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Cushing’s syndrome (CS) is a rare and severe disease caused by sustained hypercortisolism. The clinical manifestations of CS can be atypical in the elderly, and the diagnosis in these patients is often missed. Infectious Purpura Fulminans (PF) is a life-threating, thrombotic form of disseminated intravascular coagulation with high mortality. To our knowledge, PF occurring in a patient with CS has not been reported previously. We described an 84-year-old female presented with severe infection, but normal temperature. She suffered from a variety of diseases especially personality change. Physical examination revealed thin skin, general edema, and multiple scattered ecchymosis. Combined with obviously elevated serum cortisol (36.85 ug/dl) and adenoma revealed by adrenal CT scanning, endogenous CS was diagnosed. During hospitalization, the patient developed serious subcutaneous hemorrhage on the right thigh and back. The skin biopsy showed multiple small vessel thrombosis suggesting that the patient developed the rare complication of CS, Purpura Fulminans (PF). Chronic hypercortisolism can cause immune suppression, low-grade inflammation, endothelial damage, and a hypercoagulable state, which together increased susceptibility of PF. Fluid resuscitation, antibiotics, infusion of blood product, and debridement were effective treatment measures when CS complicated with infectious PF. Severe subcutaneous hemorrhage due to PF could occur in the patients of CS, especially in the elderly. Clinicians should be alert to the diagnosis of CS in older adults with cognitive decline and personality change.

Objective To determine the effect and safety of sequential treatment with the low-molecular-weight heparin dalteparin and the direct oral anticoagulants rivaroxaban in patients with cancer- associated venous thromboembolism (VTE). Study design Observational study. Place and duration of study Department of Oncology, the Second Affiliated Hospital of Soochow University, between January 2017 and September 2019. Methodology Patients with active cancer, diagnosed with VTE and who received sequential treatment with dalteparin and rivaroxaban, were retrospectively reviewed. Logistic regression analysis was used to identify risk factors associated with VTE recurrence. Results Ninety-nine patients with active cancer were enrolled in the study. The median delteparin treatment time was nine days (5-20 days), and 2.8 months (1-6 months) for rivaroxaban. Sixty (60.6%) patients had eliminated VTE, and 39 (39.4%) had persistent VTE, but with relieved symptoms. No major bleeding was observed. Eleven (11.1%) patients had minor bleeding, including melena (5.1%), hematuria (3.0%), vaginal bleeding (1.0%), gingival bleeding (1.0%), and subcutaneous hemorrhage (1.0%). During the 6 months follow-up period, one (1.0%) developed pulmonary embolism, and seven (7.1%) experienced recurrent VTE. Univariate logistic regression analysis showed that bleeding occurrence and anticoagulant treatment duration were the two significant factors affecting VTE recurrence (p Conclusion Maintenance of rivaroxaban after initial dalteparin treatment could effectively reduce the risk of VTE recurrence and was well tolerated by patients with cancer-associated VTE. However, in the clinical practice, the treatment duration is often insufficient, so it is essential to follow-up these patients to ensure sufficient treatment time. Key Words: Venous thromboembolism, Low-molecular-weight heparins, Directly oral anticoagulants, Cancer.

BACKGROUND The ONSTEP technique is a surgical repair method that uses an anterior approach for inguinal hernias. It is a new surgical technique that spans layers in which the medial side of the mesh is inserted into the peritoneal cavity, and the lateral side is positioned over the internal oblique muscle. Previous reports on this technique have mentioned the use of PolySoft Hernia Patch mesh; however, there have been no reports of surgical outcomes using OnFlex Mesh with absorbent rings. MATERIALS AND METHODS The authors evaluate the results of the ONSTEP technique using OnFlex Mesh. In 2017, this technique was introduced as an outpatient surgical procedure at our institution. In the past 3 years, it has been performed in 941 patients to repair 986 lesions. RESULTS Recurrences were observed in only 1 patient (0.10%), and complications included subcutaneous hemorrhage in 21 patients, hematoma in 10, seroma in 9, wound infection in 4, and mesh infection in 1. No serious events, such as postoperative ileus, chronic pain, or bladder injury, were observed. Because this technique does not require a procedure to detach the lateral preperitoneal space, the duration of surgery was 27±8 min, which was shorter than other transinguinal preperitoneal repair techniques. CONCLUSIONS The ONSTEP technique using OnFlex Mesh is a simple and safe repair method that can be performed as an outpatient surgical procedure. Although there is still a need to wait for long-term results, favorable short-term to medium-term results have been obtained.

The patient was an 88-year-old woman with a 10-year history of hypertension. She was suspected to have been hit by a car. At the time of the event, she was conscious and able to stand on her own and had no obvious injuries. She was sent home, but she lapsed into unconsciousness and was nonresponsive after 2 hours. She was sent to the hospital, and her heartbeat and breathing stopped. After half an hour of rescue attempts, her heartbeat did not recover, and she was declared dead. During the autopsy, a small subcutaneous hemorrhage was observed below the right knee joint. No obvious internal organ injuries or bone fractures were observed. The deceased also had mild atherosclerosis in the coronary arteries and an old cerebral infarction in the right cerebellum. The tissue histopathological tests showed distinct fat embolism in multiple organs, including the brain, lungs, kidneys, liver, and pancreas. A postmortem blood biochemistry test of the heart blood showed that the levels of low-density lipoprotein, cholesterol, triglycerides, and free fatty acids in the blood were increased, and the level of C-reactive protein was elevated. According to the autopsy results, the direct cause of death was multiorgan fat embolism. This case suggests that aging, hypertension, and hyperlipidemia may be risk factors for nontraumatic fat embolism under stressful conditions.

Context: Deep vein thrombosis (DVT) is a well-known complication of spinal cord injury (SCI). Low-molecular-weight heparin (LMWH) may be used in SCI patients who develop DVT, but can lead to subcutaneous bleeding. If subcutaneous bleeding occurs, then lymphedema, cellulitis, muscle or tendon tearing, or baker’s cyst rupture should be considered in the differential diagnosis. Findings: Herein, we present a 61-year-old female patient who was hospitalized for rehabilitation due to paraplegia, and used LMWH due to DVT development. The patient suddenly developed pain, swelling, and discoloration of the left lower extremity. Although subcutaneous hemorrhage was considered initially, ultrasound and MRI revealed a ruptured Baker’s cyst. In addition to supportive therapy, ultrasound-guided aspiration was performed. Conclusion/Clinical Relevance: In this report, we present a case of clinically severe Baker’s cyst rupture, which occurred in the lower extremity of a SCI patient using LMWH due to DVT in the same extremity. To our knowledge, no similar cases have been reported.

