Postpartum hemophagocytic lymphohistiocytosis: A case report.

BACKGROUND: Postpartum hemophagocytic lymphohistiocytosis (HLH) is a rare disease with unclear pathophysiology. It is a secondary HLH diagnosed using the pediatric diagnostic criteria; however, the clinical diagnosis of postpartum HLH remains challenging. Hence, HLH may remain undiagnosed, leading to poor patient prognosis. Therefore, improvements in the accuracy of postpartum HLH diagnoses and treatments are necessary. CASE SUMMARY: We report the case of a 40-year-old female with postpartum HLH. The patient attended the postpartum care center for 3 wk after giving birth and underwent needle aspiration due to thyroid gland enlargement 11 d before an emergency department visit precipitated by fever and abdominal pain. Since no abnormal emergency room findings were noted, the patient was discharged with a prescription for broad-spectrum antibiotics. Three days later, she returned to the emergency room in a hemodynamically unstable state and was admitted to the intensive care unit with suspected sepsis or hematologic disease. The patient was treated, without effect, for sepsis using broad-spectrum antibiotics, and for suspected hematologic disease with steroid therapy. However, she died due to rapidly worsening symptoms. CONCLUSION: Rapid recognition and appropriate treatment of postpartum HLH are needed to improve the prognosis.

Pediatric Application of Cuffed Endotracheal Tube.

A young child's larynx was formerly believed to be narrowest at the cricoid level, circular in section, and funnel shaped. This supported the routine use of uncuffed endotracheal tubes (ETTs) in young children despite the benefits of cuffed ETTs, such as lower risk for air leakage and aspiration. In the late 1990s, evidence supporting the pediatric use of cuffed tubes emerged largely from anesthesiology studies, while some technical flaws of the tubes remained a concern. Since the 2000s, imaging-based studies have clarified laryngeal anatomy, revealing that it is narrowest at the glottis, elliptical in section, and cylindrical in shape. The update was contemporaneous with technical advances in the design, size, and material of cuffed tubes. The American Heart Association currently recommends the pediatric use of cuffed tubes. In this review, we present the rationale for using cuffed ETTs in young children based on our updated knowledge of pediatric anatomy and technical advances.

Is there a relationship between surgical proficiency and oncologic outcome of minimally invasive radical hysterectomy for early-stage cervical cancer?

Objective: Investigate the relationship between surgical proficiency and oncological outcomes of minimally invasive surgery (MIS) in the treatment of early-stage cervical cancer. Methods: This retrospective study included patients with cervical cancer stage IB1, IB2 who were treated with minimally invasive radical hysterectomy from January 2010 to Dec 2020. Patients were divided into two groups based on the year of surgery: phase 1 (from January 2010 to December 2015) and phase 2 (from January 2016 to December 2020). Oncologic outcomes were compared between the groups. Results: In total, 142 patients were included in the final analysis. 73 and 69 patients underwent surgery in phase 1 (51.4%) and phase 2 (48.6%), respectively. Twelve recurrences (12/142, 8.5%) were observed in the entire cohort: ten (13.7%) in phase 1 and two (2.9%) in phase 2. The recurrence rate was significantly higher in phase 1 (p = 0.021). And the phase 1 group showed significantly shorter disease-free survival than the phase 2 group (p = 0.049). In the multivariate analysis, surgical proficiency, represented by the phase of operation, was the only significant predictor of disease-free survival (HR = 0.244, p = 0.042). Conclusions: Surgical proficiency in MIS is a significant factor associated with the outcomes in early-stage cervical cancer. More favorable outcomes can be obtained after operating on a certain number of MIS cases.

Prognostic value of pretreatment systemic inflammatory markers in patients with stage I endometrial cancer.

