Exophiala dermatitidis.

Exophiala is a genus comprising several species of opportunistic black yeasts, which belongs to Ascomycotina. It is a rare cause of fungal infections. However, infections are often chronic and recalcitrant, and while the number of cases is steadily increasing in both immunocompromised and immunocompetent people, detailed knowledge remains scarce regarding infection mechanisms, virulence factors, specific predisposing factors, risk factors, and host response. The most common manifestations of Exophiala infection are skin infections, and the most frequent type of deep infection is pulmonary infection due to inhalation. The invasive disease ranges from cutaneous or subcutaneous infection to systemic dissemination to internal organs. The final identification of the causative organism should be achieved through a combination of several methods, including the newly introduced diagnostic analysis, matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry, together with sequencing of the ribosomal ribonucleic acid internal transcribed spacer region of the fungi, and histological and culture findings. Regarding treatment, because anti-infective agents and natural compounds exhibited poor antibiofilm activity, few treatments have ultimately been found to be effective for specific antifungal therapy, so the optimal antifungal therapy and duration of therapy for these infections remain unknown. Therefore, most forms of disease caused by Exophiala dermatitidis require aggressive combination therapies: Both surgical intervention and aggressive antifungal therapy with novel compounds and azoles are necessary for effective treatment.

Angiotensin receptor blocker neprilysin inhibitors.

Heart failure (HF) is a clinical syndrome that results from a structural or functional cardiac disorder that reduces the ability of the ventricle of the heart to fill with, or eject, blood. It is a multifaceted clinical condition that affects up to 2% of the population in the developed world, and is linked to significant morbidity and mortality; it is therefore considered a major concern for public health. Regarding the mechanism of HF, three neurohumoral factors - the renin-angiotensin-aldosterone system, the sympathetic nervous system, and natriuretic peptides - are related to the pathology of chronic HF (CHF), and the targets of treatment. Angiotensin receptor blocker and neprilysin inhibitor (angiotensin-receptor neprilysin inhibitor), namely sacubitril/valsartan (SAC/VAL), has been introduced as a treatment for CHF. SAC/VAL is an efficacious, safe, and cost-effective therapy that improves quality of life and longevity in patients with HF with reduced ejection fraction (HFrEF), and reduces hospital admissions. An in-hospital initiation strategy offers a potential new avenue to improve the clinical uptake of SAC/VAL. In the last five years, SAC/VAL has been established as a cornerstone component of comprehensive disease-modifying medical therapy in the management of chronic HFrEF. On the other hand, further work, with carefully designed and controlled preclinical studies, is necessary for understanding the molecular mechanisms, effects, and confirmation of issues such as long-term safety in both human and animal models.

A Fatal Case of Super-super Obesity (BMI >80) in a Patient with a Necrotic Soft Tissue Infection.

A 35-year-old man (height, 169 cm; body weight, 240 kg; BMI, 84) visited the Department of Dermatology due to left leg pain and swelling. Focused enhanced computed tomography (CT) of the left leg ruled out complications of deep venous thrombosis. Surgical exploration of the left leg resulted in a diagnosis of necrotic soft tissue infection, but amputation was ruled out due to his weight. The patient ultimately died of multiple organ failure on the fourth day of hospitalization. A culture of the surgical material revealed Streptococcus dysgalactiae. The present case suggests that super-obese patients should be aggressively treated before lethal complications occur.

Difference in First Aid Activity During Mass Casualty Training Based on Having Taken an Educational Course.

BACKGROUND: The Japanese Association for Disaster Medicine developed a mass casualty life support (MCLS) course to improve cooperation among medical practitioners during a disaster, which is essential for reducing the rates of preventable disaster death. We investigated whether there was difference in first aid activity among members of the ambulance service during mass casualty training based on having taken the MCLS course. METHODS: Mass casualty training was held at the fire department of Numazu City. Twenty-one ambulance service parties participated in this training. They first evaluated the mass casualty situation, performed the appropriate services at the scene during the initial period, and then provided START triage for mock wounded patients. Throughout the training, 5 examiners evaluated their performance. RESULTS: Regarding the difference in first aid activity based on MCLS course attendance among the ambulance service members, the cooperative management (scored on a scale of 1 to 5) among the members who had taken the MCLS course was significantly better than that among those who had not taken the course (median [interquartile range]: 5 [0.5] vs. 4 [1.75], P<0.05). CONCLUSION: Attending an MCLS course may help to improve outcomes in the face of an actual mass casualty incident. (Disaster Med Public Health Preparedness. 2018;12:437-440).

