Objective: To clarify the efficacy of significant event analysis (SEA) for stress management among disaster relief operation doctors.
Participants and Methods: 67 physicians sent to a disaster site (Tohoku, Japan) as part of the Jichi Medical University Alumni Reunion Earthquake Disaster Support Project. Participants were randomly assigned to two groups: one group completed a self-administered SEA test 4 weeks after returning from the disaster site (SEA group), and the other group did not complete a SEA test (non-SEA group).
Main Outcome Measures: Stress scores on the Impact of Event Scale-Revised (IES-R) and K6 scales were recorded 4 and 8 weeks after returning from the disaster site.
Results: No significant differences in IES-R or K6 scores at both 4 and 8 weeks were observed between the SEA group (1.27±5.08 [mean±SD] and 1.83±2.68, respectively) and the non-SEA group (2.43±4.05 and 0.76±3.01, respectively) (p=0.30 and p=0.13, respectively).
Conclusion: The present results suggest that the SEA test is not effective for reducing stress among disaster support doctors.

View full abstract

Objectives: To describe intracranial pressure (ICP) and cerebral perfusion pressure (CPP) of acute severe encephalopathy of childhood and to evaluate its association with neurological outcome.
Design: Retrospective observational study.
Participants: Children with acute severe encephalopathy were admitted to the pediatric ICU from January 2007 - December 2010. Patients who originally had neurological complications were excluded.
Method: We reviewed patients’ characteristics, time from the onset to performing ICP monitoring, days of ICP monitoring, maximum ICP, total time of sustained ICP over 20 mmHg, minimum CPP, and total time of sustained CPP below 40 mmHg. Neurological outcomes were divided into poor and favorable using the pediatric cerebral performance category (PCPC) scale and these were compared with ICP and CPP values. All numerical values were expressed as the median (minimum - maximum).
Results: Fifteen patients received ICP monitoring. Nine patients had acute encephalopathy with biphasic seizures and late reduced diffusion, while one had acute necrotizing encephalopathy. The maximum ICP was 37 (19-59) mmHg and the minimum CPP was 38 (20-48) mmHg. ICP was elevated greater than 20mmHg in fourteen patients. ICP monitoring was monitored for a median of 6 (4-16) days.The median ICU stay was 19 (8-35) days. The PCPC score at the time of discharge was 2, 3, and 4 for five, two, eight patients, respectively. Patients with a poor outcome had higher maximum ICP (40 (16-59) vs.28 (18-31) mmHg, p<0.05) and sustained ICP over 20 mmHg for a longer duration (395 (33-3,600) vs.16 (0-188) min, p<0.05) than those with a favorable outcome. There were no significant differences in minimum CPP and the total time of sustained CPP below 40 mmHg between two groups.
Conclusion: In many children with acute severe encephalopathy, ICP is elevated to greater than 20 mmHg, and sustained in patients with poor outcome.

View full abstract

The patient was a 56-year-old woman, who was referred to our hospital from a local doctor for the treatment of epigastric pain and retroperitoneal hematoma. She was conscious and lucid at admission, with a blood pressure of 127/71 mmHg and pulse rate of 82/min. Abdominal dynamic CT revealed a well-delineated tumorous shadow of uniform density measuring 8 mm in diameter below the head of the pancreas and a surrounding retroperitoneal hematoma. Angiography showed a fusiform to saccular aneurysm in the anterior pancreaticoduodenal artery. The portion from the anterior superior pancreaticoduodenal artery and anterior inferior pancreaticoduodenal artery to the inferior pancreaticoduodenal artery was embolized with a microcoil. Oral intake was started from day 3, however, the patient developed vomiting on day 7; contrast-enhanced abdominal CT showed an expanded retroperitoneal hematoma, and upper gastrointestinal tract radiography revealed a stenotic segment extending from the descending to transverse part of the duodenum. We waited for spontaneous regression of the hematoma, but as obstruction persisted even after shrinkage of the hematoma, we performed a gastrojejunostomy on day 36. The patient was discharged on day 46. In cases of ruptured pancreaticoduodenal artery aneurysm, attention must be paid to the possibility of development of the complication of duodenal stenosis, even in cases where transcatheter arterial embolization is successful.

