Although cerebrovascular disorders (CVD) are rare complication during pregnancy and puerperium period, they may result in mortality or significant morbidity. An arterial aneurysm and an arteriovenous malformation are the most common causes of intracranial hemorrhage and the incidence of aneurysmal rupture will increase in relation to gestational age. The occurrence of cerebral infarction, on the contrary, will increase during the puerperium. The care of obstetric patients with CVD can be approached rationally. Both radiological examination and surgical intervention are safely undergone during all stages of pregnancy and should be taken place in precedence over obstetric consideration. Once a patient has an aneurysm clipped or a vascular malformation extirpated, vaginal delivery is safely performed unless there are obstetric indications for cesarean section. Conservative therapies may present many clinical dilemmas and drugs should be used at the minimal effective dose. Osmolar diuretics used to reduce intracranial pressure may cause fetal dehydration. Induced hypotention may reduce uterine blood flow. Both excessive hyperventilation with less than 25mmHg arterial carbon dioxide or deep hypothermia lower than 28 degree (C) in order to reduce intracranial pressure decrease uterine blood flow and jeopardize a fetus. Arterial blood pressure, intracranial pressure, and fetal heart rate should be monitored so far as possible. Delivery should be done in the optimal timing to obtain the best outcome of a fetus. In the case of brain-dead mother, however, raising a fetus under artificial life-support to wait its growth has the most controversial ethical issues.

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Electrolysis of 0.1% NaCl solution using an electrobath with a diaphragm between the anode and the cathode results in the formation of so-called elctrolyzed water in the anode side. This electrolyzed solution shows antimicrobial activity and the following physicochemical properties; low pH (2.2-2.7), marked elevation of oxidation-reduction potential (ORP>1, 100mV), dissolved oxygen (15ppm or higher) and available chlorine. The antimicrobial spectrum covers wide varieties of pathogens including multi-drug resistant bacteria like MRSA (Methicillin-resistant Staphylococcus aureus). The antimicrobial effect is due to HOCl (hypochlorous acid) formed by the reaction of H₂O and Cl₂ which results from the electrolysis of NaCl. Hydroxyl radical (·OH) is also detected and believed to play the important role in the antimicrobial activity. Since the electrolyzed solution is not commercially available because of chemical instability, on-site production is the choice at places where the sanitation or disinfection is necessary. The handling of the apparatus is by no means difficult since once tap water is induced to the apparatus, the process goes automatically. The electrolyzed water is quite useful in clinical situations; for example disinfection of hands, endoscopes, and rinsing bedsores or other kinds of wounds. The electrolyzed water has the advantage of safe and ease as a clinical disinfectant and is expected to widen its application. This article reviewed the formation, antimicrobial effect and its mechanism, and clinical application of the electrolyzed water.

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We compared the effects of intermittent mandatory ventilation (IMV) and pressure support ventilation (PSV) on the patient's spontaneous breathing and the work of breathing (WOB) of ventilated patients during the weaning from mechanical ventilation. A total of consecutive eighteen patients with radical esophagectomy was divided randomly into IMV group or PSV group by the method of weaning. The weaning from mechanical ventilation was performed by the gradual decreases of frequency of mandatory ventilation in IMV, or of support pressure level in PSV. The influence of IMV and PSV modes on patient was completely different, although the ventilator work decreased in the same fashion. The WOB in ventilated patients increased abruptly after the commencement of the weaning by IMV. On the other hand, the WOB during the weaning by PSV increased in a stepwise fashion. The WOB during the weaning by IMV was significantly higher than that during the weaning by PSV. High values of WOB in IMV were due to the fact that spontaneous breathing was completely established on the early stage of weaning and the mechanical assist of mandatory ventilation did not contribute to the reduction of WOB. The increases of imposed WOB and work for intrinsic PEEP were also involved in the higher WOB. PSV reduced WOB effectively and also loaded WOB in a stepwise fashion in the weaning from mechanical ventilation. We concluded that the weaning from mechanical ventilation by PSV has a definite usefulness compared with the weaning by IMV from the standpoint of WOB.

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Non-group A streptococcal infections usually occur in compromised hosts who are often in a life threatening condition, and have been associated with a toxic shock-like syndrome. We present a case of streptococcal toxic shock-like syndrome caused by group G Streptococcus in a patient with myelodysplastic syndrome. This patient, a 64-year-old male, suddenly went into septic shock as purulent myositis rapidly progressed involving his entire left thigh. S. equisimilis was detected from the infected muscle. After admission to the ICU, the patient was treated with the antibiotics (ampicillin/sulbactum, clindamycin) and immunoglobulins because of multiple organ dysfunction, which subsequently developed, but amputation of the left thigh was done. The patient completely recovered from multiple organ dysfunction and was discharged from the ICU on the sixth postoperative day. A pathologic examination of the specimen revealed purulent-necrotizing myositis of the entire left thigh. We realized that the progression of group G streptococcal infections may be as rapid and invasive as that of group A streptococci.