Objective: Evaluate the prognostic value of monocyte-lymphocyte ratio (MLR) in patients with stage I endometrial cancer. Method: Data from 225 patients with stage I endometrioid endometrial cancer who underwent surgical resection between January 2010 and December 2020 were reviewed. The receiver operating characteristic (ROC) curves were generated for the neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, and MLR. Optimal cut-off values were determined as the points at which the Youden index (sensitivity + specificity - 1) was maximal. Based on the results of the ROC curve analysis, the patients were grouped into high MLR and low MLR groups. Recurrence rate, and disease-free survival were compared between the two groups. The prognostic factors were investigated using univariate and multivariate Cox proportional hazards model. Results: The optimal cut-off value of MLR was 0.220 (AUC, 0.835; p < 0.001). Significantly more patients in the high MLR group experienced recurrence (20.3% vs. 1.9%, p < 0.0001). In multivariate analysis, grade, depth of myometrial invasion, adjuvant RT, and high MLR were independent prognostic factors for disease-free survival. Conclusion: Elevated MLR was significantly associated poor clinical outcomes in patients with stage I endometrioid endometrial cancer. Our findings suggest that MLR may be clinically reliable and useful as an independent prognostic marker for patients with stage I endometrioid endometrial cancer.

Intra and extra pelvic multidisciplinary surgical approach of retroperitoneal sarcoma: Case series report.

BACKGROUND: Retroperitoneal sarcoma (RPS) is a rare malignancy arising from mesenchymal cells that most commonly presents as an abdominal mass and is associated with poor prognosis. Although several studies have assessed the survival benefits of wide excision, few have reported detailed methods for achieving wide excision in patients with RPS. AIM: To describe our experience with multidisciplinary surgical resection of RPS using intra- and extra-pelvic approaches. METHODS: Multidisciplinary surgery is an anatomical approach that combines intra- and extra-peritoneal access within the same surgery to achieve complete RPS removal. This retrospective review of the records of patients who underwent multidisciplinary surgery for RPS analyzed surgical and survival outcomes. RESULTS: Eight patients underwent 10 intra- and extra-pelvic surgical resections, and their median mass size was 12.75 cm (range, 6-45.5 cm). Using an intrapelvic approach, laparoscopy-assisted surgery was performed in four cases and laparotomy surgery in six. Using an extrapelvic approach, ilioinguinal and posterior approaches were used in four cases each, and the prone position and midline skin incision were shared in one. All patients' RPS masses were removed completely, and four achieved R0 resection through intra- and extra-pelvic surgery. The median estimated blood loss was 2000 mL (range, 300-20000 mL) and the median hospitalization was 12.6 d (range, 9-69 d). Reoperation was needed in two patients (one for wound necrosis and the other for bowel perforation and wound necrosis). The median overall survival rate and median progression-free survival were 64.6 and 13.7 mo, respectively. CONCLUSION: RPS is therapeutically challenging because of its location and high risk of recurrence. Therefore, intra- and extra-pelvic surgical approaches can improve the macroscopic security of the surgical margin.

Accuracy of Catheter Positioning during Left Subclavian Venous Access: A Randomized Comparison between Radiological and Topographical Landmarks.

Left subclavian venous access increases the risk of vascular damage and thrombosis based on the catheter course and location of the catheter tip. We investigated the accuracy of tip positioning with conventional landmarks using transesophageal echocardiography. The carina as a radiological landmark and the right third intercostal space as a topographical landmark were selected for tip positioning within the target zone, defined as 2 cm above and 1 cm below the right atrial junction. A total of 120 participants were randomized into two groups. The catheter insertion depth was determined as 1.5 cm more than the distance between the venous insertion point and the carina via the right first intercostal space in the radiological group, and between the venous insertion point and the right third intercostal space via the right first intercostal space in the topographical group. The determined insertion depth and actual distance to the right atrial junction of the radiological and topographical groups were 19.5 cm and 20.5 cm, and 19.8 cm and 20.4 cm, respectively. Acceptable positioning was more frequent in the topographical group (96.4% vs. 85.7%; p = 0.047). The catheter tip is more accurately positioned in the distal superior vena cava using topographical landmarks than radiological landmarks.

Genotyping-by-sequencing-based QTL mapping reveals novel loci for Pepper yellow leaf curl virus (PepYLCV) resistance in Capsicum annuum.

