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OBJECTIVE: To evaluate the hypothesis that the extent of corpus callosum injury indicates the depth of shearing lesions in the central brain structure and therefore relates to the clinical severity of diffuse axonal injury. METHODS: A simple and objective procedure for semiquantitative analysis of magnetic resonance images (MRI)-the maximum signal intensity ratio (MSIR)-was employed prospectively in 21 patients with diffuse axonal injury but without apparent injury to the ventral pons. All were diagnosed using serial combination MRI scans of fluid attenuated inversion recovery (FLAIR) and T2* weighted gradient echo imaging during the initial two weeks after the injury. The signal intensity ratio between the two regions of interest-the corpus callosum and the normal appearing ventral pons-was calculated serially in mid-sagittal and parasagittal FLAIR image sections in each patient. The MSIR during the study period was determined as a semiquantitative index of corpus callosum injury in each patient. The correlations between MSIR and the duration of unconsciousness, Glasgow outcome scale at six months, and the presence of apparent midbrain injury were investigated. RESULTS: The mean (SD) MSIR value was 1.12 (0.18) at 7.4 (3.1) days after the injury (n = 21). MSIR correlated strongly with the duration of unconsciousness (n = 19, R(2) = 0.74, p < 0.0001), and was higher in patients with both an unfavourable GOS outcome (p = 0.020) and apparent midbrain injury (p < 0.001). CONCLUSIONS: MSIR, which is a simple and objective procedure for semiquantitative analysis of corpus callosum damage in diffuse axonal injury, correlated with clinical severity. A high MSIR value may indicate the presence of concomitant midbrain injury.

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The risk of envenomations by venomous exotic spiders have not been well recognized in Japan. Two cases of finger bite from Asian pet tarantula, Haplopelma lividum (Cobalt blue), are reported. In both cases, initial severe pain and inflammatory signs were completely healed with only symptomatic treatments within several hours. In one case, arthritic stiffness lasted for a few weeks following bite but resulted no permanent deficit. Bites from Haplopelma lividum seemed relatively harmless like other various tarantulas, although the composition of the venom has been unknown.

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The aim of this study was to evaluate the effects of combination psychotropic drug treatment on heart rate variability (HRV), which was mainly controlled by the parasympathetic nervous system. Mean R-R intervals (mRR) and coefficient of variation (CV), an index of HRV, were studied in 22 psychiatric patients and 21 age- and sex-matched healthy controls. Next, in the patient group focusing on both anticholinergic and antidopaminergic properties, combination psychotropic drug daily doses were converted into biperiden milligram equivalents (BPDeq) and chlorpromazine milligram equivalents (CPZeq), respectively. The relationship between mRR and CV and these equivalent dosages was examined. A significant reduction in both mRR (P < 0.05) and CV (P < 0.05) was found in the patient group. In addition, significant negative correlations were observed between the dose of BPDeq and mRR (P < 0.05), and between the dose of BPDeq and CV (P < 0.005). In contrast, no significant correlations were observed between the dose of CPZeq and either parameter. These findings suggest that the effects of combination psychotropic drug treatment on HRV are mainly due to their anticholinergic properties. Therefore, CV is a useful indicator to assess the parasympathetic activity of psychiatric patients under combination psychotropic drug treatment.

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The present paper examines Typus melancholicus (TM), which is widely accepted as premorbid personality of depression in Germany and Japan, from the view-point of the five-factor model of personality, which has recently been gaining international popularity as the comprehensive model of personality traits. Two measures of TM, von Zerssen's F-list and Kasahara's scale, as well as the personality questionnaire for the five-factor model, NEO Five Factor Inventory, were completed for 140 consecutive psychiatric outpatients by their close relatives. It was found that (a) the two measures of TM had good internal consistency reliability, (b) they had reasonable concurrent validity, and (c) TM was characterized by high Conscientiousness, high Agreeableness and, to a lesser degree, high Extraversion. The results were largely in agreement with theoretical prediction and provide further support to the construct validity of the TM measures. Whether combining the three personality traits into one type is meaningful in depicting a particular premorbid personality constellation awaits further empirical examination.

