Laryngopharyngeal Mucosal Injury Due to Nasogastric Tube Insertion during Cardiopulmonary Resuscitation: A Retrospective Cohort Study.

BACKGROUND: Patients under cardiopulmonary resuscitation (CPR) are at high risk of aspirating gastric contents. Nasogastric tube insertion (NGTI) after tracheal intubation is usually performed blindly. This sometimes causes laryngopharyngeal mucosal injury (LPMI), leading to severe bleeding. This study clarified the incidence of LPMI due to blind NGTI during CPR. METHODS: We retrospectively analyzed 84 patients presenting with cardiopulmonary arrest on arrival, categorized them into a Smooth group (Smooth; blind NGTI was possible within 2 min), and Difficult group (blind NGTI was not possible), and consequently performed video laryngoscope-assisted NGTI. The laryngopharyngeal mucosal condition was recorded using video laryngoscope. Success rates and insertion time for the Smooth group were calculated. Insertion number and LPMI scores were compared between the groups. Each regression line of outcome measurements was obtained using simple regression analysis. We also analyzed the causes of the Difficult group, using recorded video laryngoscope-assisted videos. RESULTS: The success rate was 78.6% (66/84). NGTI time was 48.8 ± 4.0 s in the Smooth group. Insertion number and injury scores in the Smooth group were significantly lower than those in the Difficult group. The severity of LPMI increased with NGT insertion time and insertion number. CONCLUSIONS: Whenever blind NGTI is difficult, switching to other methods is essential to prevent unnecessary persistence.

Effect of PACAP on Heat Exposure.

Heat stroke is a life-threatening illness caused by exposure to high ambient temperatures and relative humidity. The incidence of heat stroke is expected to increase due to climate change. Although pituitary adenylate cyclase-activating polypeptide (PACAP) has been implicated in thermoregulation, the role of PACAP on heat stress remains unclear. PACAP knockout (KO) and wild-type ICR mice were subjected to heat exposure at an ambient temperature of 36 °C and relative humidity of 99% for 30-150 min. After heat exposure, the PACAP KO mice had a greater survival rate and maintained a lower body temperature than the wild-type mice. Moreover, the gene expression and immunoreaction of c-Fos in the ventromedially preoptic area of the hypothalamus, which is known to harbor temperature-sensitive neurons, were significantly lower in PACAP KO mice than those in wild-type mice. In addition, differences were observed in the brown adipose tissue, the primary site of heat production, between PACAP KO and wild-type mice. These results suggest that PACAP KO mice are resistant to heat exposure. The heat production mechanism differs between PACAP KO and wild-type mice.

Benign noninfectious subcutaneous emphysema with minor injury: A case report.

Posttraumatic subcutaneous emphysema, which can be benign and noninfectious, is associated with necrotizing fasciitis. Rarely, extensive emphysema occurs after a minor traumatic injury. A 23-year-old man came to our hospital with extensive emphysema, ranging from the left hand to the axilla, after a minor injury. Necrotizing fasciitis was suspected. Based on the blood and imaging tests, necrotizing fasciitis was not actively suspected. He was admitted and observed for one day, and he was discharged the following day. The mechanism by which air can enter through a small injury is unclear, but the one-way ball-valve mechanism is the most commonly proposed explanation. The nontraumatic causes of non-infectious subcutaneous emphysema include insect bites, skin biopsies, and the use of shock absorbers. Since it developed from a minor wound, other mechanisms, aside from the one-way ball-valve, were possibly involved. Based on the imaging results of this case, the air was predominantly distributed in the subcutaneous tissue along the neurovascular bundle. The relatively sparse tissue likely caused the extensive subcutaneous emphysema. While evaluating post-traumatic subcutaneous emphysema, benign and noninfectious cases should be differentiated to prevent unnecessary therapeutic intervention.

Corrigendum to "Repeated hypocalcemia in a patient with "Hikikomori" following veganism" [Heliyon 8 (6), (July 2022), Article e09563].

