Excited State Engineering in Ag29 Nanocluster through Peripheral Modification with Silver(I) Complexes for Bright Near-Infrared Photoluminescence.

The optical property of an ionic metal nanocluster (NC) is affected by the ionic interaction with counter ions. Here, we report that the modification of trianionic [Ag29(BDT)12(TPP)4]3- NC (BDT: 1.3-benzenedithiol; TPP: triphenylphosphine) with silver(I) complexes led to the intense photoluminescence (PL) in the near-infrared (NIR) region. The binding of silver(I) complexes to the peripheral region of Ag29 NC is confirmed by the single-crystal X-ray diffraction (SCXRD) measurement, which is further supported by electrospray ionization mass spectrometry (ESI-MS) and nuclear magnetic resonance (NMR) spectroscopy. The change of excited-state dynamics by the binding of silver(I) complexes is discussed based on the results of a transient absorption study as well as temperature-dependent PL spectra and PL lifetime measurements. The modification of Ag29 NCs with cationic silver(I) complexes is considered to give rise to a triplet excited state responsible for the intense NIR PL. These findings also afford important insights into the origin of the PL mechanism as well as the possible light-driven motion in Ag29-based NCs.

Effectiveness of Administration of Fibrinogen Concentrate as Prevention of Hypofibrinogenemia in Patients with Traumatic Brain Injury with a Higher Risk for Severe Hyperfibrinolysis: Single Center Before-and-After Study.

BACKGROUND: Coagulopathy is often observed in severe traumatic brain injury (sTBI), and hyperfibrinolysis (HF) is associated with a poor prognosis. Although the efficacy of fibrinogen concentrate (FC) in multiple trauma has been reported, its efficacy in sTBI is unclear. Therefore, we delineated severe HF risk factors despite fresh frozen plasma transfusion. Using these risk factors, we defined high-risk patients and determined whether FC administration to this group improved fibrinogen level. METHODS: In the first part of this study, successive adults with sTBI treated at our hospital between April 2016 and March 2019 were reviewed. Patients underwent transfusion as per our conventional protocol and were divided into two groups based on whether fibrinogen levels of ≥ 150 mg/dL were maintained 3-6 h after arrival to delineate the risk factors of severe HF. In the second part of the study, we conducted a before-and-after study in patients with sTBI who were at a higher risk for severe HF (presence of at least one of the risk factors identified in the first part of the study), comparing those treated with FC between April 2019 and March 2021 (FC group) with those treated with conventional transfusion before FC between April 2016 and March 2019. The primary outcome was maintenance of fibrinogen levels, and the secondary outcome was 30-day mortality. RESULTS: In the first part of the study, 78 patients were included. Twenty-three patients did not maintain fibrinogen levels ≥ 150 mg/dL. A D-dimer level on arrival > 50 µg/mL, a fibrinogen level on arrival < 200 mg/dL, depressed skull fracture, and multiple trauma were severe HF risk factors. In the second part, compared with 46 patients who were identified as being at high risk for severe HF but were not administered FC (non-FC group), fibrinogen levels ≥ 150 mg/dL 3-6 h after arrival were maintained in 14 of 15 patients in the FC group (odds ratio: 0.07; 95% confidence interval: 0.01-0.59). Although there were significant differences in fibrinogen levels, no significant differences were observed in terms of 30-day mortality between the groups. CONCLUSIONS: Coagulation abnormalities on arrival, severe skull fracture, and multiple trauma are severe HF risk factors. FC administration may contribute to rapid correction of developing hypofibrinogenemia.

Association of skull fracture with in-hospital mortality in severe traumatic brain injury patients.

