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INTRODUCTION: Quetiapine is available in both immediate-release (IR) and extended-release (XR) formulations. Quetiapine XR overdose is known to cause delayed increase in serum quetiapine concentrations. However, it is not certain whether quetiapine IR overdose would similarly cause a delayed increase in serum quetiapine concentrations. CASE REPORT: A 57-year-old woman with depression who was taking half a tablet of 25 mg quetiapine IR daily was transported to our emergency department with a complaint of disturbance of consciousness 12 h after a quetiapine IR overdose. On arrival, her initial vital signs were heart rate of 116 beats per minute, blood pressure of 77/43 mm Hg, and oxygen saturation of 91% under 10 L oxygen administration. Whole body plain computed tomography showed a large amount of gastric hyperdense content suggesting pharmacobezoar with a volume of 71.2 ml. After treatment with respiratory and circulatory support, gastric lavage was performed. Her disturbance of consciousness persisted until day 5, and she was extubated on day 7. The serum concentrations of quetiapine were 2690 ng/mL at 12 h after overdose, 5940 ng/mL at 40 h, and 350 ng/mL at 124 h after overdose. Serum concentrations of other co-ingestions were all below lethal levels. CONCLUSION: A massive quetiapine IR overdose with pharmacobezoars can cause a delayed increase in serum quetiapine concentrations.
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Laser hair removal for esthetic purposes has commonly been performed worldwide. This procedure is considered to be safe and effective, and severe complications such as systemic bacterial infections have seldom been reported. We present a case of native valve infective endocarditis (IE) potentially associated with laser hair removal. A 32-year-old female with a history of childhood atopic dermatitis presented with fever and arthralgia. She had been receiving monthly total body laser hair removal treatments for nine months. Physical examination revealed numerous painful purpuras on her fingers and soles. Laboratory examinations revealed a positive troponin level, and a 12-lead electrocardiogram revealed ST-segment elevation in inferolateral leads. Transthoracic echocardiography revealed mild wall motion abnormalities from the mid-posterior wall to the apex and thickening of the anterior mitral valve leaflet. Blood cultures grew methicillin-susceptible Staphylococcus aureus (MSSA). Based on these findings, we made a diagnosis of native valve Staphylococcal IE and acute myocardial infarction due to septic embolism. Due to the progression of mitral valve destruction, she underwent mitral valve replacement surgery and received an eight-week course of antibiotics, leading to a successful recovery. This case highlights a potential association between laser hair removal and Staphylococcal IE. Laser hair removal may compromise the skin barrier, potentially allowing the entry of bacteria such as S. aureus. Increased awareness of this potential complication is necessary, especially in populations at high risk for IE. Further research is needed to investigate the link between laser hair removal and bacteremia, particularly in high-risk populations, to guide prevention strategies.
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Spontaneous ruptured hepatocellular carcinoma (HCC) remains a life-threatening condition despite improvements in diagnostic methods and established treatment strategies. Although typical clinical presentations of spontaneous ruptured HCC facilitate easy diagnosis, this condition can present with unexpectedly varied symptoms, making diagnosis challenging. We describe an atypical clinical presentation of spontaneous ruptured HCC mimicking an inguinal hernia. A 66-year-old man presented to the emergency department with groin discomfort and swelling, suggesting an inguinal hernia. He had no history of an inguinal hernia or known liver cirrhosis. Physical examination revealed a palpable, tender left groin mass. Point-of-care ultrasonography showed bowel-like structures with an echo-free space in the left groin. Unenhanced computed tomography (CT) of the pelvis demonstrated mesenteric fat prolapse and hyperdense fluid in the left inguinal canal and scrotum. Considering the possibility of a strangulated hernia, emergency exploratory laparotomy was performed. Unexpectedly, blood retention in the hernia sac was found, with no intestinal involvement. Further exploration revealed a hematoma and tumor on the liver surface. Finally, he was diagnosed with spontaneous ruptured HCC and underwent successful emergency hepatic resection. Spontaneous ruptured HCC can potentially mimic other abdominal conditions such as an inguinal hernia, even in cases of undiagnosed liver cirrhosis. Although unenhanced CT can reveal bloody ascites suggesting hemoperitoneum, the underlying cause should be carefully considered. Emergency physicians should recognize various clinical presentations of spontaneous ruptured HCC to ensure prompt diagnosis and treatment of this potentially fatal complication.