Disease caused by Pepper yellow leaf curl virus (PepYLCV) is one of the greatest threats to pepper (Capsicum spp.) cultivation in the tropics and subtropics. Resistance to PepYLCV was previously identified in a few Capsicum accessions, but no resistance QTLs have been mapped. This study aimed to elucidate the genetics of PepYLCV resistance in C. annuum L. Augmented inoculation by the viruliferous whitefly Bemisia tabaci was used to evaluate parental lines and an F2 segregating population derived from a cross between resistant C. annuum line LP97 and susceptible C. annuum line ECW30R. Final evaluation was performed six weeks after inoculation using a standardized 5-point scale (0 = no symptoms to 4 = very severe symptoms). A high-density linkage map was constructed using genotyping-by-sequencing (GBS) to identify single-nucleotide polymorphism (SNP) markers associated with PepYLCV resistance in the F2 population. QTL analysis revealed three QTLs, peplcv-1, peplcv-7, and peplcv-12, on chromosomes P1, P7, and P12, respectively. Candidate genes associated with PepYLCV resistance in the QTL regions were inferred. In addition, single markers Chr7-LCV-7 and Chr12-LCV-12 derived from the QTLs were developed and validated in another F2 population and in commercial varieties. This work thus provides not only information for mapping PepYLCV resistance loci in pepper but also forms the basis for future molecular analysis of genes involved in PepYLCV resistance.

Oncologic safety of minimally invasive surgery in non-endometrioid endometrial cancer.

OBJECTIVE: This study was aimed to compare the oncologic outcomes of patients with non-endometrioid endometrial cancer who underwent minimally invasive surgery with the outcomes of patients who underwent open surgery. METHOD: This is a retrospective, multi-institutional study of patients with non-endometrioid endometrial cancer who were surgically staged by either minimally invasive surgery or open surgery. Oncologic outcomes of the patients were compared according to surgical approach. RESULTS: 113 patients met the inclusion and exclusion criteria. 57 underwent minimally invasive surgery and 56 underwent open surgery. Patients who underwent minimally invasive surgery had smaller tumors (median size, 3.3 vs. 5.2%, p = 0.0001) and a lower lymphovascular space invasion rate (29.8% vs. 48.2%, p = 0.045). In the overall population, the numbers and rate of recurrence were significantly higher in the open surgery group (p = 0.016). In multivariate analysis, disease stage and tumor size were associated with DFS in contrast to surgical procedure. CONCLUSION: Minimally invasive surgery showed similar survival outcomes when compared to open surgery in non-endometrioid endometrial cancer patients, irrespective of disease stage. When minimally invasive surgery is managed by expert surgeons, non-endometrioid histological subtypes should not be considered a contraindication for minimally invasive surgery.

Strategies to Improve the Quality and Freshness of Human Bone Marrow-Derived Mesenchymal Stem Cells for Neurological Diseases.

Human bone marrow-derived mesenchymal stem cells (hBM-MSCs) have been studied for their application to manage various neurological diseases, owing to their anti-inflammatory, immunomodulatory, paracrine, and antiapoptotic ability, as well as their homing capacity to specific regions of brain injury. Among mesenchymal stem cells, such as BM-MSCs, adipose-derived MSCs, and umbilical cord MSCs, BM-MSCs have many merits as cell therapeutic agents based on their widespread availability and relatively easy attainability and in vitro handling. For stem cell-based therapy with BM-MSCs, it is essential to perform ex vivo expansion as low numbers of MSCs are obtained in bone marrow aspirates. Depending on timing, before hBM-MSC transplantation into patients, after detaching them from the culture dish, cell viability, deformability, cell size, and membrane fluidity are decreased, whereas reactive oxygen species generation, lipid peroxidation, and cytosolic vacuoles are increased. Thus, the quality and freshness of hBM-MSCs decrease over time after detachment from the culture dish. Especially, for neurological disease cell therapy, the deformability of BM-MSCs is particularly important in the brain for the development of microvessels. As studies on the traditional characteristics of hBM-MSCs before transplantation into the brain are very limited, omics and machine learning approaches are needed to evaluate cell conditions with indepth and comprehensive analyses. Here, we provide an overview of hBM-MSCs, the application of these cells to various neurological diseases, and improvements in their quality and freshness based on integrated omics after detachment from the culture dish for successful cell therapy.

Takotsubo syndrome as an overlooked and elusive cause of a single episode of dyspnea in young women: a case report.

