Right subclavian artery injury during catheter insertion into the right internal jugular vein treated with endovascular stent graft placement after balloon occlusion test: A case report.

Subclavian artery injuries during internal jugular vein puncture when attempting central venous catheter insertion are rare. A 60-year-old man undergoing treatment for neuromyelitis optica with paralysis and sensory loss developed a complication during catheter placement into his right internal jugular vein for plasmapheresis. His previous physician felt resistance and discontinued the procedure. The patient later developed mild dyspnea and dysphagia. Computed tomography scans indicated thrombus formation and tracheal deviation. Contrast-enhanced computed tomography scans showed right subclavian artery injury with extravasation and a large pseudoaneurysm. Following transferal to our hospital, he was stable and asymptomatic; however, contrast-enhanced computed tomography scans showed a pseudoaneurysm located proximal to the right subclavian artery. Considering challenges with compression hemostasis and the invasiveness of open surgery, endovascular treatment was selected using a VIABAHN stent graft. A balloon occlusion test of the right vertebral artery was performed to assess stroke risk. Prophylactic embolization of the right vertebral artery, internal thoracic artery, and thyrocervical trunk were performed to prevent a type 2 endoleak. On hospital day 5, our patient showed no postoperative complications and was transferred to the referring hospital. Follow-up imaging showed the graft was intact with no pseudoaneurysm, confirming successful treatment. Endovascular treatment with a stent graft is highly effective for peripheral artery injuries. Using a balloon occlusion test to assess collateral blood flow and stroke risk is essential pretreatment, especially when a graft might occlude the vertebral artery. Balloon occlusion tests are recommended when planning treatment for iatrogenic and other types of subclavian artery injuries.

Medication reconciliation by pharmacists for pre-admission patients improves patient safety.

BACKGROUND: Medication errors related to the pre-admission medication history obtained on admission are a major cause of medication error during hospitalization. Medication reconciliation (MR) improves patient safety through the detection of inadvertent medication discrepancies at transitions of care. The aim of this study was to evaluate the effect of MR by pharmacists for patients prior to hospital admission on the incidence of medication errors in the early post-admission period. PATIENTS AND METHODS: Patients admitted to the orthopedic ward for surgery between April 2012 and March 2020 were included. Pharmacist-led MR for pre-admission patients was started on April 1, 2017. The incidence of medication errors related to pre-admission medications that occurred during hospitalization were compared between the pre- and post-initiation of pharmacist-led MR (pre-initiation: April 1, 2012 to March 31, 2015, post-initiation: April 1, 2017 to March 31, 2020). RESULT: In the post-initiation group, 94.2% (1245/1321) of patients who were taking medications on admission had a pharmacist-led MR before admission. The proportion of patients whose physicians ordered the prescription of their pre-admission medications at the time before hospitalization to continue from admission was significantly higher in the post-initiation group than in the pre-initiation group (47.4% vs. 1.0%, p < 0.001). The incidence of medication errors related to pre-admission medications during hospitalization was significantly lower in the post-initiation group than in the pre-initiation group (1.83% vs. 0.85%, p = 0.025). Pharmacist-led MR prior to admission was a significant protective factor against incidents related to pre-admission medication (odds ratio (OR), 0.3810; 95% confidence interval (CI); 0.156-0.9320, p = 0.035). CONCLUSION: Pharmacist-led MR for patients prior to hospital admission led to a reduction in medication errors related to pre-admission medications during hospitalization. Patient safety during hospitalization can be improved by accurate medication histories provided early by pharmacists.

Adjunct Acupuncture Improved Respiratory Status and Weaning from Mechanical Ventilation After Severe COVID-19 Pneumonia.

