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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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Neurofibromatosis is rare genetic disorder that predisposes patients to tumor formation. Although the clinical manifestations are variable, vascular malformations are known to occur. We report a case of life-threatening massive subcutaneous hemorrhage after minor trauma in a patient with neurofibromatosis. Physicians need to be aware that bleeding from vascular malformations, even in the subcutaneous space, may be life threatening.

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disorder that has three major features: multiple neural tumors, cafe-au-lait spots, and pigmented iris hamartomas (Lisch nodules). The purpose of this case report is to advise physicians of the danger associated with the progression of fast-onset massive hemorrhage to hemodynamic instability, which mandates rapid treatment to prevent the development of a life-threatening condition. A 64-yr-old woman with NF-1 was admitted to the Emergency Department (ED) because of a rapidly growing, 10 x 5 x 3 cm-sized mass on the left back area. She had previously undergone surgery for a large subcutaneous hematoma, which had developed on her right back area 30 yr before. She became hemodynamically unstable with hypotension during the next 3 hr after admission to ED. Resuscitation and blood transfusion were done, and the hematoma was surgically removed. The mass presented as a subcutaneous, massive hematoma with pathologic findings of neurofibroma. We report a case of NF-1 that presented as recurrent, massive, subcutaneous hemorrhage on the back region combined with hypovolemic shock.

We present a 16-year-old boy with mild hemophilia A who developed superficial fibromatosis mimicking subcutaneous hematoma of the right upper dorsal region of the foot. This condition is very rare. Hematoma originally developed after the patient sprained the right ankle. Although cast immobilization and replacement therapy with factor VIII (FVIII) concentrates reduced the symptoms, the swelling and pain reappeared in the same region 4 weeks after the cast was removed. A clinical diagnosis of intramuscular hemorrhage was made. Despite readministration of regular FVIII concentrates and cast immobilization, the patient experienced a relapse after removal of the second cast. Magnetic resonance imaging demonstrated a tumor in the extensor digitorum brevis muscle of the right foot with high intensity on T2-weighted images. Marginal excision resulted in symptom resolution. A histopathologic examination of the tissue showed proliferation of fibroblastic cells with abundant collagen bundles. When a mass is found under the skin in hemophilia A patients, an etiology other than bleeding can be overlooked because subcutaneous hemorrhage in limited areas often results in a mass; however, the possibility of rare soft tissue tumors in hemophilia patients should be kept in mind.

Head injuries can be broadly divided into blunt force and penetrating, or closed and open injuries, simple in concept, but infinitely variable in individual cases. The types of injuries are limited in number, but extremely complex in each case. In this chapter, types of head injuries are listed and reviewed in turn with illustrated case examples. The scalp provides an ideal anatomic arrangement for development of abrasions, contusions, and lacerations because of scalp soft tissue overlying the hard, rounded bony prominences of the cranium. Traumatic subcutaneous hemorrhage of the scalp may be broadly localizing, but when it underlies an abrasion, contusion, or laceration, it would be an indicator of the impact point. The biomechanics of the mechanisms at play in skull fractures are relevant in assessing types and directions of forces occurring in any injury. Head injury potentially results in a wide variety of consequences that interact in complex ways. A common method of categorizing these consequences is to divide them into primary and secondary effects. Primary effects result from direct injury to central nervous system (CNS) parenchymal and supporting structures. Secondary vascular effects may include events, such as external compression due to brain parenchymal swelling or hematoma, hydrocephalus, an increase in intracranial pressure, impaired reactivity to physiologic stimuli, vascular dilatation; vascular spasm, thrombosis or embolism, infarction, abnormal vascular permeability with tendency for edema and/or hemorrhage, and traumatic aneurysms or arteriovenous fistulae. The role of immediate post-head injury apnea as a contributory factor in subsequent events, leading to hypoxic-ischemic CNS injury, has been increasingly appreciated.

