Self-penile glans amputation: a report of two cases.

Case: Self-penile amputation, especially at the glans, has rarely been reported. Most reported cases of self-amputation were performed at the proximal or peripubic area, and there only one case of self-amputation at the glans has been reported in Japan. We report two cases of self-penile amputation at the glans. Case 1: A 31-year-old man with no psychiatric disease completely amputated his penis at the glans. He underwent a stump plasty under spinal anesthesia. Case 2: A 46-year-old man with schizophrenia amputated his penis at the glans. Surgery and the post-surgical course were almost the same as described in Case 1. Outcome: Both patients experienced few functional problems except for slight urinary stream disorders. Conclusion: A stump plasty is a good procedure to treat self-penile amputation at the glans. It is simple, quick, does not require special technical skills, and is not associated with serious complications.

Direct intrahepatic portocaval shunt for refractory hepatic hydrothorax: a case report.

Case: A 64-year-old man with complaints of dyspnea and orthopnea secondary to a hepatic hydrothorax refractory to diuretic medication underwent the transjugular intrahepatic portosystemic shunt (TIPS) procedure to decrease the portal vein pressure. The TIPS procedure failed due to severe liver stiffness. Direct intrahepatic portocaval shunt (DIPS), a modified TIPS procedure that directly inserts a stent from the inferior vena cava to the portal vein, was successfully carried out. Outcome: The DIPS procedure significantly decreased the patient's pleural effusion and respiratory symptoms. Conclusion: No other medical treatment is available to control refractory pleural effusion caused by portal hypertension; however, the TIPS (or DIPS) procedure can be successfully carried out in patients <60 years old with a Model of End-Stage Liver Disease score <15.

Noradrenalin effectively rescues mice from blast lung injury caused by laser-induced shock waves.

BACKGROUND: Blast lung injuries (BLI) caused by blast waves are extremely critical in the prehospital setting, and hypotension is thought to be the main cause of death in such cases. The present study aimed to elucidate the pathophysiology of severe BLI using laser-induced shock wave (LISW) and identify the initial treatment. METHODS: The current investigation comprised two parts. For the validation study, mice were randomly allocated to groups that received a single shot of 1.2, 1.3, or 1.4 J/cm(2) LISW to both lungs. The survival rates, systolic blood pressure (sBP), heart rate (HR), peripheral oxyhemoglobin saturation (SpO2), and shock index were monitored for 60 min, and lung tissues were analyzed histopathologically. The study evaluated the effects of catecholamines as follows. Randomly assigned mice received 1.4 J/cm(2) LISW followed by the immediate intraperitoneal administration of dobutamine, noradrenalin, or normal saline. The primary outcome was the survival rate. Additionally, sBP, HR, SpO2, and the shock index were measured before and 5 and 10 min after LISW, and the cardiac output, left ventricular ejection fraction, and systemic vascular resistance (SVR) were determined before and 1 min after LISW. RESULTS: The triad of BLI (hypotension, bradycardia, and hypoxemia) was evident immediately after LISW. The survival rates worsened with increasing doses of LISW (100 % in 1.2 J/cm(2) vs. 60 % in 1.3 J/cm(2), 10 % in 1.4 J/cm(2)). The histopathological findings were compatible with those of human BLI. The survival rate in LISW high group (1.4 J/cm(2)) was highest in the group that received noradrenalin (100 %), with significantly elevated SVR values (from 565 to 1451 dyn s/min(5)). In contrast, the survival rates in the dobutamine and normal saline groups were 40 and 10 %, respectively, and the SVR values did not change significantly after LISW in either group. CONCLUSIONS: The main cause of death during the initial phase of severe BLI is hypotension due to the absence of peripheral vasoconstriction. Therefore, the immediate administration of noradrenalin may be an effective treatment during the initial phase of severe BLI.

Resveratrol increases CD68⁺ Kupffer cells colocalized with adipose differentiation-related protein and ameliorates high-fat-diet-induced fatty liver in mice.