A system of delivering medical staff members by helicopter to manage severely wounded patients in an area where medical resources are limited.

Aim: We review the case of a severely injured patient to evaluate the system of delivering medical staff by helicopter in areas with limited medical resources. Methods: The patient's chart was reviewed, summarized, and presented. Results: A 22-year-old woman attempted a suicidal fall after using a knife to stab herself. She was transported to a local hospital. A radiological study revealed fractures to the patient's face and the base of her skull, pneumocephalus, traumatic subarachnoid hemorrhage, stab wounds to the neck and chest, pneumothorax, unstable pelvic fracture, and right femoral shaft fracture. Her circulation status became unstable. We sent medical staff members to the local hospital by doctor helicopter. The patient underwent tracheal intubation and the insertion of a chest drain, and was evacuated by doctor helicopter. After aggressive intensive treatments in our hospital, the patient finally obtained social rehabilitation. Conclusion: In an area where medical resources are limited, sending trained physicians to a referring hospital to appropriately prepare a severely wounded patient for transportation might be the key for the patient to maximize his or her chance of survival.

Bite Wounds Caused by a Wild Boar: A Case Report.

A 74-year-old man was attacked by a wild boar while on his way home from his farm in the daytime in winter 2017 on the rural Izu peninsula. He did not provoke the boar; however, hunters were hunting animals in the mountains near the farm around the same time. The boar bit his left leg, and the man fell to the ground. The boar continued biting the man's left leg, and the man delivered a few kicks to the boar's face with his right leg. The boar then bit his right foot and ran away. The man was taken to a hospital, and a physical examination revealed 3 bite wounds on his left leg and right foot. The wounds were irrigated with sterilized saline and closed with sutures under local anesthesia. He received antibiotics and a tetanus toxoid booster. The next day, his wounds were found to be infected, and pus was drained from them. After these treatments, his wounds healed successfully. Animal bite wounds are frequently contaminated. Accordingly, in addition to early proper wound treatment, close observation of the wound is required for both the early detection of any signs of infection and early medical intervention, including appropriate drainage of pus and irrigation as necessary.

Acute Coronary Syndrome Evacuated by a Helicopter From the Scene.

OBJECTIVE: The purpose of this study was to investigate the safety of evacuating patients using a physician-staffed helicopter (Dr. Heli). METHODS: We retrospectively investigated all of the patients with acute coronary syndrome (ACS) who were transported by a Dr. Heli between April 2004 and March 2016. The scene group included subjects evacuated from the scene by the Dr. Heli. The interhospital group included subjects transported to a nearby medical facility by a ground ambulance and then transported to our hospital by a Dr. Heli. RESULTS: The scene and interhospital groups included 170 subjects and 592 subjects, respectively. There were no significant differences between the 2 groups with regard to sex and survival ratios. However, the patients in the scene group were significantly younger than those in the interhospital group. The ratio of prehospital cardiopulmonary arrest in the scene group was significantly higher than in the interhospital group. After excluding subjects who were over 80 years of age, there were no significant differences between the 2 groups with regard to age. However, the same tendencies remained. CONCLUSION: This result indirectly suggests the safety of using the Dr. Heli to evacuate ACS patients from the scene.

Management of Mass Casualties Using Doctor Helicopters and Doctor Cars.

At approximately 10 o'clock in September 2015, a minibus carrying 18 people accidentally slid backwards because of a malfunctioning brake system while climbing a steep incline on Togasayama Mountain, colliding with a van (Toyota HiAce wagon) carrying 11 people that was situated behind the minibus. Togasayama Mountain is located 1 hour by car and 10 minutes by helicopter from our hospital. The minibus slid off a roadside cliff at a height of 0.5 m and rolled over after colliding with the van. There were 7 victims with yellow tags and 22 with green tags. Two Doctor Helicopters and 1 Doctor Car cooperated with the fire departments by providing medical treatments, selection of medical facilities, and dispersion transportation. In this mass casualty event, there were no mortalities, and all of the victims recovered without sequelae. The coordinated and combined use of Doctor Helicopters and Doctor Cars in addition to the activities of the fire department in response to a mass casualty event resulted in appropriate triage, medical treatments, selection of medical facilities, and dispersion transportation.

