Percutaneous Reduction of a Dislocation of the Interphalangeal Joint of the Great Toe: A Case Report.

Dorsal dislocation of the interphalangeal joint of the great toe is quite rare. Closed reduction is often attempted in the emergency setting, but this measure is seldom successful because of invagination of the sesamoid-plantar plate complex into the interphalangeal space. Generally, open reduction is indicated when closed reduction fails. In this report, percutaneous reduction of the incarcerated sesamoid was performed under local and intraarticular anesthesia at our outpatient clinic, leading to successful reduction.

[Successful Extracorporeal Membrane Oxygenation for a Patient with Nearly Fatal Hypoxemia Induced by Transfusion-related Acute Lung Injury].

Transfusion-related acute lung injury (TRALI) is known to be the leading cause of transfusion-related mortality. A nearly fatal case of postoperative TRALI, successfully managed with extracorporeal membrane oxygenation (ECMO), is reported. The patient was a 70-year-old woman for whom laparoscopic nephrectomy was planned. She received several units of packed red blood cells and fresh-frozen plasma (FFP) intraoperatively due to massive bleeding. At the end of the operation, her PaO2/FIO2 ratio was 504, and she was extubated. Shortly after extubation, she developed severe hypoxemia. A chest X-ray showed bilateral infiltrates without cardiac enlargement. After entering the ICU, her respiratory condition deteriorated rapidly despite treatment with noninvasive positive pressure ventilation followed by re-intubation 8 hours after the operation. Even with very high positive pressure ventilation above 35 mmHg, her oxygenation decreased to PaO2 39.9 mmHg (FIO2 1.0). As a lifesaving measure, venovenous ECMO was started 15 hours after the operation. The pulmonary infiltration improved significantly over the next 5 days. Anti-HLA antibodies were detected in the FFP donor serum, that was transfused at the time of extubation. Now that TRALI is thought to be reversible, ECMO might be useful for even what was previously fatal hypoxemia.

[Non-electrocardiogram-gated and Non-contrast-enhanced Magnetic Resonance Angiography of the Lower Limb Arteries Using Three-dimensional Multishot T1-weighted Fast-field Echo-Echo Planar Imaging].

We performed a non-electrocardiogram-gated and non-contrast-enhanced magnetic resonance angiography (MRA) of the lower limb arteries using three-dimensional multishot T1-weighted fast-field echo-echo planar imaging (3D multishot T1-FFE-EPI), and it was optimized the protocol. The image distortion for the change in the EPI factor was calculated using 3.0 T-MRI and MRI phantom. We also calculated the signal-to-noise ratio (SNR) of the femoral artery with a change in the flip angle on images of 8 healthy volunteers. Furthermore, the optimal EPI factor was determined from the SNR of the femoral artery and the contrast ratio between the femoral artery and the adductor magnus. Two radiological technologists performed a retrospective visual assessment of the pelvis, thigh, and leg of 10 patients who underwent lower limb non-contrast-enhanced MRA and contrast-enhanced tomography angiography (CTA). The optimum flip angle and EPI factor were 25° and 3, respectively. In the visual assessment of clinical cases, there was no significant difference between the non-contrast-enhanced MRA and contrast-enhanced CTA in the pelvis and the leg (p=0.52 and p=0.88, respectively). In the thigh, non-contrast-enhanced MRA was significantly higher (p=0.02), namely, the ability to visualize the lower limb arteries was not much difference between this method and contrast-enhanced CTA. Our method without electrocardiogram gated and contrast medium is expected for screening tests or detailed examinations.

Severe Hypermagnesemia with Normal Renal Function Can Improve with Symptomatic Treatment.