INTRODUCTION: To identify the association between skull fracture (SF) and in-hospital mortality in patients with severe traumatic brain injury (TBI). MATERIALS AND METHODS: This multicenter cohort study included a retrospective analysis of data from the Japan Trauma Data Bank (JTDB). JTDB is a nationwide, prospective, observational trauma registry with data from 235 hospitals. Adult patients with severe TBI (Glasgow Coma Scale <9, head Abbreviated Injury Scale (AIS) ≥ 3, and any other AIS < 3) who were registered in the JTDB between January 2004 and December 2017 were included in the study. Patients who (a) were < 16 years old, (b) developed cardiac arrest before or at hospital arrival, and (c) had burns and penetrating injuries were excluded from the study. In-hospital mortality was the primary outcome assessed. Multivariable logistic regression analyses were performed to calculate the adjusted odds ratios (ORs) of SF and their 95% confidence intervals (CIs) for in-hospital mortality. RESULTS: A total of 9607 patients were enrolled [median age: 67 (interquartile range: 50-78) years] in the study. Among those patients, 3574 (37.2%) and 6033 (62.8%) were included in the SF and non-SF groups, respectively. The overall in-hospital mortality rate was 44.1% (4238/9607). A multivariate analysis of the association between SF and in-hospital mortality yielded a crude OR of 1.63 (95% CI: 1.47-1.80). A subgroup analysis of the association of skull vault fractures, skull base fractures, and both fractures together with in-hospital mortality yielded adjusted ORs of 1.60 (95% CI: 1.42-1.98), 1.40 (95% CI: 1.16-1.70), and 2.14 (95% CI: 1.74-2.64), respectively, relative to the non-SF group. CONCLUSIONS: This observational study showed that SF is associated with in-hospital mortality among patients with severe TBI. Furthermore, patients with both skull base and skull vault fractures were associated with higher in-hospital mortality than those with only one of these injuries.

[A Case of Breast Cancer in a Female-to-Male Transsexual during Androgen Therapy].

Gender identity disorder is defined as a condition in which physical and mental sexuality do not match. A female-to-male (FTM)has the mental sexuality of males and the physical sexuality of females. FTM transsexuals generally receive androgen therapy, mastectomy, and sex reassignment surgery to live as their desired sex. The risk of breast cancer in FTM transsexual patients remains unclear. We report a case of breast cancer in an FTM transsexual. A 44-year-old man who underwent mastectomy and sex reassignment surgery and received androgen as hormone therapy developed breast cancer. At first glance, mastectomy and sex reassignment surgery may reduce the risk of breast cancer by suppressing estrogen. However, there are reports of breast cancer in FTM transsexuals. It is important to provide sufficient information that patients may develop breast cancer from residual breast tissue and that they should therefore start hormone therapy even if they have undergone mastectomy and sex reassignment surgery. In order to decide whether to restart androgen therapy after breast surgery, it is necessary to consider not only the risk of recurrence of breast cancer but also their gender identity.

Drowning of a patient with epilepsy while showering.

In Japan, because the most common site of drowning among patients with epilepsy is the bathtub, showering is generally recommended as an alternative to bathing. We herein report a case involving a female patient with epilepsy who drowned while showering. She had been diagnosed with epilepsy approximately 25 years previously, and her condition had progressed to refractory epilepsy. Carbamazepine, levetiracetam, lamotrigine, clobazam, and perampanel were prescribed daily. One day while showering, the patient was found lying with her face immersed in water that had accumulated on the floor of the bathtub. A forensic autopsy revealed water in the stomach, trachea, and proximal regions of both lung bronchi as well as white and red foam on the pharynx and larynx. A total of 1.9 µg/mL of lamotrigine, 0.14 µg/mL of carbamazepine, and 0.069 µg/mL of perampanel were detected in the patient's blood. The patient's cause of death was determined to be drowning due to an epileptic seizure. Although the patient was prescribed five types of antiepileptic medication, only three were detected in her blood. The current case demonstrates that drowning can occur while showering, suggesting that it is unsafe for patients with medication nonadherence. To prevent unintentional deaths in the bathroom, we recommend that patients with epilepsy maintain high adherence to all prescriptions and are supervised by a family member, even when showering. The current case is the first autopsy report of a patient with epilepsy who drowned while showering.

Left Upper Lung Lobectomy Is an Embolic Risk Factor for Cerebral Infarction.

Cerebral embolism is typically caused by a cardiogenic thrombus. The patent foramen ovale is a well-known cause of paradoxical embolism. However, some idiopathic cases of stroke have been reported. Such strokes are designated as embolic stroke of undetermined sources. Among them, lung lobectomy may be a new embolic risk factor for cerebral embolism. The risk of thrombus formation is high at the pulmonary vein stump after lung lobectomy, especially in the left upper lobe. Interestingly, the risk remains several years after surgery. This condition is mostly overlooked, and reported cases of this condition are rare. Methods of early detection, prevention, and treatment have not been established. Here we report the case of a 66-year-old man who suffered a cerebral infarction 2 days after left upper lobectomy. Three-dimensional computed tomography scan clearly revealed the structural feature of the pulmonary vein stump. The stump of patients with cerebral infarction after lung lobectomy should be checked.