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Carcinoma Hepatocelular , Hérnia Inguinal , Neoplasias Hepáticas , Tomografia Computadorizada por Raios X , Humanos , Masculino , Hérnia Inguinal/complicações , Hérnia Inguinal/diagnóstico por imagem , Hérnia Inguinal/diagnóstico , Carcinoma Hepatocelular/complicações , Carcinoma Hepatocelular/diagnóstico por imagem , Carcinoma Hepatocelular/diagnóstico , Idoso , Neoplasias Hepáticas/complicações , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/diagnóstico , Ruptura Espontânea , Diagnóstico Diferencial , Ultrassonografia , Serviço Hospitalar de EmergênciaRESUMO
BACKGROUND: Having no or few confidants is found to be associated with more severe mental health problems and a higher prevalence of depression in adults, but research examining this association in adolescents is scarce. Social relationships may be particularly critical during adolescence, as it is an important developmental period during which vulnerability to mental health problems increases. The present study examined the relationship between having no or few confidants and anxiety/depressive symptoms in adolescents. METHODS: Cross-sectional self-report survey targeting 7-12th grade students (age range: 12-18) was conducted in public junior and senior high schools in Mie and Kochi, Japan. Data from 17,829 students (49.7% boys) were analyzed. Associations between anxiety/depressive symptoms (12-item General Health Questionnaire; score range: 0-12) and the number of confidants (None, 1-3, or ≥ 4) were examined using multilevel regression analyses. The analyses were stratified by gender and school level (junior/senior high), and adjusted for experiences of being physically abused and bullied and the interactions of these experiences with the number of confidants. RESULTS: Having no or 1-3 confidants was associated with more anxiety/depressive symptoms, compared to having ≥ 4 confidants (p < 0.001) in all stratified groups. Having no confidants was associated with more anxiety/depressive symptoms than having 1-3 confidants (p < 0.001); in senior high boys, no difference was observed between having no confidants and having 1-3 confidants. In addition, in senior high boys, victims of bullying who have confidants reported significantly less anxiety/depressive symptoms than the victims who have no confidants (p < 0.01). CONCLUSIONS: Adolescents who had no or few confidants had more anxiety/depressive symptoms. Attention needs to be paid to better identify these adolescents, and avenues to support them need to be established.
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Chest tube insertion is a common and relatively safe procedure in an emergency setting. However, a potentially fatal complication, vasovagal reflex, may be under-recognized due to its generally mild severity. We present a case of pulseless electrical activity (PEA) requiring chest compression due to vasovagal reflex during chest tube insertion for spontaneous pneumothorax. A 23-year-old male who had a history of spontaneous pneumothorax presented with left chest pain to our emergency department. Based on point-of-care ultrasonography and chest radiography, we made a diagnosis of recurrent pneumothorax. Although he had stable vital signs and received adequate pain control, during chest tube insertion, he developed severe sinus bradycardia with a six-second pause, leading to PEA requiring chest compressions. After a few compressions, his heart rate increased and he regained consciousness. He underwent video-assisted thoracoscopic surgery for pneumothorax and was discharged without complications. Vasovagal reflex during chest tube insertion in young patients with spontaneous pneumothorax may cause severe bradycardia and cardiac arrest. Physicians should be aware of this rare but potentially fatal complication and be prepared with appropriate measures, such as pre-administration of atropine, before chest tube insertion.