Endoscopic Sinus Surgery (ESS) is generally accepted as a safe surgery, however, surgeons who have poor understanding of surgical anatomy and variation of paranasal sinus cause troubles such as injury lamina papyracea, blood vessel and ethmoid roof (CSF leak) during surgery. Orbital tissue injury is the most frequent among the problems of sinus surgery. When only orbital fat tissue is pulled out, the patient will have just edema and subcutaneous hemorrhage around the eye. However, if the orbital muscle, especially medial rectal muscle, is injured, disturbance of eye movement occurs. Severe bleeding during surgery generally causes these problems, because surgical field is not identified under endoscope. Therefore, the important things which prevent injury and perform safe surgery are as f of lows : 1. Full knowledge of surgical anatomy 2. Manipulation of forceps under clear observation 3. Control bleeding, pain and blood pressure by sufficient anesthesia 4. Selection of appropriate forceps and correct manipulation of forceps 5. Adequate and quick treatment for injuries.

A 57-year-old patient who was on Coumadin was placed on a very vigorous sports medicine rehabilitation program for a left hemiparesis. His prothrombin was stable at 16 seconds with a control of 12.4 seconds. After doing knee flexion and extension exercises on an isokinetic machine, he developed an extensive posterior thigh ecchymosis. Rehabilitation clinicians need to be aware of the possibility of such a complication in an anticoagulated patient.

An unusual case of traumatic basal subarachnoid hemorrhage (SAH) due to a mechanical tear of the basilar artery is reported. A 70-year-old man who had been suffering from cerebrovascular dementia was found dead in a ditch. Externally, subcutaneous hemorrhage with abrasions was observed on the left side of the forehead, face, and lower jaw, together with small contusions in the left superciliary arch. Internally, a 3-mm-long transversal tear of the basilar artery was observed, and dislocations of both C6-C7 and T1-T2 as well as a small fracture of the processus spinosus of C5 were found. No pathological vascular lesions such as aneurysms and vasculitis, other than arteriosclerosis, were observed in the vertebral-basilar system. Ethanol was not detected in the intracardiac blood or in the urine. These findings indicate that when the man fell into the ditch, severe hyperextension occurred as a result of minor blunt forces to the face, and that the traumatic tear of the basilar artery was mechanically caused by overstretching due to hyperextension of the head. It is also suggested that due to his advanced age the muscle tone of the neck might have declined, impairing its defense action, and that head hyperextension might, therefore, occur rather more readily under such conditions.

A 49-year-old man collided against an infielder when he slid into second base during a recreational baseball game. He was unable to continue in the game due to diffuse pain and swelling of his hindfoot. A rupture of the Achilles tendon was diagnosed incidentally on palpation and observation of a positive Thompson's squeeze test. Subcutaneous hemorrhage at the lateral aspect of the heel and a small bone fragment under the lateral malleolus on an anteroposterior plain radiograph indicated a fracture of the calcaneal wall. At surgery, a complete rupture of the Achilles tendon and an avulsion of the calcaneofibular ligament from the calcaneal wall were seen. Both injuries were surgically repaired, and the patient subsequently did well. The mechanism of injury was thought to be impact hyperdorsiflexion of the ankle with rupture of the Achilles tendon accompanied by an inversion injury. Using a literature search, it was found that this combination of injuries has not been previously reported.