Iatrogenic pseudoaneurysm formation at the deep temporal artery (DTA) is a rare complication after neurosurgical intervention by craniotomy, and its management strategy has yet to be determined. We report a patient who developed iatrogenic pseudoaneurysm at the DTA after fronto-temporal craniotomy manifesting as repeated subcutaneous hemorrhage. A 44-year-old man underwent standard fronto-temporal craniotomy for the microsurgical clipping of a ruptured anterior communicating artery aneurysm in the acute stage. The initial postoperative course was uneventful, but he developed a massive subcutaneous hematoma that penetrated the surgical wound, leading to hypovolemic shock 23 days after the aneurysm surgery. Due to the continuous hemorrhage after temporary hemostasis by ligation of the superficial temporal artery, he underwent catheter angiography, which revealed a newly-formed pseudoaneurysm at the DTA that was 16 mm in diameter. Neuroendovascular obliteration of the pseudoaneurysm was successfully performed using liquid embolization material, n-butyl-2-cyanoacrylate, under local anesthesia. Pseudoaneurysm at the DTA is a rare but possible complication after fronto-temporal craniotomy, which can be fatal due to marked hemorrhage. Due to the anatomically deep location of the DTA under the temporal muscle, we recommend accurate diagnosis of the pseudoaneurysm by catheter angiography and prompt obliteration of the affected vessel by a neuroendovascular procedure under local anesthesia, especially when the hemodynamic status is unstable.

Snake bite envenomations in farm animals are generally overestimated as the cause of mortality in rural areas in Latin America. However, most cases are based only on anecdotal information and assumptions, and lack diagnostic evidence. There are few proven reports of envenomation and death in horses caused by snakebites from members of the Bothrops genus (lancehead pit vipers). This study presents epidemiological and clinical-pathological findings of fatal bothropic envenomation in horses from Central Western Brazil in order to contribute to the correct diagnosis of this condition. A survey of the records of equine necropsies from the Veterinary Pathology Laboratories of the University of Brasilia, Federal University of Mato Grosso and Federal University of Mato Grosso do Sul, from January 2010 to February 2018, was performed. Five fatal cases of bothropic snakebite were identified in 755 necropsies of horses, corresponding to 0.66% of these cases, ranging annually from 0.33% to 0.89%. The main necropsy findings were marked swelling and diffuse subcutaneous hemorrhage, and identification of the fang marks in 2 out of five horses. Hemorrhage in most organs and tissues was the pathological hallmark of systemic envenomation. Myonecrosis, dermonecrosis, and moderate to severe kidney degeneration and necrosis were also observed. Fatal Bothrops snakebites in horses have a low occurrence in Central Western Brazil and most cases occur in the rainy season. The diagnosis of this condition may be substantiated by clinical signs and pathological findings. Local hemorrhage and necrosis, systemic hemorrhagic disorders and injuries related to acute kidney injury are the predominant clinical signs. These findings should be considered in the diagnosis and therapeutic management of these envenomations.

The Milwaukee County Zoo has housed common vampire bats (Desmodus rotundus) since 1973. The bats are fed defibrinated cow's blood supplemented with a liquid pediatric multivitamin. From July 2013 to May 2014, multiple deaths occurred in colony bats, including five juveniles with multiple bone fractures and failure of endochondral ossification, three adults with cerebellar necrosis, and one adult with subcutaneous hemorrhage. In November 2013, an adult bat developed a nonhealing left wing hematoma and eventually succumbed 9 mo later. A postmortem examination revealed multifocal extensive necrohemorrhagic and suppurative ulcerative dermatitis with no underlying cause determined. From July to December 2014, five of nine adult bats in the colony developed similar hematomas along with gingival bleeding. One euthanized bat had a serum ascorbic acid level of 0.08 mg/dl and marked generalized subcutaneous hemorrhage. A therapeutic trial was initiated in which two bats received defibrinated cow's blood supplemented only with oral vitamin C, 100 mg/kg PO q24h for 3 d, and then 50 mg/kg PO q24h. Two other bats received nonsupplemented defibrinated cow's blood and were given vitamin K 3.3 mg/kg SC q12h for 3 d, and then 3.3 mg/kg SC q24h for 7 d. The bats supplemented with vitamin C improved, supporting a diagnosis of vitamin C deficiency. All bats were subsequently supplemented with vitamin C leading to resolution of all lesions within 10 d to 2 mo. Vitamin C is necessary for collagen synthesis, which is required for proper wound healing, capillary and cartilage strength, osteoid production, and pial membrane formation of the cerebellum. Several bat species cannot synthesize vitamin C and require a dietary source. This is the first report of vitamin C deficiency in a colony of vampire bats leading to severe chronic subcutaneous hemorrhage, bone fragility, microfractures, cerebellar necrosis, and death.

Background Apixaban, a non‐vitamin K oral anticoagulant (NOAC), was approved in Japan in 2012 for the prevention of thromboembolic events in patients with nonvalvular atrial fibrillation (NVAF). However, the safety and effectiveness of apixaban in clinical practice have not yet been elucidated thoroughly among Japanese NVAF patients. Methods A postmarketing surveillance study was conducted to determine the safety and effectiveness of apixaban. Patients were followed‐up for 104 weeks. Outcome events included adverse drug reactions (ADRs), hemorrhages, and thromboembolic events (ischemic stroke, systemic embolism [SE], and transient ischemic attack [TIA]). Results Among 6306 NVAF patients in the safety analysis set (age, 74.5 ± 10.1 years; women, 41.1%; and CHADS 2 score, 2.0 ± 1.4), 3600 patients (57.1%) received the standard dose (5 mg twice daily) and 2694 (42.7%) received a reduced dose (2.5 mg twice daily) of apixaban. ADRs occurred in 604 patients (9.58%), with the most common being epistaxis (0.86%), subcutaneous hemorrhage (0.67%), and hematuria (0.57%). Incidence rate of any hemorrhages and major hemorrhage was 5.52% per year and 2.36% per year, respectively. Incidence rate of ischemic stroke/SE/TIA was 1.00% per year among 6286 patients in the effectiveness analysis set. Among three subgroups (3106 apixaban initiators, 2038 patients switched from warfarin, and 1118 patients switched from other NOACs), incidence rates of major hemorrhage (P = 0.221 for trend) and ischemic stroke/SE/TIA (P = 0.686 for trend) were comparable. Conclusions No new safety signals of apixaban were identified in Japanese NVAF patients. Safety and effectiveness of apixaban were consistent with those in the ARISTOTLE study.