Effective Use of Calcineurin Inhibitor in Combination Therapy for Interstitial Lung Disease in Patients With Dermatomyositis and Polymyositis.

OBJECTIVE: The current study demonstrated the potential use of calcineurin inhibitor (CNI) in combination therapy for interstitial lung disease (ILD) complicated with dermatomyositis (DM) and polymyositis (PM). METHODS: Thirty DM/PM patients with ILD were enrolled in this study. Continuous intravenous administration of cyclosporine A (IV-CsA) was simultaneously started with corticosteroid in patients presenting more than two respiratory distress factors as follows: <70 mmHg of PaO2, percentage of vital capacity <70%, and/or exertional dyspnea. Other patients took CNI orally with corticosteroid. When a patient presented exacerbation of ILD, intravenous cyclophosphamide pulse therapy (IVCY) was additionally administrated. Clinical outcomes were compared with those of 21 patients who had been previously treated in our hospital before starting this study, as the historical comparison group. RESULTS: Seven patients underwent IV-CsA, maintaining the drug concentration in blood between 300 and 350 ng/mL, and six of them had favorable outcomes without any adverse events. Eight out of the 30 patients additionally required IVCY. Meanwhile, the frequency of death ascribable to respiratory failure was 6.7%, which was significantly lower than that of the historical comparison group (P = 0.043). Furthermore, longer survival free from exacerbation and severe adverse event was significantly shown (P = 0.029). CONCLUSIONS: For repressing the activity of ILD in DM/PM patients, stabilizing the blood concentration of CNI immediately is a reasonable treatment as well as initiating immunosuppressive therapy in the early phase of the illness. IV-CsA may be a useful option for achieving this purpose in patients with severe ILD.

Imbalanced expression of dysfunctional regulatory T cells and T-helper cells relates to immunopathogenesis in polyarteritis nodosa.

OBJECTIVES: We investigated the characteristics of circulating T-helper (Th) cells and CD4+ regulatory T cells (Tregs) in polyarteritis nodosa (PAN). METHODS: Peripheral blood samples were obtained from 14 patients with PAN. Nine patients having granulomatosis with polyangiitis (GPA) and 11 healthy individuals (HC) were enrolled as controls. Th cells and Tregs were analyzed by flow cytometry. Suppression assay of Tregs was simultaneously performed by evaluating the proliferation of conventional CD4+ T cells cocultured with Tregs. RESULTS: The frequencies of Th cells were significantly higher in PAN than in HC. In comparison with GPA, the expression of Th1 cells was higher but that of Th17 cells was lower. Additionally, significant increase in Tregs was observed in PAN, which was correlated with the expression of Th1 cells; however, defects in suppressive ability and CTLA-4 expression were observed. The Th1-cell frequency was significantly decreased after immunosuppressive therapy in PAN; however, there were no improvements in other phenotypes or in Treg function. CONCLUSION: T-helper cell expansion and Treg dysfunction are thought to be associated with the pathogenesis of PAN. Th1 cells show a response to immunosuppressive therapy; however, the persistent immune abnormalities may interfere with complete recovery in patients with PAN.

Assembly of anionic silver nanoclusters with controlled packing structures through site-specific ionic bridges.

The assembly of metal nanoclusters (NCs) into crystalline lattice structures is of interest in the development of NC-based functional materials. Here we demonstrate that the assembled structures of tri-anionic tetrahedral symmetric [Ag29(BDT)12]3- (Ag29 NC, BDT: 1,3-benzenedithiol) NCs are controlled into a polyethylene-like zigzag chain and a "poly-ring-fused-cyclohexane"-like honeycomb arrangement through ionic interactions with alkali metal cations such as K+ and Cs+. The site-specific binding of alkali metal ions on the tetrahedrally arranged binding sites of Ag29 NCs successfully connects the adjacent NCs into various packing modes. The number and type of bridges between NCs determine the Ag29 NC packing structures, which are affected by the solvent species, enabling the transformation of packing modes in the single-crystalline state. The photoluminescence (PL) properties of the crystals responded to the packing modes of the NCs in terms of anisotropy and bridge linkage style inducing a varied degree of relaxation of the excited state depending on the relocation mobility of alkali metal ions in the crystals.

