Massive Transfusion Protocol and Outcome of Patients with Acute Variceal Bleeding.

Background/Aims: The massive transfusion protocol (MTP) can improve the outcomes of trauma patients with hemorrhagic shock and some patients with non-traumatic hemorrhagic shock. However, no information is available regarding whether MTP can improve the outcomes of acute variceal bleeding (AVB). This study aimed to determine the effects of MTP on the outcomes of patients with AVB. Methods: Consecutive patients (n = 218) with AVB who did not have current malignancy and visited the emergency room between July 2014 and June 2022 were analyzed. 42-day mortality and failure to control the bleeding were compared between patients with and without MTP activation. Additionally, propensity-score matching was conducted. Results: The amount of blood product transfused was higher in the MTP group. The 42-day mortality rate (42.1% vs. 1.5%, p < 0.001) and the rate of failure to control bleeding (36.8% vs. 0.5%, p < 0.001) were significantly higher in those who received blood transfusions by MTP. MTP was an independent factor associated with 42-day mortality in the multivariable-adjusted analysis (HR 21.05; 95% CI 3.07-144.21, p = 0.002, HR 24.04; 95% CI 3.41-169.31, p = 0.001). The MTP group showed consistently higher 42-day mortality and failure to control bleeding in all subgroup analyses, stratified by systolic blood pressure, hemoglobin level, and the model for end-stage liver disease score. The MTP group also showed higher 42-day mortality (42.9% vs. 0%, p = 0.001) and failure to control bleeding (42.9% vs. 0%, p = 0.001) in a propensity score-matched analysis (n = 52). Conclusions: MTP was associated with poor outcomes in patients with AVB. Further studies are needed to see whether MTP can be an option for patients with massive AVB.

Clinical factors predicting return emergency department visits in chemotherapy-induced febrile neutropenia patients.

BACKGROUND: Although chemotherapy-induced febrile neutropenia (FN) is the most common and life-threatening oncologic emergency, the characteristics and outcomes associated with return visits to the emergency department (ED) in these patients are uncertain. Hence, we aimed to investigate the predictive factors and clinical outcomes of chemotherapy-induced FN patients returning to the ED. METHOD: This single-center, retrospective observational study spanning 14 years included chemotherapy-induced FN patients who visited the ED and were discharged. The primary outcome was a return visit to the ED within five days. We conducted logistic regression analyses to evaluate the factors influencing ED return visit. RESULTS: This study included 1318 FN patients, 154 (12.1%) of whom revisited the ED within five days. Patients (53.3%) revisited the ED owing to persistent fever (56.5%), with no intensive care unit admission and only one mortality case who was discharged hopelessly. Multivariable analysis revealed that shock index >0.9 (odds ratio [OR]: 1.45, 95% confidence interval [CI], 1.01-2.10), thrombocytopenia (<100 × 103/uL) (OR: 1.64, 95% CI, 1.11-2.42), and lactic acid level > 2 mmol/L (OR: 1.51, 95% CI, 0.99-2.25) were associated with an increased risk of a return visit to the ED, whereas being transferred into the ED from other hospitals (OR: 0.08; 95% CI, 0.005-0.38) was associated with a decreased risk of a return visit to the ED. CONCLUSION: High shock index, lactic acid, thrombocytopenia, and ED arrival type can predict return visits to the ED in chemotherapy-induced FN patients.

Use of Gallbladder Width Measurement by Computed Tomography in the Diagnosis of Acute Cholecystitis.

This study aimed to evaluate the diagnostic value of gallbladder width measurement with computed tomography (CT) in patients with acute cholecystitis. This retrospective case−control study was conducted between March 2016 and March 2020 at a tertiary emergency department. Of 310 patients, 254 patients with acute cholecystitis confirmed by surgery were compared with 254 patients diagnosed with other diseases (controls). In the acute cholecystitis group, the number of older patients with underlying illnesses was much higher (64% of men). Upon CT, the median (interquartile range [IQR]) gallbladder width was significantly longer in patients with acute cholecystitis (2.26 [1.82−2.78] cm vs. 3.73 [3.32−4.16] cm, p < 0.001). The optimal cut-off value of gallbladder width for differentiating acute cholecystitis was 3.12 cm, showing a sensitivity of 88% and specificity of 86%. In a multivariable analysis using a logistic regression model for diagnosing acute cholecystitis with CT findings (gallbladder width, length, stone, wall thickening, and pericholecystic fluid), a gallbladder width of ≥3.12 cm was significantly meaningful, even when adjusting for other variables (odds ratio 37.9; p < 0.001). Therefore, an increase in gallbladder width (≥3.12 cm) measured with CT can be a simple and sensitive diagnostic sign of acute cholecystitis, supporting the underlying pathophysiology of bile outflow obstruction.