View full abstract

An unconscious 84-year-old female with a fever of 40°C, hypoxia and metabolic alkalosis was transferred to our hospital following intubation. Laboratory data after admission revealed hypercalcemia, while a chest CT showed consolidation with air bronchogram in the left lung. There were no abnormal findings in a brain CT. We considered the cause of unconsciousness to be hypercalcemia, complicated by aspiration pneumonia. Mechanical ventilation and antibacterial chemotherapy were provided. We postulated that milk-alkali syndrome (MAS) was the cause of the observed hypercalcemic crisis, since there were no findings of hyperparathyroidism or malignancy, and the patient had taken calcium and magnesium sulfate hydrate over a prolonged period. These agents were stopped and calcitonin and bisphosphonate were administered. Consciousness gradually improved, as did serum calcium level. The patient was extubated on the fifth day and transferred to the referring hospital on the sixth day. The incidence of MAS has gradually increased because there are many cases administered calcium for the treatment and prevention of osteoporosis and laxatives including magnesium (a weak alkali) for chronic constipation over long periods especially in elderly people. Consequently, when elderly patients are diagnosed with hypercalcemia, it is important to consider the possibility of MAS.

View full abstract

A post-marketing surveillance study reported fatalities following tissue plasminogen activator administration among acute cerebral infarction patients with acute aortic dissection (AAD). Acute physicians must distinguish between acute cerebral infarction and AAD in the emergency room. To distinguish these diseases, oral consultation a regarding pain and chest X-ray and ultrasound examination should be performed. However, it is difficult to distinguish AAD and acute cerebral infarction by these means alone. We experienced four patients with acute cerebral infarction with AAD. From these experiences, we considered diagnostic methods for AAD in patients with cerebral infarction. In all four patients, blood test results upon admission showed high level of fibrin/fibrinogen degradation products (FDP). Measurement of FDP may be useful for distinction between acute cerebral infarction and AAD in the emergency room.

View full abstract

A patient with primary peritonitis and empyema was diagnosed with group A streptococcal toxic shock-like syndrome, as reported here. A 70-year-old male complaining of back pain and a fever was diagnosed with acute pancreatitis by a previous physician based on an abdominal CT and referred to this hospital. Diagnostic criteria for acute pancreatitis, however, were not met and the patient was diagnosed with sepsis due to bacterial pneumonia and acute prerenal failure. Antibiotics were administered and vigorous volume replacement was provided. After admission, the patient’s condition was relatively stable but it gradually worsened. Despite combined-modality therapy, the patient deteriorated to multiple organ failure and disseminated intravascular coagulation on day 3 of hospitalization and died. Based on an autopsy and various cultures, the patient’s condition was ultimately diagnosed as group A streptococcal toxic shock-like syndrome. Primary peritonitis due to group A hemolytic streptococci is extremely rare. Seven cases have been reported in Japan, but none of those patients died. Peritoneal lavage and drainage have been performed and patients’ lives have been saved through combined-modality therapy in previous report.Whether the life of the patient in the current case could have been saved is discussed.

View full abstract

Acute spontaneous spinal epidural hematoma (ASSEH) is rare. The classical clinical symptom is acute onset of severe back pain, followed by the signs and symptoms of a rapidly evolving spinal cord compression. Early diagnosis is important and immediate treatment results good recovery. We encountered a case of ASSEH. A 49 -year-old man, he felt severe chest and back pain when he had been playing golf. He was transferred to our hospital and his severe chest and back pain was continued. He was in the absence of injury and anti-platelet drugs. At first, these findings suggested acute aortic dissection (AAD) but enhanced computed tomography did not reveal aortic dissection. Finally, we diagnosed ASSEH by magnetic resonance imaging (MRI). We treated him wit conservative therapy because his symptom was mild, and he got good recovery. This case presented a diagnostic challenge because his symptoms were similar to AAD and he did not have traumatic episode. This experience suggests that knowledge regarding ASSEH is important, and a health care personnel should be aware that ASSEH.

View full abstract

Heatstroke causes various complications, frequently resulting in hepatic and renal dysfunction. Altered consciousness, rhabdomyolysis, shock, disseminated intravascular coagulation (DIC), and multiple organ failure are observed in serious cases. DIC results from peripheral circulatory failure due to severe hypovolemia, heat-induced direct tissue and vascular endothelial cell damage, hypercytokinemia, bacterial translocation due to increased permeability of the intestinal mucosa, and hemorrhagic diathesis caused by hepatic dysfunction-induced decreased coagulation factor synthesis. Standard anticoagulant therapy protocols have not yet been established for DIC due to heatstroke. We treated two patientsof heatstroke-induced DIC with recombinant thrombomodulin alpha (rTM). Both patients were elderly and had classical heatstroke. They were stuporous and developed hepatic and renal dysfunction. Their scores based on the Japanese Association for Acute Medicine criteria for DIC diagnosis were 5 and 7 points, respectively. They received anticoagulation therapy. They were administered rTM monotherapy, and rTM with gabexate mesilate combination therapy, respectively. The condition of both the patients improved without hemorrhagic complications, and they recovered from DIC ondays 5 and 14 after admission, respectively. They were transferred to different hospitals ondays 57 and 27 after admission, respectively, without side effects. Therefore, we suggest that rTM therapy is effective for heatstroke-induced DIC.

View full abstract