Acute alcohol intoxication presenting acquired lesion of the corpus callosum in a young healthy woman: A case of possible Marchiafava-Bignami disease.

Background: Marchiafava-Bignami disease is a rare neurological disease characterized by acquired lesions of the corpus callosum. Although the major causative etiology is chronic alcoholism, a case caused by acute alcohol intoxication has not yet been reported. Case Presentation: A 19-year-old female with no known medical history or a history of chronic alcohol consumption was brought to the emergency department in a coma after binge alcohol consumption. Even after an overnight observation, she remained comatose. After a thorough examination including magnetic resonance imaging, which showed lesions of the corpus callosum, she was treated with thiamine for Marchiafava-Bignami disease. She recovered completely and at the follow-up, the callosum lesion had resolved. Conclusion: This is a rare case within the spectrum of Marchiafava-Bignami disease caused by acute consumption of alcohol. Clinicians should be aware of this potentially devastating critical condition among patients with severe alcohol intoxication, which might have been overlooked.

Case study observational research: inflammatory cytokines in the bronchial epithelial lining fluid of COVID-19 patients with acute hypoxemic respiratory failure.

BACKGROUND: In this study, the concentrations of inflammatory cytokines were measured in the bronchial epithelial lining fluid (ELF) and plasma in patients with acute hypoxemic respiratory failure (AHRF) secondary to severe coronavirus disease 2019 (COVID-19). METHODS: We comprehensively analyzed the concentrations of 25 cytokines in the ELF and plasma of 27 COVID-19 AHRF patients. ELF was collected using the bronchial microsampling method through an endotracheal tube just after patients were intubated for mechanical ventilation. RESULTS: Compared with those in healthy volunteers, the concentrations of interleukin (IL)-6 (median 27.6 pmol/L), IL-8 (1045.1 pmol/L), IL-17A (0.8 pmol/L), IL-25 (1.5 pmol/L), and IL-31 (42.3 pmol/L) were significantly greater in the ELF of COVID-19 patients than in that of volunteers. The concentrations of MCP-1 and MIP-1ß were significantly greater in the plasma of COVID-19 patients than in that of volunteers. The ELF/plasma ratio of IL-8 was the highest among the 25 cytokines, with a median of 737, and the ELF/plasma ratio of IL-6 (median: 218), IL-1ß (202), IL-31 (169), MCP-1 (81), MIP-1ß (55), and TNF-α (47) were lower. CONCLUSIONS: The ELF concentrations of IL-6, IL-8, IL-17A, IL-25, and IL-31 were significantly increased in COVID-19 patients. Although high levels of MIP-1 and MIP-1ß were also detected in the blood samples collected simultaneously with the ELF samples, the results indicated that lung inflammation was highly compartmentalized. Our study demonstrated that a comprehensive analysis of cytokines in the ELF is a feasible approach for understanding lung inflammation and systemic interactions in patients with severe pneumonia.

Prediction of acute lung injury assessed by chest computed tomography, oxygen saturation/fraction of inspired oxygen ratio, and serum lactate dehydrogenase in patients with COVID-19.

INTRODUCTION: In treating acute hypoxemic respiratory failure (AHRF) caused by coronavirus disease 2019 (COVID-19), clinicians choose respiratory therapies such as low-flow nasal cannula oxygenation, high-flow nasal cannula oxygenation, or mechanical ventilation after assessment of the patient's condition. Chest computed tomography (CT) imaging contributes significantly to diagnosing COVID-19 pneumonia. However, the costs and potential harm to patients from radiation exposure need to be considered. This study was performed to predict the quantitative extent of COVID-19 acute lung injury using clinical indicators such as an oxygenation index and blood test results. METHODS: We analyzed data from 192 patients with COVID-19 AHRF. Multiple logistic regression was used to determine correlations between the lung infiltration volume (LIV) and other pathophysiological or biochemical laboratory parameters. RESULTS: Among 13 clinical parameters, we identified the oxygen saturation/fraction of inspired oxygen ratio (SF ratio) and serum lactate dehydrogenase (LD) concentration as factors associated with the LIV. In the binary classification of an LIV of ≥20 % or not and with the borderline LD = 2.2 × [SF ratio]-182.4, the accuracy, precision, diagnostic odds ratio, and area under the summary receiver operating characteristic curve were 0.828, 0.818, 23.400, and 0.870, respectively. CONCLUSIONS: These data suggest that acute lung injury due to COVID-19 pneumonia can be estimated using the SF ratio and LD concentration without a CT scan. These findings may provide significant clinical benefit by allowing clinicians to predict acute lung injury levels using simple, minimally invasive assessment of oxygenation capacity and biochemical blood tests.

