Objective: This study was performed in order to investigate the effects of combined therapy with antithrombin (AT) products and recombinant human soluble thrombomodulin (rTM) in patients with severe sepsis and disseminated intravascular coagulation (DIC) based on a retrospective historical cohort analysis.
Methods: Diagnoses of DIC were made according to the criteria of acute DIC of the Japan Association of Acute Medicine. We examined 111 patients with severe sepsis diagnosed with DIC who were admitted to the intensive care unit and treated with AT products for anticoagulant therapy. The patients were divided into two groups: 51 patients received rTM for six days in addition to AT products (combination group), and 60 patients received AT products only, without rTM (control group). Changes in the coagulation parameters, DIC scores, and sequential organ failure assessment (SOFA) scores that occurred during the treatment were compared between the two groups. Furthermore, the survival outcomes of the patients at 28 days were evaluated by using the Kaplan-Meier method.
Results: Before treatment, the platelet counts were significantly lower, and both the systemic inflammatory response syndrome (SIRS) positive scores and SOFA scores were significantly higher in the patients in the combination group. However, there were no differences between the two groups regarding the other parameters. During the treatment, no differences were observed between the two groups regarding the changes of PT ratios, fibrinogen levels, or AT activity levels were detected. However, statistically significant improvements were seen in the platelet counts, D-dimer test results, SIRS positive scores, and DIC scores for the patients in the combination group. The patients receiving combined therapy also showed significant improvements in SOFA scores. There were no differences between the two groups in the frequency of bleeding complications. The survival outcomes were significantly better for the patients in the combination group than for those in the control group (28 day survival rates: 86.3% versus 60%, p=0.0016). Significant improvements were only observed in the severely ill patients, such as those with acute physiology and chronic health evaluation (APACHE) II scores > 25 or AT activity levels < 50%. A multivariate analysis indicated the baseline AT activity levels and the administration of rTM to be independent beneficial factors associated with the 28-day survival rates.
Conclusion: The combined therapy with AT and rTM showed a superior efficacy in the treatment of septic DIC, with improvements observed in coagulation parameters, and organ failure rates, and survival rates. This therapy is therefore considered to be a new and effective strategy for treating severe cases of the septic DIC.

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Serious infectious diseases typically have an unfavorable outcome because they often lead to disseminated intravascular coagulation (DIC), which in turn leads to multiple organ dysfunction due to ischemia. Therefore, it is essential to control the infection and treat DIC simultaneously. Although, antithrombin (AT) is the most recommended drug for the treatment of infectious DIC in Japan, the efficacy of recombinant thrombomodulin (rTM) therapy has also been reported. In this study, we compared the efficacy of rTM monotherapy with that of rTM and AT combination therapy for infectious DIC. There was no significant difference with regard to patient background or disease severity at the time of treatment initiation in both groups. Furthermore, the rate of recovery from DIC within 7 days and the rate of recovery, survival rate after 28 days were not significantly different between the two groups. rTM administration could improve the markers of inflammation, coagulation, fibrinolysis, and Japanese association for acute medicine (JAAM) DIC diagnostic criteria score significantly, but there were no significant differences between two groups. Considering these findings, the prognosis for patients with infectious DIC may not necessarily improve by adding AT to rTM, and as such, rTM monotherapy may be considered equally efficacious as rTM and AT combination therapy.

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Background: Gangrenous ischemic colitis occurs in about 10% of patients with acute ischemic colitis, and requires surgery as soon as possible. However, it cannot almost be diagnosed easily in the elderly due to the lack of clear signs of necrotic inflammation, and the mortality rate is about 60% in elderly patients. We herein clarify the significant diagnostic signs and prognostic factors of gangrenous ischemic colitis.
Method: We reviewed 24 patients who underwent emergency surgery for gangrenous ischemic colitis between 2002 and 2010.
Results: The average age of 24 patients was 77.4 years. Before surgery, all patients had some underlying atherosclerotic disease and signs of systemic inflammatory response syndrome (SIRS), and 87.5% had abnormally elevated lactate levels, whereas only 66.7% had signs of peritoneal irritation. Furthermore, 45.8%, 37.5%, 70.8% and 29.1% of patients had DIC, shock vital, metabolic acidosis and perforation of the colon, respectively. A Hartmann’s operation, which resected the necrotic colon, was performed in 23 patients, and a colectomy followed by primary anastomosis was performed in one patient, and the overall survival rate was 58.3%. Next, to examine the risk factors affecting the survival of these patients, both univariate and multivariate analyses using logistic regression were performed. A short time from onset of symptoms to surgery (<24hr) was the only independent prognostic determinant of survival identified by this study (p<0.05).
Conclusion: To obtain an accurate diagnosis, evaluation of SIRS signs, elevated lactate and underlying atherosclerotic disease in the elderly are very useful, although the presence of signs of peritoneal irritation is infrequent. An emergency operation should be performed within 24 hours from the onset of symptoms in order to improve the prognosis.

