Post-traumatic hypopituitarism: report of a child case.

Case: We report a case of post-traumatic hypopituitarism in a 9-year-old boy who was injured in a car accident. Outcome: Post-traumatic hypopituitarism might be caused by moderate to severe head trauma, and while this possibility has recently drawn attention in adults, few reports are available regarding children. Our patient experienced head and facial injury, resulting in post-traumatic hypopituitarism. Six hours after injury he suffered from diabetes insipidus and hormone replacement therapy was started. On day 12 he underwent facial fracture reduction under general anesthesia. On day 24 he was discharged from the hospital. One year after the injury, secretory function and water dehydration tests suggested the possibility of post-traumatic hypopituitarism. Conclusion: We experienced a child case of post-traumatic hypopituitarism. Emergency physicians should pay attention to the possibility of post-traumatic hypopituitarism in cases of traumatic brain injury.

Massive hemothorax due to inferior phrenic artery injury after blunt trauma.

Injury to the inferior phrenic artery after blunt trauma is an extremely rare event, and it may occur under unanticipated conditions. This case report describes an injury to the left inferior phrenic artery caused by blunt trauma, which was complicated by massive hemothorax, and treated with transcatheter arterial embolization (TAE). An 81 year-old female hit by a car while walking at the traffic intersection was transferred to the emergency department, computed tomography scanning revealed active extravasations of the contrast medium within the retrocrural space and from branches of the internal iliac artery. The patient underwent repeated angiography, and active extravasation of contrast medium was observed between the retrocrural space and the right pleural space originating from the left inferior phrenic artery. The injured left inferior phrenic artery was successfully embolized with N-butyl cyanoacrylate, resulting in stabilization of the patient's clinical condition. Inferior phrenic artery injury should be recognized as a rare phenomenon and causative factor for hemothorax. TAE represents a safe and effective treatment for this complication and obviates the need for a thoracotomy.

Study on the Effectiveness of Cardiopulmonary Resuscitation in Elderly Patients Presenting with Cardiopulmonary Arrest on Arrival.

OBJECTIVE: This study was conducted to determine whether a policy of not attempting to resuscitate patients who are 80 years of age and older with cardiopulmonary arrest on arrival is justifiable. METHODS: The protocol of this study was approved without the need for informed consent by the research ethics board of Gunma University Hospital. We prospectively analyzed patients with cardiopulmonary arrest on arrival that was due to an intrinsic reason who were taken to Gunma University Hospital between January 2013 and March 2014. The patients were divided into two groups: patients who were less than 80 years of age (L group) and those aged 80 years and older (H group). We compared the patients' characteristics, including the etiology of cardiac arrest, and the prognosis between the two groups. RESULTS: A total of 103 patients with cardiopulmonary arrest on arrival were enrolled. There were no significant differences in the patients' characteristics, such as age, sex, witness and bystander cardiopulmonary resuscitation, and transportation time between the two groups. The return of spontaneous circulation was obtained in 14 patients (25.5%) in the L group and in 9 patients (18.8%) in the H group; however, no significant difference was seen between the two groups. Two patients in the L group were in good neurological condition when they were discharged; however, the other patients did not survive. CONCLUSION: Even patients 80 years of age and older can be resuscitated to spontaneous circulation. We do not endorse a policy that recommends not performing cardiopulmonary resuscitation based solely on the age of the patient.

A case of Trousseau syndrome caused by pulmonary adenocarcinoma that was controlled for one year and 10 months with thrombosis treatment using an EGFR tyrosine kinase inhibitor and chemotherapy.

A 47-year-old female with no history of previous illnesses developed cerebral infarction and was diagnosed with lung cancer, specifically EGFR mutation-positive adenocarcinoma, and Trousseau syndrome. The patient's response to anticoagulant therapy with non-fractionated heparin was very poor; however we were able to control the thrombosis with chemotherapy. She survived for one year and 10 months following treatment with gefitinib, CBDCA + PEM and erlotinib, without recurrence of thrombosis. Trousseau syndrome carries a poor prognosis and controlling thrombosis is difficult. In this case, the administration of anticancer therapy allowed use to control the patient's thrombosis. Therefore, this case highlights the importance of treating cancer in patients with Trousseau syndrome. In addition, the FDP and D-dimer levels changed in parallel with changes in the CEA level, which suggests that the activity of cancer is related to an internal thrombotic tendency. Hence, changes in the FDP and D-dimer values are associated with the efficacy of treatment with EGFR tyrosine kinase inhibitors and chemotherapy and may function as markers of recurrence.

Model for predicting the injury severity score.