Objective: Patients with severe motor and intellectual disabilities (SMID) often develop complications, including paralysis of the extremities due to abnormal muscular tonicity. Furthermore, the incidence of sudden death, which may be caused by pulmonary thromboembolism (PTE), is approximately 4.2%. Deep vein thrombosis (DVT) is attracting attention as an embolic source. In this study, DVT was confirmed in SMID patients by lower extremity venous ultrasound. The oral anticoagulant, warfarin, and novel oral anticoagulant, edoxaban tosilate hydrate, were administered, and their efficacies and safeties were evaluated. Materials and Methods: DVT patients were randomly allocated to warfarin and edoxaban groups. The frequency of hemorrhagic events and incidence of adverse events were investigated to evaluate efficacy and safety. Results: DVT was detected in 14 (8.4%) out of 167 patients. Four (0.067/person-month) hemorrhagic events occurred in the warfarin group from subcutaneous hemorrhage due to bruises caused by postural changes. Three (0.042/person-month) events occurred in the edoxaban group due to nasal hemorrhage caused by tracheal aspiration. There was no significant difference (p=0.5383) between groups. Conclusion: No significant differences were observed in hemorrhagic events between SMID patients with DVT treated with warfarin and edoxaban.

Objective: To investigate the efficacy and safety of da Vinci robot-assisted thyroidectomy via an unilateral axilla-bilateral areola (UABA) approach. Methods: The clinical data of 500 patients undergoing robotic thyroidectomy via an UABA approach from July 2014 to April 2018 were retrospectively analyzed. All 500 patients were operated on by the same surgeon and divided into two groups by the time sequence. The efficacy and complications were compared between the two groups. Results: Robotic thyroidectomy via an UABA approach was performed successfully in 500 cases, including 196 cases of benign thyroid diseases with a lesion diameter of 3.1 ± 1.3 cm (0.4 - 8.2 cm) and 304 cases of thyroid cancer with a tumor diameter of 1.2 ± 0.7 cm (0.4 - 4.4 cm). Surgical procedures included unilateral lobectomy and total thyroidectomy with or without central lymph node dissection. Among the 500 patients, 9 (1.8%) had transient recurrent laryngeal nerve injury, 1 (0.2%) had permanent unilateral recurrent laryngeal nerve injury, 12 (2.4%) had subcutaneous hemorrhage of the trajectory area, and 6 (1.2%) had subcutaneous infection of the trajectory area after surgery. Among 239 thyroid cancer patients undergoing total thyroidectomy, 45 (18.8%) had transient hypoparathyroidism and 5 (2.1%) had permanent hypoparathyroidism. The incidence of permanent hypoparathyroidism was 1.9% (4/212) among the patients undergoing total thyroidectomy plus unilateral central lymph node dissection, and 3.7% (1/27) among the patients undergoing total thyroidectomy plus bilateral central lymph node dissection. During the follow-up of median 17 months, all patients were satisfied with postoperative appearance of the neck and no structural recurrence or metastases occurred. There was no significant difference in efficacy between the two groups (P > 0.05), while the complication rate in phase 2 was significantly lower than that in phase 1 (P < 0.05) as the surgeon became more proficient in the UABA approach. Conclusion: Robotic thyroidectomy via an UABA approach is simple, safe, and minimally invasive, suitable for radical resection of large benign tumors and early thyroid cancer and central lymph node dissection.

Veterinary forensic pathology plays a crucial role in animal death investigations. Recent years have seen increased attention given to this field in Taiwan. Here we report a grave crime that aroused public indignation in Taiwan, when in December 2015, a missing free-roaming cat was allegedly strangled by a suspect, according to witnesses. Surveillance video footage of the cruel incident surfaced that showed the cat, without visible signs of struggle, strangled by both hands of the suspect and kicked in the abdomen’s left side. The body was stored in a travel bag when found in the suspect’s motorcycle trunk three days after the cat had been missing. The radiographs revealed a suspected luxation of cervical vertebrae 6 and 7 (C6–C7). At forensic necropsy and histopathology, neck compression with subcutaneous hemorrhage at the left submandibular area, bruising of the neck, tears in the wall of the left external jugular vein, and pulmonary lesions were identified, all consistent with asphyxiation. Hemorrhages of the epidural space of the C7 vertebra, the spinal nerve at the level of C7, and surrounding soft tissues were noted. The pathological findings were in line with the suspect’s confession, the witnesses’ statements, and the video footage. The process and outcome of this case reflected society’s growing awareness of animal welfare and the increased attention that the authorities are giving crimes against animals in Taiwan, and the link between pathologic findings and the crime.

PURPOSE: We aimed to evaluate the clinical benefit of (125)I seed brachytherapy under DynaCT guidance for palliative local treatment of bone metastases. METHODS: From December 2014 to September 2017, 82 patients with painful bone metastases, who experienced treatment failure using standard strategies or rejected treatment were enrolled in this retrospective study. All patients underwent (125)I seed brachytherapy under DynaCT guidance. Technical success, visual analogue scale (VAS), numerical rating scale (NRS), verbal rating scale (VRS), Karnofsky performance status (KPS) and complications were analyzed. RESULTS: The success rate of (125)I seed implantation was 100%. The VAS and NRS scores for the most severe pain were 7.0 (5.0–9.0) and 8.0 (6.0–9.0) before brachytherapy. The pain scores assessed every 2 hours gradually decreased within 12 hours (p < 0.001). A comparison of KPS scores showed that patients had significantly better quality of life on weeks 1, 4, and 8 than on week 0 (p < 0.001). The associated complications were mild subcutaneous hemorrhage 25.6% (21/82), fever 7.3% (6/82), minor displacement of radioactive seeds 5.0% (4/82), pathologic fracture 2.4% (2/82), and local skin reaction 2.4% (2/82). After symptomatic treatment, all complications were relieved. Minor displacement of radioactive seeds did not cause damage to adjacent tissues. No serious life-threatening complications occurred in the study group. CONCLUSION: DynaCT-guided (125)I seed implantation is a safe and effective method for palliation of painful bone metastases from cancer after failure or rejection of conventional treatments.

