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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.

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: 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.

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.

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.

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.

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.

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.

Acoustic radiation force impulse (ARFI) Surveillance of Subcutaneous Hemorrhage (ASSH) has been previously demonstrated to differentiate bleeding phenotype and responses to therapy in dogs and humans, but to date, the method has lacked experimental validation. This work explores experimental validation of ASSH in a poroelastic tissue-mimic and in vivo in dogs. The experimental design exploits calibrated flow rates and infusion durations of evaporated milk in tofu or heparinized autologous blood in dogs. The validation approach enables controlled comparisons of ASSH-derived bleeding rate (BR) and time to hemostasis (TTH) metrics. In tissue-mimicking experiments, halving the calibrated flow rate yielded ASSH-derived BRs that decreased by 44% to 48%. Furthermore, for calibrated flow durations of 5.0 minutes and 7.0 minutes, average ASSH-derived TTH was 5.2 minutes and 7.0 minutes, respectively, with ASSH predicting the correct TTH in 78% of trials. In dogs undergoing calibrated autologous blood infusion, ASSH measured a 3-minute increase in TTH, corresponding to the same increase in the calibrated flow duration. For a measured 5% decrease in autologous infusion flow rate, ASSH detected a 7% decrease in BR. These tissue-mimicking and in vivo preclinical experimental validation studies suggest the ASSH BR and TTH measures reflect bleeding dynamics.

In this study, we retrospectively analyzed 141 cases of hanging and 178 cases of ligature strangulation recorded in the Shanghai Municipal Public Security Bureau between January 2001 and December 2014 to explore the characteristics of hanging and ligature strangulation and to supply a scientific reference for forensic pathology. Several significant differences between hanging and ligature strangulation were found. Hanging cases were mostly suicide, with some accidental cases. Strangulation cases were mostly homicide, with a few cases of suicide or sexual asphyxia. Male hanging was more common than female hanging, with a ratio of 5:2. However, there were more female than male strangulation cases, with a ratio of 13:5. The ligature marks in hanging cases were almost all of a "U" type and above the hyoid bone. The ligature marks in strangulation cases were almost always a closed circle, but the position varied. The most common vital reactions were subcutaneous hemorrhage, exfoliation and blister, which are strong evidence of antemortem injury. Hemorrhagic spots were found on the temporalis, scalp, chest and back in strangulation cases, but were rare in hanging cases. Hemorrhagic manifestations were most common in the sternocleidomastoid muscle in hanging cases, and in the sternohyoid and sternothyroid muscles in strangulation cases. Fractures occurred in only ∼17% of victims. There are notable differences between hanging and ligature strangulation, which can help distinguish between these causes of death. These characteristics should be considered in forensic practice.

A 42-year-old male had been assaulted by his family over the two previous days and went into a deep coma. When the emergency technician arrived, the patient was in a state of cardiopulmonary arrest. On arrival, his electrocardiogram showed asystole. His body showed swelling with subcutaneous hemorrhage, suggesting multiple contusional wounds. Serum biochemistry evaluation revealed blood urea nitrogen of 80 mg/dL, creatinine of 5.99 mg/dL, creatine phosphokinase of 10,094 IU/L, and potassium of 11.0 mEq/L. Advanced cardiopulmonary resuscitation failed to obtain a return of spontaneous circulation. Laboratory findings revealed rhabdomyolysis, renal failure, and hyperkalemia. Autopsy did not indicate the direct cause of death to be traumatic organ injuries. Because trauma was not the direct reason of death, we speculated that the patient died of hyperkalemia induced by multiple contusional soft tissue injuries, following rhabdomyolysis, hemolysis, and acute renal failure. The physician should maintain a high index of suspicion for hyperkalemia induced by rhabdomyolysis and acute renal failure, especially in patients presenting with symptoms of multiple soft tissue injuries with massive subcutaneous hemorrhaging.