Echocardiographic Assessment of Patients with Pulmonary Tumor Thrombotic Microangiopathy First Diagnosed in the Emergency Department.

Pulmonary tumor thrombotic microangiopathy (PTTM) is a fatal disease that obstructs pulmonary vessels, leading to pulmonary hypertension (PH) and right-sided heart failure causing rapid progressive dyspnea in patients with cancer. This retrospective chart review involved nine patients with PTTM who were first clinically diagnosed in a tertiary emergency department (ED) between January 2015 and June 2021. They underwent laboratory tests, chest radiography, chest computed tomography (CT), and echocardiography. All patients presented with severe and rapidly progressive dyspnea within a few days, a high oxygen demand. The right ventricle (RV): left ventricle ratio was >1 on chest CT, and no life-threatening pulmonary thromboembolism (PTE) was observed. Echocardiographic findings indicated that all patients had moderate-to-severe RV dilatation with a D-shaped LV. The median tricuspid regurgitation maximum velocity was 3.8 m/s, and the median RV systolic pressure was 63 mmHg, indicating severe PH. The median value of tricuspid annular plane systolic excursion was 15 mm, showing a decrease in RV systolic function, and McConnell's sign was observed in five patients. Two patients immediately underwent chemotherapy and are currently alive. PTTM should be suspected and evaluated using echocardiography in patients with cancer presenting to the ED with acute dyspnea and RV failure without PTE.

Biomarker Analysis for Combination Therapy of Vitamin C and Thiamine in Septic Shock: A Post-Hoc Study of the ATESS Trial.

INTRODUCTION: We evaluated the effects of vitamin C and thiamine administration on biomarkers in patients with septic shock. METHODS: This was a post-hoc analysis of the Ascorbic Acid and Thiamine Effect in Septic Shock (ATESS) trial, a multicenter, double-blind, randomized controlled trial. Patients were randomized to either a treatment group (intravenous vitamin C and thiamine for 48 h) or a control group. Interleukin (IL)-6, IL-10, angiopoietin-II (AP2), and S100ß were assessed at baseline and at 72 h. The primary outcomes were the biomarker levels at 72 h, and the secondary outcome was reduction rate. RESULTS: Forty-five patients were assigned to the treatment group and 52 were assigned to the control group. Baseline biomarker levels and at 72 h were not significantly different between the treatment and the placebo groups. The reduction rates were not significantly different between the two groups. These outcome variables showed fair diagnostic accuracy for predicting 28-day mortality according to the area under the receiver operating characteristic curve. CONCLUSION: Vitamin C and thiamine administration during the early phase of septic shock did not significantly change prognostic biomarker levels of IL-6, IL-10, AP2, and S100ß. TRIAL REGISTRATION: NCT, ClinicalTrials.gov NCT03756220, ATESS. Registered 28 November 2018, https://clinicaltrials.gov/ct2/show/NCT03756220.

Biorenewable, transparent, and oxygen/moisture barrier nanocellulose/nanochitin-based coating on polypropylene for food packaging applications.

Aluminum-coated polypropylene films are commonly used in food packaging because aluminum is a great gas barrier. However, recycling these films is not economically feasible. In addition, their end-of-life incineration generates harmful alumina-based particulate matter. In this study, coating layers with excellent gas-barrier properties are assembled on polypropylene films through layer-by-layer (LbL) deposition of biorenewable nanocellulose and nanochitin. The coating layers significantly reduce the transmission of oxygen and water vapors, two unfavorable gases for food packaging, through polypropylene films. The oxygen transmission rate of a 60 µm-thick, 20 LbL-coated polypropylene film decreases by approximately a hundredfold, from 1118 to 13.10 cc m-2 day-1 owing to the high crystallinity of nanocellulose and nanochitin. Its water vapor transmission rate slightly reduces from 2.43 to 2.13 g m-2 day-1. Furthermore, the coated film is highly transparent, unfavorable to bacterial adhesion and thermally recyclable, thus promising for advanced food packaging applications.