Systemic mastocytosis, characterized by infiltration of multiple organs by neoplastic mast cells, is a well-described entity in human medicine with specific criteria for diagnosis, but is ill defined in veterinary literature. Hemostatic disorders are reported in humans affected by systemic mastocytosis but have not been well described in veterinary literature. A 5-y-old, spayed female Greyhound dog had a 1-mo history of progressive ventral cutaneous edema, hemorrhage, and pain. Cytology of an antemortem aspirate from the subcutis of the ventral abdomen was suggestive of mast cell neoplasia, but no discrete mass was present. The dog was euthanized and submitted for autopsy; marked subcutaneous edema and hemorrhage were confirmed. The ventral abdominal panniculus and dermis superficial to the panniculus carnosus were infiltrated by a dense sheet of neoplastic mast cells. The neoplastic cells contained toluidine blue–positive granules and formed aggregates within the bone marrow and several visceral organs, including the liver, spleen, heart, and kidney. Diffuse edema and hemorrhage is an unusual presentation of mast cell tumors in dogs. Antemortem tests, including complete blood count, coagulation profile, and viscoelastic coagulation testing, were suggestive of a primary hemostatic defect. We discuss here the diagnostic criteria used in humans, how these can be applied to veterinary patients, and the limitations of the current diagnostic framework.

A case involving an adult dismembered body with myositis ossificans (MO) is described. A woman in her 20s was found dead in her cohabitants' room. The body had dismembered into 15 pieces. Computed tomography showed ectopic mineralization in the bilateral upper arms and thighs. On autopsy, the skin and soft tissue were in the process of adipocere formation. Darkened areas that appeared to be subcutaneous hemorrhage were distributed on the face, left chest, and back. Bilateral upper arms and thighs showed organized granulations adherent to underlying bone. Microscopically, these organized lesions represented mature bone tissue in the periphery, cartilage tissue in the middle layer, and fibrotic tissue in the central part. These were typical findings of MO. Myositis ossificans and subcutaneous hemorrhage seemed to be evidence of antemortem repetitive physical abuse. In cases of dismemberment, the absence of organs and parts of the body provide limitations to determining cause of death. In forensic fields, adult autopsy cases involving MO are rare. This is an unusual case in which MO revealed antemortem physical abuse despite dismemberment of the body.

To investigate the efficiency of high ligation, great saphenous vein stripping and subfascial perforator vein surgery for treating great saphenous vein varicosis under the assistance of sterilized electric pneumatic tourniquet and Esmarchs bandage. In total, 274 patients confirmed with primary varicosis between January 2014 and November 2017 were included in this study. Patients were divided into 1.treatment group (n = 137), received high ligation, great saphenous vein stripping, and subfascial perforator vein surgery under the assistance of sterilized electric pneumatic tourniquet and Esmarchs bandage; and2.control group (n = 137), received high ligation, great saphenous vein stripping, and subfascial perforator vein surgery only. After surgery, the affected limbs in both groups were wrapped up using the elastic bandage for 2 weeks, followed by wearing elastic stocking for 6 months. Then we analyzed the intraoperative bleeding, surgery time, subcutaneous hemorrhage after surgery and postoperative pains. The surgical time in the treatment group was significantly lower than that of control group (58.62 ± 7.47 minutes vs 76.35 ± 9.24 minutes, P

Acquired hemophilia A (AHA) is an extremely rare and serious bleeding disorder caused by autoantibodies against coagulation factor VIII (FVIII). Approximately, 10% of patients with AHA have an underlying malignancy. We report on a 46-year-old man with AHA and advanced oral cancer who presented with massive bleeding after surgery. Preoperative blood coagulation tests showed no abnormalities. He underwent radical tumor resection followed by reconstruction using a free rectus abdominal musculocutaneous flap. Massive subcutaneous hemorrhage developed in his neck and abdomen on the first postoperative day. The hemorrhage remained uncontrolled, despite embolization of the responsible vessels. Subsequent laboratory data showed prolonged activated partial thromboplastin time and decreased FVIII levels. On the basis of his clinical course and the presence of the FVIII inhibitor, we speculated that the patient suffered from AHA. We administered recombinant activated factor VII and prednisolone, after which the spontaneous bleeding stopped and the subcutaneous hemorrhage resolved. A review of the literature identified only three previous documented cases of AHA associated with head and neck cancer. This case indicates that AHA should not be ruled out in patients with uncontrolled postoperative bleeding, while attempting to ensure bleeding control and preventing potentially catastrophic fatal consequences.

The clothing of a forty-five-year-old man became entrapped by the mixing rotator while he was operating a soybean milling machine. His clothing was wound around the rotator, and tightened around his neck and chest, causing strangulation and a loss of consciousness. He was rescued by his coworkers and transported to our hospital by helicopter. Upon arrival, he regained consciousness. A physiological examination revealed multiple petechiae on his face and strangulation marks with subcutaneous hemorrhage on his neck and upper trunk. In addition, he had motor weakness of the right upper extremity and bilateral paresthesia from C5 to Th1. All radiological studies were negative. He was admitted for observation. After the patient’s creatine phosphokinase level peaked and his focal neurological signs improved, he was discharged on foot on the 6th hospital day. Accidental ligature strangulation with cervical nerve root injury, in which an article of clothing is caught in an electrical machine and strangles the wearer, is very rare. This case is presented for its rarity and the unique pattern of injury.

The recent global pandemic of coronavirus disease 2019 (COVID-19) has led to vaccination in many parts of the world for herd immunity, and as vaccination has progressed, several rare adverse events have been reported. Immune thrombocytopenia (ITP) has been reported to be one of the rare adverse events caused by vaccination with MMR (measles-mumps-rubella) vaccine and influenza vaccine. In addition, ITP has been reported to occur in a small number of cases associated with the COVID-19 messenger ribonucleic acid (mRNA) vaccine. However, there are few reports on the details of the treatment and clinical course; optimal treatment has not yet been established. We report the case of a 20-year-old woman who developed ITP after receiving Pfizer-BioNTech’s BNT162b2 vaccine. She had generalized subcutaneous hemorrhage, 14 days after vaccination. At the time of our visit, she had marked thrombocytopenia and intraoral bleeding; she was diagnosed with ITP. Treatment with oral steroids was started and the platelet count promptly improved after 4 days of treatment. Since the response to treatment was very good, we tapered off the steroids. As these vaccines will be increasingly used in the future, it is important to recognize ITP as a possible adverse event.