Background: A patient with severe COVID-19 pneumonia had adjunctive acupuncture to improve respiration and facilitate weaning off prolonged mechanical ventilation (MV). Case: A man in his 40s with COVID-19 was in an advanced critical-care center on symptom day 5 for respiratory failure due to pneumonia requiring MV therapy. He received high-dose corticosteroid pulse therapy, antiviral agents, and multiple antibiotics for complicated bacterial pneumonia and bacteremia. Repeated MV weaning attempts failed, although his pneumonia gradually improved. Then, acupuncture 4 times per week was started to improve his respiration and facilitate MV weaning from day 49 of his symptoms' onset. Results: His weaning-related indices improved, including reductions in respiratory rate and Rapid Shallow Breath Index. His O2 saturation increased immediately after each acupuncture treatment. The day after the first acupuncture treatment, his MV support was reduced by changing ventilation mode from synchronized intermittent mandatory ventilation mode to continuous positive airway pressure (CPAP) mode during the day without exacerbation of respiratory status. After 3 days of acupuncture, this patient was on CPAP support alone. MV therapy was discontinued completely after 8 days of acupuncture (6th acupuncture treatment). Conclusions: Acupuncture improved respiration and facilitated MV weaning in a patient with respiratory failure secondary to COVID-19. Adjunctive acupuncture may benefit such patients and others after severe pneumonia. Large cohort studies are needed.

Patient with suspected severe acute respiratory syndrome coronavirus 2 infection with successful emergency surgery for ulcerative colitis-associated toxic megacolon.

BACKGROUND: In patients with acute severe ulcerative colitis with concomitant severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the treatment strategy should consider the presence of pneumonia, respiratory status, and the severity of the ulcerative colitis (UC). We report a case of a 59-year-old man with SARS-CoV-2 infection who was diagnosed with toxic megacolon caused by UC. CASE PRESENTATION: Preoperative computed tomography scanning of the chest showed ground-glass opacities. The patient was treated conservatively until the pneumonia improved, but developed bleeding and liver dysfunction associated with UC. As the patient's condition worsened, emergency surgery with subtotal colorectal resection, ileostomy, and rectal mucous fistula creation was performed while undertaking adequate infection control measures. Intraoperatively, contaminated ascites was observed, and the intestinal tract was markedly dilated and fragile. Nevertheless, the postoperative outcome was positive, with no pulmonary complications. The patient was discharged on postoperative day 77. CONCLUSIONS: The COVID-19 pandemic presented challenges in surgical scheduling. Patients with SARS-CoV-2 infection required close monitoring for postoperative pulmonary complications.

Postmortem diagnosis of pulmonary tumor thrombotic microangiopathy with rapid exacerbation in a patient with gastric cancer: a case report.

BACKGROUND: Pulmonary tumor thrombotic microangiopathy (PTTM) is a condition that involves the development of pulmonary hypertension due to the presence of microscopic tumor emboli of the peripheral pulmonary arteries. Here, we report a case of rapidly exacerbating PTTM associated with gastric cancer that was identified postmortem through pathological autopsy. CASE PRESENTATION: A 52-year-old Asian woman who experienced anterior chest pain while coughing visited the orthopedic department of the Gifu University Hospital. She was diagnosed as having multiple osteolytic bone metastases throughout her body and was subsequently scheduled to undergo combined positron emission tomography and computed tomography (CT) to search for a primary lesion. However, 4 days after her visit to the orthopedic department, she was unable to stand up and thus visited the emergency department. At the time of admission, physical examination results revealed that she had a percutaneous oxygen saturation level of 90% (on room air) and cyanosis and that she was in a state of hemodynamic shock. Laboratory test results revealed elevated levels of fibrin degradation products and D-dimer in her blood. Chest CT results were normal. She was admitted to the hospital's general ward for follow-up but soon entered a gradually worsening state of shock and respiratory failure. Electrocardiography revealed findings associated with right heart strain; however, contrast-enhanced CT did not reveal the presence of pulmonary embolism. She was admitted to the intensive care unit and was treated for pulmonary hypertension; however, 45 h after her arrival at the hospital, she died of respiratory failure. A pathological autopsy revealed the presence of gastric cancer, tumor microemboli, and fibrous intimal thickening of the peripheral arteries of both lungs; thus, a diagnosis of PTTM was made. CONCLUSIONS: In patients with carcinoma of unknown primary site and pulmonary hypertension with pulmonary embolism ruled out by CT, emergency physicians and intensivists must consider the possibility of PTTM, which represents an oncologic emergency, and initiate chemotherapy administration as soon as possible.