Fibrinogen degradation product levels on arrival for trauma patients requiring a transfusion even without head injury.

BACKGROUND: There have been few reports on the clinical significance of the fibrinogen degradation product (FDP) level in trauma patients with and without head injury. We retrospectively analyzed trauma patients with or without head injury to investigate the clinical significance of the FDP level. METHODS: From April 2013 to June 2015, a medical chart review was retrospectively performed for all patients with trauma. The exclusion criteria included patients who did not receive a transfusion. The patients were divided into two groups: a FDP>100 group, which included patients who had an FDP level on arrival over 100 ng/mL, and a FDP≤100 group. RESULTS: The ratio of open fractures and the prothrombin ratio in the FDP>100 group were significantly smaller than those observed in the FDP≤100 group. The average age, ratio of blunt injury, Injury Severity Score (ISS), volume of transfusion and mortality ratio in the FDP>100 group were significantly greater than those in the FDP≤100 group. There was a weakly positive correlation between the FDP level and ISS (R=0.35, P=0.002), but it was not associated with the transfusion volume. The results of an analysis excluding patients with head injury showed a similar tendency. CONCLUSION: The FDP levels may be a useful biochemical parameter for the initial evaluation of the severity of trauma and mortality even in blunt traumatized patients without head injury or with stable vital signs.

An infant case of intraoral penetrating injury with a toothbrush causing retropharyngeal and upper mediastinal emphysema.

A 2-year-old male child who was running and fell with a toothbrush in his mouth suffered an injury to the inside of his right cheeks. His mother noticed that the toothbrush had impaled his mouth, and removed it. On arrival, a wound was observed on the right cheeks and palate. His general condition was good. However, computed tomography revealed emphysema from the left side of epipharynx to the upper mediastinum. This patient shows the importance of not only checking the medical history and performing a physical examination but also performing an imaging examination.

Suffocation due to Thoracic Deformity Caused by Acromegaly.

A 61-year-old man with gigantism and acromegaly choked and fell into a coma. Immediate tracheal intubation resulted in a return of his consciousness. Enhanced computed tomography indicated that the trachea and left main bronchus were compressed by the thoracic spine and sternum. He required tracheotomy and positive end-expiratory pressure to maintain his pulmonary function. This is the first case of suffocation due to a thoracic deformity associated with acromegaly. Physicians should focus on clearing the tracheal airway using computed tomography to elucidate the anatomical relationship between the trachea and surrounding structures in acromegalic patients suffering from dyspnea.

Cardiac arrest at high elevation with a favorable outcome.

A 36-year-old man started to climb Mount Fuji (3776m above sea level: ASL), from the Gotemba new fifth station (2400m ASL). He had no significant medical history, and this was his first attempt to climb such a high mountain. He began feeling chest discomfort but continued to climb. When he reached the ninth station of the mountain (3600mASL), he lost consciousness. One individual immediately provided basic life support using an automated external defibrillator (AED) that was located in the station. After electroshocks, he regained consciousness. He was transported to the fifth station, where an ambulance could approach, in a large crawler. When the medical staff, who were transported via helicopter and ambulance, examined him near the fifth station, he still complained of chest discomfort. A single spray of nitroglycerin and aspirin (200mg) was administered. He was transported to the Cardiac Care Unit via ambulance and helicopter under escort by a physician. A chest computed tomography angiogram indicated triple-vessel disease. He was discharged without any neurological deficits after undergoing bypass surgery. In high mountains that can be easily accessed by amateur climbers who may have cardiac disease, the placement of AED devices and the establishment of the chain of survival from the scene to the intensive care unit are essential for obtaining a favorable outcome when a climber suffers cardiac arrest.