Objective To report the use of a vascular closure device (VCD) to provide rapid arterial hemostasis following percutaneous femoral arterial catheterization and diagnostic angiography in a thrombocytopenic and coagulopathic dog. Case Summary A 6-year-old female spayed Kai Ken Tora dog presented after vehicular trauma. The dog was diagnosed with traumatic pneumothorax, degloving wounds of the right antebrachium, subcutaneous hemorrhage within the axillary tissues of the left thoracic limb, and anemia and thrombocytopenia secondary to acute hemorrhage. Treatment included therapeutic thoracocentesis and open wound management of the right thoracic limb as well as packed RBC and fresh frozen plasma transfusions. Diagnostic angiography of the left brachial artery was performed via percutaneous femoral arterial access to investigate the source of a persistent axillary hematoma. The arterial access site was closed using an extraluminal VCD and hemostasis was immediate with normal femoral arterial blood flow documented by Doppler ultrasound. New or Unique Information Provided This report describes use of a VCD for arterial closure following percutaneous access in a dog with impaired hemostasis; to the authors’ knowledge, this is the first clinical report of a VCD used in a veterinary species.

Background The distal transradial approach (dTRA) for coronary catheterisation is a newly introduced alternative to the conventional transradial approach. This technique is expected to decrease the incidence of haemorrhagic complications and improve patient comfort. However, limited data are available regarding the application of this technique in patients with acute myocardial infarction (AMI). This study investigated the feasibility and safety of the dTRA for primary percutaneous coronary intervention (PCI) in patients with AMI. Methods This study included patients with AMI who underwent primary PCI via the distal radial artery across 3 Japanese hospitals between January 2018 and January 2019. Patients' background, procedural characteristics, and clinical outcomes including the incidence of haemorrhagic complications were analysed. Results This study enrolled 95 consecutive patients with AMI, including 68 patients (71.6%) with ST-segment elevation myocardial infarction (STEMI), in whom distal radial artery puncture was attempted for primary PCI. The patients included 70 men (73.7%), and the mean age was 72.2±12.4 years. Among these patients, cannulation was successfully performed in 89 patients (93.7%). A 5-, 6-, or 7-French sheath (conventional or slender) was used in this study. Cannulation was performed using a forearm radial artery approach in patients in whom dTRA failed. PCI was successfully performed in all patients. The meantime to achieve haemostasis was 6.3±5.3 hours, and no major bleeding complications occurred. Based on The Early Discharge After Transradial Stenting of Coronary Arteries trial haematoma scale, grade I, II, and III subcutaneous haemorrhages were observed in 16 (16.8%), 4 (4.2%), and 1 patient (1.1%), respectively. No patient developed a haematoma > grade IV. In patients with STEMI, the mean door-to-balloon time was 39.4±31.9 min, and the mean puncture-to-balloon time was 19.7±14.2 min. Conclusions The distal radial approach is feasible and safefor primary PCI in selected patients with AMI.The application of the dTRA may serve as a less invasive strategy for the treatment of patients with AMI.

To investigate the effect of different pressing time on the incidence of subcutaneous hemorrhage of low molecular weight heparin (LMWH) administration by meta-analysis. Cochrane Library, PubMed, MEDLINE, CINAHL, EMbase, Springer, EBSCO, China Biomedical Literature Database, CNKI, Wanfang Database, and VIP Database were searched. To screen the literature of randomized controlled trials with different pressing time in patients with subcutaneous LMWH injection from the establishment of the database to December 2020. The quality of the literature was evaluated and the data were extracted. Meta-analysis was performed by RevMan 5.3. A total of 17 randomized controlled trials were included. Meta-analysis showed that the bleeding rate of pressing for 5 min odds ratio (OR = 3.89, 95% confidence interval [CI]: 2.68-5.64, P

Rationale: Felty syndrome is a rare and life-threatening type of rheumatoid arthritis (RA). Patient concerns: A patient with RA had skin rash and subcutaneous hemorrhage, with a significant decrease in blood hemoglobin (Hb), white blood cell count (WBC), and blood platelet count (BPC). Diagnoses: The patient had a history of RA, splenomegaly, decreased Hb, WBC, BPC, and normal immunological indexes, combined with a series of bone marrow related tests and genetic tests. Interventions: She was given high-doses of glucocorticoids intravenously, followed by oral prednisone and cyclosporine maintenance therapy. Outcomes: Her symptoms were resolved within 2 weeks after the start of immunosuppression. After 2 weeks of discharge, the Hb, WBC, BPC basically returned to normal, and prednisone gradually decreased. Lessons: Felty syndrome is a rare complication of RA. Reductions in Hb, WBC, BPC, and subcutaneous hemorrhage should be considered strongly as the possibility of Felty syndrome. Multi-disciplinary diagnosis and related tests of bone marrow and genes are helpful for diagnosis and correct treatment.

The objectives of this study were to compare the results of radiofrequency ablation (RFA) and stripping for large-diameter varicose target veins for the period of 1 year, based on a composite end point; to analyze the pain severity on a digital rating scale for 7 days after RFA and stripping; and to detect the factors affecting the level of postoperative pain using the cluster analysis.This was a multicenter retrospective cohort study. Two groups, stripping ≥14 mm and RFA ≥14 mm, of 129 varicose vein disease patients underwent surgical treatment in three specialized clinics. We eliminated symptomatic pathologic reflux with RFA in 64 patients and with stripping in 65 patients. In the postoperative phase, we evaluated the pain level, subcutaneous hemorrhage, and paresthesia. A composite end point with four components was used to analyze the results. These were three clinical adverse effects of the intervention (pain, hemorrhage, and paresthesia) and the technical outcome 1 year after the surgical intervention.The frequency of favorable outcomes was 20 (30.8%) in the stripping ≥14 mm group and 61 (95.3%) in the RFA ≥14 mm group (P .0001). The odds ratio for a favorable outcome between the RFA and the stripping groups was 45.8 (95% confidence interval, 44.5-47.0). The pain clusters that were moderate were created by patients after stripping. These clusters show a link between the pain level on the one hand and an increased body mass index and large vein diameter on the other hand.For large-diameter veins, RFA is superior to stripping in terms of favorable outcomes according to the composite end point chosen. Significant pain after stripping was linked to a large vein diameter and excess weight or adiposis.

