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Patients with poorly controlled insulin‐dependent type 1 or type 2 diabetes rarely present with glycogenic hepatopathy, which is characterized by hepatomegaly and liver enzyme abnormalities. Glycogenic hepatopathy occurs as a consequence of excessive accumulation of glycogen in hepatocytes caused by insulin. We report a young male patient with type 1 diabetes mellitus who developed glycogenic hepatopathy following a suicide attempt by insulin overdose via subcutaneous injection. The patient's medication/nutrition compliance and adherence to insulin were poorly controlled due to comorbid schizophrenia. Our patient required a large amount of continuous glucose to maintain euglycemia for persistent intractable hypoglycemia induced by overdose of long‐acting insulin. On admission day 4, the patient presented elevated transaminases, hepatomegaly, and lactic acidosis. Computed tomography revealed swollen liver parenchyma with a diffusely high absorption. The patient gradually recovered without any medical intervention except for adequate control of blood sugar and was moved to a psychiatric ward on day 8 for schizophrenia management. This report may help emergency physicians be aware of the common symptoms, clinical course, and pathophysiology of glycogenic hepatopathy. Doctors should include glycogenic hepatopathy in the differential diagnosis of abnormal liver enzymes and hepatomegaly for those with poorly controlled insulin‐dependent diabetes mellitus or unstable blood sugar levels due to insulin overdose like our patient.

Newly introduced heat‐not‐burn or electronic cigarettes can cause lethal nicotine intoxication if ingested at higher doses. Although routine gastric lavage is not recommended, it should be considered if the amount of intoxicant is lethal. A 59‐year‐old man with a history of depression was brought to our emergency department after intentional ingestion of 8 heat‐not‐burn cigarettes, which were estimated to contain a total of 100 mg of nicotine. Abdominal computed tomography confirmed the gastric contents, detecting multiple stick‐like and rod‐shaped high‐density structures. Gastric lavage was performed to minimize absorption of the potentially lethal nicotine dose. The patient exhibited only mild gastrointestinal symptoms. Emergency physicians should be aware of this novel heat‐not‐burn cigarette and its toxicity.

Acute carbon monoxide (CO) intoxication during pregnancy causes fetal death and teratogenic effects. Hyperbaric oxygen (HBO2) therapy has the potential to improve them. HBO2 therapy should be considered to treat CO intoxication during pregnancy.

Aim Although uncommon, medical emergencies arise in general dental practice. Inadequate data on their severity and frequency makes targeting medical education for general dental practitioners difficult. This also makes planning for unexpected events challenging for practitioners and makes collaborating with emergency physicians burdensome. We aimed to clarify the incidence and characteristics of a dental outpatient department’s medical emergencies. Methods This single‐center, retrospective, observational study was undertaken with patients who visited the dental outpatient department of Okayama University Hospital during the 8‐year period. The primary outcome of the study was to identify the incidence and characteristics of medical emergencies in the dental outpatient department. Then we examined the timing of medical emergencies, administered medications, and final disposition (home/admission). Results During the period, 1,146,929 patients were enrolled. Forty‐two patients (0.0037%) were consulted as medical emergencies. More than 60% of the incidents were vasovagal syncope, and dehydration and hypoglycemia were the second most prevalent at 9.5%. The most common types of dental treatments were tooth extraction (45.2%), followed by general dental treatment (28.6%), and other dental surgery such as implant placement (14.3%). Types of medical emergencies occurred equally before, during, and after dental treatment. Antihypertensive agents, sedatives, or glucose were used. For patients with emergencies, 90.5% recovered during the day and returned home, and 9.5% were hospitalized. Conclusion The incidence of medical emergencies was low in our dental outpatient department. Knowledge of basic management principles, regular education for emergency care, and practicing first aid skills are mandatory for safe patient management., Medical emergencies associated with dental treatment. Forty‐two of 1,146,929 patients (0.0037%) experienced medical emergencies needing at least emergency call and i.v. establishment.