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We report two cases of methicillin-resistant Staphylococcus aureus (MRSA) respiratory infection in which Gram's stain procedure helped the medical staff in an ICU to identify the possible infection early. Two men, 67 (case 1) and 65 (case 2) years old, were admitted to our ICU for treatment of hypoxia caused by interstitial pneumonia. The patients showed bacterial respiratory infection during respiratory therapy, and cephalosporins were administered over a long period of time against gram-negative rods.
During the treatment with antibiotics, many gram-positive cocci and white blood cells with phagocytosis were identified by Gram's stain of the sputum, so ampicillin (case 1) or fosfomycin (case 2) was administered. However, after 24-48 hours, no changes were observed in the Gram's stain of the sputum. We suspected the existence of MRSA infection. In case 2, we started oral administration of vancomycin before identification by culture in the laboratory. When the MRSA respiratory infection was confirmed by the culture results from the laboratory, the Gram' s stain of the sputum was already negative.
This suggests that Gram's stain procedure may be useful for medical staff, especially in ICUs, to identify MRSA infections early and decide on the administration of the most effective antibiotics.

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People can suffer from traumatic asphyxia as a result of being trapped underneath heavy objects or due to traffic accidents. We treated a 71 year-old man with traumatic asphyxia that resulted from a tractor injury. The accident occurred in a vinyl green house supported by iron pipes. The patients chest region had gotten stuck between two iron pipes, and to further exacerbate the situation, the handlebar of the tractor, which had moved backward, compressed the anterior chest region, thus restricting the movement of his thoracic cage in three directions. At the time of rescue, he was in respiratory arrest and upon admission his consciousness level was assessed as being 7 (E2V1M4) according to the Glasgow coma scale. Hypothermia therapy was instituted. The clinical course of the patient was favorable. In the future, we will administer this therapeutic option in a more timely and aggressive manner in severe cases of hypoxic encephalopathy caused by traumatic asphyxia.

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A 20 year-old previously healthy woman was admitted because of chest discomfort, palpitation and hypotension. Excluding fulminant myocarditis, collagen disease and cardiomyopathy, finally she was diagnosed as having coronary arterial spastic disease from coronary angiography (CAG). CAG was normally visualized, but the acetylcholine (Ach) provocation test induced severe coronary spasm with chest pain and hypotension, leading to the rare diagnosis of vasospastic angina (VSA) in a young woman. A hypertension attack occurred after discharge, resulting in the detection of pheochromocytoma, which was removed surgically.
Two months later, another CAG showed an improvement of coronary spasticity to Ach. We were able to find, in the first time, VSA accompanied by pheochromocytoma in a patient using the Ach provocation test. Considering the change in coronary spasticity to Ach before and after the operation, we suggest that the high plasma concentration of catecholamines influenced coronary endothelium function in this patient.

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We report on a 49-year-old male patient with untreated alcoholic liver disease who presented with necrotizing soft tissue infection due to Aeromonas sobria. He complained of painful swelling in his upper and lower extremities after eating sushi. On admission, his systolic blood pressure was 92mmHg, heart rate 116·min^-1, and body temperature 39.8°C. The patient was confused, cyanotic, and icteric. Marked swelling was observed in all extremities. He had purpura with subcutaneous emphysema in the right femoral region and purpura with hemorrhagic bulla on the left lower extremity. The liver was palpable at three fingerbreadths. Gram-negative rods were detected from the biopsy tissues of the right femoral purpura and sputum. Because we suspected bacteremia and soft tissue infection from the presence of gram-negative rods, we began chemotherapy with imipenem, minocycline and hemo-adsorption, using polymyxin B-immobilized fibers for suspected endotoxemia. Despite extensive treatment with inotrops, antibiotics, hemo-adsorption, and hemofiltration, the patient went into acute renal failure and died 28 hours after admission to the ICU. Aeromonas sobria was isolated from cultures of the blood, sputum, and subcutaneous samples. Autopsy revealed soft tissue necrosis, segmental necrotizing gastroenteritis with bacterial colonies, and alcoholic liver cirrhosis. We would not usually expect the infecting organism of sepsis or soft tissue infection to be Aeromonas sobria in a patient with alcoholic liver cirrhosis. This case of soft tissue infection due to Aeromonas sobria with immunosuppression followed a severe clinical course, alerting us to the need for careful treatment of infections of this type.

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