BACKGROUND: Dyspnea is a common symptom in patients presenting to the emergency department. It has a variety of causes that range from non-urgent to life-threatening. One episode of dyspnea in a healthy young person is easy to overlook. However, if the symptoms occur after physically or emotionally stressful events, careful evaluation needs to be undertaken because it may be associated with Takotsubo syndrome, which is rarely expected but can be fatal. Herein, we report the case of Takotsubo syndrome in a healthy young woman who arrived at the emergency department after experiencing a short single episode of dyspnea following a minor surgery. CASE PRESENTATION: A 23-year old woman with no underlying chronic disease underwent closed reduction surgery for a nasal bone fracture under general anesthesia (with sevoflurane as the anesthetic). Approximately 5 h later, she presented to the emergency department with dyspnea, which improved soon upon arrival at the emergency department. There were no other symptoms. The dyspnea occurred about 5 h after being discharged on observation, with an uneventful postoperative course. Her electrocardiogram and chest X-ray findings were unremarkable. On testing, troponin I and creatine kinase myocardial band levels were elevated at 6.122 ng/mL and 11.2 µg/L (reference ranges: 0.000-0.046 ng/mL and 0.0-5.0 µg/L), respectively. Bedside echocardiography revealed an ejection fraction of 25%, with mid-ventricular and apical akinesia and basal hyperkinesia. The pulmonary and coronary angiographic computed tomographic scans were unremarkable. Hence, apical Takotsubo syndrome was suspected. A follow-up echocardiogram taken 5 days after admission showed full recovery with a normalized ejection fraction (60%) and no regional wall motion abnormality. The patient was discharged on the sixth day with no other complications. CONCLUSION: When atypical symptoms, such as transient dyspnea, manifest, it becomes necessary to suspect and diagnose Takotsubo syndrome to ensure timely and appropriate medical management, especially when a preceding stressful event, such as minor surgery has occurred. It might be helpful to perform bedside point-of-care echocardiography to check for regional wall motion abnormalities that are typically associated with Takotsubo syndrome.

Point of care airway ultrasound to select tracheal tube and determine insertion depth in cleft repair surgery.

We aimed to evaluate the efficacy of using airway ultrasonography to select the correct tracheal tube size and insertion depth in pediatric patients who underwent cleft repair surgery as a way to decrease airway complications and adverse events during perioperative periods. Fifty-one patients (age < 28 months) were consecutively divided into conventional (n = 28) and ultrasound (n = 23) groups. Tracheal tube size and insertion depth were determined using the age-based formula and auscultation in the conventional group, whereas using ultrasonographic measurement of subglottic diameter with auscultation and lung ultrasonography in the ultrasound group. We evaluated the initially selected tube size, insertion depth, ventilatory indices, and the incidence of airway complications and adverse events. Tube insertion depth (median [interquartile range]) was significantly greater in the ultrasound group than in the conventional group (13.5 cm [12.5-14.0] vs 13.0 cm [11.8-13.0], P = 0.045). The number of complications and adverse events was significantly higher in the conventional group than in the ultrasound group (32.1% vs 4.3%, P = 0.013). Airway ultrasound application could reduce airway-related complications and adverse events by determining the appropriate tracheal tube size and insertion depth.

Review of simulation model for education of point-of-care ultrasound using easy-to-make tools.

Point-of-care ultrasound (POCUS) is a powerful diagnostic tool and provides treatment guidelines in acute critical settings. However, the limitation of using POCUS is operator dependent. Appropriate and validated training for acquiring and using skills in practice must be conducted before using POCUS in clinical settings in order to keep patients safe. Simulation education models have been introduced as a way to solve and overcome these concerns. However, the commercial simulator with sufficiently secured fidelity is expensive and not always available. This review focused on the inexpensive and easily made simulators for education on POCUS in critical specific situations related to the airway, breathing, circulation, and disability. We introduced the simulators that used non-infectious materials, with easily transportable features, and that had a sonographic appearance reproducibility similar to human tissue. We also introduced the recipe of each simulator in two parts: Materials surrounding disease simulators (surrounding materials) and specific disease simulators themselves (target simulators). This review article covered the following: endotracheal or oesophageal intubation, lung (A-lines, B-lines, lung sliding, and pleural effusions such as hemothorax), central vein access, pericardial fluid (cardiac tamponade), the structure related to the eyes, soft tissue abscess, nerve (regional nerve block), and skull fracture simulators.

Incidence and clinical course of septic shock in neutropenic patients during chemotherapy for gynecological cancers.