Increased CT Use and No Change in Injury Severity among Child Motor Vehicle Victims: A National Trauma Database Study in Japan.

The number of fatalities associated with traffic accidents has been declining owing to improvements in vehicle safety performance and changes in the law. However, injuries in children can lead to social and economic losses. We examined 10-year changes in the characteristics of traffic trauma among pediatric motor vehicle passengers by analyzing data from the Japan Trauma Data Bank (JTDB). Among the 36,715 injured motor vehicle passengers under the age of 15 years who were registered in the JTDB from 2004 to 2019, we compared the groups injured during 2004-2007 (n = 94) and 2017-2019 (n = 203). Physiologically, the 2004-2007 group had a lower body temperature and Glasgow Coma Scale score as well as a higher mortality. Anatomical severity was higher in the 2004-2007 group for the head, face, and neck, according to the Abbreviated Injury Scale. In terms of treatment, only craniotomy as a primary surgery was significantly lower in the 2017-2019 group. The 2017-2019 group had significantly higher rates of receiving whole-body computed tomography (CT). Because the rate of performing CT has increased, with no changes in the injury severities of the trunk and extremities, limiting the number of CT examinations is suggested for pediatric motor vehicle passengers involved in road traffic collisions. The severity of trunk and extremity injuries has not improved in more than 10 years; further preventive measures for these injuries should be considered.

Prophylactic effect of negative-pressure wound therapy and delayed sutures against incisional-surgical site infection after emergency laparotomy for colorectal perforation: A multicenter retrospective cohort study.

Aim: The prophylactic effect of negative-pressure wound therapy against incisional surgical site infection after highly contaminated laparotomies has not been sufficiently explored. This study aimed to evaluate the prophylactic effect of negative-pressure wound therapy against incisional surgical site infection after emergency surgery for colorectal perforation. Methods: This nationwide, multicenter, retrospective cohort study analyzed data from the 48 emergency hospitals certificated by the Japanese Society for Abdominal Emergency Medicine. Patients who underwent an emergency laparotomy for colorectal perforation between April 2015 and March 2020 were included in this study. Outcomes, including the incidence of incisional surgical site infection, were compared between patients who were treated with prophylactic negative-pressure wound therapy and delayed sutures (i.e., negative-pressure wound therapy group) and patients who were treated with regular wound management (i.e., control group) using 1:4 propensity score matching analysis. Results: The negative-pressure wound therapy group comprised 88 patients, whereas the control group consisted of 1535 patients. Of them, 82 propensity score-matched pairs (negative-pressure wound therapy group: 82; control group: 328) were evaluated. The negative-pressure wound therapy group showed a lower incidence of incisional surgical site infection [18 (22.0%) in the negative-pressure wound therapy group and 115 (35.0%) in the control group, odds ratio, 0.52; 95% confidence interval, 0.30 to 0.92; p = 0.026]. Conclusions: The prophylactic use of negative-pressure wound therapy with delayed sutures was associated with a lower incidence of incisional surgical site infection after emergency surgery for colorectal perforation.

Optimal Treatment of Hormone Receptor-positive Advanced Breast Cancer Patients With Palbociclib.

BACKGROUND/AIM: Palbociclib was the first cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitor approved worldwide. Currently, CDK4/6 inhibitors are strongly recommended for endocrine therapy in the first or second line with hormone receptor-positive advanced breast cancer. It is expected the use of CDK4/6 inhibitor will further increase. Therefore, the aim was to investigate and better understand the use of palbociclib. PATIENTS AND METHODS: We retrospectively analyzed the data of patients with advanced breast cancer who were treated with palbociclib in three hospitals between 2018 and 2022. Clinical data were obtained from the patients' medical electronic records. RESULTS: A total of 143 patients were enrolled. The median age was 66 years (range=33-89), and the majority (90.9%) were postmenopausal patients. In total, median time-to-treatment discontinuation (TTD) (95% confidence interval, CI) was 7 (6-10) months. Median TTD (95% CI) was 13 (7-20) months for the first or second line, and significantly prolonged compared to TTD for the third or later lines with palbociclib (p<0.0001). The importance of front-line use was indicated. Multivariate analyses showed that no visceral metastasis or first or second line therapy influenced the longer TTD. Between patients above or below 70 years of age, older age did not negatively affect TTD, though there were significantly more cases of dose reduction or withdrawal in patients over 70 years old. The variation of adverse events (AEs) among hospitals was very large (9.0%, 31.3%, 4.5%). We found that understanding of AE management was important. CONCLUSION: This study showed that dose reduction or withdrawal of palbociclib had no harmful effects in Japanese patients. Efficacy was also high in older patients. It is important to manage palbociclib administration more safely and appropriately. A combination of dose reduction and withdrawal is key to this therapeutic strategy.