Objective: To analyze the clinical values of modified injection of low-molecular-weight heparin in reducing subcutaneous bleeding and pain. Methods: Two hundred and sixty patients with cerebral infarction, acute myocardial infarction or pulmonary embolism who underwent subcutaneous injection of low-molecular weight heparin in the hospital between December 2015 and December 2016 were selected. They were randomly divided into a control group and a research group, 130 each. Patients in the control group were given conventional injection, while patients in the research group were given modified injection. The occurrence of subcutaneous bleeding and pain was observed and compared between the two groups. Results: The incidence of subcutaneous hemorrhage in the research group was 46.9%, significantly lower than 83.1% in the control group, and the difference had statistical significance (P

A 74-years-old male who was a smoker and received treatment for hypertension, dyslipidemia, peripheral arterial disease and idiopathic interstitial pneumonia complained of subcutaneous hemorrhage of the right lower thigh. Marked anemia (hemoglobin 5.5 g/dL) and prolonged activated partial thromboplastin time (≥130 seconds) were noted. The factor VIII activity level was reduced to 1.2 %, and the factor VIII inhibitor titer was 285.3 BU/mL, a diagnosis of acquired hemophilia A (AHA) was made. Then, hematomas of 5 intra-muscles were recurred. Hemostasis became difficult despite frequent and high-dose administration of recombinant human coagulation factor VIIa (total: 18 days, 305 mg). Hemostasis was achieved by switching to activated prothrombin complex concentrate (for 3 days, 18,000 units), however, cerebral infarction occurred after 36 days. After the frequent administration of bypass hemostatic agents on elderly AHA patients with several risk factors for ischemic stroke, the risk of subsequent thrombotic events may persist for 1 month.

The bruise is a significant injury in the eyes of the law and the need to determine the age of bruises is becoming important in routine clinical settings. Clinicians may be asked to comment on the age of any bruise found during child examination, while the coexistence of old and fresh bruises is a strong evidence for a diagnosis of chronic child abuse. It is accepted by forensic practitioners that visual assessment is far from accuracy and more frequently misleading and till now there is no standardized accepted scheme for bruise age determination. Ultrasonography (US) is a suitable tool for measuring the factors affecting the age of bruises, so the present study aims to investigate the possibility of age the bruises by measuring the depth, thickness and ultrasonography findings of subcutaneous hemorrhage using high-frequency US in a trial to estimate its age with a high degree of accuracy in addition to the naked eye assessment. 48 children of age less than 18 years were enrolled (31 boys and 17 girls) with bruises caused by trauma from accidents. The bruises were examined and photographed by a single observer to age them by naked eye. In addition, the depth, the thickness of subcutaneous hemorrhage and their characters were evaluated by using the high frequency Ultrasonography. The results indicated that naked eye estimation of the bruises was correct in (66.7%) of the cases. Ultrasonographic results showed that a fresh thin subcutaneous hemorrhage was observed as a thickening of the fibrous partition (hyperechoic), sometimes with an isoechoic area while fresh thicker bruise was observed as a hyperechoic area scattered around the fibrous partition. The echogenicity of the older bruise is less hyperechoic than the fresh one. The depth of subcutaneous hemorrhage did not generally change with time in contrast with the thickness of the subcutaneous hemorrhage which decreased with time. Ultrasonography estimation was correct in (93.8%) of the cases so, high frequency Ultrasonography can provide an evaluation of characters, depth and thickness of the bruise and allow a more accurate estimate of its age and may provide a clue that adds more accuracy to the naked eye estimation.

Introduction Acquired hemophilia (AH) is a rare disorder due to the production of autoantibodies against factor VIII or IX procoagulant function. The development of these autoantibodies results in hemorrhagic symptoms in patients without previous coagulopathy. The typical clinical manifestations of the acquired hemophilia are: extensive cutaneous purpura and internal hemorrhages while hemarthrosis are not common. Acquired hemophilia is less frequent than the inherited form of the disease, with an estimated incidence of 2 to 4 cases/million inhabitants/year, value that increases with age, but is extremely infrequent in children (0.045 cases/million/year). It affects all ethnic groups and has a biphasic distribution with a peak incidence in subjects between 20 and 30 years and another peak between 60 and 80 years. Objective To report a case of AH in a 2-year-old child. Clinical data: Hematoma in the left iliac flank, forearm and legs.Personal history: Otherwise healthy 2-year-old boy with a twin brother and both parents without a history of bleeding disorders. Prior to the onset of bruising, the patient suffered an important trauma on one foot without bleeding complications. A short time after this episode he presented a hematoma in the gluteus that was interpreted as result of a slight trauma due to a fall. Subsequently, he presented multiple spontaneous hematomas that motivate the consultation. • Laboratory upon admission: Hemoglobin: 12.8g/dL; PT: 11" (Control: 11"); APTT:>180" (Control: 30"). Plt: 543000/mm3 • Clinical evolution: With the suspicion of bleeding reactivation, he was referred to the Rosario Hemophilia Foundation to be evaluated. Reactivation of bleeding was ruled out and imaging had shown subcutaneous bleeding without muscle involvement. The presence of an inhibitor to Factor VIII was detected. The patient was commenced on Prednisolone 1mg/kg/day to eradicate the acquired antibody. • Laboratory Results: Hb: 12.6 g/dL, Plt: 575000/mm3, PT: 12" (11") (Innovin), APTT: 76" (30") (Actin FSL) which does not normalize after addition of normal plasma and potentiate when was incubated 2 hours at 37°C, TT: 14"(14") (Trombin), FVIII Conclusions AH is a rare autoimmune disease first described in 1940 and is extremely infrequent in children younger than 16 years. Although it is usually associated with other autoimmune disorders, in our patient, we have not found other autoimmunity markers. We should suspect this pathology in all patients who begin with cutaneo-mucosal bruising without a previous history of bleeding, with prolonged APTT that does not correct with the addition of normal plasma and whose prolongation potentiates after incubating the mixture for 2 hours at 37˚C. These results are usually associated with PT and normal platelets count. The FVIII inhibitor can be quantified by the Bethesda-Nijmegen method. Although the title of the Inhibitor does not correlate well with the clinical severity of the patient, its value is useful in monitoring the immunosuppressive therapeutic response. Finally, although AH is unusual in pediatrics, it must be taken into account among the differential diagnoses. Disclosures No relevant conflicts of interest to declare.

Acquired von Willebrand (vW) syndrome in Waldenström’s macroglobulinemia (WM) should be differentially diagnosed from hyperviscosity syndrome of WM, which exhibits a bleeding tendency. We report a rare case of acquired vW syndrome secondary to WM. A 62-year-old woman was referred to our hospital because of extensive subcutaneous hemorrhage following a light hit to the left arm. Although the platelet count was normal, APTT was prolonged to 49.4 sec. Furthermore, the serum concentration of IgM was elevated to 7,796 mg/dL, which was revealed to be IgM-κ monoclonal protein, leading to a diagnosis of WM. On ophthalmofundoscopy, mild hemorrhage, but not retinal vein dilatation, was observed. Regarding the abnormal APTT value, we measured coagulation factors in the intrinsic arm, revealing reduced activities of vW factor and factor VIII of 11 and 18%, respectively. Furthermore, the amount of vW protein was decreased to 23%. Multimer analysis of vW factor demonstrated an abnormal pattern lacking high-molecular-weight- bands. Additional diagnosis of acquired vW syndrome secondary to WM was made. The APTT cross-mixing test showed a simple but not inhibitor-related decreasing pattern of vW factor, suggesting the absorption of this factor by abnormal lymphoplasmacytic cells. The patient was treated with bendamustine, leading to reduced IgM, improvement of the APTT value, and the normal multimer pattern of vW factor.