OBJECTIVE: To identify the incidence and clinical course of septic shock combined with neutropenia during chemotherapy in gynecological cancer patients. METHODS: We retrospectively reviewed the medical records of all gynecological cancer patients who received intravenous chemotherapy between March 2009 and March 2018. Patients diagnosed with neutropenic septic shock (NSS) during the course of chemotherapy were identified. We calculated the overall incidence and mortality rate of NSS, and analyzed risk factors and clinical course. RESULTS: A total of 1,009 patients received 10,239 cycles of chemotherapy during the study period. Among these, 30 (3.0%) patients had 32 NSS events, of which 12 (1.2%) died. With respect to patient age during the first course of chemotherapy, the incidence of NSS after the age of 50 was significantly higher than that in patients under 50 (3.9% vs. 1.4%, p=0.034). As the number of chemotherapy courses increased, the incidence of NSS increased, and linear-by-linear association analysis showed a positive correlation (p=0.004). NSS events occurred on average 7.8 days after the last cycle of chemotherapy, and the median duration of vasopressor administration was 23.3 hours. The median age (64.0 vs. 56.5, p=0.017) and peak heart rate (149.5 min-1 vs. 123.5 min-1, p=0.015) were significantly higher in the group of patients who subsequently died of NSS than in those who survived. CONCLUSION: The overall incidence of NSS in gynecological cancer patients receiving chemotherapy was 3.0%, which is higher than previously estimated. Peak heart rate during NSS events may be an indicator for predicting survival.

Discrimination between pain and contracture in limited passive motion patients with rotator cuff tear: A STROBE-compliant cross-sectional study.

Either pain or contracture may limit shoulder passive range of motion (PROM) in patients with rotator cuff disease, and an appropriate treatment may be determined according to its cause. If there is no change in PROM under general anesthesia, contracture, rather than pain, may be the underlying condition. Our goal was to devise a physical examination that would help discriminate between pain and contracture in limited PROM patients with rotator cuff tear.This is a STROBE-compliant cross-sectional study. Patients with rotator cuff tears (N = 28) were scheduled for arthroscopic repair. The main outcome measure was PROM, including flexion, external rotation (ER), and abduction obtained by a blinded examiner before and after the induction of general anesthesia, and the abduction/ER ratio was calculated. In order to perform a subgroup analysis, patients were divided into 2 groups, one where abduction difference after the general anesthesia was 8°≤ (n = 22) and the other 8°> (n = 6).Patients' average age (62.6 ±â€Š7.2 years), symptom duration (13.0 ±â€Š10.0 months), intensity of shoulder pain on a visual analog scale (4.8 ±â€Š2.1), and Constant-Murley functional score (63.4 ±â€Š8.9); the ratio of gender (male: female = 12:16); and the arthroscopic findings were recorded. According to the correlation analysis, the abduction/ER ratio before general anesthesia was correlated best with the change in PROM after general anesthesia (correlation coefficient -0.74, P < .001); the correlations for abduction and flexion were -0.69 and -0.57, respectively (P < .001 and .002, respectively). The age, gender, height, weight, duration of symptoms, trauma history, visual analog score for shoulder pain, Constant-Murley functional score, size of rotator cuff tear, and biceps pathology did not differ significantly between the 2 groups in the subgroup analysis (P > .05). The only significant difference between the 2 groups was in the synovitis status (P = .04).Patients with greater abduction/ER ratio before anesthesia exhibited fewer PROM changes after anesthesia. The abduction/ER ratio was strongly and inversely correlated with PROM changes, allowing physicians to choose an appropriate treatment for limited PROM in patients with rotator cuff tears.

Metabolome Changes in Cerebral Ischemia.

Cerebral ischemia is caused by perturbations in blood flow to the brain that trigger sequential and complex metabolic and cellular pathologies. This leads to brain tissue damage, including neuronal cell death and cerebral infarction, manifesting clinically as ischemic stroke, which is the cause of considerable morbidity and mortality worldwide. To analyze the underlying biological mechanisms and identify potential biomarkers of ischemic stroke, various in vitro and in vivo experimental models have been established investigating different molecular aspects, such as genes, microRNAs, and proteins. Yet, the metabolic and cellular pathologies of ischemic brain injury remain not fully elucidated, and the relationships among various pathological mechanisms are difficult to establish due to the heterogeneity and complexity of the disease. Metabolome-based techniques can provide clues about the cellular pathologic status of a condition as metabolic disturbances can represent an endpoint in biological phenomena. A number of investigations have analyzed metabolic changes in samples from cerebral ischemia patients and from various in vivo and in vitro models. We previously analyzed levels of amino acids and organic acids, as well as polyamine distribution in an in vivo rat model, and identified relationships between metabolic changes and cellular functions through bioinformatics tools. This review focuses on the metabolic and cellular changes in cerebral ischemia that offer a deeper understanding of the pathology underlying ischemic strokes and contribute to the development of new diagnostic and therapeutic approaches.