Coadministration of tacrolimus with corticosteroid accelerates recovery in refractory patients with polymyositis/ dermatomyositis: a retrospective study.

BACKGROUND: To investigate whether or not coadministration of tacrolimus (TAC) with prednisolone (PSL) can produce a beneficial effect in the treatment of polymyositis/ dermatomyositis (PM/DM). METHODS: We reviewed medical records of 32 PM/DM patients who had been admitted to our hospital, and abstracted those who had received TAC in addition to oral PSL for treatment. The clinical usefulness of TAC in PM/DM was objectively evaluated focusing upon the manual muscle strength test (MMT) score, serum creatine kinase (CK) and tapering of PSL. RESULTS: Nine patients with PM and 6 with DM were enrolled in this study. TAC was added because of difficulty in reduction of PSL in 12 patients and recurrence with corticosteroid-induced complications in the remaining 3. Both PM and DM patients showed significant increases in the MMT score and significant decreases in serum CK 1 to 3 months after starting TAC compared with before. Skin symptoms in a clinically amyopathic DM patient also improved 1 month after starting TAC. The daily dosage of PSL could be significantly reduced in both PM and DM after starting TAC compared with before. No serious adverse events ascribable to TAC occurred in any patients. CONCLUSION: Additional use of TAC with PSL may safely promote improvement of PM/DM and also accelerate tapering of the latter.

[A case of advanced gastric cancer found to be remaining by gastrectomy after a clinically complete response to chemotherapy].

The patient was a 72-year-old woman diagnosed with advanced gastric cancer, hepatic portal lymph node and para-aortic lymph node metastases. After five courses of S-1/CDDP combination therapy, both the primary tumor and lymph node metastases disappeared clinically. She wished to continue chemotherapy instead of having a resection. After three more courses of S-1/CDDP therapy, gastric cancer and lymph node metastases were still completely regressed, but complications of carcinoma of the gallbladder were suspected. Gastrectomy was performed with cholecystectomy, and a histopathological examination revealed cancer cells remaining in the gastric submucosa and xanthogranulomatous cholecystitis. We consider surgical therapy for clinically completely disappearing advanced gastric cancer by chemotherapy, in addition to case report.

Coccyx subluxation: Coccyx pain aggravated by the prone position.

A 33-year-old woman presented with coccyx pain since her first vaginal delivery. On lateral plain radiographs, the tailbone was subluxated and dislocated ventrally.

Physiological status and anatomical severity factors associated with child versus adult bicyclist fatalities based on a national trauma dataset.

Bicyclists still account for the majority of child deaths in traffic accidents, despite a gradual decrease in incidence. Therefore, we investigated factors associated with child and adult bicyclist fatalities. In this retrospective study, we used data from a national hospital-based database, the Japan Trauma Data Bank. Data from 2004 to 2019 were obtained for child cyclists (5-18 years; n = 4832) and adult cyclists (26-45 years; n = 3449). In each age group, physiological variables, outcomes, and injury severity were compared between fatal and non-fatal cases. Multivariate logistic regression was performed to determine factors associated with fatality. In adults, fatality was associated with lower values for body temperature, Glasgow Coma Scale score, and Abbreviated Injury Scale (AIS) score for the neck and upper extremities, and with higher values for respiratory rate, heart rate, focused assessment with sonography for trauma positivity rate, and AIS scores for the head, chest, and abdomen. In children, fatality was associated with lower values for body temperature and the Glasgow Coma Scale score, and with higher values for the AIS chest score. These findings point to factors associated with bicyclist fatalities and may help in the development of effective strategies to reduce these fatalities.

Adverse events of emergency surgical front of neck airway access: an observational descriptive study.