Choice of respiratory therapy for COVID-19 patients with acute hypoxemic respiratory failure: a retrospective case series study.

Background: In the treatment of acute hypoxemic respiratory failure (AHRF) due to coronavirus 2019 (COVID-19), physicians choose respiratory management ranging from low-flow oxygen therapy to more invasive methods, depending on the severity of the patient's symptoms. Recently, the ratio of oxygen saturation (ROX) index has been proposed as a clinical indicator to support the decision for either high-flow nasal cannulation (HFNC) or mechanical ventilation (MV). However, the reported cut-off value of the ROX index ranges widely from 2.7 to 5.9. The objective of this study was to identify indices to achieve empirical physician decisions for MV initiation, providing insights to shorten the delay from HFNC to MV. We retrospectively analyzed the ROX index 6 hours after initiating HFNC and lung infiltration volume (LIV) calculated from chest computed tomography (CT) images in COVID-19 patients with AHRF. Methods: We retrospectively analyzed the data for 59 COVID-19 patients with AHRF in our facility to determine the cut-off value of the ROX index for respiratory therapeutic decisions and the significance of radiological evaluation of pneumonia severity. The physicians chose either HFNC or MV, and the outcomes were retrospectively analyzed using the ROX index for initiating HFNC. LIV was calculated using chest CT images at admission. Results: Among the 59 patients who required high-flow oxygen therapy with HFNC at admission, 24 were later transitioned to MV; the remaining 35 patients recovered. Four of the 24 patients in the MV group died, and the ROX index values of these patients were 9.8, 7.3, 5.4, and 3.0, respectively. These index values indicated that the ROX index of half of the patients who died was higher than the reported cut-off values of the ROX index, which range from 2.7-5.99. The cut-off value of the ROX index 6 hours after the start of HFNC, which was used to classify the management of HFNC or MV as a physician's clinical decision, was approximately 6.1. The LIV cut-off value on chest CT between HFNC and MV was 35.5%. Using both the ROX index and LIV, the cut-off classifying HFNC or MV was obtained using the equation, LIV = 4.26 × (ROX index) + 7.89. The area under the receiver operating characteristic curve, as an evaluation metric of the classification, improved to 0.94 with a sensitivity of 0.79 and specificity of 0.91 using both the ROX index and LIV. Conclusion: Physicians' empirical decisions associated with the choice of respiratory therapy for HFNC oxygen therapy or MV can be supported by the combination of the ROX index and the LIV index calculated from chest CT images.

High-Velocity Nasal Insufflation Increases Nasopharyngeal Pressure with Flow-Dependent Manner Compared with High Flow Nasal Cannula in Adult Volunteers - A Single-Center Prospective Observational Study.