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Background & Purpose: Despite advances in diagnostic imaging and surgical therapy, the mortality of acute aortic dissection remains high. Early stage diagnosis and intervention can improve prognosis. While enhanced computed tomography (CT) is an effective diagnostic tool, characteristic imaging findings such as inward displacement of intimal calcifications and a hematoma-filled false lumen as a crescentic, high attenuation region following the aorta wall (crescentic high-attenuation hematoma) can also be observed on unenhanced CT. However, the incidence of such findings and the diagnostic accuracy of unenhanced CT have not been reported to date. The present study investigated the possibility of diagnosing aortic dissection using unenhanced CT.
Methods: A retrospective investigation was conducted using unenhanced CT images taken on admission to hospital of 44 patients diagnosed with acute aortic dissection between January 2008 and December 2009 after excluding from a total of 54 patients two patients who had not undergone enhanced CT, five patients who had cardiopulmonary arrest on arrival, and three patients who had been transferred to our hospital after being diagnosed with dissection at another hospital. Any of the following unenhanced CT findings was considered indicative of acute aortic dissection: inward displacement of intimal calcifications, crescentic high-attenuation hematoma, a visible flap, or pericardial hemorrhage. The findings were also compared with those of 37 non-dissection patients.
Results: Inward displacement of intimal calcifications and a crescentic high-attenuation hematoma were present in 29 (65.9%) and 33 (75.0%) patients, respectively, significantly more than in the non-dissection patients (p<0.01). A visible flap and pericardial hemorrhage were present in 4 (9.1%) and 5 (11.4%) patients, respectively, but no significant difference with respect to the non-dissection patients was observed due to the low incidence. Unenhanced CT diagnosis of aortic dissection was possible in 40 of 44 (90.9%) patients.
Conclusions: Unenhanced CT is useful for the diagnosis of aortic dissection.

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Many reports have suggested that blunt cerebrovascular injuries (BCVIs) potentially carry the risk of devastating complications, which occur in approximately 1% of all blunt trauma patients. Biffl et al., proposed a classification called the Denver grading scale that classified BCVIs based on their radiological features, which are significantly associated with the incidence of stroke. However, therapeutic strategies should be determined by the zones of occurrence of BCVIs, which are often more important than the morphological differences between them. Hence, in the current study, we classified BCVIs based on their zones of occurrence and investigated the stroke rate, prognosis, and the most effective treatment for each zone. Between October 2001 and September 2008, 32 patients with BCVIs in 36 vessels were diagnosed at our hospital according to the screening protocol based on the radiological examinations. They were classified into 3 groups based on the zones of occurrence: the cervical zone was zone 1, the transitional zone of neck and intracranial space was zone 2, and the intracranial zone was zone 3. Although vertebral artery injuries were found to be the major type of injury (72%) in zone 1, they were rarely found in the other 2 zones. On the Denver grading scale, 90% of BCVIs in zone 1 were grades II and IV, while 80% of those in zones 2 and 3 were grade V. For each zone, stroke rates were 11%, 62.5%, and 80% and mortality rates were 5.6%, 50%, and 30% respectively. In zone 1, 61% of patients received interventional radiology (IVR) and antithrombotic therapy, while others received antithrombotic therapy only. The rate of IVR in zone 2 and 3 were 50% and 12.5% whereas those of direct surgery was 20% and 40%, respectively. In zone 1, the stroke rate was lower, indicating the effectiveness of IVR in preventing stroke. In contrast, the mortality rate of zone 2 BCVI was the highest; 3 out of 4 patients who received IVR died due to uncontrollable bleeding. Although the stroke rate was highest in zone 3, the mortality rate of zone 3 was lower than that of zone 2. In zone 3, direct surgery and IVR were often effective against stroke. In summary, IVR and direct surgery are effective preventive treatments against stroke in zones 1 and 3, respectively. Therapeutic strategy for zone 2 BCVI remains an unanswered issue because of the difficulty associated with access for IVR, or direct surgery.

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We report a case of fulminant hepatitis that developed in the early stage of pregnancy, which was successfully treated with living donor liver transplantation and high flow continuous hemodiafiltration (HFCHDF). A 35-year-old female (gravida 1, para 1) with no previous medical history suddenly developed severe hepatic dysfunction (total bilirubin, 7.95 mg/dl; alanine aminotransferase, 3505 IU/l; prothrombin time (%), 23%; and ammonia level, 134 μg/dl) during the 17th week of pregnancy. She had no recent history of viral infection or any other hepatic diseases, including autoimmune hepatitis or primary biliary cirrhosis. Considering that her consciousness was clear, she was diagnosed with acute severe hepatitis and treated with plasma exchange and corticosteroids. However, on the 4th hospital day, her consciousness level deteriorated, and she was diagnosed with subacute fulminant hepatitis. She underwent an abortion, following which treatment with HFCHDF was initiated. The patient’s condition improved following HFCHDF; however, she developed high fever with further deterioration in consciousness on the 15th hospital day. She subsequently underwent living donor liver transplantation and was discharged from the hospital on the 25th postoperative day. Since 1980, 22 cases of fulminant hepatitis during pregnancy have been reported in Japan. The results of all the reported cases collectively indicate that early intervention with liver transplantation along with termination of pregnancy is an effective way to treat fulminant hepatitis occurring during pregnancy.

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A 46-year-old female treated with typical antipsychotic drugs for schizophrenia was transported by ambulance to the emergency department (ED) due to altered mental status. Her mental status was Glasgow Coma Scale score of 7 on arrival and the blood chemistry examination revealed severe hyponatremia (101.5mEq/l). Hypertonic saline was infused for the correction of hyponatremia. After the insertion of a Foley catheter in ED, copious diluted urine (total 9800 ml) was collected. Two hours after arrival, QT interval was further prolonged to 620 msec. Incessant PVCs were observed and developed to polymorphic ventricular tachycardia of torsade de pointes (TdP), leading to ventricular fibrillation (VF). Resuscitation was performed, and VF and TdP were terminated successfully with cardiac defibrillation and magnesium sulphate infusion. Additional predisposing factors for cardiac arrhythmia were electrolyte loss in urine with subsequent hypocalcemia, hypokalemia and hypomagnesemia. The QT interval was normalized on the fourth hospital day with the correction of electrolytes imbalance and cessation of typical antipsychotic drugs. The present case may alert emergency physicians for the development of TdP/VF during the treatment of water intoxication with concomitant drug-induced QT prolongation and electrolyte imbalance.

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