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Congenital renal arteriovenous malformations (AVMs) occasionally manifest with recurrent gross hematuria, typically in young populations. Acute abdominal pain without previous episodes of gross hematuria in young women is frequently considered a diagnosis related to obstetric and gynecological conditions or acute appendicitis, excluding the possibility of clot retention, which is more commonly associated with the elderly. A 36-year-old woman with no history of gross hematuria presented with acute lower abdominal pain. Adnexal torsion was initially considered based on her symptoms and ultrasonography findings. However, contrast-enhanced computed tomography (CT) revealed clot retention and delayed contrast excretion in the right kidney. After bladder irrigation, she returned complaining of right flank pain. Subsequent plain CT revealed contrast pooling in the right kidney and hydronephrosis. In addition to these findings, small vessels in the right renal hilum were found to be prominent in the arterial phase on the first contrast-enhanced CT. Finally, angiography of renal arteries confirmed the diagnosis of a congenital cirsoid-type renal AVM, which was successfully treated with ethanol embolization. This case highlights the importance of understanding an atypical presentation of renal AVMs, which is acute abdominal pain, even in the absence of prior gross hematuria and the characteristic CT findings. Early diagnosis of renal AVMs is crucial for preventing potentially serious complications, including repeated clot retention and life-threatening rupture. The diverse clinical manifestations and images of renal AVMs should be recognized to facilitate prompt and accurate diagnosis.
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INTRODUCTION: Guanfacine is a central α2-adrenergic receptor agonist that produces drowsiness, bradycardia, hypotension, and occasionally QT interval prolongation. We discuss giant T waves associated with guanfacine toxicity. CASE SUMMARIES: Three patients presented to the hospital with histories and physical findings compatible with guanfacine toxicity. Supratherapeutic concentrations were confirmed in two of them. All three developed QT interval prolongation and giant T waves on the electrocardiogram. Giant T waves occur commonly in patients with acute myocardial infarct and hyperkalemia, as well as rarely with a number of other cardiac and non-cardiac causes. CONCLUSION: Guanfacine toxicity may cause the novel electrocardiographic finding of 'giant T wave with QT interval prolongation'. Further studies are warranted to investigate the association between the novel electrocardiographic finding and guanfacine toxicity, as well as its diagnostic utility in such cases.
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Agonistas de Receptores Adrenérgicos alfa 2 , Eletrocardiografia , Guanfacina , Síndrome do QT Longo , Humanos , Eletrocardiografia/efeitos dos fármacos , Agonistas de Receptores Adrenérgicos alfa 2/intoxicação , Masculino , Síndrome do QT Longo/induzido quimicamente , Síndrome do QT Longo/fisiopatologia , Feminino , Pessoa de Meia-Idade , AdultoRESUMO
Pulmonary embolism (PE) is a potentially life-threatening condition that presents with a spectrum of clinical symptoms ranging from asymptomatic to hemodynamic instability. The early diagnosis in the emergency department is often challenging. Although the association between patent foramen ovale (PFO) and thromboembolic events in patients with PE is well-documented, the significance of the presence of PFO in patients with PE may be underrecognized. In addition, the occurrence of right ventricular thrombus (RVT) in PE is a rare but significant complication with implications for disease management. We report a case of acute-on-chronic PE with concurrent bilateral renal infarction due to a paradoxical embolus, alongside RVT. A 35-year-old male presented at our emergency department with complaints of sudden onset abdominal pain. Bilateral renal infarction was identified on a contrast-enhanced computed tomography (CT). Point-of-care ultrasound showed suggestive findings of PE and RVT. Subsequently, a pulmonary CT angiography confirmed bilateral PE, a PFO, and RVT. The patient was effectively managed with thrombolytic therapy, with extracorporeal membrane oxygenation on standby. This case highlights the need to recognize the diverse clinical manifestations of PE and the importance of considering coexisting PFO and RVT in affected patients. The diagnosis of PE can be complex when symptoms overlap with arterial thrombosis, such as renal infarction secondary to a PFO. In addition, RVT, although uncommon, is a serious complication in patients with PE that may require careful evaluation for thrombolytic or anticoagulant therapy. It is critical to consider the possibility of a PFO in all cases of PE, even in the absence of arterial embolism, and to promptly evaluate for RVT prior to initiating treatment.