SCOPE: Resveratrol reportedly improves fatty liver. This study purposed to elucidate the effect of resveratrol on fatty liver in mice fed a high-fat (HF) diet, and to investigate the role of liver macrophages (Kupffer cells). METHODS AND RESULTS: C57BL/6 mice were divided into three groups, receiving either a control diet, HF diet (50% fat), or HF supplemented with 0.2% resveratrol (HF + res) diet, for 8 weeks. Compared with the HF group, the HF + res group exhibited markedly attenuated fatty liver, and reduced lipid droplets (LDs) in hepatocytes. Proteomic analysis demonstrated that the most downregulated protein in the livers of the HF + res group was adipose differentiation-related protein (ADFP), which is a major constituent of LDs and reflects lipid accumulation in cells. The HF + res group exhibited greatly increased numbers of CD68(+) Kupffer cells with phagocytic activity. Immunohistochemistry showed that several CD68(+) Kupffer cells were colocalized with ADFP immunoreaction in the HF + res group. Additionally, the HF + res group demonstrated markedly decreased TNF-alpha production, which confirmed by both liver mononuclear cells stimulated by LPS in vitro and in situ hybridization analysis, compared with the HF group. CONCLUSION: Resveratrol ameliorated fatty liver and increased CD68-positive Kupffer cells with downregulating ADFP expression.

Hypothermia does not hasten death during uncontrolled hemorrhagic shock presenting as the "triad of death" in rats.

Aim: The aim of this study was to investigate the effect of hypothermia on survival and coagulopathy in hemorrhagic shock presenting as the "triad of death". Methods: Sixteen rats were lightly anesthetized with halothane while maintaining spontaneous breathing. The triad of death was simulated by inducing hypothermia (32.0°C) with surface body cooling and hemodilution with replacement of 20 mL blood with 50 mL normal saline. Then, rats were randomly assigned to one of two rectal temperature groups (n = 8/group: group 1, rewarming to 37.0°C; group 2, maintenance at 32.0°C) and subjected to hemorrhagic shock initiated by amputation of the tail at 75% of its length. The rats were then observed for survival time without fluid resuscitation. Blood coagulability with Sonoclot analysis was also assessed. Results: The triad of death status was considered as being induced at a rectal temperature of 32°C, arterial pH of 7.22, and deteriorating coagulating values. At 45 min after randomization, Sonoclot analysis revealed prolonged activated clotting times of 355 ± 131 s and "time to peak" of 23 ± 9 min in group 2, compared to 228 ± 64 s and 12 ± 1 min (P < 0.05) in group 1, respectively. Kaplan-Meier curves showed longer survival in group 2 than group 1 (P = 0.06). Conclusions: Compared to rewarming, hypothermia aggravates coagulation parameters, but does not hasten death during untreated hemorrhagic shock presenting as the triad of death.

Community-acquired lobar pneumonia caused by Pseudomonas aeruginosa infection in Japan: a case report with histological and immunohistochemical examination.

Pseudomonas aeruginosa is a common pathogen in nosocomial and/or healthcare-associated pneumonia, but is rare in community-acquired pneumonia. A 50-year-old previously healthy woman was taken to the emergency department because of rapidly progressing dyspnea. Chest radiograph showed consolidation of the entire right upper lobe, a finding suggestive of lobar pneumonia. The patient died of respiratory failure with bronchial bleeding, on the same day of admission. Autopsy revealed that the alveoli throughout the upper right lobe were filled with dense inflammatory cells mainly consisting of macrophages and neutrophils. Immunoreactive bacilli by using an anti-P. aeruginosa antibody were localized within macrophages accumulated in the alveoli as well in the vessel walls. Lobar pneumonia composed of dense neutrophils and bacteria-laden macrophages with total lung congestion and edema may be characteristic for community-acquired P. aeruginosa pneumonia in a healthy adult.

Detection of changes in the structure and distribution map of triacylglycerol in fatty liver model by MALDI-SpiralTOF.

Matrix-assisted laser desorption/ionisation spiral orbit-type time-of-flight mass spectrometry (MALDI-SpiralTOF) can analyse lipid profiles and characterise lipid structure. Imaging mass spectrometry (IMS) also provides distribution maps of selected m/z values. Here, we investigated triacylglycerol (TG) structure and distribution using these technologies to estimate mouse fatty liver. The distribution and intensity of the most intense mass spectrum ion was indicated by IMS at m/z 881.7 (52:2). Analysis using MS/MS showed a structural change between liver TG and dietary TG. These findings suggest that MALDI-SpiralTOF is a powerful tool for clinical screening and estimating fatty liver.

Characteristics of patients that experience cardiopulmonary arrest following aortic dissection and aneurysm.