This article presents the results of the evaluation of the effectiveness of physiotherapy during the postoperative period following rhinoplastic surgery based on the analysis of the dynamics of the clinical symptoms in 374 patients divided into two groups. The main group was comprised of 286 (86.5%) patients who had undergone the comprehensive postoperative rehabilitation with the use of the chosen physiotherapeutic procedures while the group of comparison consisted of 88 (23.5%) patients treated othrerwise. The method in question included the microcurrent lymphatic drainage, the magneto-laser treatment, and ultraphonophoresis. The data obtained give evidence of the significant differences between the two groups of the patients in terms of reduction of oedema of the nasal and facial soft tissues on days 10-12 and 30-35 after the treatment as well as of subcutaneous hemorrhage and pain in the external nose on days 10-12. These effects were more pronounced in the patients of the main group. The local subcutaneous compaction was documented in both groups (though it was more pronounced in the patients of the comparison group; p0.05) after the disappearance of the bulk of the swelling approximately on days 10-12. It is concluded that the results of the study confirm the effectiveness of the staged performance of various physiotherapeutic procedures during the postoperative period after rhinoplasty.Представлены результаты исследования эффективности физиотерапии после ринопластики на основе анализа динамики клинических симптомов у 374 пациентов. Основная группа - 286 (86,5%) пациентов, которым в полном объеме проводилась послеоперационная реабилитация по разработанной методике, и группа сравнения - 88 (23,5%) пациентов, которым она не выполнялась. Использовался микротоковый лимфодренаж, воздействие магнито-лазера и ультрафонофорез. При анализе полученных результатов отмечено наличие достоверных отличий между группами по параметрам уменьшения отека мягких тканей носа и лица на 10-12-е и 30-35-е сутки, а также подкожных кровоизлияний и болезненности наружного носа на 10-12-е сутки, что было более выражено в основной группе. Локальные подкожные уплотнения появлялись в обеих группах после исчезновения основной массы отека примерно на 10-12-е сутки и были более выражены в группе сравнения (р0,05). Полученные результаты подтвердили эффективность поэтапного выполнения различных физиотерапевтических воздействий в послеоперационном периоде после ринопластики.

Amyloidosis is a heterogeneous group of diseases in which misfolding of extracellular proteins is the pathogenic factor. Light chain amyloidosis (AL) is the most common form of amyloidosis, and the causative proteins in AL are the immunoglobulin light chains produced by clonal plasma cells. Hemorrhagic events, ranging from mild subcutaneous hemorrhage to life-threatening bleeding, account for a significant proportion of morbidities and mortality in AL patients. Deficiency of factor X from deposition into amyloid fibrils has been reported to be the most common acquired factor deficiency in AL. We herein report 2 patients with acquired factor X deficiency in AL. A 55-yr-old woman with AL had a prolonged prothrombin time (PT) and an activated partial thromboplastin time (aPTT) of 2.51 International Normalized Ratio (INR) and 75.1 sec, respectively, which were corrected on mixing with normal plasma. Factor X activity was markedly decreased at 5%. The other patient was a 67-yr-old man with AL with a PT of 1.63 INR and an aPTT of 50.3 sec, which were corrected on mixing with normal plasma. Factor X activity was decreased at 17%. Neither of the patients had apparent hemorrhagic manifestations. Identification of acquired factor deficiency and timely coagulation tests are needed in the diagnostic workup and management in AL.

Acoustic Radiation Force Impulse (ARFI) ultrasound is used in ARFI Surveillance of Subcutaneous Hemorrhage (ASSH), a new in vivo hemostasis assay, to assess bleeding response in hemophilia A dogs. ASSH bleeding parameters were calculated from a small dose response study with 7 hemostatically normal dogs and 7 dogs exhibiting severe hemophilia A. Hemophilia A dogs were imaged in the naive state and/or when prophylactically treated with different levels of recombinant canine FVIII before bleeding was induced. A standardized injury of a 1–2mm vein by needle puncture induced subcutaneous bleeding in soft tissue. Bleeding was monitored by ASSH for 60 minutes. There was a significant difference (p

Severe hemophilia patients are more likely to be complicated by intra-articular hemorrhage, subcutaneous hemorrhage, and intra-mascular hemorrhage. Spontaneous intra-abdominal hemorrhage is a rare fatal disease, which is an arterial bleeding of uncertain causes from vessel feeding arteries. In case the spontaneous intra-abdominal hemorrhage is complicated to severe hemophilia patients, the mortality rate increases considerably. We experienced a patient with severe hemophilia A, who made a full recovery from spontaneous intra-abdominal hemorrhagic shock by replacement therapy of coagulation factor VII, a noninvasive procedure.

We report a case of infective endocarditis of the mitral valve, which was accompanied by pulmonary emboli traveling through an atrial septal defect. An 18-year-old male was admitted to our hospital due to a fever, polyarthritis and subcutaneous hemorrhage. Transthoracic echocardiography revealed a mobile mass and possible vegetation lodged in the mitral valve and a secundum-type atrial septal defect. Computed tomography revealed a hepatic, splenic and renal embolic infarction. During antibiotic therapy, he felt a sudden right flank pain. Follow-up computed tomography revealed a pulmonary embolic infarction that drifted through an atrial septal defect. This association is the first report, of pulmonary emboli which migrated through an atrial septal defect from the mitral valve.