Chemo-Biological Upcycling of Poly(ethylene terephthalate) to Multifunctional Coating Materials.

Chemo-biological upcycling of poly(ethylene terephthalate) (PET) developed in this study includes the following key steps: chemo-enzymatic PET depolymerization, biotransformation of terephthalic acid (TPA) into catechol, and its application as a coating agent. Monomeric units were first produced through PET glycolysis into bis(2-hydroxyethyl) terephthalate (BHET), mono(2-hydroxyethyl) terephthalate (MHET), and PET oligomers, and enzymatic hydrolysis of these glycolyzed products using Bacillus subtilis esterase (Bs2Est). Bs2Est efficiently hydrolyzed glycolyzed products into TPA as a key enzyme for chemo-enzymatic depolymerization. Furthermore, catechol solution produced from TPA via a whole-cell biotransformation (Escherichia coli) could be directly used for functional coating on various substrates after simple cell removal from the culture medium without further purification and water-evaporation. This work demonstrates a proof-of-concept of a PET upcycling strategy via a combination of chemo-biological conversion of PET waste into multifunctional coating materials.

Aicardi-Goutières syndrome-associated gene SAMHD1 preserves genome integrity by preventing R-loop formation at transcription-replication conflict regions.

The comorbid association of autoimmune diseases with cancers has been a major obstacle to successful anti-cancer treatment. Cancer survival rate decreases significantly in patients with preexisting autoimmunity. However, to date, the molecular and cellular profiles of such comorbidities are poorly understood. We used Aicardi-Goutières syndrome (AGS) as a model autoimmune disease and explored the underlying mechanisms of genome instability in AGS-associated-gene-deficient patient cells. We found that R-loops are highly enriched at transcription-replication conflict regions of the genome in fibroblast of patients bearing SAMHD1 mutation, which is the AGS-associated-gene mutation most frequently reported with tumor and malignancies. In SAMHD1-depleted cells, R-loops accumulated with the concomitant activation of DNA damage responses. Removal of R-loops in SAMHD1 deficiency reduced cellular responses to genome instability. Furthermore, downregulation of SAMHD1 expression is associated with various types of cancer and poor survival rate. Our findings suggest that SAMHD1 functions as a tumor suppressor by resolving R-loops, and thus, SAMHD1 and R-loop may be novel diagnostic markers and targets for patient stratification in anti-cancer therapy.

L1 retrotransposons exploit RNA m6A modification as an evolutionary driving force.

L1 retrotransposons can pose a threat to genome integrity. The host has evolved to restrict L1 replication. However, mechanisms underlying L1 propagation out of the host surveillance remains unclear. Here, we propose an evolutionary survival strategy of L1, which exploits RNA m6A modification. We discover that m6A 'writer' METTL3 facilitates L1 retrotransposition, whereas m6A 'eraser' ALKBH5 suppresses it. The essential m6A cluster that is located on L1 5' UTR serves as a docking site for eukaryotic initiation factor 3 (eIF3), enhances translational efficiency and promotes the formation of L1 ribonucleoprotein. Furthermore, through the comparative analysis of human- and primate-specific L1 lineages, we find that the most functional m6A motif-containing L1s have been positively selected and became a distinctive feature of evolutionarily young L1s. Thus, our findings demonstrate that L1 retrotransposons hijack the RNA m6A modification system for their successful replication.

Valorization of waste-cooking oil into sophorolipids and application of their methyl hydroxyl branched fatty acid derivatives to produce engineering bioplastics.

Waste-cooking oil (WCO) is defined as vegetable oil that has been used to fry food at high temperatures. The annual global generation of WCO is 41-67 million tons. Without proper treatment, most WCO is abandoned in sinks and the solid residue of WCO is disposed of in landfills, resulting in serious environmental problems. Recycling and valorizing WCO have received considerable attention to reduce its negative impact on ecosystems. To convert WCO into a high value-added compound, we aimed to produce sophorolipids (SLs) that are industrially important biosurfactants, using WCO as a hydrophobic substrate by the fed-batch fermentation of Starmerella bombicola. The SLs concentration was increased ~3.7-fold compared with flask culture (315.6 vs. 84.8 g/L), which is the highest value ever generated from WCO. To expand the applications of SLs, we prepared methyl hydroxy branched fatty acids (MHBFAs) from SLs, which are important chemicals for various industries yet difficult to produce by chemical methods, using a bio-chemical hybrid approach. We synthesized bio-based plastics using MHBFAs as co-monomers. Compared with the control polymer without MHBFAs, even the incorporation of 1 mol% into polymer chains improved mechanical properties (such as ultimate tensile strength, 1.1-fold increase; toughness, 1.3-fold increase). To the best of our knowledge, this is the first attempt to apply MHBFAs from SLs derived from WCO to building blocks of plastics. Thus, we extended the valorization areas of WCO to one of the world's largest industries.