[This corrects the article DOI: 10.1016/j.heliyon.2022.e09563.].

A Case of Acute Non-ST Elevation Myocardial Infarction Later Revealed by Contrast-Enhanced Computed Tomography.

BACKGROUND Acute coronary syndrome is life-threatening. The diagnosis can be confirmed by electrocardiography (ECG) and serum cardiac biomarkers. Early diagnosis and treatment of non-ST segment elevation myocardial infarction (NSTEMI) is important because delayed treatment is associated with poor prognosis, especially in older adults. CASE REPORT An 82-year-old woman presented to the Emergency Department (ED) with epigastric and back pain. Despite the symptoms, the electrocardiogram revealed no abnormality, and the high-sensitivity cardiac troponin (Hs-cTn) value was below the detection limit. Chest contrast-enhanced computed tomography (CT) performed to exclude fatal diseases such as aortic dissection revealed no obvious abnormalities. The patient's symptoms improved and she was discharged. On the following day, the radiologist reviewed the CT and noted reduced cardiac uptake of contrast medium, and so suspected a subendocardial infarction. The patient was immediately recalled to the ED. She had no symptoms, but her Hs-cTn level was markedly elevated and asynergy was found on echocardiography. Emergency coronary angiography revealed complete obstruction of the left anterior descending coronary artery. CONCLUSIONS Similar to patients with acute ST segment elevation myocardial infarction, those with unstable angina or NSTEMI should be treated early. Delayed diagnosis and treatment of acute coronary syndrome is associated with poor prognosis, especially in older adults. Therefore, in patients presenting to the ED with chest pain, careful attention should be paid to myocardial staining in addition to the aorta, pulmonary arteries, and abdominal organs, when performing contrast-enhanced CT.

Repeated hypocalcemia in a patient with "Hikikomori" following veganism.

Calcium absorption; Vitamin D deficiency; Lack of sunlight; Hikikomori; Vegan.

Heatstroke-induced late-onset neurological deficits in mice caused by white matter demyelination, Purkinje cell degeneration, and synaptic impairment in the cerebellum.

Global warming increases heatstroke incidence. After heatstroke, patients exhibit neurological symptoms, suggesting cerebellar damage. However, the potential long-term adverse outcomes are poorly understood. We studied the cerebellum after heatstroke in mouse heatstroke models. In this study, motor coordination disorder significantly appeared 3 weeks after heatstroke and gradually improved to some extent. Although white matter demyelination was detected at 1 and 3 weeks after heatstroke in the cerebellum, it was not found in the corpus callosum. The Purkinje cell numbers significantly decreased at 1, 3, and 9 weeks after heatstroke. The intensity of synaptophysin and postsynaptic density-95 temporarily appeared to attenuate at 3 weeks after heatstroke; however, both appeared to intensify at 9 weeks after heatstroke. Motor coordination loss occurred a few weeks after heatstroke and recovered to some extent. Late-onset motor impairment was suggested to be caused by cerebellar dysfunctions morphologically assessed by myelin staining of cerebellar white matter and immunostaining of Purkinje cells with pre- and postsynaptic markers. Purkinje cell number did not recover for 9 weeks; other factors, including motor coordination, partially recovered, probably by synaptic reconstruction, residual Purkinje cells, and other cerebellar white matter remyelination. These phenomena were associated with late-onset neurological deficits and recovery after heatstroke.

Guillain-Barré syndrome diagnosed as central cervical spinal cord injury after hyperextension injury.

