteria for acute DIC (JAAM) and showed a level of antithrombin (AT) lower than 70% were treated with AT products and Gabexate mesilate, and designated as the Control group. The septic DIC patients treated with rTM in addition to the above treatment were designated as TM group. Patients with severe liver dysfunction, severe bleeding tendency, or receiving other medications for DIC were excluded. The difference between TM and Control groups was investigated to see the effect of rTM by evaluating the clinical course through DIC score, and hemostatic and inflammatory markers.
Results: Twelve patients were included in the TM group, and 16 patients in the Control group. There were no differences in the APACHEII score, DIC score, or mortality between the groups. The effects of the rTM were as follows; 1) Patients in the TM group showed earlier DIC resolution at day 5 than Control at day 7. 2) Hypercoagulant state expressed by the increased levels of soluble fibrin monomer (SF) or thrombin-antithrombin complex (TAT) was improved more quickly in TM group compared with Control group. Because the levels of SF at day 3 and day 7 in TM group were lower than those in Control group, rTM may suppress thrombin production. 3) AT was more increased at day 3 after AT product administration in TM group compared to Control group, which also can be explained by suppression of thrombin production by rTM. 4) Increased levels of the complex of α2PI and plasmin (PIC), D-dimer, and fibrin/fibrinogen degradation product (FDP) were also improved earlier in TM group than Control group at day 7, suggesting the anti-thrombolytic effect of rTM. The inflammatory markers, TNF-α, IL-6, HMGB1 were decreased significantly at day 3 as compared with day 0 in TM group, but not in Control group, suggesting that rTM may act as an anti-inflammatory molecule.
Discussion: DIC was resolved more earlier in TM group than in Control group. rTM administration may preserve plasma AT and attenuate hypercogulable, hyperfibrinolytic and hyperinflammatory state in septic DIC through suppression of thrombin generation.
Conclusion: rTM may be beneficial in improving septic DIC via its anti-thrombogenic and anti-inflammatory properties.

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Background: The dispatched number of the fire and disaster management helicopters (FDM Heli) is increasing year by year, however, it is much fewer compared with the Doctor-Heli. This investigation, which evaluated the ability in FDM Heli as the rotorcraft for the utilization of emergency medical service (EMS) and visualized the differences from the Doctor-Heli, was designed to show some ideas for improvement of the FDM Heli system.
Materials and Methods: The Committee of Aircraft Emergency Medical Service in Japanese Association for Acute Medicine questionnaired for fifty-three domestic corps of FDM Heli. The items of question were scored on the basis of the Doctor-Heli system and classified into two categories,“Condition”and“Mobility”.“Condition”is the backgrounds as the rotorcraft for the use of EMS including fixation of hospital, education for safety, criteria for dispatch, boarding paramedic and operation time, and“Mobility”is the preparations to dispatch the physician to the scene swiftly including specialty of doctor boarding, way of dispatch, dispatched area, equipment and type of helicopter. The total point of each FDM Heli corps about“Condition”and“Mobility”was plotted on the two-dimensional graph, respectively.
Results: All of fifty-three FDM Heli corps filled out the questionnaire. The scores of the Doctor-Heli as evaluation basis were 12 points as“Condition”and 15 points as“Mobility”, however, the median of“Condition”and“Mobility”in FDM Heli were 5 (2-13) and 5 (2-11), respectively. Only three corps (Kochi Pref., Fukuoka City and Hyogo Pref. + Kobe City) were evaluated that their helicopters are closely operated to the Doctor-Heli.
Conclusion: This study shows that the FDM Heli still has an obvious difference from the Doctor-Heli in the utilization as EMS helicopter even if that should act as the multipurpose helicopter. Under developing of Doctor-Heli system in the whole nation, it is meaningless argument that“FDM Heli?”or“Doctor-Heli?”which helicopter should take responsibility for EMS. The effective utilization of FDM Heli for an insufficient prehospital resource has to be discussed.

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A 44-year-old man presented with neck pain and dysarthria. He had undergone operations for cervical and lumbar hernia 4 years ago. No abnormality was found in vital signs excluding the heart rate of 100/min on his first visit; since no significant neurological findings were found, we decided to let him return to our Orthopedics Department the next day. But 4 hours later, his condition became rapidly worse, and he was returned to our emergency room. The Glasgow Coma Scale was E3V5M6, his blood test showed 20,500/μl leukocytes and a C-reactive protein level of 33.8 mg/dl. Additionally, he underwent a head MRI for suspicion of cerebellitis or cerebellar infarction. Blood cultures were positive for Streptococcus agalactiae. Enhanced CT scan showed images of multiple abscesses and a thrombus at the left internal jugular vein, and Lemierre syndrome was susupected. This syndrome is defined as an oropharyngeal infection, followed by thrombophlebitis of the internal jugular vein, and septic emboli. Although it is now called“forgotten disease”, its reemergence has been observed. This syndrome can be critical if appropriate therapy is not performed at an early stage. It should be considered as one of the differential diagnosis of neck pain and fever.