Cardiac troponin I predicts clinical outcome of patients with cancer at emergency department.

BACKGROUND: The prognostic ability of cardiac troponin I (TnI) has been demonstrated in general populations and among cardiovascular disease patients, but it has not been evaluated in cancer patients. HYPOTHESIS: This study assumes to have the prognostic ability of cardiac troponin in cancer patients visiting the emergency department. METHODS: Cancer patients visiting the emergency department were enrolled in this retrospective cohort study. Patients with previously known coronary artery disease or clinically indicated coronary angiography were not included. The maximal value from Siemens ADVIA Centaur troponin I Ultra assay within 24 hours was assessed. The primary endpoint was 180-day all-cause death, including cardiovascular and noncardiovascular death. RESULTS: A total of 9135 cancer patients (mean age: 63 years, male gender: 60%) were enrolled. Lowest (0.006 ng/mL), assay-specific <99th % (0.007-0.039 ng/mL), below median ≥ 99th % (0.040-0.129 ng/mL), and above median ≥ 99th % (≥0.130 ng/mL) TnI were found in 4487 (49.1%), 3158 (34.6%), 852 (9.3%), and 638 (7.0%) patients, respectively. There was 3192 (34.9%) all-cause deaths including 137 (1.5%) cardiovascular and 3047 (33.4%) noncardiovascular deaths in the 180-day follow-up period. The risks of all-cause, cardiovascular, and noncardiovascular death increased across higher TnI strata (hazard ratio [HR] = 1.3-2.9; 2.1-9.3; 1.3-1.8; P < .001, all). These findings were consistent within clinical subgroups including solid and hematologic cancers. CONCLUSIONS: Cancer patients visiting the emergency department with elevated troponin I were at increased risk of 180-day death. Cancer patients with elevated TnI may need additional evaluation or careful follow-up even without cardiovascular disease diagnosis.

Epidemiology and Outcome of Powered Mobility Device-Related Injuries in Korea.

BACKGROUND: This study described and analysed the features of powered mobility device (PMD)-related injuries and compared elderly and younger adult injuries. METHODS: Data from Korea Emergency Department-based Injury In-depth Surveillance (EDIIS) database involving eight emergency departments in 2011-2016 were analysed. The inclusion criteria were injuries sustained during the use of PMDs. The variables were compared between adults aged ≥ 65 years and younger adults. Primary and secondary outcomes were severe trauma and poor clinical course accordingly. The logistic regression analysis was used to identify risk factors for study outcomes. RESULTS: A total of 231 adults were enrolled, of whom 150 were ≥ 65 years of age. The total number of PMD-related injuries and the proportion of elderly injured patients increased annually, and most injuries occurred on the roadway and did not involve crash opponents. By multivariate analysis, patients aged ≥ 65 years had a higher injury severity score (adjusted odds ratio [AOR], 2.78; 95% confidence interval [CI], 1.50-5.40) and had a higher incidence of intensive care unit admissions, surgery, and death (AOR, 2.42; 95% CI, 1.16-5.28). CONCLUSION: Given the higher number and severity of injuries sustained among elderly adults ≥ 65 years of age shown in this study, we recommend that safety educations, such as the use of protective equipment and the safe driving on the roadway, are considered for PMD users ≥ 65 years of age.

Study on the Synthetic Characteristics of Biomass-Derived Isosorbide-Based Poly(arylene ether ketone)s for Sustainable Super Engineering Plastic.