The clinical features of Guillain-Barré syndrome (GBS) are progressive, fairly symmetric muscle weakness, and patients present a few days to a week after onset of symptoms. A 63-y-old man strongly hit his forehead, and next day felt paresthesia in both upper limbs, with difficulty in walking. Spinal cord injury (SCI) was suspected; the cervical cord was severely compressed at the C4 level. He was diagnosed with central cervical SCI and transferred to a community hospital. Three days after the injury, oxygenation worsened, and the patient was transferred to our hospital for laminoplasty. After admission, we noticed bilateral ptosis-an atypical finding for SCI. Under analgesic sedation, he could only move his fingertips. Severe respiratory muscle weakness and absence of reflexes were observed. Moreover, albuminocytologic dissociation and decreased motor nerve conduction were observed, and GBS was suspected. Intravenous immunoglobulin was administered; thereby, the muscle weakness gradually improved, and the patient returned to work. Muscle weakness usually starts in the legs in GBS; however, in 10% of patients, it starts in the arms. In our patient, the symptoms started with paresthesia, followed by severe respiratory muscle weakness in a short period. Furthermore, intubation made history-taking and neurological examination difficult. The degree of inflammation in the acute GBS phase correlates with the severity of nerve injury. Therefore, early diagnosis and treatment of GBS is important. We should perform detailed history-taking and consider GBS as a differential diagnosis, especially when neurological examination cannot be performed at the emergency department.

Hypovolemic shock induced by a large chest wall hematoma caused by a single rib fracture in an elderly patient.

Displaced rib fractures can injure intercostal vessels leading to chest wall hematomas. As the bleeding occurs within the vessel, compression of the vessel wall helps in preventing further bleeding. Therefore, chest wall hematomas rarely result in shock. A thin 78-year-old man transferred to the emergency department with complaints of left dorsal pain due to an injury. He had a history of hypertension and aorta dissection. He arrived at the ED in a state of shock and presented with a large left dorsal wall mass. Subsequent imaging using computed tomography angiography revealed a large hyperdense hematoma at the left dorsal-flank wall along with rib fracture (11th intercostal artery). Moreover, a large fusiform aneurysm was detected from the abdominal aorta to the iliac arteries. Extravasation of the contrast agent was detected at the branch of the 11th intercostal artery, and hence, embolization was performed. The dermis, which comprises collagen and elastin fibers, plays an important role in vessel compression to prevent bleeding. The aortic media also comprises collagen and elastin fibers. Cell turnover, loss of collagen, and excessive elastolysis are associated with the formation of abdominal aortic aneurysms. The systemic degeneration of connecting tissue (collagen and elastin fiber) appears to be progress in patients with an aortic aneurysms and history of aortic dissection compared with other healthy older individuals. Physicians should be cognizant of the potential unexpected large hematoma complications if a risk of systemic connecting tissue degradation exists, as seen in patients with aortic aneurysm or aortic dissection.

A novel mouse model of heatstroke accounting for ambient temperature and relative humidity.

BACKGROUND: Heatstroke is associated with exposure to high ambient temperature (AT) and relative humidity (RH), and an increased risk of organ damage or death. Previously proposed animal models of heatstroke disregard the impact of RH. Therefore, we aimed to establish and validate an animal model of heatstroke considering RH. To validate our model, we also examined the effect of hydration and investigated gene expression of cotransporter proteins in the intestinal membranes after heat exposure. METHODS: Mildly dehydrated adult male C57/BL6J mice were subjected to three AT conditions (37 °C, 41 °C, or 43 °C) at RH > 99% and monitored with WetBulb globe temperature (WBGT) for 1 h. The survival rate, body weight, core body temperature, blood parameters, and histologically confirmed tissue damage were evaluated to establish a mouse heatstroke model. Then, the mice received no treatment, water, or oral rehydration solution (ORS) before and after heat exposure; subsequent organ damage was compared using our model. Thereafter, we investigated cotransporter protein gene expressions in the intestinal membranes of mice that received no treatment, water, or ORS. RESULTS: The survival rates of mice exposed to ATs of 37 °C, 41 °C, and 43 °C were 100%, 83.3%, and 0%, respectively. From this result, we excluded AT43. Mice in the AT 41 °C group appeared to be more dehydrated than those in the AT 37 °C group. WBGT in the AT 41 °C group was > 44 °C; core body temperature in this group reached 41.3 ± 0.08 °C during heat exposure and decreased to 34.0 ± 0.18 °C, returning to baseline after 8 h which showed a biphasic thermal dysregulation response. The AT 41 °C group presented with greater hepatic, renal, and musculoskeletal damage than did the other groups. The impact of ORS on recovery was greater than that of water or no treatment. The administration of ORS with heat exposure increased cotransporter gene expression in the intestines and reduced heatstroke-related damage. CONCLUSIONS: We developed a novel mouse heatstroke model that considered AT and RH. We found that ORS administration improved inadequate circulation and reduced tissue injury by increasing cotransporter gene expression in the intestines.

