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Case report
SUBACUTE ADRENAL HEMORRHAGE BY BLUNT
ABDOMINAL CONTUSION DURING
SNOWBOARDING SUBACUTE ADRENAL HEMORRHAGE BY BLUNT ABDOMINAL
CONTUSION
Hiroshi USHIDA1), Kazuyoshi JOHNIN1), Shuichi KOIZUMI2), Takashi KADOWAKI3), Tomoya MASADA2)
AND Yusaku OKADA1)
1) The Department of Urology 2) The Department of Urology and Radiology, Uji Tokushukai Hospital
3) The Department of Health Science Abstract The adrenal glands lies deep in the abdomen, seemingly protected from blunt contusion. We
report a case of a young female presenting left adrenal hemorrhage due to blunt abdominal contusion
caused by a collision during snowboarding, which was successfully treated with embolization.
Keyword subacute adrenal hemorrhage, blunt abdominal contusion, embolization
INTRODUCTION As snowboarding is becoming popular as a winter
sport among young people, the number of accidents has
been increasing rapidly1)-3). Extremities are the most
frequently affected by such accidents, but visceral
injuries are rare1)-3). We report a case of a young
female presenting left adrenal hemorrhage by blunt
abdominal contusion caused by a collision during
snowboarding, which was successfully treated with
embolization.
CASE REPORT A 22-year-old woman visited our hospital with a
complaint of left back pain presenting for two weeks.
Vital signs were normal with blood pressure
106/72mmHg and pulse rate 92/min. However,
hematological examination revealed severe anemia,
with hemoglobin 5.7g/dl and hematocrit 17.8%.
Abdominal ultrasonography (US) revealed a
heterogeneous retroperitoneal mass of 10cm in
diameter, between the left kidney and the spleen.
Computed tomography (CT) showed a left adrenal
mass (8 Ã 7 Ã 10cm in diameter), which was
heterogeneous on contrast enhancement, and an injury
in the lower pole of spleen (Fig. 1-A). CT also
showed fluid collection in the pelvic cavity. We
suspected rupture of the left adrenal tumor at first.
However, by detailed history talking, we noticed that
she had a history of abdominal contusion by collision
with some other snowboard player two weeks before.
1
æ»è³å»å€§èªã21(1), 1-3, 2008
2
Based on this clinical history, we made the diagnosis of
left adrenal hematoma induced by abdominal contusion.
Emergency abdominal angiography was performed to
find the bleeding sites. Angiography showed the
peripheral branch bleeding of left superior and inferior
adrenal arteries (Fig. 2-A, B). To stop bleeding,
embolization using gelform was performed. The
splenic artery was compressed laterally by the
retroperitoneal hematoma, although itself bleeding
points were not clarified. Possibility of hemorrhage
due to rupture of the left adrenal tumor was completely
ruled out by magnetic resonance imaging (MRI).
During the long-term follow-up, CT performed 6
months later showed cystic mass with thick wall
without tumor signs (Fig. 1-B), and 36 months later
cystic mass disappeared .
DISCUSSION The adrenal glands lie in the perirenal space
surrounded by fat and enclosed by the fascia of Gerota.
The adrenal glands lie deep in the abdomen, seemingly
protected from traumatic contusion. General causes of
adrenal hemorrhage include fulminant septicaemia
(Waterhouse-Friderichsen syndrome), birth trauma
during delivery in new born babies, venography for
adrenal gland, particularly resulting from infarction of
adrenal adenoma, post-myocardial infarction especially
in patients on thrombolytic and anticoagulation therapy,
and rarely follow idiopathic adrenal vein thrombosis.
On the other hand, traumatic hemorrhage of the adrenal
gland is being identified with increasing frequency and
may be present in up to 25% of severely traumatized
patients4). They reported that the prevalence of
adrenal bleeding among patients with blunt abdominal
trauma undergoing CT scanning is 2%, among which
60% occur on the right side, 25% on the left and 15%
are bilateral4). They are typically small, asymptomatic
and resolve spontaneously. Post-traumatic adrenal
pseudocyst has been reported to be observed. Two
possible mechanisms of traumatic hemorrhage in the
right adrenal gland are (a) direct compression of the
gland between the spine and the liver and (b) an acute
rise in intraadrenal venous pressure due to compression
of the inferior vena cava with adrenal hemorrhage as a
secondary reaction5). The third possibility is that the
hemorrhage may be secondary to decelerative forces,
which cause shearing of small vessels that perforate the
adrenal capsule5). In our case the cause of traumatic
hemorrhage in the left adrenal gland was unidentified,
but we assumed direct compression of the gland
between the spleen and the spine when occurred the
splenic injury. Management of adrenal hemorrhage
has continued to be either surgical or conservative, but
our case was successfully treated with embolization,
thereby obviating surgical exploration of the abdomen.
To our knowledge there are only few reports6-9) on the
treatment with embolization for unilateral adrenal
hemorrhage. Our case suggests that angiography and
embolization procedure is a viable alternative to
surgical exploration in the management of unilateral
traumatic adrenal injuries.