Severe heat stroke complicated by multiple cerebral infarctions: a case report.

BACKGROUND: Heat-related illnesses include symptoms such as heat syncope/cramps, heat exhaustion, and life-threatening heat stroke. Usually, a heat stroke causes cerebellar ataxia, cognitive impairment, dysphagia, and aphasia. We report a very rare case of a patient who developed severe heat stroke complicated by multiple cerebral infarctions. CASE PRESENTATION: An 80-year-old Asian woman was found lying unconscious at her house, with no air conditioner and closed windows; the highest outside temperature was 36.1 °C. She was brought to our hospital unconscious with a high bladder temperature (42.5 °C) and disseminated intravascular coagulation (DIC score 4). She was diagnosed with severe heat stroke and managed with rapid cooling, intravenous fluids therapy, antibiotic therapy, and anti-coagulation therapy for DIC. Anti-coagulation therapy consisted of treatment with recombinant thrombomodulin for 4 days (days 1-4) and recombinant antithrombin for 1 day (day 1). A head computed tomography (CT) and magnetic resonance imaging (MRI) examination were performed on day 3, because she was still unconscious. Diffuse-weighted imaging showed high-signal intensities, indicating multiple lesions. An intracranial magnetic resonance angiography showed normal results. Imaging indicated new multiple cerebellar infarctions complicated with DIC. A tracheotomy was performed on day 9 because her conscious condition had not improved. She was transferred to another hospital for subacute care on day 23. CONCLUSIONS: Early management of heat stroke using anti-DIC, anti-bacterial, and fluid resuscitation therapy can help prevent complications such as intracranial hemorrhaging.

Recombinant thrombomodulin protects against LPS-induced acute respiratory distress syndrome via preservation of pulmonary endothelial glycocalyx.

BACKGROUND AND PURPOSE: Disruption of the endothelial glycocalyx is causally related to microvascular endothelial dysfunction, a characteristic of sepsis-induced acute respiratory distress syndrome (ARDS). Recombinant human thrombomodulin (rhTM) attenuates vascular endothelial injuries, but the underlying mechanism remains elusive. Here, we investigated the structural basis and molecular mechanisms of rhTM effects on vascular endothelial injury in a model of sepsis. EXPERIMENTAL APPROACH: LPS (20 mg·kg-1 ) was intraperitoneally injected into 10-week-old male C57BL6 mice, and saline or rhTM was intraperitoneally injected 3 and 24 h after LPS injection. Using serum and/or lung tissue, histological, ultrastructural, and microarray analyses were performed. KEY RESULTS: Survival rate of rhTM-treated mice was significantly higher than that of control mice 48 h after LPS injection. Serum concentrations of IL-6 and high-mobility group box 1 were lower in the rhTM-treated group than in the control. Injury to the endothelial glycocalyx in pulmonary capillaries was attenuated by rhTM treatment. Gene set enrichment analysis revealed up-regulation of gene sets corresponding to cell proliferation/differentiation and anti-inflammation, such as the TGF-ß pathway, and negative regulation of IL-6, upon rhTM treatment. Gene expression of heparan sulfate 6-O-sulfotransferase 1 and endothelial cell-specific molecule 1 (components of the endothelial glycocalyx) was significantly preserved by rhTM treatment, and their protein expression levels were maintained in endothelial cells. CONCLUSION AND IMPLICATIONS: Our findings show that rhTM treatment affected inflammation, cell proliferation/differentiation, and glycocalyx synthesis in serum and lung tissue, subsequently attenuating ARDS caused by endothelial injury.

Incidental findings on whole-body computed tomography in trauma patients: the current state of incidental findings and the effect of implementation of a feedback system.