Diagnosis of neurofibromatosis type 1 after rupture of aneurysm and consequent fatal hemothorax.

Patients with neurofibromatosis type 1 (NF1) can develop both benign and malignant tumors throughout their lives. A 49-year-old man was transferred to the emergency department with complaints of sudden right dorsal pain and respiratory discomfort. He was in shock on arrival. On finding significantly decreased permeability of the left lung field in chest X-ray, drainage was immediately performed. Subsequent computed tomography (CT; Lammert et al., 2005) angiography revealed the extravasation of contrast media from the deep carotid artery, a branch of subclavian artery. It suggested rupture of an aneurysm located at a rare site; the ruptured aneurysm penetrated the pleura, causing shock. The patient was resuscitated. Transcatheter arterial embolization (TAE; Evans et al., 2010) was successfully performed. Immediate drainage, resuscitation, and TAE 2 improved his condition. Most NF1 patients have café-au-lait macules; café-au-lait macules tend to fade with age. Importantly, café-au-lait macules, neurofibromas, and Lisch nodules were noticed at admission. NF1 patients are likely to have a malignant neoplasm when they are young. The patient had been diagnosed with thyroid cancer when he was young. As his deceased mother was an NF1 patient, we diagnosed him with NF1. Detailed patient history and early-stage examination led to the early diagnosis. NF1 should be considered as an early differential diagnosis to improve the outcome of patients in such cases.

The enhancement of CCL2 and CCL5 by human bone marrow-derived mesenchymal stem/stromal cells might contribute to inflammatory suppression and axonal extension after spinal cord injury.

Human bone marrow-derived mesenchymal stem/stromal cells (hMSCs) have shown potential in facilitating recovery from spinal cord injury (SCI) through communicating with microglia/macrophages (MG/MΦ). We here focused on chemokines as a candidate for the communication. Selected MG/MΦ-related chemokines were determined gene expression after SCI and further focused CCL2/CCR2 and CCL5/CCR5 to estimate role of the chemokines by hMSCs. Male C57/BL6 mice were subjected to spinal cord transection. Gene expression was assayed in the spinal cords following SCI for selected MG/MΦ-related chemokines and their receptors. hMSCs (5×105 cells) were then transplanted into parenchyma of the spinal cord, and the expressions of the Ccl2/Ccr2 and Ccl5/Ccr5 axes, inflammation, MG/MΦ-polarization, and axonal regeneration were evaluated to measure the influence of the hMSCs. Finally, mouse CCL5 was injected into the spinal cords. Acute increases in gene expression after SCI were observed for most chemokines, including Ccl2; chronic increases were observed for Ccl5. CCL2+-cells merged with NeuN+-neurons. CCR2+ immunoreactivity was principally observed in Ly-6G+/iNOS+-granulocytes on postoperative day (pod) 1, and CCL5+ and CCR5+ immunoreactivity overlapped with NeuN+-neurons and F4/80+-MG/MΦ on pod 14. The hMSC transplantation enhanced Ccl2 and Ccl5 and improved locomotor activity. The hMSC implantation did not alter the number of Ly-6G+/CCR2+ but decreased Il1, Elane, and Mpo on pod 3. Conversely, hMSC transplantation increased expression of Zc3h12a (encodes MCP-1-induced protein) on pod 14. Moreover, hMSC increased the Aif1, and two alternatively activated macrophage (AAM)-related genes, Arg1 and Chil3 (Ym1), as well as axonal regenerative markers, Dpysl2 and Gap43. Gene expression indicative of AAM polarization and axonal regeneration were partially recovered by CCL5 injection. These results suggest that hMSC implantation increases Ccl2 and Ccl5, improves locomotor activity, enhances MG/MΦ polarization to AAM, and increases the gene expression of axonal regenerative markers. These functions of hMSCs might be partially mediated by the CCL2/CCR2 and CCL5/CCR5 axes.