BACKGROUND: High flow nasal cannula (HFNC) can produce positive airway pressure, and the pressure increases in proportion to the gas flow. Recently, high-velocity nasal insufflation (HiVNI) was developed as a new system of HFNC. However, it is still unclear whether HiVNI can increase the airway pressure. The purpose of our study was to evaluate whether the HiVNI can increase the airway pressure compared to HFNC, under various gas flows. METHODS: This single-center prospective observational study recorded nasopharyngeal pressures in fifteen healthy volunteers who received both normal HFNC and HiVNI. After a 10 Fr catheter was inserted via the nose, the catheter was connected to the manometer and high flow oxygen therapy was performed using both systems. The measurements were carried out at flows of 20, 30, and 40 L/min, and the pressures were recorded at 50 Hz. The measurements were repeated with the mouth in the open and closed positions for each high-flow system. RESULTS: With the mouth open, the mean nasopharyngeal pressure was low in both systems, and the difference between the two systems was not significant. However, with the mouth closed, a significantly higher nasopharyngeal pressure was recorded with the HiVNI system compared to the HFNC system at all flows (P < .01). Furthermore, the difference between HiVNI and HFNC at each flow became significantly greater with the increase of flow (P < .01). CONCLUSION: In healthy volunteers, HiVNI can produce higher nasopharyngeal pressure than normal HFNC in a flow-dependent manner.

Molecular diversity of extended-spectrum ß-lactamases and carbapenemases, and antimicrobial resistance.

Along with the recent spread of multidrug-resistant bacteria, outbreaks of extended-spectrum ß-lactamase (ESBL) and carbapenemase-producing bacteria present a serious challenge to clinicians. ß-lactam antibiotics are the most frequently used antibacterial agents and ESBLs, and carbapenemases confer resistance not only to carbapenem antibiotics but also to penicillin and cephem antibiotics. The mechanism of ß-lactam resistance involves an efflux pump, reduced permeability, altered transpeptidases, and inactivation by ß-lactamases. Horizontal gene transfer is the most common mechanism associated with the spread of extended-spectrum ß-lactam- and carbapenem resistance among pathogenic bacterial species. Along with the increase in antimicrobial resistance, many different types of ESBLs and carbapenemases have emerged with different enzymatic characteristics. For example, carbapenemases are represented across classes A to D of the Ambler classification system. Because bacteria harboring different types of ESBLs and carbapenemases require specific therapeutic strategies, it is essential for clinicians to understand the characteristics of infecting pathogens. In this review, we summarize the current knowledge on carbapenem resistance by ESBLs and carbapenemases, such as class A carbapenemases, class C extended-spectrum AmpC (ESAC), carbapenem-hydrolyzing class D ß-lactamases (CHDLs), and class B metallo-ß-lactamases, with the aim of aiding critical care clinicians in their therapeutic decision making.

Transcutaneous pressure at which the internal jugular vein is collapsed on ultrasonic imaging predicts easiness of the venous puncture.

Even though we use ultrasound guidance for central venous puncture, we sometimes experience difficulties. We infer that in such cases the vein is collapsed and that the transcutaneous ultrasound probe pressure at which the vein is collapsed (P (tc)) may predict the easiness of the venous puncture. We measured P (tc) and the diameter of the internal jugular vein in 47 adult patients in our ICU. After successful puncture, we also measured venous pressure (P (v)). The patients were divided into two groups based on the number of puncture attempts: ≥3 attempts constituted the "difficult group" and <3 attempts was considered the "easy group:" 33 patients were in the easy group and 14 patients were in the difficult group. The easy group showed significantly higher P (tc) value (9.3 ± 3.8 vs. 3.5 ± 0.9 cmH(2)O, P < 0.0001) and larger vertical diameter (9.2 ± 3.1 vs. 6.8 ± 2.2 mm, P = 0.013) than the difficult group. We observed a clear border between the minimum P (tc) in the easy group (6 cmH(2)O) and the maximum value in the difficult group (5 cmH(2)O). In conclusion, venous collapsibility and vertical diameter determine difficulty in performing venous puncture.

Hemorrhagic shock 3 days after catheterization from the axillary vein.