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INTRODUCTION: Guanfacine, an alpha-2 adrenergic agonist, is used to treat attention deficit hyperactivity disorder (ADHD). Although cardiovascular effects including hypotension and bradycardia are common adverse effects of guanfacine, the effect of guanfacine on QT intervals remains unclear. The association between the serum concentration of guanfacine and its toxicity has also not been fully investigated. CASE REPORT: This is a case of a 21-year-old woman with ADHD who developed repeated presyncope 1 day before admission. She was taking 3 mg of extended-release guanfacine and 50 mg of sertraline. On admission, she had bradycardia and hypotension. An electrocardiogram (ECG) showed a QT interval of 0.68 s and a QTcF interval of 0.648 s. The QT intervals were manually measured and corrected by the Fridericia formula (QTcF = QT/RR1/3). Although she denied taking an overdose of guanfacine and other drugs, we suspected guanfacine toxicity. The serum guanfacine concentration was 13.0 ng/mL on admission and decreased to 3.2 ng/mL on day 1 and 0.4 ng/mL on day 2. Changes in QTcF intervals and her vital signs correlated with serum guanfacine concentrations. CONCLUSION: Supratherapeutic serum guanfacine concentrations may induce QT prolongation.
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Transtorno do Deficit de Atenção com Hiperatividade , Hipotensão , Feminino , Humanos , Adulto Jovem , Agonistas de Receptores Adrenérgicos alfa 2/toxicidade , Transtorno do Deficit de Atenção com Hiperatividade/induzido quimicamente , Transtorno do Deficit de Atenção com Hiperatividade/tratamento farmacológico , Bradicardia/induzido quimicamente , Guanfacina/toxicidade , Hipotensão/induzido quimicamenteRESUMO
Neuroleptic malignant syndrome (NMS) is a potentially fatal side effect that occurs in patients taking antipsychotics. Patients with NMS are often forced to rechallenge antipsychotic medications to control the underlying psychiatric symptoms. We present a case of severe recurrence of NMS in a patient in whom the administration of antipsychotics was restarted two days after NMS resolution. A 19-year-old man with somatic symptom disorder had been transported for fever, tachycardia, rigidity, and disturbance of consciousness. He was taking atypical antipsychotics with poor medication compliance. A diagnosis of NMS was made, and he was treated with administration of dantrolene sodium and benzodiazepines under tracheal intubation. On day 2, he was extubated. On day 4, his symptoms of NMS improved, but psychiatric symptoms rapidly exacerbated. He and his family strongly insisted on discharge, and we therefore unavoidably restarted the administration of antipsychotics. On day 37, he was retransported, and a diagnosis of recurrence of NMS was made. Blood examination showed marked deterioration of acute kidney injury and disseminated intravascular coagulation compared to those at the first admission. Without the administration of antipsychotics, his psychiatric symptoms were poorly controlled. Administration of dexmedetomidine helped his agitation to be well controlled without antipsychotics for two weeks. Short-term restart of antipsychotic drugs in patients with NMS may result in more severe NMS relapse. Dexmedetomidine may be useful for NMS patients when the administration of antipsychotics cannot be restarted. When antipsychotics are unavoidably rechallenged in patients with NMS, the risk of severe relapse should be taken into consideration, and dexmedetomidine may be used for prolongation of the withdrawal period.
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Background: Zooplankton plays an important role in the marine ecosystem. A high level of taxonomic expertise is necessary for accurate species identification based on morphological characteristics. As an alternative method to morphological classification, we focused on a molecular approach using 18S and 28S ribosomal RNA (rRNA) gene sequences. This study investigates how the accuracy of species identification by metabarcoding improves when taxonomically verified sequences of dominant zooplankton species are added to the public database. The improvement was tested by using natural zooplankton samples. Methods: rRNA gene sequences were obtained from dominant zooplankton species from six sea areas around Japan and registered in the public database for improving the accuracy of taxonomic classifications. Two reference databases with and without newly registered sequences were created. Comparison of detected OTUs associated with single species between the two references was done using field-collected zooplankton samples from the Sea of Okhotsk for metabarcoding analysis to verify whether or not the newly registered sequences improved the accuracy of taxonomic classifications. Results: A total of 166 sequences in 96 species based on the 18S marker and 165 sequences in 95 species based on the 28S marker belonging to Arthropoda (mostly Copepoda) and Chaetognatha were registered in the public database. The newly registered sequences were mainly composed of small non-calanoid copepods, such as species belonging to Oithona and Oncaea. Based on the metabarcoding analysis of field samples, a total of 18 out of 92 OTUs were identified at the species level based on newly registered sequences in the data obtained by the 18S marker. Based on the 28S marker, 42 out of 89 OTUs were classified at the species level based on taxonomically verified sequences. Thanks to the newly registered sequences, the number of OTUs associated with a single species based on the 18S marker increased by 16% in total and by 10% per sample. Based on the 28S marker, the number of OTUs associated with a single species increased by 39% in total and by 15% per sample. The improved accuracy of species identification was confirmed by comparing different sequences obtained from the same species. The newly registered sequences had higher similarity values (mean >0.003) than the pre-existing sequences based on both rRNA genes. These OTUs were identified at the species level based on sequences not only present in the Sea of Okhotsk but also in other areas. Discussion: The results of the registration of new taxonomically verified sequences and the subsequent comparison of databases based on metabarcoding data of natural zooplankton samples clearly showed an increase in accuracy in species identification. Continuous registration of sequence data covering various environmental conditions is necessary for further improvement of metabarcoding analysis of zooplankton for monitoring marine ecosystems.