Image findings of bisphosphonate related osteonecrosis of jaws comparing with osteoradionecrosis.

OBJECTIVES: The aim of this study was to evaluate image characteristics of bisphosphonate-related osteonecrosis of the jaws (BRONJ) and compare these with osteoradionecrosis (ORN). METHODS: 34 patients with BRONJ and 16 patients with ORN were included in this study. We investigated the CT and dental panoramic radiograph (DPR) images for osteolysis, osteosclerosis, sequestration, periosteal reaction, pathological fracture and spread of soft tissue inflammation around the jaws. RESULTS: Osteolysis, osteosclerosis, sequestration and spread of soft tissue inflammation around the jaws were common radiological features in both BRONJ and ORN. Osteolysis and spreading of soft tissue inflammation around the jaws were predominant in ORN, and by contrast osteosclerosis was predominant in BRONJ. Periosteal reaction was established in 15 of the 34 BRONJ cases, but none in the ORN cases. Pathological fractures were observed in 6 of 16 ORN cases, but none in BRONJ cases. CT was better for detection than DPR for osteolysis, osteosclerosis, sequestration and periosteal reactions. CONCLUSIONS: Image findings of BRONJ were characterized as a severe sclerotic change combined with osteolysis, sequestration, periosteal reaction and spread of soft tissue inflammation around the jaws.

Changes in parotid gland morphology and function in patients treated with intensity-modulated radiotherapy for nasopharyngeal and oropharyngeal tumors.

OBJECTIVE: To evaluate the morphological changes of the parotid glands in patients treated with intensity-modulated radiotherapy (IMRT) for nasopharyngeal and oropharyngeal tumors and the correlations with parotid function. METHODS: Ten patients with nasopharyngeal and oropharyngeal tumors treated with IMRT between May 2009 and January 2010 at Hokkaido University Hospital were included in this study. In the morphological assessment of the parotid glands, the sizes and computed tomography (CT) numbers of the bilateral parotid glands before and after IMRT with CT were calculated. For functional assessment of the parotid glands, we conducted the Saxon test and used a visual analog scale (VAS) for xerostomia evaluation. RESULTS: Reductions in saliva secretion were observed in the patients treated with IMRT for nasopharyngeal and oropharyngeal tumors, and there was a significant correlation between the reduction in saliva secretion and the VAS. The reductions in the parotid gland size and CT number were larger on the ipsilateral side than on the contralateral side. The reduction in saliva secretion was not significantly correlated with the reduction in parotid gland size, but was significantly correlated with the reduction in CT number. CONCLUSIONS: Morphological and functional changes of the parotid glands were observed after IMRT for nasopharyngeal and oropharyngeal tumors, and preservation of the contralateral parotid glands was only partly achieved. Among the morphological changes of the parotid glands, the CT number may be considered a predictor of parotid function after radiotherapy.

An investigation of accidental ingestion during dental procedures.

Twenty-three cases of accidental ingestion during dental procedures, which occurred at the Center for Dental Clinics of Hokkaido University Hospital between 2006 and 2010, were analyzed retrospectively. We examined not only the objects ingested, but also details of the circumstances (treated teeth, types of treatment, professional experience of the practitioners). Except for two cases (an unidentified endodontic file and the tip of an ultrasonic scaler, which were recovered by vacuuming), the other 21 accidentally ingested objects were all found in the digestive tract, and none in the respiratory tract, by radiographic examination of the chest and abdomen. The ingested objects were mostly metal restorations (inlays or onlays) or prostheses (crowns or cores). Ingestion occurred more frequently during treatment of lower molars, and when procedures were being conducted by practitioners with less than 5 years of experience. No adverse events related to ingestion were reported. The present study found no cases of aspiration or complications related to the ingested objects. However, considering the risk of life-threatening emergencies related to accidental aspiration and ingestion, dentists must take meticulous precautions and be ready to deal with this kind of emergency during dental procedures.