Demand for the development of novel polymers derived from biomass that can replace petroleum resources has been increasing. In this study, biomass-derived isosorbide was used as a monomer in the polymerization of poly(arylene ether ketone)s, and its synthetic characteristics were investigated. As a phase-transfer catalyst, crown ether has increased the weight-average molecular weight of polymers over 100 kg/mol by improving the reaction efficiency of isosorbide and minimizing the effect of moisture. By controlling the experimental parameters such as halogen monomer, polymerization solvent, time, and temperature, the optimal conditions were found to be fluorine-type monomer, dimethyl sulfoxide, 24 h, and 155 °C, respectively. Biomass contents from isosorbide-based polymers were determined by nuclear magnetic resonance and accelerator mass spectroscopy. The synthesized polymer resulted in a high molecular weight that enabled the preparation of transparent polymer films by the solution casting method despite its weak thermal degradation stability compared to aromatic polysulfone. The melt injection molding process was enabled by the addition of plasticizer. The tensile properties were comparable or superior to those of commercial petrochemical specimens of similar molecular weight. Interestingly, the prepared specimens exhibited a significantly lower coefficient of thermal expansion at high temperatures over 150 °C compared to polysulfone.

Poisonous Caterpillar-Inspired Chitosan Nanofiber Enabling Dual Photothermal and Photodynamic Tumor Ablation.

As caterpillars detect the presence of predators and secrete poison, herein, we show an innovative and highly effective cancer therapeutic system using biocompatible chitosan nanofiber (CNf) installed with a pH-responsive motif that senses tumor extracellular pH, pHe, prior to delivering dual-modal light-activatable materials for tumor reduction. The filamentous nanostructure of CNf is dynamic during cell interaction and durable in blood circulation. Due to its amine group, CNf uptakes a large amount of photothermal gold nanoparticles (AuNPs, >25 wt %) and photodynamic chlorin e6 (Ce6, >5 wt %). As the innovative CNf approaches tumors, cationic CNf effectively discharges AuNPs connected to the pH-responsive motif via electrostatic repulsion and selectively binds to tumor cells that are generally anionic, via the electrostatic attraction accompanied by CNf. We demonstrated via these actions that the endocytosed Ce6 (on CNf) and AuNPs (free from CNf) significantly elicited tumor cell death under light irradiation. As a result, the synergistic interplay of thermogenesis and photodynamic action was observed to switch on at the pHe, resulting in a striking reduction in tumor formation and growth rate upon light exposure.

The usefulness of C-reactive protein and procalcitonin to predict prognosis in septic shock patients: A multicenter prospective registry-based observational study.

The objective of this study was to evaluate the prognostic value of C-reactive protein (CRP), procalcitonin (PCT), and their combination for mortality in patients with septic shock. This multicenter, prospective, observational study was conducted between November 2015 and December 2017. A total of 1,772 septic shock patients were included, and the overall 28-day mortality was 20.7%. Although both CRP and PCT were elevated in the non-survivor group, only CRP had statistical significance (11.9 mg/dL vs. 14.7 mg/dL, p = 0.003, 6.4 ng/mL vs. 8.2 ng/mL, p = 0.508). Multivariate analysis showed that CRP and PCT were not independent prognostic markers. In the subgroup analysis of the CRP and PCT combination matrix using their optimal cut-off values (CRP 14.0 mg/dL, PCT 17.0 ng/dL), both CRP and PCT elevated showed significantly higher mortality (Odds ratio 1.552 [95% Confidence intervals 1.184-2.035]) than both CRP and PCT not elevated (p = 0.001) and only PCT elevated (p = 0.007). However, both CRP and PCT elevated was also not an independent predictor in multivariate analysis. Initial levels of CRP and PCT alone and their combinations in septic shock patients had a limitation to predict 28-day mortality. Future research is needed to determine new biomarkers for early prognostication in patients with septic shock.

Crab-on-a-Tree: All Biorenewable, Optical and Radio Frequency Transparent Barrier Nanocoating for Food Packaging.

