Persistent Air Embolism after Blunt Chest Trauma with Recovery to Pre-Existing Consciousness Level: A Case Report and Literature Review.

We report the case of a 71-year-old woman in whom cerebral air embolism resulted from blunt chest trauma. The woman had been lying on her left side for a while after the injury, and air traveled to the right side of the brain. As a result, a cerebral infarction occurred in the right cerebral hemisphere that caused loss of consciousness for more than 40 days. The patient recovered consciousness eventually; thus, it is important to monitor the improvement in a patient's state of consciousness, with repeated multi-modality imaging evaluations over a long period.

Association between inflammation in acute phase and early onset pneumonia in patients with out-of-hospital cardiac arrest treated with extracorporeal cardiopulmonary resuscitation.

BACKGROUND: Early onset pneumonia (EOP) in patients with cardiac arrest treated with targeted temperature management is a recently debated issue. We assessed the association between C-reactive protein (CRP) levels and development of EOP in patients treated with extracorporeal cardiopulmonary resuscitation (ECPR). METHODS AND RESULTS: We reviewed the data of all patients admitted to our hospital after out-of-hospital cardiac arrest treated with ECPR between April 2006 and April 2019 who survived for at least 48 h. We collected demographic data, cardiac arrest characteristics, prophylactic antibiotic use, and neurologic outcomes. Diagnosis of EOP was made based on clinical, radiological, and microbiological criteria. The primary endpoint was the association between the incidence of EOP and CRP levels from day 1 to day 4. A total of 55 patients were included, of which 20 developed EOP. CRP levels on days 3 and 4 were significantly elevated in patients who developed EOP (13.1 [11.8-21.1] mg/dL versus 11.6 [7.4-15.2] mg/dL, P = 0.005; and 19.0 [16.9-27.1] mg/dL versus 14.7 [7.4-21.2] mg/dL, P = 0.019, respectively). In the multivariable logistic regression model, the CRP level on day 3 was significantly associated with the development of EOP (odds ratio 1.22; 95% confidence interval 1.06-1.41; P = 0.001). CONCLUSIONS: Increased inflammation in acute phase was associated with development of EOP in patients treated with ECPR.

Rapid influenza diagnostic test at triage can decrease emergency department length of stay.

OBJECTIVE: Even if performing rapid influenza diagnostic tests test will not change clinical decision making, we sometimes perform at triage to reduce length of stay in Japan. Whether performing rapid influenza diagnostic tests at triage may shorten emergency department (ED) length of stay (LOS) is remains unclear. We aimed to determine the utility of rapid influenza diagnostic tests at triage in shortening ED length of stay LOS. METHODS: We retrospectively reviewed medical records of patients discharged from our ED after receiving results from rapid influenza diagnostic tests during the influenza season from December, 2013 to March, 2019. Eligibility criteria were a walk-in visit, age ≥15 years, triage performed, rapid influenza diagnostic test administered, and no admission. The triage group received rapid influenza diagnostic tests at triage. The after-examination group received their tests only after examination by a doctor. The primary outcome was ED LOS after propensity score matching to adjust for several covariates. RESULTS: Of 2,768 eligible patients, 2,554 patients were enrolled in the triage group (n = 363) or after examination group (n = 2,191). There were 329 matched pairs after propensity score matching. Median ED LOS was significantly shorter in the triage group than in the after-examination group after propensity score matching (81 min (interquartile range [IQR] 60 to 111) vs 106 min (IQR 80-142); median difference 24 min (95% confidence interval 17-30)). CONCLUSIONS: Performing rapid influenza diagnostic tests at triage was associated with shorter ED LOS during the influenza season.

Impaired mental health status following intensive care unit admission in a patient with COVID-19.

