Search

OBJECTIVE Issues with spinopelvic fixation for adult spinal deformity (ASD) include loss of the physiological mobility of the entire lumbar spine, perioperative complications, and medical costs. Little is known about the factors associated with successful short fusion for ASD. The authors evaluated radiographic and clinical outcomes after shorter fusion for different subtypes of ASD at 2 years postoperatively and examined factors associated with successful short fusion. METHODS This was a single-center study of 37 patients who underwent short fusion and a minimum 2 years of follow-up for ASD in which lumbar kyphosis was the main deformity. The exclusion criteria were 1) age < 40 years, 2) previous lumbar vertebral fracture, 3) severe osteoporosis, 4) T10–L2 kyphosis > 20°, 5) scoliotic deformity with an upper end vertebra (UEV) above T12, and 6) concomitant Parkinson’s disease or neurological disease. The surgical procedures, radiographic course, and Oswestry Disability Index (ODI) were assessed, and correlations between radiographic parameters and postoperative ODI at 2 years were analyzed. RESULTS A mean of 3.5 levels were fused. The mean radiographic parameters preoperatively, at 2 weeks, and at 2 years, respectively, were as follows: coronal Cobb angle: 22.9°, 11.5°, and 12.6°; lumbar lordosis (LL): 12.9°, 35.8°, and 32.2°; pelvic incidence (PI) minus LL: 35.5°, 14.7°, and 19.2°; pelvic tilt: 29.4°, 23.1°, and 25.0°; and sagittal vertical axis 85.3, 36.7, and 59.2 mm. Abnormal proximal junctional kyphosis occurred in 8 cases. Revision surgery was performed to extend the length of fusion from a lower thoracic vertebra to the pelvis in 2 cases. The mean ODI scores preoperatively and at 2 years were 50.7% and 24.1%, respectively. Patient age, number of fused intervertebral segments, and radiographic parameters were analyzed by the stepwise method to identify factors contributing to the ODI score at 2 years, preoperative PI, and sagittal vertical axis at 2 years. On receiver operating characteristic curve analysis of the minimal clinically important difference of ODI (15%) and preoperative PI, the cutoff value of the preoperative PI was 47° (area under the curve 0.75). CONCLUSIONS In terms of subtypes of ASD in which lumbar kyphosis is the main deformity, if the PI is < 47°, then the use of short fusion preserving mobile intervertebral segments can produce adequate LL for the PI, improving both postoperative global spinal alignment and quality of life.

Acute urinary tract infection (UTI) is a highly common clinical condition. Although bacterial culture is the gold standard diagnostic test, false negative results may be possible, leading to the pathogen being unidentified. In recent years, bacterial DNA sequencing analysis has garnered much attention, but clinical studies are rare in Japan. In this study, we assessed the usefulness of next-generation DNA sequencing (NGS) analysis for acute UTI patients. We thus performed an observational, retrospective case series study. Urine and blood samples were collected from ten acute UTI patients, of whom four had also been diagnosed with urosepsis. Seven variable regions of bacterial 16S rRNA genes were amplified by PCR and then sequenced by IonPGM. The identified bacterial species were compared with those identified using the culture tests and the clinical parameters were analyzed. As a result, the NGS method effectively identified predominant culture-positive bacteria in urine samples. The urine NGS also detected several culture-negative species, which have been reported to be potentially pathogenic. Out of four urosepsis cases, three were pathogen-positive in blood NGS results, while two were pathogen-negative in blood culture. In one sepsis case, although blood culture was negative for Escherichia coli, this species was detected by blood NGS. For non-sepsis cases, however, blood NGS, as well as blood culture, was less effective in detecting bacterial signals. In conclusion, NGS is potentially useful for identifying pathogenic bacteria in urine from acute UTI patients but is less applicable in patients who do not meet clinical criteria for sepsis.

Background Advances in medical equipment have resulted in changes in the management of severe trauma. The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) in this scenario is still unclear. This study aimed to evaluate the usage of REBOA and utility of computed tomography (CT) in the setting of aortic occlusion in our current trauma management. Methods This Japanese single-tertiary center, retrospective, and observational study analyzed 77 patients who experienced severe trauma and persistent hypotension between October 2014 and March 2020. Results All patients required urgent hemostasis. Twenty patients underwent REBOA, 11 underwent open aortic cross-clamping, and 46 did not undergo aortic occlusion. Among patients who underwent aortic occlusion, 19 patients underwent prehemostasis CT, and 7 patients underwent operative exploration without prehemostasis CT for identifying active bleeding sites. The 24-hour and 28-day survival rates in patients who underwent CT were not inferior to those in patients who did not undergo CT (24-hour survival rate, 84.2% vs. 57.1%; 28-day survival rate, 47.4% vs. 28.6%). Moreover, the patients who underwent CT had less discordance between primary hemostasis site and main bleeding site compared with patients who did not undergo CT (5% vs. 71.4%, p = 0.001). In the patients who underwent prehemostasis CT, REBOA was the most common approach of aortic occlusion. Most of the bleeding control sites were located in the retroperitoneal space. There were many patients who underwent interventional radiology for hemostasis. Conclusion In a limited number of patients whose cardiac arrests were imminent and in whom no active bleeding sites could be clearly identified without CT findings, REBOA for CT diagnosis may be effective; however, further investigations are needed. Level of evidence Therapeutic/care management study, level V.