A 38 years male, admitted in the department of Internal Medicine with a history of snake bite in his left lower leg during agriculture work. He was treated with anti snake venom after admission. He had history of dimness of vision in both eyes. On examination, swelling and subcutaneous hemorrhage was noted in his left leg. His best corrected visual acuity (BCVA) was 6/60 in the both eyes. Fundus examination with 90 D lens and Indirect Ophthalmoscopy of both eyes showed retinal hemorrhage with cotton wool spots. Blood tests revealed increased titers of D-dimer and fibrin degradation products. The patient was followed up regularly at 2 weeks interval and BCVA and Fundus examination was carried out. At the end of 10 weeks, retinal hemorrhages had significantly cleared in both eyes with improvement of vision in both eyes (BCVA of right eye at last follow-up 6/6 and left eye 6/9).Bangladesh Journal of Medical Science Vol.14(3) 2015 p.297-298

Necrotizing fasciitis is relatively rare. We report a case of necrotizing fasciitis secondary to anorectal abscess. A 32-year-old man was admitted to the hospital because of perianal pain. The patinet had had incision and drainage for anorectal abscess on outpatient base at a clinic, but the condition was aggravated. The patient was admitted to the hospital when the seemed very sick and showed oliguria and shock. At the right side of his anus there was seriously gangrenous skin with erosion and subcutaneous hemorrhage. We performed additional incision, drainage and resection of necrotic tissue 11×6cm in size under spinal anesthesia. There was neither purulent discharge nor muscular involvement. After the surgery the patient was transferred to the intensive care unit, because shock and acute renal failure persisted since before surgery and respiratory failure subsequently occurred. Despite our treatment, he died of DIC and MOF three days after admission. Culture yielded Escherichia coli and Bacteroides. We consider that our case was compatible of necrotizing fasciitis. Necrotizing fasciitis is surgical emergency with high mortality rate. Early diagnosis and wide resection of necrotic tissue are very important.

Objectives Intracavernous needle injection is an effective delivery method for pharmacotherapy of erectile dysfunction. Needle phobia, pain, and concern about local tissue injury have stimulated the search for new, less invasive means of inducing penile erection. In this preliminary communication, we evaluate a jet injector as an alternative to needle injection for intracavernous delivery of vasoactive drugs. Methods Jet injection was evaluated in three groups of rats receiving either India ink, saline, or papaverine into the penis. The ability of the jet injection to penetrate through the tunica albuginea and deliver liquid to the corpora cavernosa smooth muscle was assessed by the degree of staining within the corpus cavernosum (ink group), histologic change (saline group), and rise in intracavernous pressure (papaverine group). Erectile capacity following cavernous nerve electric stimulation was compared before and 1 hour after injection of saline or papaverine. Results Ink traversed the skin and tunica albuginea with extensive deposition noted within the cavernous spaces. Varying degrees of subcutaneous hemorrhage were seen with saline jet injection; however, the corpus cavernous smooth muscles showed no evidence of injury. Jet injection of papaverine 3250 gmg significantly increased cavernous pressure (39.4 ± 4.6 cm H2O) compared with saline injection (2.8 ± 1.3 cm H2O). Conclusions We conclude that acute jet injection is an effective method for intracavernous delivery of drugs. Long-term effects should be evaluated prior to clinical use.

Abnormal development in Bh quail embryos was histologically examined. In addition to the abnormal plumage pigmentation in Bh-heterozygotes and homozygotes, and subcutaneous hemorrhage and liver degeneration in homozygotes as previously reported, the lungs in all 10-day homozygotes examined showed hemorrhage, suggesting that the Bh gene may also be expressed in this organ. Other organs, including the esophagus, the gizzard, the small intestine, the large intestine, the pancreas, the metanephros, the heart, the gonads and the hemopoietic organs in heterozygotes and homozygotes were histologically normal on days 7 and 10, though the development of homozygotes was slightly delayed. Primordial germ cells and hemopoietic cells were normally developed in gonads and hemopoietic organs such as the bursa of Fabricius and the spleen of the homozygote, respectively. These results suggest that Bh is a mutation inducing pleiotropic effects such as plumage pigmentation changes in both heterozygotes and homozygo...