In this issue of the journal the possibility that heme oxygenase activity is responsible for the delay in the appearance of the yellow color in bruises has been investigated [1]. Although bruises may have been a ‘‘very much neglected branch of injuries’’ [2] for many years, recent investigations, including the current paper [1] have revealed some unexpected and highly relevant findings. Bruises in the skin and subcutaneous tissues occur when there has been extravasation of blood following the application of blunt force. Generally the requirements for their formation are injury, compromise of the integrity of vessel walls, and blood pressure [3]. The most useful bruises in a forensic context are those that have a patterned appearance reflecting the nature of the impacting object. Questions that are commonly asked in court regarding bruises involve their age, the amount of force required for their production, and whether they occurred before or after death. Although it was once considered possible to provide answers to all of these queries, recent studies have shown that forensic assessments, particularly of the age of these injuries, may be less reliable than was previously considered. For example, it was once generally accepted that bruises could be dated from their macroscopic appearance and standard text books gave quite precise times for this, with bruises appearing red, purple, and swollen in the first 2 days, green from 4 to 7 days, yellow from 7 to 10 days, with resolution between 14 and 30 days. Of note, even then there was disagreement among the texts in the exact timeline for these color changes [4–7]. The paper by Langlois and Gresham in 1990 debunked this certainty, and demonstrated that the only reliable comment that could be made was that yellow bruises were likely to be older than 18 h [8]. It should be noted, however, that this study did rely on photographs of bruises, which may present additional complication in interpretation (see below). The reasons for the great variation in individual bruising responses to blunt trauma are varied and include differences in the nature of the impacting object and forces, age of the victim, variations in subcutaneous tissue thickness, variability in bleeding tendencies, the effects of underlying disease states, the influence of medications (both pharmaceutical and herbal) [9], and background skin pigmentation. Other issues concern considerable interobserver variability in the perception of yellow in bruises [10] and in the identification of specific colors [11], i.e. one observer’s brown may be another observer’s yellow, and the tendency for single bruises from one episode of trauma to develop different colors in different areas at the same time. All of this tells us that dating of bruises macroscopically is, at best, highly inaccurate. Photographing bruises introduces further variables as a bruise can be made to disappear if a picture is overexposed; in addition, an apparent ‘‘bruise’’ can be created if shadows occur from under-exposure. For this reason photographs should not be relied upon for the assessment of the age of bruises. Ideally bruises should be photographed in color at autopsy in suspicious cases, both before and after incision (the latter to confirm the presence of subcutaneous hemorrhage). Photography in black and white using infra-red or alternative light source illumination may provide additional information, and trace wound patterns may be detected by use of an alternative light source (although alternative light source [polilight ] illumination with digital image analysis does not assist in determining age). R. W. Byard (&) N. E. I. Langlois Discipline of Anatomy and Pathology, Level 3 Medical School North Building, The University of Adelaide, Frome Road, Adelaide, SA 5005, Australia e-mail: roger.byard@sa.gov.au

We herein report the cases of two elderly patients with acquired hemophilia A (AHA) for whom treatment was difficult.An 89-year-old woman (Case 1) was admitted to our department with subcutaneous hemorrhage and melena. Her activated partial thromboplastin time (APTT), factor VIII activity, and factor VIII inhibitor level were 127.7 seconds, 1.0%, and 48 BU/mL, respectively, which was suggestive of AHA. The administration of prednisolone (PSL 0.5 mg/kg) was initiated. After 3 weeks, PSL was combined with cyclophosphamide (CPA 50 mg). Two months after the start of treatment, her factor VIII inhibitor level decreased to 3.4 BU/mL. However, hemorrhagic signs were repeatedly observed during the discontinuation of recombinant activated factor VII (rFVIIa) preparation; bleeding control became insufficient, and pneumonia developed, thus leading to a fatal outcome.An 81-year-old woman (Case 2) was admitted to our department with subcutaneous hemorrhage, anemia (Hb: 9.2 g/dL), and a prolonged APTT (78.7 seconds). Her factor VIII activity was reduced to 0.9%, and her factor VIII inhibitor level was markedly increased to 1,364.9 BU/mL, suggesting AHA. Treatment with PSL (0.5 mg/kg) was initiated. After one month, it was combined with CPA (50 mg); however, her hemorrhagic signs were protracted, and her Hb level decreased to 8.0 g/dL. Subsequently, pneumonia occurred. However, weekly rituximab therapy (375 mg/m2) for 4 weeks decreased her factor VIII inhibitor level, leading to the disappearance of the inhibitor at 1 year and 5 months. During this period, there were no episodes requiring the administration of bypassing agents, such as rFVIIa.

Migrating bats have increased mortality near moving turbine blades at wind farms. The authors evaluated competing hypotheses of barotrauma and traumatic injury to determine the cause. They first examined the utility of lungs from salvaged bat carcasses for histopathologic diagnosis of barotrauma and studied laboratory mice as a model system. Postmortem time, environmental temperature, and freezing of carcasses all affected the development of vascular congestion, hemorrhage, and edema. These common tissue artifacts mimicked the diagnostic criteria of pulmonary barotrauma; therefore, lung tissues from salvaged bats should not be used for barotrauma diagnosis. The authors next compared wind farm (WF) bats to building collision (BC) bats collected near downtown Chicago buildings. WF bats had an increased incidence in fracture cases and specific bone fractures and had more external lacerations than BC bats. WF bats had additional features of traumatic injury, including diaphragmatic hernia, subcutaneous hemorrhage, and bone marrow emboli. In summary, 73% (190 of 262) of WF bats had lesions consistent with traumatic injury. The authors then examined for ruptured tympana, a sensitive marker of barotrauma in humans. BC bats had only 1 case (2%, 1 of 42), but this was attributed to concurrent cranial fractures, whereas WF bats had a 20% (16 of 81) incidence. When cases with concurrent traumatic injury were excluded, this yielded a small fraction (6%, 5 of 81) of WF bats with lesions possibly consistent with barotrauma etiology. Forensic pathology examination of the data strongly suggests that traumatic injury is the major cause of bat mortality at wind farms and, at best, barotrauma is a minor etiology.