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Acute drug overdose is common among emergency outpatients. We present such a case caused by an overdose of loxoprofen, in which we measured the serum concentrations of loxoprofen and its metabolites. A woman in her 30s took 3,600 mg of loxoprofen and came to the emergency room 3 hours later. There were no subjective symptoms, vital signs were stable and consciousness was clear. She was hospitalized for the observation, with no particular abnormalities found in laboratory tests. The patient refused administration of activated charcoal and an aperient. The following day, digestive symptoms, mild liver dysfunction, acute kidney injury, and thrombocytopenia developed, which worsened by day 3 of hospitalization. Thereafter, symptoms and blood tests improved, and she was discharged on day 4 with no sequelae. The blood concentration of loxoprofen was 126μg/ml at 3 hours, 26μg/ml at 17 hours, 3.18μg/ml at 40 hours, and 0.25μg/ml at 64 hours after ingestion. The maximum concentration of loxoprofen was estimated to occur at 0.41 hours and absorption lag was not observed. The drug was absorbed within 3.5 hours after ingestion. Furthermore, metabolization to an activator occurred quickly, while the half-life of the drug was prolonged, due to egestion delay.

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We describe rare envenomation by an eastern green mamba (Dendroaspis angusticeps). A 40-years-old man was bitten by an eastern green mamba that he had kept illegally and brought to the emergency room within 30 minutes of the bite. We confirmed severe pain, swelling and continuous bleeding from his left index finger. We did not administer antivenom considering the risk of anaphylaxis and the time required to obtain it. We simply washed the wound and observed the patient. Swelling spread to the trunk within 3 days and blood blisters formed on his left forearm. A coagulation disturbance that seemed to be caused by the snake venom spontaneously improved within 6 days. The blood blisters were all epithelialized within 13 days. The patient was discharged on hospital day 44. The focal puncture site was deeply ulcerated and required 136 days to epithelialize. Mamba venom reportedly contains neurotoxins that cause paralysis and death due to respiratory failure, but disordered blood coagulation is rare. Accumulated case reports will help to understand mamba envenomation.

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The Great Eastern Japan Earthquake was an unprecedented combined disaster involving a huge earthquake and tsunami, and a nuclear power plant accident. On March 11th, 2011, a huge earthquake and tsunami severely damaged the Fukushima Daiichi nuclear power plant. The next day, on March 12th, a hydrogen explosion occurred at the No. 1 reactor, and the government ordered the evacuation of a 20 km radius around the plant. On March 14th, the No. 3 reactor exploded, followed by the No.2 and 4 reactors on March 15th, which caused the emission of a vast nuclear plume. At this critical moment, the Fukushima Nuclear Disaster Management Center, which was supposed to function as the nuclear disaster headquarters, was also damaged, resulting in the loss of the control center. Most of the residents left, but approximately 700 patients in hospitals and nursing care facilities remained in the area. An emergency evacuation was planned for these patients on March 14th. However, difficulties were encountered in finding appropriate facilities for these patients, and some of them had to wait in buses or at evacuation sites for longer than 24 hours. These evacuation conditions unfortunately resulted in more than 20 casualties due to deterioration of underlying illnesses, dehydration and/or hypothermia.
Fifteen power plant workers were injured in the series of explosions. Later, efforts were made to restore the cooling systems of the damaged reactors. Injuries occurred because of trauma and exposure to high levels of radiation. The radiation emergency medical system in Fukushima did not function properly, and great difficulties were encountered in treating those with radioactive contamination.
Fortunately, no deaths due to explosion or acute radiation injury were reported for the Fukushima Daiichi nuclear power plant accident. However, the evacuation of patients from the 20 km evacuation zone was accompanied by loss of life. Temporary shelters should be developed for those in hospitals and other care facilities in such areas. Alternative hospital and other facilities for patients should be designated in advance, and staged evacuation should be considered. In addition, further development of emergency medical systems for radiation exposure, and education of medical staff and students, are urgently needed.

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