AIM: Whole-body computed tomography (CT) for trauma occasionally reveals significant incidental findings not related to trauma, which require an adequate response. In this study, we examined the current state of incidental findings in trauma patients on whole-body CT and the effects of the feedback system. METHODS: The subject sample included trauma patients who underwent whole-body CT while being examined for trauma during the 2-year period, with the interpretation of the CT reported by a radiologist. The frequency and recognition of incidental findings and the involved body region were investigated. The state of incidental findings before and after implementation of a radiography report feedback system was also examined. RESULTS: During the study period, whole-body CT revealed incidental findings in 79 of 199 trauma patients (40.1%). The mean age of the 79 patients with incidental findings was 62.8 ± 19.5 years, and the mean injury severity score was 16.6 ± 10.0. No difference was observed in the severity of trauma, age, or length of hospital stay. The incidental findings were related to the liver/gallbladder in 22 patients, kidneys in 17, lungs in 14, and the intracranial area in 13. The recognition rate of incidental findings after the implementation of the feedback system increased from 23.3% to 32.6%. CONCLUSIONS: Considering that not all incidental findings are accurately recognized, a proper feedback system is required. A feedback system is beneficial and a need to ensure improvement in the recognition of incidental findings.

Effect of high-flow high-volume-intermittent hemodiafiltration on metformin-associated lactic acidosis with circulatory failure: a case report.

BACKGROUND: Metformin-associated lactic acidosis is a well-known life-threatening complication of metformin. We here report the case of a patient who developed metformin-associated lactic acidosis without organ manifestations, due to the simultaneous ingestion of an overdose of metformin and alcohol, and who recovered with high-flow high-volume intermittent hemodiafiltration. CASE PRESENTATION: A 44-year-old Asian woman with type 2 diabetes attempted suicide by ingesting 10 tablets of metformin 500 mg and drinking approximately 600 mL of Japanese sake containing 15% alcohol. She was transferred to our emergency department because of disturbed consciousness. Continuous intravenous administration of noradrenalin (0.13 µg/kg per minute) was given because she was in shock. Laboratory findings included a lactate level of 119 mg/dL (13.2 mmol/L), bicarbonate of 14.5 mmol/L, and serum metformin concentration of 1138 ng/mL. She was diagnosed as having metformin-associated lactic acidosis worsened by alcohol. After 4560 mL of bicarbonate ringer (Na+ 135 mEq/L, K+ 4 mEq/L, Cl- 113 mEq/L, HCO3- 25 mEq/L) was administered, high-flow high-volume intermittent hemodiafiltration. (dialysate flow rate: 500 mL/min, substitution flow rate: 3.6 L/h) was carried out for 6 h to treat metabolic acidosis and remove lactic acid and metformin. Consequently, serum metformin concentration decreased to 136 ng/mL and noradrenalin administration became unnecessary to maintain normal vital signs. On hospital day 12, she was moved to the psychiatry ward. CONCLUSIONS: HFHV-iHDF may be able to remove metformin and lactic acid efficiently and may improve the condition of hemodynamically unstable patients with metformin-associated lactic acidosis.

Ultrastructural Alteration of Pulmonary Capillary Endothelial Glycocalyx During Endotoxemia.

BACKGROUND: The most recent diagnostic criteria for sepsis include organ failure. Microvascular endothelial injury is believed to lead to the multiple organ failure seen in sepsis, although the precise mechanism is still controversial. ARDS is the primary complication during the sequential development of multiple organ dysfunction in sepsis, and endothelial injury is deeply involved. Sugar-protein glycocalyx coats all healthy vascular endothelium, and its disruption is one factor believed to contribute to microvascular endothelial dysfunction during sepsis. The goal of this study was to observe the three-dimensional ultrastructural alterations in the pulmonary capillary endothelium, including the glycocalyx, during sepsis-induced pulmonary vasculitis. METHODS: This study investigated the three-dimensional ultrastructure of pulmonary vascular endothelial glycocalyx in a mouse lipopolysaccharide-induced endotoxemia model. Lungs were fixed with lanthanum-containing alkaline fixative to preserve the glycocalyx. RESULTS: On both scanning and transmission electron microscopic imaging, the capillary endothelial glycocalyx appeared as a moss-like structure entirely covering the endothelial cell surface in normal mice. In the septic lung following liposaccharide injection, however, this structure was severely disrupted; it appeared to be peeling away and coagulated. In addition, syndecan-1 levels were significantly reduced in the septic lung, and numerous spherical structures containing glycocalyx were observed on the endothelial surface. CONCLUSIONS: It appears that endothelial glycocalyx in the lung is markedly disrupted under experimental endotoxemia conditions. This finding supports the notion that disruption of the glycocalyx is causally related to the microvascular endothelial dysfunction that is characteristic of sepsis-induced ARDS.