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We report four patients in whom gas was seen in the head on CT shortly after cardiopulmonary resuscitation. The gas was in the posterior cranial fossa, presumably within veins, or in the cavernous sinus. The cause of the cardiac arrest was myocardial infarction in three patients and hanging in one. All had peripheral or central venous lines. The mechanism by which gas appeared in the intracranial veins is discussed.

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We report a case of colonic type adenocarcinoma of the appendix with perforating peritonitis in a 92-year-old man. The preoperative diagnosis was localized peritonitis due to acute appendicitis and emergency laparotomy was performed. A gray, hard tumor was palpated at the base of the appendix. Appendiceal cancer was suspected, and right hemicolectomy was performed. The histopathological diagnosis was moderately differentiated adenocarcinoma of the appendix. The tumor obstructed the orifice of the appendix, and this may have caused the perforation of the appendix. The patient had an uneventful postoperative course and there have been no signs of recurrence in the 2 years since the operation.

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OBJECTIVE: To investigate plasma concentrations of adrenomedullin in patients with septic shock and the potential association of these concentrations with relaxation of vascular tone. DESIGN: Prospective, case series. SETTING: Department of Emergency and Critical Care Medicine, Nara Medical University. PATIENTS: Twelve patients who fulfilled the clinical criteria for severe sepsis or septic shock (as defined by the Members of the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference Committee) and 13 healthy volunteers. INTERVENTIONS: Arterial blood samples were obtained via a 20-gauge cannula inserted into each patient's radial artery. MEASUREMENTS AND MAIN RESULTS: After extraction and purification, plasma adrenomedullin was measured by radioimmunoassay. Systemic vascular resistance index, pulmonary vascular resistance, cardiac index, and stroke volume index were determined with a thermodilution catheter. The mean plasma concentration of adrenomedullin was markedly higher in patients than in controls (226.1 +/- 66.4 [SEM] vs. 5.05 +/- 0.21 fmol/mL, p < .01). Moreover, these concentrations correlated significantly with cardiac index, stroke volume index, and heart rate values, and correlated significantly with decreases in diastolic blood pressure, systemic vascular resistance index, and pulmonary vascular resistance index values. CONCLUSIONS: Enhanced production of adrenomedullin in patients with septic shock may contribute to reduced vascular tone, hypotension, or both. More data are needed to clarify the role of adrenomedullin in the regulation of vascular tone in this patient population.

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The number of stimulant-drug addicts has recently been on the rise again, and they are being increasingly encountered in the emergency room. There are also frequent reports of cerebrovascular disorders complicating drug toxicity. These cerebrovascular disorders have included subarachnoid hemorrhage, intracranial hematoma, and a few cases of cerebral infarction. Here, we report the case of a 37-year-old male with drug toxicity, consciousness disorder, and hyperthermia. He was in a coma with a temperature of 43.1 degrees C and blood pressure of 58/35 mmHg when brought to our hospital. His condition worse rapidly deteriorated, and he died the same day. Cerebral infarction caused by gram-positive bacillus embolism, not necrotizing angiitis, was found at autopsy. Because drug addicts, especially stimulant-drug addicts, tend to inject themselves drug under unsanitary conditions, the possibility of this type of complication is always present. This is the first such case ever reported, and is therefore regarded as a rare complication of stimulant-drug intoxication.

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It is difficult to save a patient with acute cardiac free wall rupture due to blunt trauma; only 9 patients abroad and 2 patients in Japan are reported to have survived rupture of the left ventricle. A 30-year-old female was injured in a motor-vehicle accident. Distension of the neck vein, chest X-P and echocardiograms suggested cardiac tamponade due to cardiac rupture. After relieving the cardiac tamponade by left thoractomy, ruptures at the apex of the left ventricle and two sites in the right atrium could be repaired by median sternotomy, and the patient survived the injury. Cardiac rupture should be suspected in all cases of blunt trauma, and the early diagnosis of cardiac tamponade is a key to patient survival. Echocardiography is especially convenient and useful for the diagnosis of this condition. Repair should be performed by median sternotomy and the potential necessity for cardiopulmonary bypass should not be ignored.