Single and repeated intravenous toxicity studies of Pamiteplase (genetical recombination) YM866, a novel recombinant human tissue-type plasminogen activator, were conducted. No animal died from toxic effects of YM866 after single administration to F344 rats, squirrel monkeys and cynomolgus monkeys. Male and female F344 rats were given YM866 intravenously for 4 weeks at doses of 0 (vehicle), 0.1, 0.3 and 1 mg/kg/day. An increase in platelet count, slight decreases in hemoglobin and hematocrit, increases in plasma phospholipids, total cholesterol and total protein, and liver weight were observed at 1.0 mg/kg. Histopathology revealed no changes in any organ except for hemorrhage at the injection sites. These changes recovered after 4 weeks of withdrawal. Male and female squirrel monkeys were given YM866 intravenously for 4 weeks at doses of 0 (saline), 0 (vehicle), 0.1, 0.3 and 1 mg/kg/day. Prolongation of coagulation time at the injection site was observed at 0.3 mg/kg or more. Subcutaneous hemorrhage and a transient decrease in locomotor activity were observed at 1 mg/kg. Prolongation of coagulation time at the injection site was considered to be related to the pharmacological action of YM866. The results show that the approximate single lethal dose of YM866 is more than 60 mg/kg in rats, and more than 10 mg/kg in squirrel monkeys and cynomolgus monkeys. The no-toxic-effect level of YM866 after repeated administration for 4 weeks in rats and squirrel monkeys is considered to be 0.3 mg/kg.

We report a rare case in which life-threatening subcutaneous hemorrhage following minor blunt trauma developed in an elderly patient taking ticlopidine and aspirin. An 82-year-old woman taking ticlopidine and aspirin tripped on a road. She noted only mild pain at the left lower abdomen. However, the hematoma gradually enlarged, and she developed hemorrhagic shock. Emergently performed contrast-enhanced abdominal computed tomography showed a large hematoma (20 x 10 x 7 cm), including contrast extravasation, which was located beneath the skin of the left lower abdominal quadrant and within the external and internal oblique muscles. Emergency pelvic arteriography showed massive contrast extravasation from the left superficial iliac circumflex artery. Transcatheter arterial embolization (TAE) was successfully performed, using gelatin sponge pledgets and micro-size stainless steel coils. After TAE, hemodynamics stabilized. The patient was discharged uneventfully on day 12.

The incidence of acute massive hemorrhage in hemodialysis (HD) patients is thought to be higher than in healthy individuals, and a large, expanding subcutaneous hematoma can result in necrosis of the overlying skin. We evaluated the efficacy of intra-arterial treatment for acute massive subcutaneous hemorrhage in HD patients. Seven HD patients with subcutaneous hemorrhage following minor blunt trauma were treated using superselective transarterial embolization, between July 2005 and October 2012. After examining the site of the hemorrhage using contrast-enhanced computed tomography (CT), embolizations were performed using microcoils, gelatin sponges, or N-butyl cyanoacrylate. Hematoma evacuation or skin grafting was performed as needed. Four men and three women with a mean age of 70 years (range, 63-82 years) comprised the study population. Sites of bleeding were as follows: lower leg (N = 3), upper leg (N = 1), buttock (N = 1), precordia (N = 1), and forearm (N = 1). Blood transfusions were administered to five cases. All patients were successfully salvaged using transarterial embolization. Six patients underwent hematoma evacuation after transarterial embolization, and two patients underwent split-thickness skin grafting for skin necrosis. We established a treatment strategy for HD patients with acute subcutaneous hemorrhage. Immediate confirmation of the site and the degree of bleeding with contrast-enhanced CT and early treatment using the transarterial embolization and as needed, hematoma evacuation are effective for preventing skin necrosis in HD patients with acute subcutaneous hemorrhage.

We report a case of lethal acute aortic dissection revealed by a large ecchymotic area at the root of the neck; the subject was an 86-year-old man who died suddenly in his hospital room. His medical history included ischemic heart disease with pacemaker implantation and an aortic surgical prosthesis. Forensic autopsy showed a major subcutaneous hemorrhage in the neck and large left pleural and pericardial adhesions secondary to thoracic surgery. The cause of death was an acute aortic dissection. Large adhesions led to an extensive mediastinal hemorrhage, spreading to the subcutaneous tissues of the neck. This case report highlights the difficulties in differentiating between traumatic and pseudo-bruising during a death scene investigation. The etiologies of pseudo-bruising are reviewed.