Thyrotoxic and pheochromocytoma multisystem crisis: a case report.

BACKGROUND: Thyrotoxic crisis and pheochromocytoma multisystem crisis are rare, life-threatening, emergency endocrine diseases with various clinical manifestations. Here we report a case of a patient who simultaneously developed thyrotoxic crisis and pheochromocytoma multisystem crisis and required intensive cardiovascular management. CASE PRESENTATION: A 60-year-old Asian man experienced nausea and vomiting, and subsequently developed dyspnea and cold sweats while farming. His serum free thyroxine, free triiodothyronine, and thyrotropin receptor antibody levels were elevated at 2.9 ng/dL, 7.2 pg/dL, and 4.7 IU/L, respectively. Serum thyrotropin levels were suppressed at less than 0.01 µIU/mL. Thyroid echography demonstrated no thyroid swelling (23 × 43 mm). A whole body computed tomography was performed for systemic evaluation. This revealed exophthalmos and a mass of size 57 × 64 mm in the anterior pararenal space. Based on these findings, we made an initial diagnosis of thyrotoxic crisis secondary to exacerbation of Grave's hyperthyroidism. Treatment was begun with an iodine agent at a dose of 36 mg/day, thiamazole at a dose of 30 mg/day, and hydrocortisone at a dose of 300 mg daily for 3 consecutive days. To control tachycardia, continuous intravenously administered propranolol and diltiazem infusions were given. At the same time, small doses of doxazosin and carvedilol were used for both alpha and beta adrenergic blockade. On hospital day 5, his blood pressure and serum catecholamine concentrations (adrenalin 42,365 pg/mL, dopamine 6409 pg/mL, noradrenalin 72,212 pg/mL) were still high despite higher beta blocker and calcium channel blocker doses. These findings contributed to the diagnosis of pheochromocytoma multisystem crisis with simultaneous thyrotoxic crisis. We increased the doses of doxazosin and carvedilol, which stabilized his hemodynamic status. On hospital day 16, metaiodobenzylguanidine scintigraphy showed high accumulation in the right adrenal gland tumor. After retroperitoneal laparoscopic adrenalectomy on hospital day 33, his condition stabilized. He was discharged on hospital day 58. CONCLUSIONS: Since he required more intensive cardiovascular management for thyrotoxic crisis, beta blockade was increased under intensive care unit monitoring even though initial alpha blockade is recommended in pheochromocytoma. When these crises occur simultaneously, cardiovascular management can be very challenging.

Blunt cardiac injury due to trauma associated with snowboarding: a case report.

BACKGROUND: Cardiac trauma is associated with a much higher mortality rate than injuries to other organ systems, even though cardiac trauma is identified in less than 10% of all trauma admissions. Here we report blunt trauma of the left atrium due to snowboarding trauma. CASE PRESENTATION: A 45-year-old Asian man collided with a tree while he was snowboarding and drinking. He lost consciousness temporarily. An air ambulance was requested and he was transported to an advanced critical care center. On arrival, a pericardial effusion was detected by a focused assessment with sonography for trauma. His presenting electrocardiogram revealed normal sinus rhythm and complete right bundle branch block. Laboratory findings included a white blood cell count of 13.5 × 103/µl, serum creatine kinase level of 459 IU/l, and creatine kinase-myocardial band level of 185 IU/l. Enhanced computed tomography showed a large pericardial effusion and bleeding from his left adrenal gland. There were no pelvic fractures. A diagnosis of cardiac tamponade due to blunt cardiac injury and left adrenal injury due to blunt trauma was made. Subsequently, emergency thoracic surgery and transcatheter arterial embolization of his left adrenal artery were performed simultaneously. A laceration of the left atrial appendage in the lateral wall of his left ventricle was detected intraoperatively and repaired. His postoperative course progressed favorably, although a pericardial effusion was still detected on chest computed tomography on hospital day 35. His electrocardiogram showed normal sinus rhythm and the complete right bundle branch block pattern changed to a narrow QRS wave pattern. He was discharged on hospital day 40. CONCLUSIONS: The present case report illustrates two points: (1) severe injuries resulted from snowboarding, and (2) complete right bundle branch block was caused by blunt cardiac injury. The present report showed blunt trauma of the left atrium with complete right bundle branch block as an electrocardiogram change due to snowboarding trauma. To detect cardiac trauma in snowboarding accidents, an examination of an electrocardiogram is required in all patients who might have a bruised chest.