Aim: To determine the formula that predicts the injury severity score from parameters that are obtained in the emergency department at arrival. Methods: We reviewed the medical records of trauma patients who were transferred to the emergency department of Gunma University Hospital between January 2010 and December 2010. The injury severity score, age, mean blood pressure, heart rate, Glasgow coma scale, hemoglobin, hematocrit, red blood cell count, platelet count, fibrinogen, international normalized ratio of prothrombin time, activated partial thromboplastin time, and fibrin degradation products, were examined in those patients on arrival. To determine the formula that predicts the injury severity score, multiple linear regression analysis was carried out. The injury severity score was set as the dependent variable, and the other parameters were set as candidate objective variables. IBM spss Statistics 20 was used for the statistical analysis. Statistical significance was set at P < 0.05. To select objective variables, the stepwise method was used. Results: A total of 122 patients were included in this study. The formula for predicting the injury severity score (ISS) was as follows: ISS = 13.252-0.078(mean blood pressure) + 0.12(fibrin degradation products). The P-value of this formula from analysis of variance was <0.001, and the multiple correlation coefficient (R) was 0.739 (R2 = 0.546). The multiple correlation coefficient adjusted for the degrees of freedom was 0.538. The Durbin-Watson ratio was 2.200. Conclusions: A formula for predicting the injury severity score in trauma patients was developed with ordinary parameters such as fibrin degradation products and mean blood pressure. This formula is useful because we can predict the injury severity score easily in the emergency department.

Prognostic factors in emergency patients aged 90 years and older.

AIM: We evaluated the relation between general status on arrival and prognosis in patients aged 90 years and older who were admitted to our department through the emergency room, with the aim of assisting the development of a treatment policy for elderly people. METHODS: We retrospectively analyzed patients aged 90 years and older who were admitted to our department from January 2006 to September 2013. Patients were divided into two groups, patients who were discharged from our hospital or transferred to another hospital, and patients who died in our hospital. Comparisons of the patients' general status and the results of blood examinations were carried out between the two groups. Independent parameters to predict prognosis were also evaluated. RESULTS: Fifty-eight patients were enrolled in this study. The mean age was 93.2 ± 3.4 years (range, 90-106 years). Forty-five patients (77.6%) were discharged from our hospital (group A), and 13 patients (22.4%) died (group B). The percentage of patients with the inability to walk independently was significantly higher in group B. Mean arterial pressure, Glasgow Coma Scale (GCS), PaO2/FiO2 ratio, and serum albumin level on arrival were significantly better in group A. Multivariate logistic regression analysis indicated that the inability to walk independently (odds ratio, 22.4; 95% confidence interval, 4.4-113.1; P < 0.0001) and GCS (odds ratio, 7.0; 95% confidence interval, 1.8-27.7; P = 0.003) were the parameters to predict prognosis. CONCLUSION: The inability to walk independently and GCS (consciousness status) are the most sensitive predictors of prognosis in emergency patients aged 90 years and older.

Usefulness of serum fibrin degradation products and D-dimer levels as biomarkers to predict return of spontaneous circulation in patients with cardiopulmonary arrest on arrival: comparison with acid-base balance.

AIM: We evaluated the usefulness of fibrin degradation products and D-dimer levels in blood to predict return of spontaneous circulation in patients with cardiopulmonary arrest on arrival compared with anion gap and albumin-corrected anion gap. METHODS: We retrospectively reviewed the medical records of patients with cardiopulmonary arrest on arrival who had been transferred to the emergency department of our hospital in 2012. Patients were divided into two groups: patients with return of spontaneous circulation (ROSC(+) group), and those without (ROSC(-) group). The levels of anion gap, albumin-corrected anion gap, fibrin degradation products and D-dimer measured on arrival were compared between the two groups. RESULTS: Fifty-three patients could be analyzed. The anion gap and albumin-corrected anion gap levels were significantly better in the ROSC(+) group than in the ROSC(-) group (anion gap, 28.7 mmol/L [median] versus 39.1 mmol/L; albumin-corrected anion gap, 31.1 mmol/L versus 40.9 mmol/L). The fibrin degradation product and D-dimer levels were significantly lower in the ROSC(+) group than in the ROSC(-) group (fibrin degradation products, 32.1 µg/mL versus 157.4 µg/mL; D-dimer, 9.9 µg/mL versus 37.4 µg/mL). The area under receiver operating characteristic curves to evaluate the relationship with return of spontaneous circulation of anion gap, albumin-corrected anion gap, fibrin degradation products, and D-dimer were 0.664, 0.667, 0.714, and 0.707, respectively. CONCLUSION: Fibrin degradation products and D-dimer levels might be more useful as predictors of return of spontaneous circulation than anion gap and albumin-corrected anion gap.