Abstract 4697 Background Edoxaban, an oral, selective, direct factor Xa inhibitor, is approved in Japan as a once-daily dose (15 mg or 30 mg tablets) for the prevention of venous thromboembolism (VTE) following major orthopedic surgery, including total knee arthroplasty, total hip arthroplasty, and hip fracture surgery. Currently, edoxaban is in phase 3 clinical development for the prevention of stroke and systemic embolic events in patients with atrial fibrillation as well as treatment and prevention of recurrence of VTE. This report describes the adverse drug reactions (ADRs) that were spontaneously reported during early post-marketing phase vigilance (EPPV) since the July 2011 commercial launch in Japan. Methods EPPV was conducted for the initial 6 months from launch: July 19, 2011, to January 18, 2012. All ADRs that were spontaneously reported, were collected and analyzed. Results The estimated exposure was approximately 20,000 patients. A total of 67 ADRs were reported in 56 patients, of which 15 (in 14 patients) were serious. The mean age of the patients was 74.1 years, mean weight was 59.4 kg, and approximately 70% of the patients were female. The majority of ADRs were bleeding events (51 ADRs in 42 patients), and serious ADRs included cerebral hemorrhage (n=1), gastric hemorrhage (n=1), gastric ulcer hemorrhage (n=1), and surgical site hemorrhage (n=12). Most of these ADRs occurred within the first week of treatment and there were no fatalities. The majority of non-serious adverse events associated with bleeding that occurred in more than one patient included subcutaneous hemorrhage (n=9), wound hemorrhage (n=5), post-procedural hematoma (n=4), anemia (n=4), and hemarthrosis (n=3). Other non-serious adverse events occurring in more than one patient included abnormal hepatic function (n=4) and diarrhea (n=2). Conclusions Preliminary data from EPPV for the first 6 months of commercial use of edoxaban did not identify any unforeseen safety signals. This evidence confirms the known safety profile of edoxaban—that edoxaban has been shown to be well tolerated. Disclosures: Kuroda: Daiichi Sankyo Pharma Development: Employment. Hotoda:Daiichi Sankyo Co., Ltd.: Employment. Nishikawa:Daiichi Sankyo Co., Ltd.: Employment. Nishiwaki:Daiichi Sankyo Co., Ltd.: Employment.

Abstract 4634 Summary: Autoimmune factor XIII (FXIII) deficiency is an extremely rare bleeding disorder that can be life-threatening without prompt diagnosis and treatment. Many clinicians, even experienced hematologists, are unaware of this critical disorder. The causes and mechanisms of autoimmune FXIII deficiency remain unclear, but patients should be given top priority in receiving FXIII concentrate and immunosuppressive drugs when this is suspected to avoid fatal hemorrhage. We report the first Japanese case of autoimmune FXIII deficiency presenting as acute intracerebral hemorrhage. The clinical manifestations allowed prompt diagnosis and effective treatment in the form of emergency open drainage and infusion of FXIII concentrates combined with prednisolone therapy, leading to success in saving the life of this patient. Case: A 68-year-old man was hospitalized in another department of our hospital with abdominal pain and diffuse purpura of the abdominal skin in the absence of any history of trauma. He did not have a family history of bleeding tendency. Since he had been receiving low-dose aspirin because of a previous stroke, he received a transfusion of red cell concentrate and was discharged after cessation of aspirin. Two weeks later, he was taken to an emergency room with left hemiplegia. Computed tomography (CT) revealed an intracerebral hemorrhage measuring 4 cm in diameter. Sixteen hours after hospitalization, emergency open drainage was performed because of decreased levels of consciousness due to an expanding intracerebral hemorrhage measuring 7 cm with midline shift. Bleeding was controlled during the operation and CT showed no evidence of further bleeding after surgery. However, on postoperative day 2, subcutaneous bleeding spontaneously developed on the patient's head. Platelet counts and coagulation tests were normal, and other tests showed no evidence of factor VIII, factor IX or von Willebrand factor deficiencies. Given the lack of evidence of other autoimmune disorders or family history of bleeding tendency, we suspected idiopathic autoimmune FXIII deficiency and immediately initiated administration of FXIII concentrate. After treatment with FXIII concentrate, subcutaneous bleeding on the head was arrested and level of consciousness had recovered at all. 3 days after it was confirmed that FXIII activity was as low as 11%, and was not corrected by normal plasma at 1:1 in the cross-mixing test, suggesting the presence of anti-FXIII inhibitor and corroborating our clinical diagnosis. Based on the detection of anti-FXIII A autoantibodies in dot blot assay, we immediately started immunosuppressive therapy using prednisolone at 1 mg/kg combined with FXIII concentrate. Three weeks later, inhibition of FXIII activity was partly improved. FXIII activity was 36%, and 1:1 cross-mixing test was corrected, indicating that immunosuppressive therapy with prednisolone was proving successful. Four weeks later, his surgical wound had healed and FXIII concentration injection was discontinued. Prednisolone tapering was started, and after 8 weeks, with prednisolone tapered to 35 mg, FXIII activity was elevated to 53%. This was not yet sufficient, but anti-FXIII A subunit autoantibodies had disappeared completely, first as free-form antibody and then as bound/complexed antibody. Successful results were achieved in response to short-term treatment. In fact, in some of the 28 cases reported from Japan, anti-FXIII inhibitors were continued despite immunosuppressive therapy for a few years. The next target was to stop prednisolone therapy, because the major causes of death in patients with autoimmune FXIII deficiency is bleeding or infection. Why and when the patient developed autoantibodies remains unclear, as he had no evidence of other autoimmune disorders. This report describes a remarkably successful case in which early diagnosis and treatment of autoimmune FXIII deficiency achieved good outcomes for a case complicated by intracerebral hemorrhage. All clinicians should consider the possibility of this rare disease when they encounter patients who present with life-threatening bleeding and normal coagulation tests are inconclusive. Prompt diagnosis and treatment are crucial in saving the life of the patient. Disclosures: No relevant conflicts of interest to declare.