Trauma is a primary cause of death globally, with non‐compressible torso hemorrhage constituting an important part of “potentially survivable trauma death.” Resuscitative endovascular balloon occlusion of the aorta has become a popular alternative to aortic cross‐clamping under emergent thoracotomy for non‐compressible torso hemorrhage in recent years, however, it alone does not improve the survival rate of patients with severe shock or traumatic cardiac arrest from non‐compressible torso hemorrhage. Development of novel advanced maneuvers is essential to improve these patients’ survival, and research on promising methods such as selective aortic arch perfusion and emergency preservation and resuscitation is ongoing. This review aimed to provide physicians in charge of severe trauma cases with a broad understanding of these novel therapeutic approaches to manage patients with severe hemorrhagic trauma, which may allow them to develop lifesaving strategies for exsanguinating trauma patients. Although there are still hurdles to overcome before their clinical application, promising research on these novel strategies is in progress, and ongoing development of synthetic red blood cells and techniques that reduce ischemia‐reperfusion injury may further maximize their effects. Both continuous proof‐of‐concept studies and translational clinical evaluations are necessary to clinically apply these hemostasis approaches to trauma patients., This review aimed to provide physicians in charge of severe trauma cases with a broad understanding of these novel therapeutic approaches to manage patients with severe hemorrhagic trauma, which may allow them to develop lifesaving strategies for exsanguinating trauma patients. Although there are still hurdles to overcome before their clinical application, promising research on these novel strategies is in progress.

Prolonged intestinal cold storage causes considerable mucosal breakdown, which could bolster bacterial translocation and cause life-threatening infection for the transplant recipient. The intestine has an intraluminal compartment, which could be a target for intervention, but has not yet been fully investigated. Hydrogen gas exerts organ protection and has used been recently in several clinical and basic research studies on topics including intestinal transplantation. In this study, we aimed to investigate the cytoprotective efficacy of intraluminally administered hydrogen-rich saline on cold IR injury in intestinal transplantation. Isogeneic intestinal transplantation with 6 hours of cold ischemia was performed on Lewis rats. Hydrogen-rich saline (H2 concentration at 5 ppm) or normal saline was intraluminally introduced immediately before preservation. Graft intestine was excised 3 hours after reperfusion and analyzed. Histopathological analysis of control grafts revealed blunting of the villi and erosion. These mucosal changes were notably attenuated by intraluminal hydrogen. Intestinal mucosa damage caused by IR injury led to considerable deterioration of gut barrier function 3 h post-reperfusion. However, this decline in permeability was critically prevented by hydrogen treatment. IR-induced upregulation of proinflammatory cytokine mRNAs such as IL-6 was mitigated by hydrogen treatment. Western blot revealed that hydrogen treatment regulated loss of the transmembrane protein ZO-1. Hydrogen-rich saline intraluminally administered in the graft intestine modulated IR injury to transplanted intestine in rats. Successful abrogation of intestinal IR injury with a novel strategy using intraluminal hydrogen may be easily clinically applicable and will compellingly improve patient care after transplantation.

Background Topical forms of nonsteroidal anti‐inflammatory drugs (NSAIDs) have been created to lessen systemic adverse effects. In general, they are believed to be well tolerated and appropriate for use as an over‐the‐counter (OTC) drug. Case Presentation A 68‐year‐old woman visited our clinic due to tarry stool. The patient reported multiple episodes of recurrent bleeding from a gastric ulcer for 2 months and was treated with endoscopic hemostatic clipping. The patient disclosed she had been using a large number of diclofenac patches for more than 3 months. The patient was treated conservatively by discontinuation of diclofenac patches and treatment with a proton pump inhibitor and omeprazole. Conclusion In conclusion, inappropriate use of topical NSAID patches can be a cause of peptic ulcer bleeding. Patients reporting multiple episodes of recurrent bleeding from a gastric ulcer should be questioned, particularly about the use of OTC medications that might include topical NSAID patches., We report a case of refractory gastric ulcer bleeding presumably due to topical use of diclofenac epolamine patches. The patches were purchased over the counter.

要旨 症例は既往・内服歴のない56歳の男性で，搬入26日前に転倒し近医で胸部レントゲンを撮影され右肋骨骨折と診断されていた。保存的治療が選択され外来で経過観察されていたが，ワインボトルを開栓しようとした際に突然胸痛と冷汗が出現したため当センターに救急搬送された。搬入時はショックバイタルであり，胸部CTで右第9–11肋骨骨折と大量の胸腔内液貯留を認め大量血胸・出血性ショックと診断した。血管造影検査で肺動脈・第8–11肋間動脈からの造影剤漏出像を認めなかったが，2時間後に再検した胸部CTで血胸の増悪を認めていたため，直ちに胸腔鏡補助下で開胸手術を行った。術中所見では横隔膜損傷と同部位から動脈性の出血を認めており，肋骨骨折の治癒過程で横隔膜と癒着し，腹圧がかかったことで裂離し出血を来したものと推察された。術後経過良好であり，術後9日目に軽快退院となった。肋骨骨折において遅発的に血胸を認める症例報告の多くは肋間動脈からの出血であり，当症例のように横隔膜損傷に伴う血胸の報告は稀であるため，報告する。