Effect of Rumex Acetosa Extract, a Herbal Drug, on the Absorption of Fexofenadine.

Herbal drugs are widely used for the auxiliary treatment of diseases. The pharmacokinetics of a drug may be altered when it is coadministered with herbal drugs that can affect drug absorption. The effects of herbal drugs on absorption must be evaluated. In this study, we investigated the effects of Rumex acetosa (R. acetosa) extract on fexofenadine absorption. Fexofenadine was selected as a model drug that is a substrate of P-glycoprotein (P-gp) and organic anion transporting polypeptide 1A2 (OATP1A2). Emodine-the major component of R. acetosa extract-showed P-gp inhibition in vitro and in vivo. Uptake of fexofenadine via OATP1A2 was inhibited by R. acetosa extract in OATP1A2 transfected cells. A pharmacokinetic study showed that the area under the plasma concentration-time curve (AUC) of fexofenadine was smaller in the R. acetosa extract coadministered group than in the control group. R. acetosa extract also decreased aqueous solubility of fexofenadine HCl. The results of this study suggest that R. acetosa extract could inhibit the absorption of certain drugs via intervention in the aqueous solubility and the drug transporters. Therefore, R. acetosa extract may cause drug interactions when coadministered with substrates of drug transporters and poorly water-soluble drugs, although further clinical studies are needed.

Effect of overhang and stiffness on accessibility of catheter tip to lung defects under surgical constraints.

BACKGROUND: Steering a catheter tip to a defective spot on a lung during fibrin glue application under pleurography (FGAP) constitutes a very challenging task. Accurate control of tip position/slope of steerable catheters is critical for providing glue to air-leaking defects on lung during FGAP. Steerable catheters are composed of multiple segments with different flexural rigidities and experience nonlinear deformation. Therefore, predicting tip position with accuracy is difficult. The purpose of this paper is to present a novel method that can accurately control the tip of the catheter, and thus enhance its target accessibility. METHODS: The tip position of a deflected steerable catheter can be accurately predicted using a simulation tool depicting the curvature of a bent catheter based on a mechanics of materials analysis. The proposed method utilizes the simulation tool to enhance the target accessibility of the catheter's tip. This assists medical doctors to not only select the optimal catheter prior to operation, but also to steer the catheter to the defects effectively. Simulation reliability is tested by performing a catheter deflection experiment and measuring the tip position. RESULTS: The simulation result accurately predicts the location of the catheter tip with an error of less than 5 mm to the experimental results. CONCLUSIONS: Controlling pull-wire tensions and overhang lengths based on simulation results substantially improves the target accessibility of the catheter tip.

Elevated procalcitonin levels in patients with acetaminophen intoxication: two case reports: A CARE-compliant article.

RATIONALE: Procalcitonin (PCT) is used as a biomarker for identifying the occurrence of sepsis. Previous studies have reported high levels of PCT with acetaminophen intoxication without evidence of infection. Here, we report two patients with acetaminophen intoxication with high levels of PCT without showing any symptoms of bacterial infection. PATIENT CONCERNS: This case study examined two unrelated patients with acetaminophen intoxication admitted to emergency at different times. The first patient was admitted to the emergency department after ingesting approximately 8000 mg (153.8 mg/kg) of acetaminophen. On admission, C-reactive protein (CRP), glutamic oxaloacetic transaminase (GOT), and glutamic pyruvic transaminase (GPT) were normal. PCT and acetaminophen levels were 31.89 ng/mL and below 0.5 µg/mL, respectively. The second patient was admitted to the emergency department 8 h after ingesting ∼23,600 mg (280.6 mg/kg) of acetaminophen. By the second day of admission, GOT and GPT increased to 2508 and 1473 IU/L, respectively. PCT was 45.66 ng/mL with acetaminophen level at 116.9 µg/mL. Both patients were clear of symptoms associated with bacterial infection. DIAGNOSIS: Acetaminophen intoxication. INTERVENTIONS: N-acetylcysteine was given intravenously to both patients for 20 h per protocol. OUTCOMES: Both patients were discharged without complications. LESSONS: Observations suggests that elevated levels of PCT in patients intoxicated with acetaminophen may be associated with involvement of other organs impacted by cytokine stimuli from sterile inflammation resulting from hepatic damage rather than PCT secretion directly caused by hepatic cell damage.