A comparison of diagnostic tools for Sjögren syndrome, with emphasis on sialography, histopathology, and ultrasonography.

OBJECTIVE: The present study examined the reliability and correlation of sialography, salivary gland biopsy, and ultrasonography for Sjögren syndrome (SS) and evaluated the usefulness of ultrasonography as a diagnostic tool for SS compared with sialography and histopathology. STUDY DESIGN: Seventy-three patients who underwent sialography, ultrasonography, and salivary gland biopsy were included in this study. The study evaluated the diagnostic reliability and correlation of each kind of examination with SS. RESULTS: There was a statistically significant difference in the sensitivities of sialography and histopathology, in the specificities of sialography and ultrasonography, and in the accuracies of sialography and both ultrasonography and histopathology. The correlation coefficient (r) between sialography and ultrasonography was significantly higher than the others and indicated a good correlation. CONCLUSIONS: Ultrasonography can be used as a diagnostic tool for SS, with its advantage of noninvasiveness and ease of use.

Experience of high-dose-rate brachytherapy for head and neck cancer treated by a customized intraoral mold technique.

Radiotherapy of head and neck cancer has become more successful with the advances in treatment modalities and use of a multidisciplinary approach. Higher quality treatment and a team approach to radiotherapy have thus been required for head and neck cancer. This study presents the clinical experience of high-dose-rate (HDR) brachytherapy for head and neck cancer treated by a customized intraoral mold technique. Two patients are reported for whom we created dental prostheses as the radiation carriers for HDR brachytherapy of their head and neck cancers. HDR brachytherapy with the dental prostheses reported here was feasible and effective for eradicating the head and neck cancer. It has been demonstrated that HDR brachytherapy using a customized intraoral technique can be a treatment option for patients who are not candidates for surgery or external irradiation. It is strongly suggested that specialized dentists are needed who are familiar with not only the anatomy and function of the head and neck region but also radiotherapy. Dental radiologists should take responsibility for constructing irradiation prostheses. If they do, they have the potential to improve the quality of life of patients who undergo radiotherapy for head and neck cancer.

Impacted teeth in the maxilla: usefulness of 3D Dental-CT for preoperative evaluation.

OBJECTIVE: To compare the shapes of roots of impacted teeth shown in three-dimensional computed tomographic images (3D Dental-computed tomography (CT) images) and plain radiographs and to determine whether 3D Dental-CT images are useful for examination before performing an operation for extraction of a maxillary impacted tooth. METHODS AND PATIENTS: Images obtained from patients who had impacted teeth in the maxilla, including impacted mesial supernumerary teeth in 13 patients, impacted incisors in two patients, impacted canines in 11 patients, impacted premolars in four patients and impacted molars in three patients, were used in this study. In all patients, plain radiographs and 3D Dental-CT images were retrospectively reviewed by an oral radiologist for evidence of root dilaceration before operations to extract the impacted teeth were performed. The findings in the images were compared with intraoperative findings in all cases. RESULTS: The mean specificity and sensitivity of plain radiographs were 95 and 8%, respectively, while those of 3D Dental-CT images were 100 and 77%, respectively. There was a statistically significant (P<0.01) difference between the depiction capabilities of plain radiographs and 3D Dental-CT images with regard to dilacerations of roots of impacted teeth. DISCUSSION AND CONCLUSION: CT may enable radiologists to make a quick and accurate diagnosis of tooth impaction. 3D Dental-CT images are useful for determining the root shape of an impacted tooth in the maxilla.