Aim: Emergency front of neck access (eFONA), such as scalpel cricothyroidotomy, is a rescue technique used to open the airway during "cannot intubate, cannot oxygenate" situations. However, little is known about the adverse events associated with the procedure. This study aimed to describe the adverse events that occur in patients who undergo eFONA and their management. Methods: This retrospective observational cohort study included emergency patients who underwent eFONA between April 2012 and August 2020. We described the patients' characteristics and the adverse events during or immediately after the procedure. Results: Among 75,529 emergency patients during the study period, 31 (0.04%) underwent an eFONA. The median (interquartile range) age was 53 (39-67) years, and 23 patients (74.2%) were men. Of all cases, 13 (41.9%) experienced adverse events. Of these, three cases (23.2%) were cephalad misplacement of the intubation tube, one case (7.7%) was cuff injury, one case (7.7%) was tube obstruction due to vomiting, and one case (7.7%) was tube kink. In cases with these adverse events, the initial attempt of eFONA failed, and alternative immediate action was necessary to secure the airway. Conclusion: This single-center retrospective observational study described several adverse events of eFONA. In particular, it is important to understand the possible life-threatening adverse events that lead to failure of securing airways such as cephalad displacement, tube obstruction, and tube kink and respond promptly to ensure a secure definitive airway for patients' safety.

Body temperature and in-hospital mortality in trauma patients: analysis of a nationwide trauma database in Japan.

PURPOSE: Avoiding body temperature (BT) abnormalities has been emphasized in trauma care, and BT correction in the initial treatment period may improve patient outcome. However, the effect of hyperthermia at hospital arrival on mortality in trauma patients is unclear. This study aimed to identify the association between BT and in-hospital mortality among adult trauma patients. METHODS: This was a retrospective analysis of a multi-centre prospective cohort study. Data were obtained from the Japan Trauma Data Bank (JTDB). Adult trauma patients who were transferred directly from the scene of injury to the hospital and registered in the JTDB between January 2004 and December 2017 were included. The primary outcome was the association between BT at hospital arrival and in-hospital mortality. BT at hospital arrival was classified by 1 °C strata. We conducted multivariable logistic regression analyses to calculate the adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for in-hospital mortality for each BT group using 36.0-36.9 °C as a reference. RESULTS: Overall, 153,117 patients were included. The total mortality rate was 7% (n = 10,118). The adjusted OR for in-hospital mortality for < 35.0 °C was 1.65 (95% CI 1.51-1.79, p < 0.001), 35.0-35.9 °C was 1.33 (95% CI 1.25-1.41, p < 0.001), 37.0-37.9 °C was 0.99 (95% CI 0.91-1.07, p = 0.639), 38.0-38.9 °C was 1.30 (95% CI 1.08-1.56, p = 0.007) and > 39.0 °C was 1.62 (95% CI 1.18-2.22, p = 0.003) compared to that for normothermia. CONCLUSIONS: Our results reveal that hypothermia and hyperthermia at hospital arrival are associated with increased in-hospital mortality in adult trauma patients.

Open pneumothorax with extensive thoracic defects sustained in a fall: a case report.

BACKGROUND: Open pneumothorax with chest wall deficit is a rare chest trauma that is serious and can lead to severe respiratory failure; however, it is a potentially lifesaving injury if utilized appropriately. CASE PRESENTATION: Herein, we report a case of an open pneumothorax with extensive chest wall deficit due to falling from a height and highlight the importance of appropriate evaluation and intervention. The patient was a Japanese man in his 50 s who fell from the 6th floor to the 3rd floor while working at a height. The left chest wall was punctured due to injury, the thoracic cavity was open as if a left anterolateral thoracotomy had been performed, and the left lung had prolapsed from the thoracic cavity to the outside. In our emergency department, tracheal intubation with a double lumen tube for differential positive pressure ventilation and a right thoracic drain were inserted, and an emergency operation was started immediately. A pulmonary suture for lung injury and closure of the left thorax were performed during the surgery. The defect was closed with the remaining tissue, but the anterior thoracic skin with poor blood flow was necrotic, so debridement was undertaken. After his general condition was improved, pedicled latissimus dorsi myocutaneous flap was implanted. He was discharged home on the 63rd hospital day. CONCLUSIONS: Although open pneumothorax is rare and sometimes presents lurid findings, we highlighted that it is important to quickly assess the life-threatening organ injury, perform positive pressure ventilation by tracheal intubation, thoracic drainage, and wound closure simultaneously respond calmly as a team.