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Ecossistema , Zooplâncton , Animais , Zooplâncton/genética , RNA Ribossômico 28S/genética , Genes de RNAr , BiodiversidadeRESUMO
BACKGROUND: Level of care-need (LOC) is an indicator of elderly person's disability level and is officially used to determine the care services provided in Japan's long-term care insurance (LTCI) system. The 2018 Japan Floods, which struck western Japan in July 2018, were the country's second largest water disaster. This study determined the extent to which the disaster affected the LOC of victims and compared it with that of non-victims. METHODS: This is a retrospective cohort study, based on the Japanese long-term care insurance claims from two months before (May 2018) to five months after the disaster (December 2018) in Hiroshima, Okayama, and Ehime prefectures, which were the most severely damaged areas in the country. A code indicating victim status, certified by a residential municipality, was used to distinguish between victims and non-victims. Those aged 64 years or younger, those who had the most severe LOC before the disaster, and those whose LOC increased even before the disaster were excluded. The primary endpoint was the augmentation of pre-disaster LOC after the disaster, which was evaluated using the survival time analysis. Age, gender, and type of care service were used as covariates. RESULTS: Of the total 193,723 participants, 1,407 (0.7%) were certified disaster victims. Five months after the disaster, 135 (9.6%) of victims and 14,817 (7.7%) of non-victims experienced the rise of LOC. The victim group was significantly more likely to experience an augmentation of LOC than the non-victim group (adjusted hazard ratio 1.24; 95% confidence interval 1.06-1.45). CONCLUSIONS: Older people who were affected by the disaster needed more care than before and the degree of care-need increase was substantially more than non-victims. The result suggests that natural disasters generate more demand for care services among the older people, and incur more resources and cost for society than before.
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Inundações , Necessidades e Demandas de Serviços de Saúde , Seguro de Assistência de Longo Prazo , Idoso , Humanos , População do Leste Asiático , Japão/epidemiologia , Assistência de Longa Duração , Estudos RetrospectivosRESUMO
Early diagnosis of basilar artery occlusion (BAO) based only on clinical findings is challenging. We present a fully recovered case of BAO caused by pulmonary arteriovenous malformation (PAVM) that was diagnosed early using a protocol for CT angiography (CTA) and promptly treated with endovascular therapy (EVT). A woman in her 50s complained of vertigo with normal level of consciousness (LOC). On arrival, her LOC decreased to a Grass Coma Scale score of 12, and we performed a CT chest-cerebral angiography protocol. Head CTA showed BAO, and an intravenous tissue plasminogen activator was administered, followed by EVT. Chest contrast-enhanced CT showed PAVM in segment 10 of the left lung, which was treated with coil embolisation. For patients with a complaint of vertigo, BAO should be suspected, even if they have an initially normal LOC. A CT chest-cerebral angiography protocol is useful for prompt diagnosis and treatment of BAO and can reveal undetermined causes.