REFERENCES 1. Abu-Laban RB. : Snowborading injuries : an
analaysis and comparison with alpine skiing
injuries. CMAJ, 145(9): 1097-1103, 1991.
2. Bladin C., McCrory P. : Snowboarding injuries.
An overview. Sports Med, 19(5): 358-364, 1995.
3. Davidson TM., Laliotis AT. : Snowboarding
injuries, a four-year study with comparison with
alpine ski injuries. West J Med, 164(3): 231-237,
1996.
4. Burks D.W., Mirvis S.E., Shanmuganthan K. :
Acute adrenal injury after blunt abdominal
trauma : CT findings. Am J Roentgenol, 158(3):
503-507, 1992.
5. Murphy B.J., Casillas J., Yrizarry J.M. : Traumatic
adrenal hemorrhage : Radiologic findings.
Radiology, 169(3): 701-703, 1988.
6. Igwilo O.C., Sulkowski R.J., Shah M.R.,
2
3
MessinkW.F., Kinnas N.C. : Embolization of
traumatic adrenal hemorrhage. J Trauma, 47(6):
1153-1155, 1999.
7. Ikeda O., Urata J., Araki Y., Yoshimatsu S., Kume
S., Torigoe Y., Yamashita Y. : Acute adrenal
hemorrhage after blunt trauma. Abdom Imaging,
32(2): 248-252, 2007.
8. John W.K., Michael D.K., Victoria M.M., Donald
S.H., Sue E.H. : N-Butyl Cyanoacrylate
Embolization for Control of Acute Arterial
Hemorrhage. JVIR, 15(2): 689-695, 2004.
9. Julei C., Irum B., John M., Lena M. : Adrenal
artery rupture in pregnancy. BJOG, 111(2):
185-187, 2004.
LEGEND FOR FIGURES Fig. 1-A Contrast enhanced CT showed a left adrenal
heterogeneous mass (8Ã7Ã10 ã) and an
injury in the lower pole of spleen.
1-B Plain CT showed a cystic mass with a thick
wall without a tumor sign 6 months later.
Fig. 2-A, B Angiography showed left superior and
inferior adrenal arterial bleeding.
Arrow â1 ; left inferior phrenic artery,
Arrowâ2 ; left superior adrenal artery
Arrow â3 ; left inferior adrenal artery,
Arrow head ; extravasation
Fig.1-A
â
Fig. 2-A
Fig. 2-B
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Fig.1-B
3
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Mizuho Konishi1) 2) Naoto Yamada1) Suguru Sato3)
1) Department of Psychiatry, Shiga University of Medical Science 2) Graduate School of Psychology, Faculty of Letters, Doshisha University
3) Department of Psychology, Faculty of Letters, Doshisha University Abstract: In recent years, narcissistic personality is seen as a trait especially among young people. This personality trait has an ambivalent feature that unsettled self-valuation easily influenced by others, while it is energetic and a self-centered, being filled with confidence. In this research, we examined the relationship between narcissistic personality and five ego states -critical parent (CP), nurturing parent (NP), adult (A), free child (FC), adapted child (AC), using the Egogram. Moreover, in order to consider the relevance to narcissistic personality and mental health, we measured depression as a negative side of mental health and subjective happiness as a positive side. The results showed that CP, A and FC increased narcissistic personality. CP reflected the authority, dominant and exclusive characteristics. A reflected cool and not confused attitude by the others' feeling. FC reflected the less consideration for others and selfish behavior. From these results, this study confirmed the features of the narcissistic personality more clearly. Finally, the subjects with high narcissistic personality had lower depression and higher subjective happiness than the subjects with low narcissistic personality. The narcissistic personality was supposed to be the factor to enhance the mental health. Keywords: narcissistic personality, ego-state, depression, subjective happiness
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å尺床 (NPI-35)ã®äœæã®è©Šã¿ ããŒãœããªãã£ç 究 , 14, 214-226. å°è¥¿çç©ã»å±±ç°å°ç»ã»äœè€ 豪 2007 èªå·±æäººæ ŒåŸ
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åŠïŒ, 14, 183-190. Raskin, R. ïŒHall, C. S. 1981 The narcissistic
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Aging and Atrial Fibrillation
Hideki Hayashi, MD, PhD Shiga University of Medical University
Department of Respiratory and Cardiovascular Medicine
Abstract
Atrial fibrillation is a rhythm disorder, which is most commonly seen in the field of cardiovascular medicine. Multiple wavelets are persistently meandering in both right and left atria during atrial fibrillation. Atrial fibrillation occurs with or without organic heart diseases. Once atrial fibrillation occurs, regular heart beat becomes lost and atrial contraction is no longer strong enough to expel out blood. As a result, blood flow in the left appendage becomes stagnant, forming thrombus in there. The thrombus can be a source of cerebral infarction when it moves from the left appendage to the cerebral artery. Cerebral infarction reduces activities of daily life substantially and shortens longevity. Epidemiological studies have demonstrated that the incidence and prevalence of atrial fibrillation increase with age, especially in people older than 65 years. Thus, the preventive therapy for atrial fibrillation in the elder is important in maintaining healthy condition. Key Words: atrium, fibrillation, aging ã¯ããã«
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1. The Stroke Prevention in Atrial Fibrillation
Investigators. Prevention of stroke in atrial fibrillation. N Engl J Med 1990;323(7):481-4.
2. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 1991 August;22:983-8.
3. Feinberg WM, Blackshear JL, Laupacis A, Kronmal R, Hart RG. Prevalence, age distribution, and gender of patients with atrial fibrillation. Analysis and implications. Arch Intern Med 1995 March 13;155:469-73.
4. Wolf PA, Dawber TR, Thomas HE, Kannel WB. Epidemiologic assessment of chronic atrial fibrillation and risk of stroke: The Framingham study. Neurology 1978;28:973-7.
5. Tanizaki Y, Kiyohara Y, Kato I, Iwamoto H, Nakayama K, Shinohara N, Arima H, Tanaka K, Ibayashi S, Fujishima M. Incidence and risk factors for subtypes of cerebral infarction in a general population: the Hisayama study. Stroke 2000 November;31(11):2616-22.
6. Hayashi H, Wang C, Miyauchi Y, Omichi C, Pak H-N, Zhou S, Ohara T, Mandel WJ, Lin S-F, Fishbein MC, Chen P-S, Karagueuzian HS. Aging-related increase to inducible atrial fibrillation in the rat model. J Cardiovasc Electrophysiol 2002 August;13(8):801-8.
7. Hayashi H, Omichi C, Miyauchi Y, Mandel WJ, Lin SF, Chen PS, Karagueuzian HS. Age-related sensitivity to nicotine for inducible atrial tachycardia and atrial fibrillation. Am J Physiol Heart Circ Physiol 2003 November;285(5):H2091-H2098.
8. van Kempen MJ, Fromaget C, Gros D, Moorman AF, Lamers WH. Spatial distribution of connexin43, the major cardiac gap junction protein, in the developing and adult rat heart. Circ Res 1991 June;68(6):1638-51.
9. Heist EK, Ruskin JN. Atrial fibrillation and congestive heart failure: risk factors, mechanisms, and treatment. Prog Cardiovasc Dis 2006 January;48(4):256-69.
10. Polontchouk L, Haefliger JA, Ebelt B, Schaefer T, Stuhlmann D, Mehlhorn U, Kuhn-Regnier F, De Vivie ER, Dhein S. Effects of chronic atrial fibrillation on gap junction distribution in human and rat atria. J Am Coll Cardiol 2001 September;38(3):883-91.
11. Manabe I, Shindo T, Nagai R. Gene expression in fibroblasts and fibrosis: involvement in cardiac hypertrophy. Circ Res 2002 December 13;91(12):1103-13.
12. Weiss JN, Karma A, Shiferaw Y, Chen PS, Garfinkel A, Qu Z. From pulsus to pulseless: the saga of cardiac alternans. Circ Res 2006 May 26;98(10):1244-53.
13. Bers DM. Cardiac excitation-contraction coupling. Nature 2002 January 10;415(6868):198-205.
14. Carbonin PU, Di Gennaro M, Pahor M, Bernabei R, Sgadari A, Gambassi G, Jr. Cardiac aging, calcium overload, and arrhythmias. Exp Gerontol 1990;25(3-4):261-8.
15. Ono N, Hayashi H, Kawase A, Lin SF, Li H, Weiss JN, Chen PS, Karagueuzian H. Spontaneous atrial fibrillation initiated by triggered activity near the pulmonary veins in aged rats subjected to glycolytic inhibition. Am J Physiol Heart Circ Physiol 2006 August 18;292:H639-H648.
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Norovirus outbreaks in a university hospital
Akiko FURUKAWA, Yoshitomo OZAKI, Katsuyuki KITO, Teiji SASAKI, Taishi NAGAO, Kenichi KITAMURA, Hiroyuki NAITHO, Kenichi TATEWAKI, Kunihiko Moro, Yoshihiro IKUNO,
Hiroki KONISHI, Shinichi KINJO, Yasuharu IWATA, Tomoko NAKAGAWA and Yasutaka NAKANO
Infection Control Team, Shiga University of Medical Science Hospital
Abstract An outbreak of norovirus-related gastroenteritis occurred in one ward at a university hospital in June 2006. A total of 32 people (16 patients and 16 staffs) suffered and it took 17 days from the recognition to the end of the outbreak. We speculated that the virus was brought to the hospital from the outside by a patient and spread from person to person. Infection control measures, including the closure of the ward, may have prevented the spread to other wards. When the outbreak was over, we looked back the case with all the hospital staff members and reconfirmed how to prevent norovirus outbreak. In November 2006, another outbreak occurred in a different ward. It took 11 days from the recognition to the end and 13 people (10 patients and 3 staffs) suffered this time. It seemed that the familiarization with a norovirus outbreak and the reconfirmation of prevention measures made it possible to respond earlier to the second outbreak.
Keyword outbreak, university hospital, norovirus, gastroenteritis
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