Hypermagnesemia is a rare disorder and commonly occurs in patients with renal dysfunction. Supportive therapy for hypermagnesemia consists of administration of high-volume fluids, calcium preparation, diuretics, and, in severe cases, hemodialysis. Few reports have described severe hypermagnesemia patients with normal renal function who improved without hemodialysis. A 56-year-old woman presented with a history of constipation in spite of taking constipation medicine, including MgO. She was brought to our emergency department due to vomiting and diffuse distension of the abdomen. Sudden vomiting, weakness, and lower level of consciousness occurred during examination. Her blood pressure dropped to 77/34 mmHg, and deep tendon reflexes of the limbs disappeared. Abdominal computed tomography showed bowel distension with wall edema, and biochemical testing showed serum Mg at 13.5 mg/dl. She was diagnosed with severe hypermagnesemia associated with intestinal obstruction and administered intravenous loop diuretics and calcium preparation in addition to high volumes of normal saline. As the serum Mg level steadily declined, her level of consciousness returned to usual. This case suggests that severe hypermagnesemia can occur in patients with normal renal function and constipation under MgO. Severe hypermagnesemia with normal renal function can improve with symptomatic treatment without hemodialysis.

A rare case of right-sided infective endocarditis caused by group B Streptococcus complicated with septic knee arthritis and subcutaneous abscess in the lower extremity.

BACKGROUND: Several reports have assessed group B Streptococcus (GBS) infections in non-pregnant cohorts, especially in immunocompromised hosts and patients with severe disease, including diabetes mellitus. CASE PRESENTATION: We report a rare case of large GBS -associated tricuspid valve infective endocarditis (IE) complicated with septic knee arthritis and s.c. abscess formation in the lower extremity of a non-i.v. drug user. After confirming the absence of vegetation on transthoracic echocardiography (TTE) at admission, the lower extremity was irrigated, and antibiotic therapy was initiated. One week later, the causes of persistent fever were reinvestigated. The TTE detected a large mass around the tricuspid valve. The cultured GBS was penicillin sensitive. The vegetation completely disappeared without surgery within 4 weeks. CONCLUSION: When patients with untreated diabetes mellitus have persistent fever and s.c. abscess or septic arthritis, IE is a possible differential diagnosis. Repetitive evaluation by TTE is warranted to avoid this fatal complication.

Efficiency of a pelvic circumferential compression device for continuous hemorrhage of peripheral soft tissue of the pelvis: A case report.

BACKGROUND: A pelvic circumferential compression device (PCCD) is a belt that is wrapped around a fractured pelvis and tightened with a closing mechanism. The SAM Sling® is one of the most common PCCDs used for trauma management. Although the use of the SAM Sling® for reduction and stabilization of unstable pelvic ring fracture has become the standard of care in most relevant trauma scenarios, it is not usually used for stopping continuous hemorrhage of the peripheral soft tissue of the pelvis without unstable pelvic ring fractures. CASE PRESENTATION: We report the case of a 79-year-old woman with life-threatening and unexpected continuous subcutaneous and intramuscular hemorrhage of the buttocks and groin area. She did not have unstable pelvic ring fractures but had hemorrhagic shock and acute traumatic coagulopathy (ATC). By use of the SAM Sling®, the hemorrhage was controlled, and she was eventually rescued. CONCLUSIONS: We propose the use of the SAM Sling® to stop continuous bleeding in the state of ATC regardless of unstable pelvic ring fracture.

Repetitive transient paraplegia caused by painless acute aortic dissection.

CASE: Making a precise diagnosis of type A acute aortic dissection (AAD) presenting with atypical symptoms might be challenging for clinicians. Misdiagnosis and misuse of thrombolytic therapy can have devastating consequences. OUTCOME: Herein, we report a case of painless type A AAD complicated by transient leg paresthesia, which was successfully treated with surgery. On admission, sudden onset of right leg numbness and muscle weakness was the only clue toward the correct final diagnosis. CONCLUSION: When patients present with vague neurological symptoms, physicians should not rule out the possibility of AAD until proven otherwise.

Acute traumatic superficial femoral arterial laceration findings on computed tomographic angiography: A case report.

We present a case of superficial femoral artery laceration that was identified on computed tomographic angiography. The patient was a 25-year-old man who injured his right proximal thigh while using a wood sanding machine and was transferred to our emergency department in a state of hemorrhagic shock. Following resuscitation, preoperative computed tomographic angiography helped predict the arterial injury and aided us in prompt diagnosis and decisive management.