To protect children from abuse, it is important to identify victims at an early date, but diagnosis is often difficult. We used ultrasonography for objective examination of bruises arising from subcutaneous hemorrhages, and determined whether we could precisely measure the depth and thickness of a subcutaneous hemorrhage. We compared macroscopic findings, microscopic findings and ultrasonographic images of 10 bruises in forensic autopsy cases. In addition, we measured chronologic changes in subcutaneous hemorrhages using ultrasonography of 16 bruises in healthy volunteer children. Mild or moderate subcutaneous hemorrhages spreading along the fibrous partition in subcutaneous fatty tissue were observed by histological examination. There was a thickened fibrous partition or an isoechoic or hyperechoic area in the ultrasonographic images. A good correlation between the thickness of the subcutaneous hemorrhages by macroscopic examination and by ultrasonographic imaging was found in postmortem cases. We were also able to confirm objectively that the thickness of the subcutaneous hemorrhage of healthy children decreased with time. It is possible to measure the depth from the skin surface to the subcutaneous hemorrhage, and the thickness of the subcutaneous hemorrhage accurately using ultrasonography. Thus, the age of a bruise can be estimated more precisely using information on the subcutaneous hemorrhage from ultrasonography in addition to established evaluations by the naked eye and by spectrophotometry.

We describe a patient with subcutaneous hematoma associated with manual cervical massage during carotid artery stenting. A 73-year-old man with left cervical carotid artery stenosis presented with left amaurosis fugax. We performed carotid artery stenting using distal embolic protection with balloon occlusion. Dual antiplatelet therapy was maintained in the periprocedural period and an anticoagulant agent was administered during the procedure. Because the aspiration catheter became entrapped by the stent, it did not reach the distal side of the stenotic lesion, and manual compression of the cervical region was therefore performed. Immediately afterwards, a subcutaneous hemorrhage occurred in the cervical region. There was no postoperative dyspnea due to enlargement of the hematoma, which was absorbed spontaneously. Cervical subcutaneous hematoma can occur in the cervical region due to cervical massage in patients who are receiving adjuvant antiplatelet therapy and anticoagulation therapy.

Aim: Hemorrhage is an important complication of heparin-thromboprophylaxis after surgery. We attempted to clarify the incidence rate of prolonged activated partial thromboplastin time (APTT), representative of hemorrhagic tendency, in Japanese women who received thromboprophylaxis with unfractionated subcutaneous heparin administration after cesarean section (CS). We also determined factors which affected postoperative APTT. Methods: We studied 280 women who were administered thromboprophylaxis with unfractionated subcutaneous heparin 5000 IU two times per day after CS. Postoperative APTT under heparin was measured and the incidence of its prolongation was determined. Preoperative APTT, blood loss during surgery, postoperative hematocrit, postoperative serum total protein level, and postpartum body weight were measured, and their correlation with postoperative APTT was determined. Results: Preoperative and postoperative APTT values were 28.3 (26.7–30.3) and 33.8 (31.0–37.5) seconds for median (interquartile range), respectively. Overall, 7.1% of patients showed ≥45 s postoperative APTT. Two patients (0.7%) showed ≥60 s APTT, one of whom suffered subcutaneous hemorrhage around the abdominal incision with complete healing. There were no other hemorrhagic complications. Preoperative APTT positively, and postpartum body weight inversely, correlated with postoperative APTT. The amount of blood loss, postoperative hematocrit, and postoperative serum total protein level did not correlate with postoperative APTT. No discernible deep vein thrombosis or pulmonary embolism occurred. Conclusion: Although 7.1% of women under heparin-thromboprophylaxis showed a prolonged APTT that was 150% of the preoperative APTT, serious side effects were not observed. Subcutaneous administration of unfractionated heparin, if checking APTT prolongation 1 day after surgery, may be safe method of thromboprophylaxis after CS.

患者は78歳，女性．2009年5月，頸部違和感，咽頭痛の後，頸部腫大，頸部皮下出血を認め当院紹介となった．入院時検査所見で橋本病と貧血を認めた．血清カルシウム値は正常であった．頸部に圧痛を訴え，CTにて左甲状腺下極の血腫を，造影CTで腫瘤内に血流を認めたが，動脈瘤は認めなかった．上部消化管内視鏡では咽頭喉頭に壁外性の圧排と内出血を認めた．ガリウムシンチにて集積を認めず，腫瘍ではなく甲状腺嚢胞の出血と診断した．入院後絶食し頸部冷却と止血剤投与にて一週間後に手術を施行した．皮下に内出血と甲状腺下極に連続しない内出血した40mm大の嚢腫を認め，左下副甲状腺嚢胞内出血と診断し摘出した．術前血清インタクトPTHの上昇はわずかであったが，内腔穿刺液のインタクトPTHは59,110pg/mlと高値であった．病理組織学的には副甲状腺嚢胞と橋本病であった．副甲状腺嚢胞内出血の自然穿破で頸部皮下出血をきたした患者を経験したので報告する．

Aortic aneurysm is a rare cause of disseminated intravascular coagulopathy (DIC). We present the developmental course of DIC in a 70-year-old male patient who had a thoracoabdominal aortic aneurysm characterized by a progressive descending aortic aneurysm presenting as subcutaneous hemorrhage of acute onset. He was diagnosed as having aortic aneurysm–induced DIC. After adequate infusion of blood components, surgical repair of the descending aortic aneurysm was carried out successfully. The patient's bleeding tendency stopped dramatically in the early postoperative period as identified by clinical and laboratory findings. We concluded that the occurrence of DIC was due mainly to the progressive descending aortic aneurysm in the present patient and that surgical repair could be the definitive treatment of DIC in this setting.

Objective – To investigate the efficacy of low dose of botulinum toxin type A (BTX-A) for facial synkinesis and hyperlacrimation. Material and methods – Eleven patients suffering from facial synkinesis after Bell's palsy or facial nerve injury were treated with a low dose of BTX-A, 0.5–1.25 U per point into several points. One patient showing hyperlacrimation was also treated with BTX-A. The whole observational period was 43 months. Results – On average, 5.76 U of BTX-A, which was lower than that of previous reports, was injected per treatment. In seven cases, synkinesis disappeared completely after three or fewer sessions of BTX-A injection. The mean interval between treatments was 14.5 weeks. Hyperlacrimation was completely suppressed after a single subcutaneous injection of BTX-A. Only mild subcutaneous hemorrhage was observed as adverse reactions. Conclusion – Facial synkinesis can be treated with a lower dose of BTX-A without relevant adverse reactions.