A comparison between evacuation from the scene and interhospital transportation using a helicopter for subarachnoid hemorrhage.

PURPOSE: We investigated the changes in the vital signs and the final outcomes subarachnoid hemorrhage (SAH) patients who were evacuated from the scene using the doctor-helicopter (Dr. Heli) service and those who only underwent interhospital transportation using the doctor-helicopter Dr. Heli service to investigate safety of this system. METHODS: We retrospectively investigated all of the patients with non-traumatic SAH who were transported by a Dr. Heli between January 2010 and March 2016. The subjects were divided into two groups: the Scene group included subjects who were evacuated from the scene by a Dr. Heli, while the Interhospital group included subjects who were transported by a ground ambulance to a nearby medical facility and then transported by a Dr. Heli to a single tertiary center. RESULTS: The systolic blood pressure, ratio of cardiac arrest, and Fisher classification values of the patients in the Scene group were significantly greater than those in the Interhospital group. The Glasgow Coma Scale in the Scene group was significantly lower than that in the Interhospital group. After excluding the patients with cardiac arrest, the Glasgow Coma Scale scores of the patients in the two groups did not differ to a statistically significant extent during, before or after transportation. There were no significant differences in Glasgow Outcome Scores or the survival ratio of the two groups, even when cardiac arrest patients were included. CONCLUSION: The present study indirectly suggests the safety of using a Dr. Heli to evacuate SAH patients from the scene.

Fibrinogen degradation product levels on arrival for trauma patients requiring a transfusion even without head injury / 世界急诊医学杂志（英文）

@#BACKGROUND:There have been few reports on the clinical significance of the fibrinogen degradation product (FDP) level in trauma patients with and without head injury. We retrospectively analyzed trauma patients with or without head injury to investigate the clinical significance of the FDP level. METHODS:From April 2013 to June 2015, a medical chart review was retrospectively performed for all patients with trauma. The exclusion criteria included patients who did not receive a transfusion. The patients were divided into two groups:a FDP>100 group, which included patients who had an FDP level on arrival over 100 ng/mL, and a FDP≤100 group. RESULTS:The ratio of open fractures and the prothrombin ratio in the FDP>100 group were significantly smaller than those observed in the FDP≤100 group. The average age, ratio of blunt injury, Injury Severity Score (ISS), volume of transfusion and mortality ratio in the FDP>100 group were significantly greater than those in the FDP≤100 group. There was a weakly positive correlation between the FDP level and ISS (R=0.35, P=0.002), but it was not associated with the transfusion volume. The results of an analysis excluding patients with head injury showed a similar tendency. CONCLUSION:The FDP levels may be a useful biochemical parameter for the initial evaluation of the severity of trauma and mortality even in blunt traumatized patients without head injury or with stable vital signs.

Heat stroke with bimodal rhabdomyolysis: a case report and review of the literature.

BACKGROUND: Severe heat stroke tends to be complicated with rhabdomyolysis, especially in patients with exertional heat stroke. Rhabdomyolysis usually occurs in the acute phase of heat stroke. We herein report a case of heat stroke in a patient who experienced bimodal rhabdomyolysis in the acute and recovery phases. CASE PRESENTATION: A 34-year-old male patient was found lying unconscious on the road after participating in a half marathon in the spring. It was a sunny day with a maximum temperature of 24.2 °C. His medical and family history was unremarkable. Upon arrival, his Glasgow Coma Scale score was 10. However, the patient's marked restlessness and confusion returned. A sedative was administered and tracheal intubation was performed. On the second day of hospitalization, a blood analysis was compatible with a diagnosis of acute hepatic failure; thus, he received fresh frozen plasma and a platelet transfusion was performed, following plasma exchange and continuous hemodiafiltration. The patient's creatinine phosphokinesis (CPK) level increased to 8832 IU/L on the fifth day of hospitalization and then showed a tendency to transiently decrease. The patient was extubated on the eighth day of hospitalization after the improvement of his laboratory data. From the ninth day of hospitalization, gradual rehabilitation was initiated. However, he felt pain in both legs and his CPK level increased again. Despite the cessation of all drugs and rehabilitation, his CPK level increased to 105,945 IU/L on the 15th day of hospitalization. Fortunately, his CPK level decreased with a fluid infusion. The patient's rehabilitation was restarted after his CPK level fell to <10,000 IU/L. On the 31st day of hospitalization, his CK level decreased to 623 IU/L and he was discharged on foot. Later, a genetic analysis revealed that he had a thermolabile genetic phenotype of carnitine palmitoyltransferase II (CPT II). CONCLUSIONS: Physicians should pay special attention to the stress of rehabilitation exercises, which may cause collapsed muscles that are injured by severe heat stroke to repeatedly flare up.