AIM: The aim of this study is to investigate the characteristics of patients experience cardiopulmonary arrest (CPA) in the acute phase following aortic dissection and aneurysm (AD). MATERIALS AND METHODS: Patients who were transported to this department from January 2005 to December 2010 and subsequently diagnosed with AD were included in this study. Patients with asymptomatic AD or those with AD that did not develop CPA were excluded. The AD was classified into four categories: Stanford A (SA), Stanford B (SB), thoracic aortic aneurysm (TAA) and abdominal aortic aneurysm (AAA). The frequency of witnessed collapse, gender, average age, past history including hypertension, vascular complications and diabetes mellitus, the initial complaint at the timed of dissection, initial electrocardiogram at scene, classification of CPA and survival ratio were compared among the patient groups. RESULTS: There were 24 cases of SA, 1 case of the SB, 8 cases of ruptured TAA and 9 cases of ruptured AAA. The frequency of males among all subjects was 69%, the average age was 72.3 years old and the frequency of hypertension was 47.6%. There was no ventricular fibrillation (VF) when the patients with AD collapsed. A loss of consciousness was the most common complaint. The outcome of the subjects was poor; however, three patients with SA achieved social rehabilitation. Two out of the three had cardiac tamponade and underwent open heart massage. CONCLUSION: The current study revealed that mortality of cardiac arrest caused by the AD remains very high, even when return of spontaneous circulation was obtained. VF was rare when the patients with AD collapsed. While some cases with CPA of SA may achieve a favorable outcome following immediate appropriate treatment.

Hemodilution as a result of aggressive fluid resuscitation aggravates coagulopathy in a rat model of uncontrolled hemorrhagic shock.

BACKGROUND: The relationship between dilution caused by fluid resuscitation and blood coagulability during ongoing, uncontrolled hemorrhagic shock (UHS) remains unclear. We hypothesized that dilution caused by fluid resuscitation may impair blood coagulability in UHS. METHODS: Eighteen rats underwent under halothane anesthesia. The UHS model consisted of the following phases: (1) an initial blood withdrawal of 2.5 mL per 100 g during 15 minutes, followed by UHS via tail amputation and fluid resuscitation with lactated Ringer's (LR) solution (0-60 minutes); (2) hemostasis and reinfusion of withdrawn blood and additional LR solution (60-100 minutes); and (3) observation of awake rats for 72 hours. Rats were randomized into three resuscitation regimens (n = 6 per group) during Phase I. LR solution was infused at a rate of 0.1 mL/min in Group 1, 0.25 mL/min in Group 2, and 0.75 mL/min in Group 3. Blood coagulability was assessed with a Sonoclot analysis, and survival to 72 hours were compared between groups. RESULTS: Both resuscitation regimens of Groups 2 and 3 increased the blood pressure and bleeding volume from the tail stump compared with Group 1 (p < 0.05). At the end of Phase I, the hematocrit decreased to 29% (3%) in Group 1, 23% (3%) in Group 2, and 12% (3%) in Group 3 (p < 0.05). Sonoclot analysis revealed a decreased clot rate of 16 (9) clot signal per minute in Group 2 and 14 (10) clot signal per minute in Group 3 compared with Group 1 (40 [10] clot signal per minute; p < 0.01). There was a significant correlation between clot rate and hematocrit values (r = +0.67, p < 0.01). Compared with Group 1, survival improved in Groups 2 and 3 (p < 0.05). CONCLUSION: In a rat model of UHS, aggressive fluid resuscitation aggravated hemodilution and blood coagulability as well as and bleeding but improved the hemodynamics and survival. There was a positive correlation between hemodilution and coagulation indexes. Hemodilution, as part of fluid therapy, may affect coagulopathy in UHS.

The epidemiological findings and characteristic ground glass appearance on chest CT among patients with blunt lung injury.

AIM: To clarify the epidemiological findings and characteristics of ground glass lesions on chest computed tomography (CT) after blunt trauma. SETTING AND DESIGN: A medical college hospital and retrospective study. MATERIALS AND METHODS: We retrospectively investigated all blunt chest trauma patients who were admitted from January 2004 to December 2010. The inclusion criteria were patients with: (1) chest CT examination on arrival, (2) intrathoracic traumatic lesions confirmed by initial CT, and (3) a second chest CT examination within 7 days from admission. We divided the subjects into two groups. A GG group included subjects who had ground glass lesions on initial chest CT and a control group included subjects who did not have the ground glass appearance. RESULTS: The average age in the GG group was significantly lesser than that in the control group. The ratio of improvement for the value of SpO(2)/FiO(2) between on arrival and the second hospital day and ratio of improvement for CT findings between on arrival and the second CT examination in the GG group was greater than in the control group. CONCLUSION: The ground glass appearance on chest CT after blunt trauma was not rare, and the patients with ground glass lesions were younger and tended to have a better improvement of oxygenation and CT images in comparison with the patients without these characteristic lesions.

Results of single burr hole drainage for acute subdural hematoma with non-reactive pupil.