A 72-year-old woman presented pulmonary embolism. Continuous intravenous administration of heparin was controlled with values of activated clotting time targeted from 150 to 180 s. On the sixth intensive care unit (ICU) day, a central vein (CV) catheter was inserted through the right axillary vein. On the ninth ICU day, her blood pressure dropped and her right breast was obviously larger than the left. Chest computed tomography showed a large hematoma under the greater pectoral muscle. CV catheterization under anticoagulant therapy is risky for bleeding, but catheterization of the internal jugular vein rarely leads to hemorrhagic shock, even if it causes airway obstruction. The axillary vein is in a compartment filled with loose tissue. As there is no structure to cover the bleeding site, the hematoma would expand from the lateral region of the thorax to near the fifth or sixth rib, to which greater and smaller pectoral muscles are attached. Ultrasound-guided catheterization from the axillary vein is introduced as a new and promising alternative to that from the subclavian vein because of its safety, but we should be conservative about applying the axillary approach to patients with anticoagulant therapy, especially in case of an unskilled operator, and be aware of the possibility of late-onset bleeding.

[Mechanical supports for stunned myocardium after esophagectomy].

Coronary vasospasm can cause a wide spectrum of clinical syndromes ranging from transient myocardial ischemia to irreversible infarction. A 72-year-old male patient had intense vasospasms intraoperatively, which led to stunned myocardium. Though MB fraction of creatine kinase after the spasms was almost within normal limits, postoperative transcutaneous echocardiogram showed diffuse hypokinesis of heart wall motion. He developed low output syndrome, acute respiratory distress syndrome and acute renal failure. He was treated with mechanical supports (intra-aortic balloon pumping, high frequency oscillatory ventilation, and continuous hemodiafiltration), in addition to intravenous administration of cathecolamines, on the first postoperative day. It took 6 days to wean the patient from these mechanical supports and catecholamine infusion. This case suggests stunned myocardium after coronary vasospasm, despite the rapid disappearing ST elevation, and of importance of mechanical supports for the circulatory failure.

[Plasma ionized magnesium concentration following cardiopulmonary bypass].

We performed a retrospective study to analyze plasma ionized magnesium concentration following cardiopulmonary bypass. Severe decrease of ionized magnesium concentration associated with frequent abnormal ECG sign was found in a patient with magnesium-free cardioplegia. Cardioplegia containing 16 mmol.l-1 of magnesium ion maintained ionized magnesium concentration within normal ranges without postoperative magnesium loading. Use of cardioplegia containing magnesium or adequate magnesium supplement is thought to be essential for patients receiving cardiopulmonary bypass.

Elevated expression of inducible nitric oxide synthase and inflammatory cytokines in the alveolar macrophages after esophagectomy.

OBJECTIVE: To evaluate the role of inducible nitric oxide (NO) synthase (iNOS) and inflammatory cytokines in alveolar macrophages (AMs) after esophagectomy in the pathogenesis of acute lung injury. DESIGN: Prospective, exploratory, open-labeled clinical study. SETTING: Intensive care unit and operating room in a university hospital. PATIENTS: Thirteen patients receiving esophagectomy with carcinoma of the esophagus (postesophagectomy group), ten patients just before the surgery (preoperation group), and seven patents receiving surgery less invasive than esophagectomy (other surgery group) were selected. INTERVENTIONS: Bronchoalveolar lavage fluid (BALF) and blood samples were obtained from study groups. MEASUREMENTS AND MAIN RESULTS: The AMs in the BALF collected from each group were stained immunohistochemically with antibodies against iNOS, interleukin (IL)-6, and IL-8. The intensities of these expressions were determined by semiquantitative cytofluorometric system. NOx (NO2- + NO3-), IL-6, and IL-8 levels in the BALF and plasma were measured concurrently. The expressional intensities of iNOS, IL-6, and IL-8 in AMs obtained from the postesophagectomy group were maximal 24 hrs after the skin incision and significantly more evident than those from other groups. The IL-6, IL-8, and NOx levels in BALF and IL-6 and IL-8 levels in plasma in the postesophagectomy patients were also elevated. The intensities of iNOS and inflammatory cytokines expressions in AMs were closely related to postoperative respiratory failure. CONCLUSIONS: The activation of topical alveolar macrophages may be involved in the pathogenesis of pulmonary complications in the postoperative period after esophagectomy.