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We describe the complications of pericardiocentesis and their management in an 18 year-old man. This patient was admitted because of dyspnea and was found on echocardiogram to have cardiac tamponade with coexisting left ventricular dysfunction. He developed acute left ventricular failure with severe pulmonary edema immediately after pericardiocentesis. This complication may have been caused by an abrupt increase in venous return to the failing left ventricle following the release of the pericardial compression. Therefore, pericardial fluid must be drained with caution in pericardiocentesis, especially in cardiac tamponade patients with left ventricular dysfunction, and hemodynamics should be monitored both during and after this procedure.

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A 63-year-old man (case 1) was brought to our emergency unit following a high speed collision. He developed fatal cardiopulmonary arrest shortly after arrival despite resuscitation efforts. Tension pneumopericardium was revealed by chest X-ray and CT examination. An 18-year-old man (case 2) was admitted after a motorcycle accident. Pneumopericardium was noted on admission chest X-ray and CT examination. He developed cardiac tamponade after the examination. He was intubated and mechanically ventilated after the subxiphoid pericardial drainage. Pneumopericardium following blunt chest trauma is realized with tracheobronchial, pulmonary or esophageal injury. The clinical significance of pneumopericardium is the development of tension pneumopericardium resulting into cardiac tamponade. In a patient with traumatic pneumopericardium who requires mechanical ventilatory support, continuous pericardial drainage should be considered. In addition, tension pneumopericardium may occur in patients with breathing spontaneously as in our cases. In these cases, careful observation and immediate subxiphoid pericardial drainage are required.

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A gastric hemorrhage in a patient with pseudoxanthoma elasticum (PXE) is reported. A 44-year-old woman was admitted to our hospital with hematemesis. Bleeding point was located at upper body of the stomach. As neither endoscopic alcohol injection nor operative hemostasis by over sewing under gastrotomy were unsuccessful, total gastrectomy was performed. Histologic examination of the stomach revealed fragmentation of elastic fiber in the internal lamina of arteriole and degeneration of muscle layer. This change was observed fundamentally in all specimens obtained from different region of the stomach. In addition to describing clinical and pathological feature of this case, the management of gastric hemorrhage in patients with PXE is discussed.

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The effect of therapy for hyponatremia with central origin (cerebrovascular disease and head injury) was investigated in order to examine contributing factors. Out of a total of 58 subjects admitted to the hospital during the previous three years with cerebrovascular disease (49 cases), and head injuries (9 cases), hyponatremia with central origin occurred within 2 weeks. Special treatment for hyponatremia was not given in 30 of the 58 cases (control group). The group (28 cases) which underwent therapy was optionally selected in terms of the following-SIADH, natriuretic polypeptide involvement and sick cells resulting from Na-K pump disorder. These 28 cases were classified into subgroups: water restricted (7 cases), hypertonic NaCl load (9 cases), glucose/insulin/potassium (GIK) therapy (4 cases), phenytoin administration (8 cases). In all of the 58 patients, the serum sodium, potassium and osmolarity and urinary sodium and potassium were measured daily. The balance of water, sodium and potassium were calculated on hyponatremic phase. Plasma levels of such hormones as antidiuretic hormone, aldosterone and cortisol were measured on hyponatremic phase. For each group, onset day and duration of hyponatremia and lowest sodium value were investigated for the sake of comparison. No significant difference for onset day and lowest sodium value was found between each group. Duration was as follows: control group 9.4 +/- 3.3 days, water restricted 7.4 +/- 2.1 days, hypertonic NaCl load 3.3 +/- 1.4 days, GIK therapy 7.3 +/- 2.9 days and phenytoin administration 8.9 +/- 3.7 days. Hypertonic NaCl load indicated a significantly shorter duration compared with the other groups. Hypertonic NaCl load was found to be most effective for hyponatremia with central origin.(ABSTRACT TRUNCATED AT 250 WORDS)