AIM: To investigate the effects of emergency burr hole drainage for acute subdural hematoma (ASDH) with bilateral non-reactive pupils. MATERIAL AND METHODS: A retrospective study was conducted by reviewing medical records from 1998 to 2007. Patients meeting the following criteria were included: 1) head injury with unconsciousness (Glasgow Coma Scale score 8); 2) bilateral non-reactive pupils on arrival; 3) ASDH with disappearance of basal cistern on computed tomography (CT); and 4) performance of emergency single burr hole drainage. Subjects were divided into survival and non-survival groups. RESULTS: Pupil size on the small side was significantly smaller in the survival group than in the non-survival group. All pupils on the small side in the survival group were 4 mm. CONCLUSION: Emergency burr hole drainage should still be considered in patients with ASDH showing bilateral non-reactive pupils and one pupil 4 mm.

A case of degloving injury of the colon.

The left side of a truck driven by a 71-year-old man was hit by another car at an intersection, and his abdomen was compressed by the steering wheel. On arrival, he complained of severe lower abdominal pain; and physical examination demonstrated involuntary rigidity and rebound tenderness. Enhanced truncal computed tomography exhibited that the descending colon was shifted ventral and medial because of a low-density mass with contrast extravasation. An emergency laparotomy disclosed injuries of the descending colon, which could be mobile because of degloving of the colon, left mesenterium, spleen, and tail of pancreas. During resection of these injured organs, difficulty in controlling the bleeding from the degloving injury site resulted in the requirement of a "second look" operation. The postoperative course was eventful; however, the patient's physiologic condition stabilized, and he was discharged on foot on the 108th hospital day.

Hypothermia reduces resuscitation fluid volumes required to maintain blood pressure in a rat hemorrhagic shock model.

OBJECTIVE: To examine the hypothesis that resuscitative hypothermia would (1) reduce fluid requirements and reactive oxygen species production during a period of resuscitation and (2) improve survival after hemorrhagic shock (HS) in rats. METHODS: Sixteen rats underwent an HS phase (phase I: 0-75 minutes), with pressure-controlled HS at a mean arterial pressure of 30 mm Hg ± 5 mm Hg; a resuscitation phase (phase II: 75-150 minutes), with fluid resuscitation to maintain mean arterial pressure ≥75 mm Hg; and an observation phase (phase III: from 150 minutes to 72 hours). During phase II, eight rats were randomized into a normothermia group (group 1: 38°C) or a hypothermia group (group 2: 34°C). Fluid requirements during phase II and survival at 72 hours were compared between groups. Plasma levels of Vitamin E and %coenzyme Q9 (%CoQ9) were also assessed. RESULTS: The fluid requirement during resuscitation in phase II was 8.2 ± 1.4 mL/100 g in group 1 versus 2.1 mL/100 g ± 0.7 mL/100 g in group 2 (p < 0.01). Vitamin E level decreased to 10.8 µmol/L ± 1.8 µmol/L during HS in all rats. After resuscitation, it was restored to a baseline level of 15.9 µmol/L ± 3.1 µmol/L in group 2 but remained at 10.2 µmol/L ± 0.8 µmol/L in group 1 (p < 0.05). %CoQ9 did not differ significantly between the groups. At 72 hours, six of eight rats in group 1, and all rats in group 2 survived (NS). CONCLUSION: In a rat HS model, hypothermia during resuscitation from HS reduces resuscitation fluid volume required to maintain blood pressure and restores Vitamin E to the baseline level, and appears to have no adverse impact on long survival after HS.

[Investigation of the Hounsfield number of drugs in stomach using computed tomography in vitro].

BACKGROUND: A high density area (HDA) that may represent ingested drugs was detected in the stomach of a patient with a drug overdose (OD) by computed tomography (CT). However, there is no prior evidence that drugs can be visualized as an HDA by abdominal CT. We investigated whether drugs can be imaged as an HDA by CT. METHODS: Ten tablets, 5 tablets, 1 tablet and 0.1 tablet of either Solanax (0.4 mg) or Depas (0.5 mg) or Tryptanol (10 mg) or Paxil (10 mg) or Wintermin (25 mg) or Phenobal (30 mg) or Hiberna (25 mg) were each added to 10 ml of artificial gastric juice. We then measured the Hounsfield numbers immediately after mixing, 1 hour later and 7 hours later using CT images. RESULTS: All of the drugs precipitated in the artificial gastric juice and these precipitations were imaged as HDAs over 100 Hounsfield units. Moreover, the drugs maintained high Hounsfield numbers after 7 hours although there was a trend to decrease sequentially. CONCLUSION: We demonstrated that the precipitated drugs in the artificial gastric juice could be imaged as HDAs by CT.