Background: Severe respiratory failure patients with coronavirus disease (COVID-19) sometimes do not receive post-intensive care syndrome prevention bundles. No detailed report has been published on the practical observations of mental impairments in these patients. Case presentation: A 33-year-old man was admitted with COVID-19 pneumonia. On day 6, he was admitted to the intensive care unit (ICU). Considering the risk of nosocomial infection, as per the hospital policy, early rehabilitation could not be initiated for COVID-19 patients at that time and family visits were not allowed. Thereafter, his respiratory condition gradually improved; he was discharged on day 19. When the ICU nurse called to assess his medical condition, the patient complained of insomnia after ICU discharge. Therefore, we called him for an outpatient visit 28 days after discharge and scored his mental health status. Conclusion: Careful follow-up is required to treat mental impairment in patients with COVID-19.

Pneumonia and Extracorporeal Cardiopulmonary Resuscitation Followed by Targeted Temperature Management in Patients With Out-of-Hospital Cardiac Arrest　- Retrospective Cohort Study.

Background: We examined the association between initiation of extracorporeal cardiopulmonary resuscitation (ECPR) and the incidence of infectious complications, such as pneumonia, sepsis, and bacteremia, after out-of-hospital cardiac arrest (OHCA) in patients who received targeted temperature management (TTM). Methods and Results: This retrospective study used data from hospital medical records of patients with OHCA treated with TTM who had been admitted to St. Luke's International Hospital between April 2006 and December 2018. The primary endpoint was the association between the type of CPR and the incidence of early onset pneumonia in the intensive care unit (ICU; between 48 h and 7 days of hospitalization). Univariate and multivariate logistic regression analyses were performed for the primary endpoints. After applying the inclusion/exclusion criteria, 254 patients were included in the analyses; of these, 52 were enrolled in the ECPR group, and 202 were enrolled in the CCPR group. Median age was 58 years, 88.5% were male, prophylactic antibiotics were used in 80.3%, and favorable neurological outcomes were observed in 51.9%. On multivariate analysis, ECPR (odds ratio [OR], 2.78; 95% CI: 1.16-6.66; P=0.037) was significantly associated with the development of early onset pneumonia. Conclusions: ECPR was an independent predictor of pneumonia after OHCA in patients who received TTM.

Effects of ARB or ACE-inhibitor administration on plasma levels of aldosterone and adiponectin in hypertension.

Aldosterone production causes vascular injury and may occur despite the long-term administration of angiotensin converting enzyme-inhibitors (ACE-I) (ie, aldosterone breakthrough). The angiotensin II receptor blocker (ARB) telmisartan can function as a ligand for peroxisome proliferator-activated receptor (PPAR) gamma. Stimulation of PPAR gamma has been demonstrated to raise adiponectin production and suppress angiotensin II type 1 receptor expression. Thus, we investigated the effect of the ACE-I perindopril erbumin (perindopril) and the ARB telmisartan on plasma levels of aldosterone and adiponectin.Patients with essential hypertension were randomly assigned to receive 48 weeks of perindopril (2-8 mg/d) or telmisartan (20-80 mg/d). We measured adiponectin, aldosterone, angiotensin II, and renin at weeks 0, 8, 24, and 48.A total of 53 subjects were randomized. Data on 51 subjects (25 in the perindopril group and 26 in the telmisartan group; mean age, 65.1 years) were available for analyses. Plasma aldosterone decreased significantly in both the telmisartan (69.9+/-5.6 to 58.1+/-5.4 pg/mL) and perindopril (74.1+/-4.7 to 64.7+/-5.3 pg/mL) groups at 8 weeks, but returned toward the baseline in the perindopril group (67.9+/-4.1 pg/mL) at 24 weeks. Plasma glycated hemoglobin levels or urine albumin did not change significantly after the treatment in either group.Telmisartan seemed to be more effective at suppressing aldosterone and raising adiponectin levels than perindopril; however, improvements in insulin sensitivity and albuminuria were not detected. These results are consistent with the idea that the use of an ARB with PPAR gamma stimulating activity is equivalent to ACE-I for the treatment of hypertension.

Ischemia/reperfusion in rat heart induces leptin and leptin receptor gene expression.