Simplified method for creating a density-absorbed dose calibration curve for the low dose range from Gafchromic EBT3 film.

Radiochromic film dosimeters have a disadvantage in comparison with an ionization chamber in that the dosimetry process is time-consuming for creating a density-absorbed dose calibration curve. The purpose of this study was the development of a simplified method of creating a density-absorbed dose calibration curve from radiochromic film within a short time. This simplified method was performed using Gafchromic EBT3 film with a low energy dependence and step-shaped Al filter. The simplified method was compared with the standard method. The density-absorbed dose calibration curves created using the simplified and standard methods exhibited approximately similar straight lines, and the gradients of the density-absorbed dose calibration curves were -32.336 and -33.746, respectively. The simplified method can obtain calibration curves within a much shorter time compared to the standard method. It is considered that the simplified method for EBT3 film offers a more time-efficient means of determining the density-absorbed dose calibration curve within a low absorbed dose range such as the diagnostic range.

[Evaluation of preoperative anxiety in patients with and without premedication].

BACKGROUND: The purpose of this investigation was to determine whether elimination of premedication before general anesthesia affects preoperative anxiety. METHODS: Subjects were assigned to one of two groups: a sedative group (0.5 mg midazolam i.m., n = 111) or a no-premedication group (n = 98). We used patients' responses to a questionnaire to compare the no-premedication group and the sedative group. RESULTS: Eighty-three percent of patients in the no-premedication group entered the operating room ambulatory. The responses concerning preoperative anxiety were not different between the two groups. There was a high rate of recall of the conversation before anesthesia induction in the no-premedication group, and most of these patients replied that making conversation before general anesthesia was beneficial to them. Increases in heart rate and blood pressure at the point of entrance to operating room were observed in the no-premedication group, but the degrees of increase were not considered clinically important. CONCLUSION: We conclude that elimination of premedication does not increase anxiety in comparison with patients receiving sedatives, but makes patients feel comfortable by way of preoperative conversation. Elimination of premedication also makes ambulatory entrance possible, both improving safety with respect to patient identification and reducing the demand on nursing.

[A comparison of perioperative factors with two methods of coronary artery bypass grafting (CABG): off-pump and conventional].

BACKGROUND: The safety and efficiency of off-pump coronary artery bypass grafting (OPCAB) are still controversial. The purpose of this study was to evaluate this approach in comparison with the conventional cardiopulmonary bypass technique (cCABG). METHODS: A retrospective review of patients who had undergone coronary artery bypass grafting independently without other operations between January 1, 1999 and September 30, 2001 was performed. The patients were divided into two groups: those who underwent OPCAB and the remainder for cCABG. The perioperative factors of the two groups were compared. RESULTS: A total of 152 OPCAB and 142 cCABG cases were reviewed. Compared with cCABG, OPCAB significantly reduced the amount of catecholamine needed on admission to ICU, intubation time, overall hospital length of stay, and neurologic events. There were also trends for decreases in ICU length of stay, mortality, and renal failure. On the other hand, OPCAB did not affect perioperative blood loss. CONCLUSIONS: Overall OPCAB is safer and more efficient than cCABG. However, we have to note in anesthetic management that OPCAB does not reduce blood loss.

Evaluation of GAFCHROMIC EBT2 dosimetry for the low dose range using a flat-bed scanner with the reflection mode.

Recently developed radiochromic films can easily be used to measure absorbed doses because they do not need development processing and indicate a density change that depends on the absorbed dose. However, in GAFCHROMIC EBT2 dosimetry (GAF-EBT2) as a radiochromic film, the precision of the measurement was compromised, because of non-uniformity problems caused by image acquisition using a flat-bed scanner with a transmission mode. The purpose of this study was to improve the precision of the measurement using a flat-bed scanner with a reflection mode at the low absorbed dose dynamic range of GAF-EBT2. The calibration curves of the absorbed dose versus the film density for GAF-EBT2 were provided. X-rays were exposed in the range between ~0 and 120 mGy in increments of about 12 mGy. The results of the method using a flat-bed scanner with the transmission mode were compared with those of the method using the same scanner with the reflection mode. The results should that the determination coefficients (r (2) ) for the straight-line approximation of the calibration curve using the reflection mode were higher than 0.99, and the gradient using the reflection mode was about twice that of the one using the transmission mode. The non-uniformity error that is produced by a flat-bed scanner with the transmission mode setting could be almost eliminated by converting from the transmission mode to the reflection mode. In light of these findings, the method using a flat-bed scanner with the reflection mode (only using uniform white paper) improved the precision of the measurement for the low absorbed dose range.