Successful conservative management of a spontaneous intraperitoneal rupture of bladder diverticulum in a critical patient: A case report. A CARE-compliant article.

RATIONALE: A spontaneous rupture of the bladder diverticulum in an adult patient is extremely rare. The recommended treatment is surgery. However, some cases can be successfully treated with urinary catheterization, antibiotics, and/or percutaneous peritoneal drainage. In this case report, a spontaneous rupture of the bladder diverticulum was successfully treated non-surgically because it was deemed too risky for surgical intervention, such as non-ST segment elevation myocardial infarction (NSTEMI). PATIENT CONCERNS: A 76-year-old man presented with abdominal pain, distention, diarrhea, and oliguria for 3 days and hypotension for 1 day with no history of trauma. The patient showed direct and rebound tenderness in the lower abdomen. Computed tomography revealed an intraperitoneal bladder rupture associated with the bladder diverticula. Electrocardiography, echocardiography, and elevated cardiac enzyme suggested NSTEMI. DIAGNOSES: A spontaneous rupture of the bladder diverticulum, NSTEMI, and suspected sepsis due to gastroenteritis or urinary infection. INTERVENTIONS: The patient was treated conservatively with urinary catheterization and antibiotics for a bladder rupture and an infection. Percutaneous transluminal coronary angioplasty was performed for NSTEMI. OUTCOMES: The patient fully recovered without complications on hospitalization day 13. LESSONS: Conservative management might be an alternative for a spontaneous intraperitoneal bladder rupture in some cases. However, close observation is required, and surgical intervention is the first option for a spontaneous intraperitoneal rupture of the bladder diverticulum.

Application of point-of-care ultrasound for different types of esophageal foreign bodies: three case reports: A CARE-compliant article.

RATIONALE: Esophageal point-of-care ultrasound (POCUS) has recently been reported as a useful, quick, safe, and simple technique to detect esophageal foreign bodies (FBs). However, case series to detect esophageal FB using POCUS have been rarely reported. Chicken bones and pills, especially, have not yet been reported as esophageal FBs. The objective of this case series was to describe the POCUS findings of 3 different materials-food, pill, and chicken bone. PATIENT CONCERNS: Case 1, a 75-year-old woman with odynophagia and neck pain occurring 30 min after eating chicken porridge; Case 2, a 32-year-old woman with neck discomfort occurring 2 h after taking a pill; Case 3, a 29-year-old woman reporting FB sensation in the neck that occurred 1 h after eating sausage and rice soup. DIAGNOSIS: Case 1. Cervical esophageal FB (chicken bone), Case 2. Cervical esophageal FB (oral pill), Case 3. Cervical esophageal FB (food). INTERVENTIONS: Case 1. POCUS, urgent esophagogastroduodenoscopy (EGD) with alligator forceps. POCUS findings; hyperechoic material (suspected FB) that did not disappear by swallowing and esophageal dilatation with pooling of secretions. Case 2. POCUS. POCUS findings; hypoechoic material (suspected FB) that did not disappear by swallowing, and esophageal bulging above the FB, especially observed in the longitudinal view. Case 3. POCUS. POCUS findings; hyperechoic material (suspected FB) with reverberation artifact that did not disappear with swallowing efforts. Prior FB esophageal bulging with persistent air-fluid level was especially observed in the longitudinal view. OUTCOMES: Case 1. FB was removed by EGD with alligator forceps. Case 2. Symptoms disappeared under observation without EGD. Follow-up POCUS revealed normalized bulging esophagus. Case 3. These symptoms improved after vomiting a large piece of food material. Three patients were discharged without complications. LESSONS: In this case series, the impacted materials were chicken bone, pill, and food. However, POCUS findings were similar (esophageal dilation, hyperechoic or hypoechoic lesion with mixed echogenic contents in food or secretion, and no change with swallowing efforts). A longitudinal view was useful to assume the presence of cervical esophageal FB in all three cases. Thus, POCUS findings could be indirect signs of a FB in the esophagus.