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To study the protective effect of phenytoin on postischemic brain damage, total cerebral ischemia was produced for 8-12 min (aortic occlusion balloon catheter method) in 36 adult mongrel dogs. The regional cerebral blood flow (rCBF), sodium:potassium ratio in the cerebral cortex, electroencephalogram (EEG), and plasma electrolytes in the superior sagittal sinus blood were examined before ischemia and during the acute stage up to 120 min after recirculation in the control and phenytoin-treated groups. Measurement of rCBF (microsphere method) indicated easing of postischemic hypoperfusion of the cerebral cortex. The time from total cerebral ischemia to EEG electrical silence was significantly prolonged, and recovery of the electrical activity after recirculation was hastened. The increase in plasma potassium concentration in the superior sagittal sinus tended to be suppressed immediately after recirculation, and the sodium:potassium ratio in the cerebral cortex was lowered. Phenytoin increased the rCBF in the cerebral cortex, hastened the recovery of electrical activity, and stabilized the water and electrolyte balance in the cerebral cortex, suggesting some protecting effect on total cerebral ischemia.

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Sixty-three mongrel dogs were exposed to 8-10 min. of complete cerebral ischemia with Aortic occlusion balloon catheter and followed by 120 min. of recirculation. The degree and distribution of post-ischemic reperfusion in 11 different cerebral regions were then assessed using radioactive labelled microspheres (15 +/- 3 micrometers). The animals were divided into 3 groups by the administration of drugs as follows: 1) no additional drugs; 2) Indomethacin (selective inhibitor of cyclooxygenase) 4 mg/kg 5 min. after ischemia; 3) Pyridine deriv. (OKY-1580 Na-salt, selective inhibitor of thromboxane synthetase) infusion 100 gamma/kg/min. beginning 5 min. after ischemia. Animals receiving no additional drugs had low cerebral blood flow rates at 120 min. after ischemia especially in basal ganglia and cerebral cortex. Animals receiving Indomethacin did not differ significantly from the no additional drug group. The significant enhancement and redistribution of post-ischemic reperfusion at 120 min. after ischemia occurred in animals receiving Pyridine deriv. with reversal of the state of poor reperfusion. These observations implicate an imbalance of prostaglandin pathways in platelets and blood vessel walls in the genesis of impaired post-ischemic reflow and suggest the usefulness of Pyridine deriv. in the treatment of local vasoconstriction of the brain after total cerebral ischemia.

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In normothermic 53 mongrel dogs complete cerebral circulatory arrest for 8 to 10 min was produced with Aortic occlusion balloon catheter and followed by blood recirculation of the brain for 2 hrs. Local cerebral blood flow in 11 different regions were measured before and after ischemia using radioactive labelled microspheres (15 +/- 3 micrometers). Before ischemia, regional blood flow rates within the brain varied between 26.1 +/- 5.8 and 61.3 +/- 7.9 ml/100 g/min (mean +/- SD). Reactive hyperemia was present in the brain 8 to 15 min after the beginning of the recirculation. Local cerebral blood flow rates increased two to ten times above the control flow, more increased in brain stem, cerebellum, thalamus and basal ganglia. Regional cerebral blood flow returned to or slightly below normal 30 min after ischemia, and subsequently decreased 60 to 120 min after ischemia. At 120 min after ischemia local cerebral blood flow rates decreased 40 to 60% of the control flow in cerebral cortices and basal ganglia, 70 to 90% of control flow in subcortical white matter and brain stem. With these result: 1) There is considerable redistribution and inhomogeneity of of flow rates within the brain after total cerebral ischemia for 8 to 10 min. 2) It is indicated that low flow rates of the brain 60 to 120 min after ischemia can not maintain the nutritive blood flow in some cerebral regions, especially in cerebral cortices and basal ganglia. Farther more it may be resulted in secondary brain tissue damage. 3) It is suggested that post-ischemic recirculation may be a factor in the genesis of "selective vulnerability." 4) The inhomogeneity of regional cerebral blood flow rates can be associated with the animal species of the dog.

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