Hirschsprung's disease has been considered to cause intestinal perforation in rare cases. Even if a perforation occurs, the majority of cases are associated with the long-segment or total colonic type. Our case developed the perforation in the neonatal period in spite of being of the recto-sigmoidal type, and it affected the cecum. We do not have a good explanation for this condition. However, the pathological examination of the specimens of the perforated cecum revealed some necrosis (ulceration, subcutaneous hemorrhage, congestion and severe edema) which was considered to be caused by ischemia, secondary to a localized vascular accident in the wall of the distended intestine.

Highlights • Key learning points. • Treatment of the shock state while searching for the possible cause is essential in trauma patient. • Bleeding into the subcutaneous plane is underestimated cause of hypovolemic shock. • Treatment of closed degloving lesions depends on the size and duration of the lesions., Introduction Hemorrhage is the most common cause of shock in injured patients. Bleeding into the subcutaneous plane is underestimated cause of hypovolemic shock. Presentation of case Unrestrained male driver involved in a rollover car crash. On examination, his pulse rate was 144 bpm, blood pressure 80/30 mmHg, and GCS was 7/15. His right pupil was dilated but reactive. Back examination revealed severe contusion with friction burns and lacerations. A Focused Assessment Sonography for Trauma (FAST) was performed. No free intraperitoneal fluid was detected. CT scan of the brain has shown right temporo-parietal subdural hematoma and extensive hematoma in the deep subcutaneous soft tissues of the back. Decompressive cranicotomy and evacuation of the subdural hematoma was performed. On the 4th postoperative day, three liters of dark brown altered blood was drained from the subcutaneous plane. Discussion The patient developed severe hypovolemic shock and our aim was to identify and control the source of bleeding during the resuscitation. The source of bleeding was not obvious. Severe shearing force in blunt trauma causes separation between the loose subcutaneous tissues and the underlying relatively immobile deep fascia. This is known as post-traumatic closed degloving injury. To our knowledge this is the first reported case in the English Literature with severe subcutaneous hemorrhage in blunt trauma patients without any previous medical disease. Conclusion Bleeding into the subcutaneous plane in closed degloving injury can cause severe hypovolemic shock. It is important for the clinicians managing trauma patients to be aware this serious injury.