Reduction of medication errors related to sliding scale insulin by the introduction of a standardized order sheet.

Insulin is frequently used for glycemic control. Medication errors related to insulin are a common problem for medical institutions. Here, we prepared a standardized sliding scale insulin (SSI) order sheet and assessed the effect of its introduction. Observations before and after the introduction of the standardized SSI template were conducted at Gifu University Hospital. The incidence of medication errors, hyperglycemia, and hypoglycemia related to SSI were obtained from the electronic medical records. The introduction of the standardized SSI order sheet significantly reduced the incidence of medication errors related to SSI compared with that prior to its introduction (12/165 [7.3%] vs 4/159 [2.1%], P = .048). However, the incidence of hyperglycemia (≥250 mg/dL) and hypoglycemia (≤50 mg/dL) in patients who received SSI was not significantly different between the 2 groups. The introduction of the standardized SSI order sheet reduced the incidence of medication errors related to SSI.

Rare central venous catheter malposition - an ultrasound-guided approach would be helpful: a case report.

BACKGROUND: A central venous catheter enables the measurement of hemodynamic variations, such as accurate central venous pressure; catheter malposition may induce potentially fatal complications. This case report describes a rare central venous catheter tip malposition in the right internal mammary artery. CASE PRESENTATION: A 56-year-old Japanese woman who presented with severe pneumonia secondary to scleroderma was treated under ventilator support because of acute respiratory failure. A right central venous catheter was inserted using a landmark technique to monitor central venous pressure and administer medications. However, central venous waveforms detected by the catheter using a pressure lot transducer were later found to be absent. Further imaging studies, including plain radiography, computed tomography, and angiography, confirmed central venous catheter malposition in the internal mammary artery. Her right internal mammary artery was embolized using two interlocking detachable coils, and the central venous catheter was removed from her internal mammary artery without further complications. CONCLUSIONS: Internal mammary artery malposition is a rare but potentially lethal complication of central venous catheter catheterization; however, caution should be taken regarding the assessment of risk factors and management of a severe complication. An ultrasound-guided approach would be helpful.

Comparison of two pediatric flail chest cases.

Flail chest is a rare complication in pediatric patients with blunt chest trauma. There is no general consensus on which treatment is most appropriate for flail chest in pediatric patients, although it has been reported that surgical fixation is associated with beneficial outcomes for flail chest in adults. The present report described two pediatric cases of flail chest, which was rare in pediatric blunt trauma. In small children, functional residual capacity is smaller, and the thorax is pliable due to high thoracic compliance. Therefore, it is only advisable to select intubation and mechanical ventilation treatment. Likewise, in pediatric flail chest, the available evidence does not suggest that ventilator management protocols should be adopted routinely, and the treatment for pediatric flail chest was not established completely. There were not huge different between the described patients, including injury severity and ventilation setting. However, one had a relapse of flail chest after extubation and chest taping was required, while the other patient's condition was stable after decannulation. As described above, it is difficult to predict a recurrence of flail chest in pediatric patients even if treatment goes well. Therefore, T-piece trial should be considered prior to extubation.

Preliminary experience with air transfer of patients for rescue endovascular therapy after failure of intravenous tissue plasminogen activator.