In the multivariable analysis, age (adjusted odds ratio [OR] 1.07; 95% confidence interval [CI], 1.00–1.14; P = 0.038) D‐dimer (adjusted OR 1.02; 95% CI, 1.00–1.03; P = 0.005), and transtricuspid pressure gradient (adjusted OR 1.03; 95% CI, 1.00–1.07; P = 0.015) were independently associated with hypoxia in patients with femoral neck fractures., Aim Femoral neck fractures in elderly patients needing oxygen therapy are often encountered in the emergency department. This single‐center, retrospective, observational study aimed to examine the frequency, cause, and factors related to hypoxia in elderly patients with femoral neck fractures. Methods We analyzed data from 241 patients admitted to Okayama Saiseikai General Hospital (Okayama, Japan) from April 2016 to March 2019. Hypoxia was defined as PaO2 / FiO2 ratio under 300. The independent factors for hypoxia were determined by multiple logistic regression analysis. Results There were 194 patients who met the study inclusion criteria, 148 in the non‐hypoxia group and 46 in the hypoxia group. The hypoxia group included patients with pneumonia (n = 3), chronic obstructive pulmonary disease (n = 2), pulmonary edema (n = 1), and pulmonary embolization (n = 1). The cause of hypoxia was undetermined in 39 cases. However, occult fat embolism syndrome was suspected in 29 of these 39 cases based on Gurd and Wilson criteria after considering clinical examination results. Barthel indexes were significantly lower in the hypoxia group on discharge. Age (adjusted odds ratio [OR] 1.07; 95% confidence interval [CI], 1.00–1.14; P = 0.038), D‐dimer (adjusted OR 1.02; 95% CI, 1.00–1.03; P = 0.005), and transtricuspid pressure gradient (adjusted OR 1.03; 95% CI, 1.00–1.07; P = 0.015) were independently associated with the hypoxia. Conclusion We found that hypoxia, including undetermined hypoxia, was commonly encountered in the emergency department. Hypoxia in elderly patients with femoral neck fractures was associated with age, D‐dimer, and transtricuspid pressure gradient and needs further investigation.

Case A 73-year-old woman was transferred to our department due to severe abdominal pain with peritonitis. Her laboratory data showed that her white blood cell count was elevated to more than 50,000/mm3. Antibodies to HTLV-I were positive and we made the diagnosis of adult T-cell leukemia (ATL). Outcome Emergency laparotomy was performed and revealed two separate small perforations of the ileum, requiring bowel resection. Immunohistochemistry for cytomegalovirus (CMV) antigen revealed positive staining in the intestinal stromal cells. Despite surgery and antiviral therapy with ganciclovir, she died after 28 days. Conclusion Adult T-cell leukemia patients may present acute abdominal pain due to intestinal perforation caused by CMV infection. We should be aware of CMV infection as one of the pathogens causing acute abdominal crises such as massive hemorrhage or visceral perforation.

Case We report a case of hemorrhagic shock due to a ruptured gastric artery aneurysm successfully treated with transarterial embolization. A 72-year-old woman with cholangitis presented with hemoperitoneum following a ruptured aneurysm of the gastric artery. Outcome Emergent computed tomography and angiography were carried out and the patient was found to have spontaneous bleeding from both branches of the left and right gastric arteries. Transcatheter embolization was carried out at the distal branch of both gastric arteries with a coil. The patient recovered well with no recurrent bleeding. Conclusions Although rare, visceral artery rupture should be considered in the differential diagnosis of unexplained hemorrhagic shock with abrupt onset of hemoperitoneum. Computed tomography and angiography are useful tools for obtaining prompt and accurate localization of the bleeding points.