In the last twenty years, the field of bronchoscopy has become increasingly more complex and invasive. It is now widely used in the management of pulmonary diseases and has the benefit of low mortality and complication rates. Overall incidence of complications and mortality reported ranges around 1% and 0.02% respectively. Common complications of bronchoscopy include pulmonary haemorrhage, desaturation, pneumothorax, and pulmonary oedema. However, facial and neck petechiae associated with subcutaneous hemorrhage post-bronchoscopy has not been reported before in the literature. We hereby report two novel cases of facial/neck petechiae post-bronchoscopy as a complication to be recognized by bronchoscopists. It is essential that bronchoscopists recognise such phenomenon as the clinical presentation is visually alarming to both the patient and clinician. It is usually self-resolving. However such presentation after bronchoscopy may trigger extensive and unnecessary investigations from the physician.

DDD mice were fed 4, 2, or 0.5 g of d -penicillamine/kg of commercial diet from 3 weeks of age for periods ranging from 10 to 48 weeks. In male mice fed 4 g/kg diet, subcutaneous hemorrhage, dorsal hernia, priapism, and paralysis of the digits were observed. In a few mice, there was a ruptured aortic aneurysm. In most advanced cases, ataxia due to hindleg paralysis was observed. In male mice fed 2 g/kg diet, priapism and paralysis of the digits were noted at a lower incidence. No abnormalities were observed also in the mice fed 0.5 g/kg diet. Subcutaneous hemorrhage, dorsal hernia, and priapism were observed exclusively in males and orchidectomy significantly reduced the incidence. The incidence of digit paralysis, however, showed no sex difference and was not prevented by orchidectomy and administration of estrogen. Histologically, nerves, such as the optic and sciatic, showed moderate to marked demyelination and axonal degeneration, and spinal ganglion cells showed degenerative changes in mice fed the 4 g/kg diet. Back muscle covering the herniated area became thin or almost disappeared, and was replaced by a thin layer of collagenous tissue. When the onset of penicillamine feeding was delayed until 3 months of age, all the toxicities were remarkably reduced. Copper supplementation significantly prevented the toxicity while pyridoxine hydrochloride did not.

A 72-year-old man underwent aortic valve replacement and coronary artery bypass graft using cardiopulmonary bypass with right axillary artery cannulation. After undraping, petechial and subcutaneous hemorrhage with blister formations were found in right upper extremity. Axillary artery cannula was considered to compress right subclavian and disturb venous return in the right subclavian vein, which caused an acute compartment syndrome during cardiopulmary bypass. This case was a rare,but severe complication of cardiopulmonary bypass with right axillary artery cannulation.

H. McC., aged 2, was brought to Children's Hospital at Denver from Lead, S. D., with a history of having swallowed a jackstone one week previously. Two unsuccessful attempts to remove the foreign body had been made, and as a result the boy was in a serious condition, with high fever and rapid pulse. Physicial examination showed interstitial emphysema of the neck and of the supraclavicular fossae, with some mottling of the skin in the latter regions due to subcutaneous hemorrhage, presumably from a laceration in the esophagus. Roentgenograms showed the presence of a jackstone in the esophagus at the level of the manubrium. Mediastinal emphysema was seen to be present, extending downward around and below the heart and upward into the neck. Roentgenograms taken subsequently, after the patient had ingested a small amount of barium sulfate, showed evidence of an opening in the esophagus, with some of the swallowed

To the Editor.— Hemophilia is an inherited defect in coagulation characterized by persistent bleeding following trauma. Hemarthrosis represents the most characteristic type of hemorrhage but bleeding also frequently occurs from the mouth, gums, lips, tongue, gastrointestinal tract, lungs, and even intracranially. 1,2 The skin may be involved with subcutaneous hemorrhage which spreads rapidly over the body. We are unaware of any report regarding acne as a potential source of bleeding in this disease. Recently, we have done follow-up studies on two brothers with classical hemophilia, one of whom experienced prolonged bleeding into nodular cystic lesions of acne. Report of a Case A 17-year-old white boy with a one year history of progressively severe acne involving his face, shoulders, and back was referred to the Acne Clinic of the Hospital of the University of Pennsylvania. The patient also suffered from hemophilia A with a factor VIII level of less than