The present report describes our experience with air transfer of patients with acute ischemic stroke in whom intravenous tissue plasminogen activator (IV t-PA) failed for rescue endovascular therapy (EVT). Twenty-three consecutive patients in whom IV t-PA failed were transferred to our hospital for rescue EVT between February 2011 and April 2013. The amount of time required for transfer, distance, clinical outcomes, and complications were compared between patients transferred by ground (TG group; n = 17) and by air (TA group; n = 6). Computed tomography imaging on arrival revealed hemorrhagic transformation in 1 (5.9%) patient in the TG group, whereas none of the patients in the TA group developed any type of complication. The remaining 22 patients received rescue EVT. The elapsed time from the request call to arrival at our hospital did not significantly differ between the TG and TA groups (45.8 ± 4.9 min vs. 41.6 ± 2.3 min). However, the distance from the primary hospital to our institution was significantly longer for the TA group than for the TG group (38.8 ± 10.4 km vs. 13.5 ± 1.2 km, p = 0.001). The frequency of favorable outcomes (modified Rankin Scale 0-1 at 90 days after onset) in the TG and TA groups were 25.0% and 50.0%, respectively (p = 0.267). Air transfer for patients after IV t-PA failure allowed for more rapid delivery of patients over longer distances than ground transfer.

Hyperbaric oxygenation therapy for crush injuries reduces the risk of complications: research report.

BACKGROUND: Hyperbaric oxygen (HBO2) therapy has been adopted for crush injuries, but there are few studies supporting its use. We therefore investigated the effects of HBO2 on management of patients with complicated crush injuries. METHODS: This historic cohort study included patients with crush injuries and open fractures with severities greater than or equal to Gustilo class IIIA. We divided the patients into two groups: Control and HBO2. The control group received conventional treatment, while the HBO2 group received conventional treatment plus HBO2. We compared the groups with respect to the incidence of infection, need for additional surgery, and length of intensive care unit (ICU) and hospital stays. RESULTS: There were 16 patients in the HBO2 group and 13 in the control group. There were no patients with infections in the HBO2 group, whereas in the control group six patients had infections and five needed another drainage procedure. These incidences were significantly lower in the HBO2 group (p = 0.003 and 0.013). However, the durations of ICU and hospital stays were similar across the two groups. CONCLUSIONS: HBO2 is effective in the management of crush injuries from the viewpoint of reducing complications and reoperations. These observations should be verified in additional studies with larger sample sizes because the patient number is limited.

Distribution of micafungin in the tissue fluids of patients with invasive fungal infections.

The distribution of micafungin (MCFG) in tissue fluids, such as cerebrospinal fluid (CSF), pleural effusions, ascites, and wound tissue fluids, was examined in seven patients with invasive fungal infections. MCFG (100-300 mg) was administered once daily over a 1-h intravenous infusion. Blood and tissue fluid samples were collected from 1 to 24 h after infusion. Although two patients had similar MCFG concentrations in their plasma, the concentrations in the CSF differed between these two patients. The concentration in the CSF of one patient was much higher than the MIC(90) for Candida albicans, Candida glabrata, and Aspergillus fumigatus, whereas the MCFG concentration in the CSF of the other patient was comparable to the MIC(90). By contrast, MCFG concentrations in pleural effusions, ascites, and wound tissue fluids were above the MIC(90). These results suggest that intravenous MCFG may be effective to treat invasive fungal infections that invade the organs and tissues.

[Ethylene glycol poisoning complicated by central nervous system abnormalities].

We report a case of ethylene glycol (EG) poisoning complicated by central nervous system abnormalities. A long-distance truck driver aged 36 year old ingested 200ml of EG in a suicidal attempt. He was referred to our hospital from another hospital because of vomiting and altered mental status. On arrival at our hospital, he had low level of consciousness (Glasgow Coma Scale: E3V4M5), miosis, and external ophthalmoplegia. Laboratory analysis revealed a severe metabolic acidosis with wide anion gap. Many crystals were detected in the urinary sediment. After admission, acute oliguric renal failure required continuous hemodialysis for 6 days. Despite the treatment, the level of consciousness did not improve. The CT scan of the brain obtained on the fourth day revealed low density areas in the bilateral basal ganglia, mid brain and pons. The renal biopsy showed tubular oxalate deposits. After 12 days, the volume of urination increased. At the same time the mental status gradually recovered. He was discharged on 36 days after admission without any sequelae.