High resolution T2 weighted liver MR imaging using functional residual capacity breath-hold with a 1.0-Tesla scanner.

PURPOSE: During acquisition of rapid high resolution (HR) T2 weighted (T2W) liver magnetic resonance (MR) images using a 1.0-Tesla (T) scanner, the liver is segmented into odd and even sections that are acquired at two different times using the multi-breath-hold (MBH) strategy. Misalignment between the two breath-hold (B-H) images may result in the occurrence of a blind area and a decrease in diagnostic accuracy. Here, a functional residual capacity (FRC) B-H method was developed to overcome this problem. MATERIAL AND METHODS: Twenty-five volunteers were enrolled. The sagittal images were reconstructed from whole liver transverse images. When the B-H phases are different, misalignment may occur in the craniocaudal and anterior-posterior (AP) directions. In this study, misalignments of the abdominal wall were measured in the AP direction. The misalignment was compared between four B-H phases, maximum inspiration (MI), maximum expiration (ME), voluntary expiration (VE) and FRC using one-way repeated measures ANOVA. Differences between groups were compared using the t-test for multi-group comparisons. In addition, qualitative analysis of misalignment was performed between VE and FRC in 52 clinical patients and the chi(2) test was performed. RESULTS: The misalignment widths of FRC, ME, MI and VE B-Hs were 2.7+/-3.8, 6.4+/-7.4, 9.1+/-8.4 and 6.0+/-6.7 mm, respectively. Misalignment of the liver position using FRC was significantly smaller than for the other B-H methods (p<0.05). Significant differences between the VE B-H and FRC B-H were also observed in the qualitative analysis (p<0.05). CONCLUSION: The liver positions obtained when using FRC B-H were significantly more reproducible than when using the other B-H methods. The FRC B-H method resulted in a reduction in the blind area and an extension of the diagnostic area to the whole liver.

Functional residual capacity breath hold for subtraction image of dynamic liver MRI.

PURPOSE: In dynamic liver magnetic resonance imaging (MRI) studies, there are problems with misregistration when subtraction images are processed. For reduction of the misregistration, a functional residual capacity (FRC) phase breath-hold (FRC B-H) method was used. MATERIAL AND METHODS: Sixty patients (32 males and 28 females, aged 33-85 years, median age 69 years) were examined. The subjects were chronologically categorized into two groups: a voluntary expiratory (VE) B-H group and a FRC B-H group. The blood-flow phase images were classified as plain, arterial, portal and parenchymal phases. To evaluate the reproducibility of liver positions between VE B-H and FRC B-H in each phase (between Plain and Arterial, Arterial and Portal, Plain and Parenchymal), the misregistration areas were compared on the top of the liver. RESULTS: The misregistration area between Plain-Arterial, Arterial-Portal and Plain-Parenchymal in VE B-H was 731.0+/-1153.6, 1134.9+/-1357.2 and 628.4+/-844.5 (cm(2)), respectively. The misregistration area between each phase in FRC B-H was 386.4+/-874.9, 574.5+/-1086.1 and 279.8+/-551.2 (cm(2)), respectively. Using the Mann-Whitney U-test as quantitative analysis, the difference in misregistration areas between two groups was statistically significant (p<0.05). Differences in the qualitative analysis were also significant according to the chi(2) test (p<0.05). CONCLUSION: The liver positions with FRC B-H were markedly more reproducible than those with VE B-H. To improve the registration accuracy of subtraction dynamic liver MRI, the FRC B-H should be used.