Case A patient was transported to our hospital with swelling in his right face and neck after restorative dental treatment. Subcutaneous emphysema and pneumomediastinum were discovered using computed tomography scans. Outcome The patient had no severe symptoms. We prescribed prophylactic antibiotics and he recovered uneventfully. Conclusions Clinicians must keep this pathology in mind because prompt diagnosis and treatment contribute to early improvement. Otherwise, patients may face life-threatening complications.

Acute kidney injury in critically ill patients is common and associated with a substantial increase in morbidity and mortality. Even with aggressive medical care and renal replacement therapy, acute kidney injury remains a significant health care concern. Recent published reports offer new strategies for the prevention and amelioration of acute kidney injury using carbon monoxide. Although considered a toxic environmental gas, carbon monoxide has recently aroused scientific and clinical interest, as its beneficial effects and mechanisms of action have been substantially defined in various in vitro and in vivo experiments. The exogenous application of carbon monoxide can confer cytoprotection by modulating intracellular signaling pathways through its anti-inflammatory, anti-apoptotic, vasodilative, antithrombotic and antiproliferative properties. Thus, evidence is accumulating to support the notion of carbon monoxide treatment for acute kidney disease. In this review, we focus on the extensively analyzed advantageous value of treatment with inhaled/soluble carbon monoxide in the context of kidney injury. Mechanisms such as signaling pathways, as well as an expanded view regarding toxicity and side-effects, are described broadly. In addition, we discuss the clinical applicability of carbon monoxide as a promising therapeutic strategy for the treatment of patients with acute kidney disease based on translating basic experimental findings into clinical application.

Case An 85-year-old man was admitted to the hospital, underwent laparotomy, and was diagnosed with diffuse peritonitis due to perforation of gastric ulcer. Omental patch repair was carried out. After surgery, he suddenly vomited blood and manifested hypovolemic shock. An emergency upper gastrointestinal endoscopy was carried out immediately. However, the bleeding source was not visible. Dynamic-enhanced abdominal computed tomography showed a pseudoaneurysm of the gastroduodenal artery-communicating duodenal lumen with extravasation. Next, the patient underwent angiography for embolization. However, selective arterial embolization was not successful. Outcome Finally, duodenotomy was carried out. The fistula between the pseudoaneurysm and duodenal lumen was directly ligated. An aneurysm could be clearly identified by previous findings. Conclusions Gastroduodenal artery aneurysms are very uncommon but possibly lethal if they rupture. This life-threatening condition requires rapid diagnosis and treatment. Minimally invasive treatment is the preferred therapy for gastroduodenal artery aneurysm; however, acute care surgery should be considered without hesitation when conditions are critical.

Case We report a patient with life-threatening lung contusion who was rescued using poly-2-methoxyethyl acrylate, a biocompatible polymer surface coating for extracorporeal membrane oxygenation, which enabled reduction of the dose of systemic anticoagulation to prevent circuit thrombosis. Outcome A 56-year-old man was transferred to our hospital due to blunt chest trauma following a 30-m fall into water. Chest X-ray and computed tomography showed bilateral lung contusions with bilateral pneumothorax. Although drainage tubes were inserted and ventilation with positive-airway pressure was applied, PaO2/FiO2 remained

Background Overactivated neutrophils are causes of acute lung injury, which is a major clinical problem with significant morbidity and mortality in sepsis. Serum interleukin (IL)-18 levels correspond to severity of systemic inflammation. Aim To elucidate the roles of endogenous IL-18 in lung injury during endotoxin-induced systemic inflammation. Methods Wild-type (WT) and IL-18 gene knockout (KO) mice were injected with lipopolysaccharide (40 mg/kg) intraperitoneally and killed. Lungs were collected at 0 and 12 h to assess mRNA for intercellular adhesion molecule (ICAM)-1, inducible nitric oxide synthase, myeloperoxidase, immunohistochemistry (cleaved caspase-3, 8-hydroxy-2-deoxyguanosine), and wet/dry ratio. Blood was collected at 0, 1, 12, 18, and 24 h to assess plasma cytokine levels. Results The survival rates at 24 h were approximately 43% and 76% in the WT and KO mice, respectively. Plasma IL-18 levels were induced time-dependently only in the WT mice. Plasma interferon-γ levels were significantly higher in the WT than in the KO mice at 12 h, but IL-6 and tumor necrosis factor-α levels did not differ between the WT and KO mice. At 12 h, the WT mice showed higher myeloperoxidase activity (P