Concentrations of leptin, an adipocyte-derived hormone, are elevated in obesity. Recently, leptin has been shown to participate in multiple biological actions including inflammation, reproduction, and angiogenesis. Leptin has also been documented as a critical component in the process of wound healing; however, leptin involvement in cardiovascular disease is poorly understood. We examined the expression of leptin (ob) and leptin receptor (ob-R) genes in the rat heart following ischemia/reperfusion, which was induced by coronary artery ligation, and mRNA was obtained from hearts 0.5 to 36 h after initiating reperfusion. Expressions of ob and ob-R mRNA were examined by real-time quantitative RT-PCR and immunohistochemistry. The ob and ob-Ra mRNA and protein expressions were significantly increased (p<0.01) and ob-Rb mRNA was significantly decreased (p<0.01) in hearts after 8 h of reperfusion. Furthermore, ob and ob-R proteins were expressed in injured myocytes where inflammatory cells infiltrated. In contrast, those expressions were not influenced in hearts after 8 h of ischemia stress only. To determine the functional effects of leptin on the ischemic/reperfused heart, rats were treated with anti-leptin antibodies prior to ischemia/reperfusion; however, this treatment did not affect the elevation of mRNA expression levels of inflammatory markers such as TNF-alpha and IL-1beta in ischemic hearts. Our results demonstrated for the first time that ischemia/reperfusion induced leptin and leptin receptor gene expression in the rat heart. This study helps to elucidate the mechanisms behind the onset and development of ischemic heart disease concomitant with obesity.

Usefulness of fasting 18F-FDG PET in identification of cardiac sarcoidosis.

UNLABELLED: Cardiac PET using (18)F-FDG under fasting conditions (fasting (18)F-FDG PET) is a promising technique for identification of cardiac sarcoidosis and assessment of disease activity. The aim of this study was to investigate the usefulness of fasting (18)F-FDG PET in detecting inflammatory lesions of cardiac sarcoidosis from a pathophysiologic standpoint. METHODS: Twenty-two patients with systemic sarcoidosis were classified into 2 groups of 11 each according to the presence or absence of sarcoid heart disease. Cardiac sarcoidosis was diagnosed according to the Japanese Ministry of Health and Welfare guidelines for diagnosing cardiac sarcoidosis with the exception of scintigraphic criteria. Nuclear cardiac imaging with fasting (18)F-FDG PET, (99m)Tc-methoxyisobutylisonitrile ((99m)Tc-MIBI) SPECT, and (67)Ga scintigraphy were performed in all patients. PET and SPECT images were divided into 13 myocardial segments and the standardized uptake value (SUV) of (18)F-FDG was calculated and defect scores (DS) for (99m)Tc-MIBI uptake were assessed for each segment. The total SUV (T-SUV) and total DS (TDS) were calculated as the sum of measurements for all 13 segments, and the diagnostic accuracy of fasting (18)F-FDG PET was compared with that of the other nuclear imaging modalities. In addition, pathophysiologic relationships between inflammatory activity and myocardial damage were examined by segmental comparative study using the SUV and DS. RESULTS: In patients with cardiac sarcoidosis, fasting (18)F-FDG PET revealed a higher frequency of abnormal myocardial segments than (99m)Tc-MIBI SPECT (mean number of abnormal segments per patient: 6.6 +/- 3.0 vs. 3.0 +/- 3.2 [mean +/- SD], P < 0.05). The sensitivity of fasting (18)F-FDG PET in detecting cardiac sarcoidosis was 100%, significantly higher than that of (99m)Tc-MIBI SPECT (63.6%) or (67)Ga scintigraphy (36.3%). The accuracy of fasting (18)F-FDG PET was significantly higher than (67)Ga scintigraphy. The T-SUV demonstrated a good linear correlation with serum angiotensin-converting enzyme levels (r = 0.83, P < 0.01), and the TDS showed a significant negative correlation with the left ventricular ejection fraction (r = -0.82, P < 0.01). In abnormal myocardial segments on the nuclear scan, the SUV showed a significant negative correlation with the DS (r = -0.63, P < 0.0001). CONCLUSION: This study suggests that fasting (18)F-FDG PET can detect the early stage of cardiac sarcoidosis, in which fewer perfusion abnormalities and high inflammatory activity are noted, before advanced myocardial impairment.