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Arteriopatias Oclusivas , Malformações Arteriovenosas , Insuficiência Vertebrobasilar , Feminino , Humanos , Artéria Basilar , Ativador de Plasminogênio Tecidual/uso terapêutico , Insuficiência Vertebrobasilar/tratamento farmacológico , Angiografia Cerebral/métodos , Arteriopatias Oclusivas/tratamento farmacológico , Malformações Arteriovenosas/complicações , Malformações Arteriovenosas/diagnóstico por imagem , Malformações Arteriovenosas/terapia , Tomografia Computadorizada por Raios XRESUMO
Retroperitoneal hemorrhage is rarely associated with acute deep vein thrombosis (DVT). We present a case of retroperitoneal hemorrhage due to disruption of the external iliac vein associated with acute DVT, which was carefully treated with an anticoagulant. A 78-year-old woman complained of acute abdominal pain. Contrast-enhanced computed tomography (CT) showed left retroperitoneal hematoma and venous thrombosis from just above the bifurcation of the inferior vena cava to the left femoral vein. She was admitted for conservative treatment without an anticoagulant. The next day, she developed pulmonary embolism (PE), but administration of an anticoagulant was not started because of the possibility of rebleeding. Forty-four hours after the onset of PE, unfractionated heparin was administrated intravenously. After initiation of anticoagulation, retroperitoneal hemorrhage did not expand and PE did not get worse. Follow-up contrast-enhanced CT suggested May-Thurner syndrome (MTS). She was uneventfully discharged home on the 35th day with oral warfarin. Retroperitoneal hemorrhage is rarely caused by acute DVT in the case of potential causes such as MTS. In such cases, the timing of initiation of anticoagulation is difficult considering the possibility of rebleeding from retroperitoneal hemorrhage. We should start anticoagulation based on both the state of hemostatic and preventive procedures for PE. Learning objective: Retroperitoneal hemorrhage is rarely caused by acute deep vein thrombosis because of the iliac vein rupture. The subsequent occurrence of pulmonary embolism (PE) makes it more complicated and critical because treatment strategies for these two conditions are the opposite: hemostasis versus anticoagulation. The initiation of administration of an anticoagulant should be determined based on status of patients, the procedures of hemostasis, and prevention of PE.
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Artéria Mesentérica Superior , Isquemia Mesentérica , Humanos , Artéria Mesentérica Superior/diagnóstico por imagem , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/etiologia , Isquemia Mesentérica/cirurgia , Isquemia/diagnóstico por imagem , Isquemia/etiologia , Doença Crônica , IntestinosRESUMO
BACKGROUND: Floods and torrential rains are natural disasters caused by climate change. Unfortunately, such events are more frequent and are increasingly severe in recent times. The 2018 Japan Floods in western Japan were one of the largest such disasters. This study aimed to evaluate the effect of the 2018 Japan Floods on healthcare costs and service utilization. METHODS: This retrospective cohort study included all patients whose receipts accrued between July 2017 and June 2019 in Hiroshima, Okayama, and Ehime prefectures using the National Database of Health Insurance Claims. We used Generalized Estimating Equations (GEEs) to investigate yearly healthcare costs during the pre-and post-disaster periods, quarterly high-cost patients (top 10%), and service utilization (outpatient care, inpatient care, and dispensing pharmacy) during the post-disaster period. After the GEEs, we estimated the average marginal effects as the attributable disaster effect. RESULTS: The total number of participants was 5,534,276. Victims accounted for 0.65% of the total number of participants (n = 36,032). Although there was no significant difference in pre-disaster healthcare costs (p = 0.63), post-disaster costs were $3,382 (95% CI: 3,254-3,510) for victims and $3,027 (95% CI: 3,015-3,038) for non-victims (p < 0.001). The highest risk difference among high-cost patients was 0.8% (95% CI: 0.6-1.1) in the fourth quarter. In contrast, the highest risk difference of service utilization was in the first quarter (outpatient care: 7.0% (95% CI: 6.7-7.4), inpatient care: 1.3% (95% CI: 1.1-1.5), and dispensing pharmacy: 5.9% (95% CI: 5.5-6.4)). CONCLUSION: Victims of the 2018 Japan Floods had higher medical costs and used more healthcare services than non-victims. In addition, the risk of higher medical costs was highest at the end of the observation period. It is necessary to estimate the increase in healthcare costs according to the disaster scale and plan for appropriate post-disaster healthcare service delivery.