Background: Hydrogen selectively reduces levels of hydroxyl radicals and alleviates acute oxidative stress in many models. Hydrogen-rich saline provides a high concentration of hydrogen that can be easily and safely applied. Aims: In this study, we investigated the effects of hydrogen-rich saline on the prevention of liver injury induced by obstructive jaundice in rats. Methods: Male Sprague–Dawley rats (n = 56) were divided randomly into four experimental groups: sham operated, bile duct ligation (BDL) plus saline treatment [5 ml/kg, intraperitoneal (i.p.)], BDL plus low-dose hydrogen-rich saline treatment (5 ml/kg, i.p.) and BDL plus high-dose hydrogen-rich saline treatment (10 ml/kg, i.p.). Results: The liver damage was evaluated microscopically 10 days after BDL. Serum alanine aminotransferase and aspartate aminotransferase levels, tissue malondialdehyde content, myeloperoxidase activity, tumour necrosis factor-a, interleukin (IL)-1b, IL-6 and high-mobility group box 1 levels were all increased significantly by BDL. Hydrogen-rich saline reduced levels of these markers and relieved morphological liver injury. Additionally, hydrogen-rich saline markedly increased the activities of antioxidant enzymes superoxide dismutase and catalase and downregulated extracellular signal-regulated protein kinase (ERK)1/2 activation. Conclusions: Hydrogen-rich saline attenuates BDL-induced liver damage, possibly by the reduction of inflammation and oxidative stress and the inhibition of the ERK1/2 pathway. Obstructive jaundice (OJ) is a frequently observed condition caused by occlusion of the common bile duct or its tributaries. Surgical, endoscopic and interventional radiographic decompression are the principal treatments of biliary obstruction, but decompression alone may not be sufficient to prevent the development of lifethreatening complications such as endotoxaemia, systemic inflammatory response, liver injury and multiple organ dysfunction that carry a high risk for mortality (1, 2). The mechanisms responsible for the pathogenesis of cholestatic liver injury from acute biliary obstruction remain largely unknown, although intrahepatic accumulation of reactive oxygen species (ROS) is thought to be an important cause. Experimental and clinical studies have demonstrated the pivotal role of oxidative stress associated with an overproduction of ROS, which may cause lipid peroxidation and disturb the integrity of Contributed equally.

The patient was a 31-year-old woman, who was diagnosed as having systemic lupus erythematosus and administered 10mg/day of prednisolone. She was in pregnancy at 38 weeks. She was referred to the department of surgery because of the development of severe abdominal pain with muscle guarding and rebound tenderness. Ultrasonography revealed marked thickening of intestinal walls and a small amount of ascites. An exploratory laparotomy and caesarian section were performed. The operative findings revealed nonbacterial peritonitis with serous ascites and segmental edema of the small bowel, compatible with lupus peritonitis. According to review of the literature, pregnancy might be unlikely to a risk factor for lupus peritonitis. Surgeons should be aware of this condition and determine whether or not the symptoms require surgery without delay, so that both mother and child might not be catastrophic.

The human iNOS (hiNOS) gene is expressed in a tissue-specific manner, but the molecular basis for this regulation has not been elucidated. Here, we show that liver cell-specific hiNOS gene activation involves protein-DNA binding to an A-activator binding site (AABS) located at -192 nucleotides in the hiNOS promoter region. Mutation of this site in the -7.2 kb hiNOS promoter construct inhibited basal hiNOS promoter activity in primary rat hepatocytes (77%), and two human liver cell lines, AKN-1 (63%) and HepG2 (60%), but had no significant effect on basal hiNOS activity in three non-hepatic human cell types. Interestingly, mutation of AABS significantly abrogated cytokine-induced promoter activity in all cell types. C/EBPbeta transcription factor bound to AABS by gel shift assay. Overexpression of C/EBPbeta active form (LAP) increased hiNOS basal promoter activity approximately sixfold in liver cells, but had minimal effect in non-hepatic cells. In contrast, overexpression of the transcriptional inhibitor (LIP) strongly suppressed both basal and cytokine-inducible promoter activity. These data show that the cis-acting AABS DNA element mediates liver-specific basal hiNOS promoter activity through binding of the trans-acting C/EBPbeta factor. Further, C/EBPbeta binding to AABS functions as a "switchpoint" that is necessary for cytokine-inducible hiNOS gene expression in all cell types examined.