Hypothesis: the influence of cavitation or vacuum phenomenon for decompression sickness.

Attention has recently been focused on the vacuum phenomenon detected by computed tomography (CT), where gas in the human body is incidentally detected by CT. We introduce our hypothesis that the vacuum phenomenon increases the risk of decompression sickness (DCS) in subjects who engage in post-diving exercise. When the screw propeller of a ship operates underwater, a swirling effect called cavitation occurs. This swirling effect is closely related to the ship's propulsive efficiency as well as propeller cracking and damage. Hydrodynamic cavitation describes the process of vaporization, bubble generation, and bubble implosion that occurs in a flowing liquid as a result of a decrease and subsequent increase in local pressure. The formation of cavitation depends on the pressure, speed, temperature, viscosity, turbulence, or existence of impurities in the fluid; the evaporation of inert gas; and the form and surface roughness of the screw. These factors also resemble risk factors of DCS. In the human body, the cavitation effect has been recognized in radiological studies, where it is referred to as the 'vacuum phenomenon'. The mechanism responsible for the formation of the vacuum phenomenon has been described recently. If an enclosed tissue space is allowed to expand as a rebound phenomenon after an external impact, the volume within the enclosed space will increase. Under this condition of expanding volume, the pressure within the space will decrease. The solubility of the gas in the enclosed space will then subsequently decrease as the pressure inside the space decreases, allowing a gas such as nitrogen to leave solution. The combination of reduced nitrogen solubility and the minimal metabolism of nitrogen by the body mainly accounts for the formation of the vacuum phenomenon. The vacuum phenomenon has been observed in normal joints, degenerative intervertebral discs, the spine and spinal canal and traumatized tissues (Figure 1). Exercise induces the inflation and deflation of tissue or the extension and flexion of multiple joints. The pressure of the inflated tissue or extended joints decreases based on Henry's Law and Boyle's Law, resulting in cavitation. This phenomenon may be accelerated after diving, during the decompression phase. In an analysis of the effects of the ascent rate and post-dive exercise on the incidence of DCS in rats using ordinal logistic regression, higher rates of DCS and mortality were seen in rats which engaged in post-dive exercise than in control rats. Accordingly, DCS following post-diving exercise may be induced by the vacuum phenomenon, particularly in cases with joint pains. The fact that the vacuum phenomenon is most frequently observed in the spine or spinal disc spaces may also influence the occurrence of spinal cord neurological DCS, which is rarely due to embolization from cardiac origin.

Management of a Mass Casualty Event Caused by Electrocution Using Doctor Helicopters.

OBJECTIVE: This is the first report to show the use of doctor helicopters in a mass casualty event induced by electrocution. METHODS: We performed a narrative review. RESULTS: Two children obtained electrocution burns by breaking an electric fence. Five adults also received electrocution burns. Emergency medical technicians at the scene requested additional dispatch of an ambulance and the doctor helicopter. Two adult men with cardiopulmonary arrest were transported by 2 ambulances to a nearby hospital. One adult woman was in a restless confusional state, intubated, and transferred to another hospital using the doctor helicopter. One boy, who was initially in a coma, and his mother were transferred to our hospital by 1 ambulance. Another boy, who had finger amputation, was transferred to the other hospital by another doctor helicopter. A remaining elderly woman was transported to the other local hospital by ambulance. All the victims, except the 2 fathers who fell into cardiac arrest, survived. CONCLUSION: Early confirmation of the safety of the scene, early establishment of command and control, early request for dispatch of other parties and the doctor Helicopter, appropriate triage, appropriate treatment at the scene, selecting appropriate medical facilities, and dispersion transportation were crucial.