Plastic packaging effectively protects foods from mechanical, microbial, and chemical damage, but oxygen can still permeate these plastics, degrading foods. Improving the gas barrier usually requires metallic or halogenated polymeric coatings; however, both cause environmental concerns and metallic coatings block visible light and electromagnetic signals. This paper reports a design of a highly flexible, visible light and radio frequency transparent coating on commercial poly(ethylene terephthalate) (PET) film. Nanoscale blending was achieved between negatively charged cellulose nanofibers and positively charged chitin nanowhiskers by employing spray-assisted layer-by-layer assembly. Synergetic interplay between these highly crystalline nanomaterials results in a flexible film with superior barrier characteristics. The oxygen transmission rate was below 0.5 mL m-2 day-1. Moreover, this coating maintains its performance even when exposed to common hazards such as bending stress and hydration. The coating also notably reduces the haziness of PET with a negligible loss of transparency and provides effective inhibition of antibacterial growth. This "crab-on-a-tree" nanocoating holds high potential for biorenewable and optical and radio frequency transparent packaging applications.

Usefulness of C-MAC video laryngoscope in direct laryngoscopy training in the emergency department: A propensity score matching analysis.

OBJECTIVES: We determined the usefulness of C-MAC video laryngoscope (C-MAC) as a safe training tool for the direct laryngoscopy technique in the emergency department. METHODS: We retrospectively analyzed an institutional airway registry of adult (≥18 years old) patients from April 2014 through October 2016. In this study, the operator used C-MAC as a direct laryngoscope (DL) with limited access to the screen, and the supervisor instructed the operator via verbal feedback while watching the screen. Patients were categorized into the DL group if a conventional DL was used and the C-DL group if a C-MAC used as a DL. RESULTS: Of 744 endotracheal intubations, 163 propensity score-matched pairs were generated (1-to-n matching: C-DL group, 163 vs. DL group, 428). For the propensity-matched groups, the overall first pass success rate was 69%, while those in the C-DL and DL groups were 79% and 65%, respectively. Overall, multiple attempts were required in 8% of patients, with 4% in the C-DL group and 9% in the DL group. The overall complication rate was 11%, with 4% in the C-DL group and 14% in the DL group. In multivariable analysis, the adjusted odds ratios of C-DL use for first pass success, multiple attempts, and complications were 2.05 (95% confidence interval [CI] 1.18-2.87, p < 0.01), 0.38 (95% CI 0.15-0.94; p < 0.01), and 0.28 (95% CI 0.12-0.63; p < 0.01), respectively. CONCLUSIONS: Our study suggests that the C-MAC could be useful for training residents in the direct laryngoscopy while ensuring patient safety in the emergency department.

Interplay between RNASEH2 and MOV10 controls LINE-1 retrotransposition.

Long interspersed nuclear element 1 is an autonomous non-long terminal repeat retrotransposon that comprises ∼17% of the human genome. Its spontaneous retrotransposition and the accumulation of heritable L1 insertions can potentially result in genome instability and sporadic disorders. Moloney leukemia virus 10 homolog (MOV10), a putative RNA helicase, has been implicated in inhibiting L1 replication, although its underlying mechanism of action remains obscure. Moreover, the physiological relevance of MOV10-mediated L1 regulation in human disease has not yet been examined. Using a proteomic approach, we identified RNASEH2 as a binding partner of MOV10. We show that MOV10 interacts with RNASEH2, and their interplay is crucial for restricting L1 retrotransposition. RNASEH2 and MOV10 co-localize in the nucleus, and RNASEH2 binds to L1 RNAs in a MOV10-dependent manner. Small hairpin RNA-mediated depletion of either RNASEH2A or MOV10 results in an accumulation of L1-specific RNA-DNA hybrids, suggesting they contribute to prevent formation of vital L1 heteroduplexes during retrotransposition. Furthermore, we show that RNASEH2-MOV10-mediated L1 restriction downregulates expression of the rheumatoid arthritis-associated inflammatory cytokines and matrix-degrading proteinases in synovial cells, implicating a potential causal relationship between them and disease development in terms of disease predisposition.

Upper airway obstruction resulting from acute mucosal injury induced by direct ingestion of sodium picosulfate/magnesium citrate powder.

A 59-year-old man presented to the emergency department with a chief complaint of sore throat after swallowing sodium picosulfate/magnesium citrate powder for bowel preparation, without first dissolving it in water. The initial evaluation showed significant mucosal injury involving the oral cavity, pharynx, and epiglottis. Endotracheal intubation was performed for airway protection in the emergency department, because the mucosal swelling resulted in upper airway compromise. After conservative treatment in the intensive care unit, he underwent tracheostomy because stenosis of the supraglottic and subglottic areas was not relieved. The tracheostomy tube was successfully removed after confirming recovery, and he was discharged 3 weeks after admission.