Usefulness of computed tomography in the diagnosis of an overdose.

Computed tomography (CT) is superior for the detection of substances with low radiolucency in comparison with abdominal roentgenograms. In the present study, medical chart review was retrospectively performed for patients who were admitted and underwent plain CT including the stomach on arrival to investigate whether CT is useful for diagnosing overdose (OD). The subjects were divided into patients with OD who did not undergo gastric lavage (OD group) and those without OD (Control group). The presence of a radiopaque area (Hounsfield number over 100 on a range of interest of 3 mm2) in the stomach on CT was defined as a positive finding. The average Glasgow Coma Scale in the OD group (n=11) was significantly lower than that in the Control group (n=137). Positive findings on CT were found more frequently in the OD group than in the Control group (100 vs. 19.7%, p＜0.0001). Based on the finding of a high-density deposition in the bottom of the stomach, the CT predicted OD with 98.5% specificity. Accordingly, CT findings of a high-density deposition in the stomach of a patient with a diminished consciousness may suggest the presence of a recent overdose.

Significance of minor traumatic lesions in focal head injuries.

We investigated the significance of minor traumatic lesions associated with focal head injuries. Patients included in the study were admitted between January 2003 and December 2007 and had sustained a head injury with focal injury and undergone MRI examination including T2(∗)-weighted imaging. Patients were divided into two groups: (i) a T2(∗)-positive group - those who had hypointense lesions at sites other than the original injury site as shown by T2(∗)-weighted MRI (n=12); and (ii) a control group without hypointense lesions at sites other than the original injury (n=25). The median Glasgow Outcome Scale score was significantly lower in the T2(∗)-positive group (median=4; range=4-5) than in the control group (median=5; range=4-5; p=0.003). We conclude that patients with a focal head injury and minor traumatic lesions are likely to have a poorer prognosis than patients without additional minor traumatic lesions.

A case of thoracic degloving injury with flail chest.

A 75-year-old male patient suffered a chest degloving injury when he fell on his back and was run over by a small farm tractor he was pulling. At the time of patient admission, the paradoxical motion of the right chest wall was remarkable; and he had an open fracture of the right humerus, a dislocation of the right ankle, and a laceration of the right forearm. Chest computed tomography revealed fractures of the fifth to seventh ribs and detachment of both the right pectoralis major muscle and serratus anterior muscle from the chest wall, with a disconnected right thoracic cavity. Because the right flail chest was severe and there was a large amount of air leakage that continued under positive-pressure ventilation for pneumatic stabilization, we performed surgical fixation of the ribs and repaired the lung injury on the fifth hospital day. The patient's postoperative course was uneventful.

Effects of arterial oxygen content on oxidative stress during resuscitation in a rat hemorrhagic shock model.

OBJECTIVE: To examine whether reactive oxygen species (ROS) production is affected by arterial oxygen content (CaO(2)) in attempted resuscitation to restore blood pressure from hemorrhagic shock (HS) or not. METHODS: Under light anesthesia and spontaneous beating, 16 rats underwent HS for 80min, during which 3.0mL/100g of blood was withdrawn, followed by resuscitation attempt for 70min. At 80min, rats were randomized into a high-CaO(2) group (Group 1, transfusion under fractional inspired oxygen (F(I)O(2)) of 1.0, n=8) or a low-CaO(2) group (Group 2, fluid administration under F(I)O(2) of 0.21, n=8). In each group, either blood or lactate Ringer's (LR) solution was infused to maintain mean arterial pressure ≥75mmHg under each F(I)O(2) concentration. CaO(2), O(2) utilization coefficient (UC) and plasma %CoQ9 were compared between groups. RESULTS: Mean infused volume for attempted resuscitation was 7.6±1.0mL of blood in Group 1, and 31.4±5.5mL of LR solution in Group 2. At the end of resuscitation, CaO(2) was 18.5±1.2 vol% in Group 1, almost double the 9.1±0.8 vol% in Group 2 (P<0.01). O(2) UC and %CoQ9 in all rats increased from baselines of 0.25±0.12 and 7.6±1.8% to 0.44±0.13 and 9.7±1.8% after resuscitation, respectively (P<0.05 vs. baseline for each), but did not differ significantly between the groups. CONCLUSION: In a rat HS model, attempted resuscitation to restore blood pressure increased O(2) UC as well as %CoQ9. However, the magnitude of %CoQ9 increase that represents ROS production is not affected by CaO(2) during resuscitation from HS.