Objectives We evaluated the necessity of revascularization for acute mesenteric ischemia in symptomatic patients with spontaneous isolated dissection of the superior mesenteric artery. Methods This retrospective study included 28 consecutive, symptomatic patients with spontaneous isolated dissection of the superior mesenteric artery treated at our hospital between December 2005 and December 2017. Patients with concomitant aortic dissection were excluded. We reviewed the patients’ clinical presentation; laboratory evaluations; computed tomography findings, including the true lumen residual ratio (i.e., the minimum true lumen size compared to the diameter of the transverse section of the dissected artery) at the time of admission; the number of patients who were suspected of having bowel ischemia; and the number of patients who required surgical or endovascular treatment and their outcomes. Additionally, to evaluate the true lumen residual ratio in symptomatic patients with bowel ischemia, the true lumen residual ratio in those with abnormal laboratory data were compared with that in those without abnormal laboratory data. Initial true lumen residual ratio values were also compared with final values. Furthermore, we assessed the clinical details of patients who had bowel necrosis. Categorical variables were compared using the χ2 test or Fisher’s exact test, and continuous values were presented as either the mean ± standard deviation or median (interquartile range 25–75%). Variables were analyzed using Student’s t-test or the Mann–Whitney U test. Results The patients’ age ranged between 41 and 85 years, and 25 were men. Although nine patients were suspected of having acute mesenteric ischemia, only one underwent bowel resection. None of the patients had an indication for revascularization. The true lumen residual ratio of the nine patients with abnormal laboratory data were significantly lower than those of the 19 without abnormal laboratory data (10 [0–25]% vs. 40 [20–50]%, p = 0.005). The patient who underwent bowel resection had a true lumen residual ratio of 10%; however, there was no obvious abnormal laboratory data suggestive of bowel necrosis. Dissections were managed conservatively in all patients. True lumen residual ratio increased from initial value of 30 (10–48)% to 98 (60-100)%at the final imaging study ( p Conclusions Reintervention is rarely required for spontaneous isolated dissection of the superior mesenteric artery, even in symptomatic patients, and spontaneous resolution of the luminal compromise is the rule.

OBJECTIVE Previous studies have demonstrated that Lenke lumbar modifier A contains 2 distinct types (AR and AL), and the AR curve pattern is likely to develop adding-on (i.e., a progressive increase in the number of vertebrae included within the primary curve distally after posterior surgery). However, the results of anterior surgery are unknown. The purpose of this study was to present the surgical results in a cohort of patients undergoing scoliosis treatment for type 1AR curves and to compare anterior and posterior surgeries to consider the ideal indications and advantages of anterior surgery for type 1AR curves. METHODS Patients with a Lenke type 1 or 2 and lumbar modifier AR (L4 vertebral tilt to the right) and a minimum 2-year postoperative follow-up were included. The incidence of adding-on and radiographic data were compared between the anterior and posterior surgery groups. The numbers of levels between the end, stable, neutral, and last touching vertebra to the lower instrumented vertebra (LIV) were also evaluated. RESULTS Forty-four patients with a mean follow-up of 57 months were included. There were 14 patients in the anterior group and 30 patients in the posterior group. The main thoracic Cobb angle was not significantly different between the groups preoperatively and at final follow-up. At final follow-up, the anterior group had significantly less tilting of the LIV than the posterior group (−0.8° ± 4.5° vs 3° ± 4°). Distal adding-on was observed in no patient in the anterior group and in 6 patients in the posterior group at final follow-up (p = 0.025). In the anterior group, no LIV was set below the end vertebra, and all LIVs were set above last touching vertebra. The LIV was significantly more proximal in the anterior group than in the posterior surgery patients without adding-on for all reference vertebrae (p < 0.001). CONCLUSIONS This is the first study to investigate the surgical results of anterior surgery for Lenke type 1AR curve patterns, and it showed that anterior surgery for the curves could minimize the distal extent of the instrumented fusion without adding-on. This would leave more mobile disc space below the fusion.

The indications for early plasma transfusion, and its optimal use, remain unclear. This study suggested that plasma given before hemostasis initiation could be an important factor for improving outcomes in hemodynamically unstable patients with blunt trauma, high D‐dimer levels, or a high Injury Severity Score., Aim This study aimed to evaluate the effect of plasma transfusion before urgent hemostasis initiation on in‐hospital mortality in hemodynamically unstable patients with severe trauma. Methods This retrospective observational study of patients admitted to hospital between January 2011 and January 2019 grouped patients according to whether plasma transfusion was initiated before (Before group) or after (After group) hemostasis initiation. Patients with severe trauma who were unable to wait for plasma transfusion and had started hemostasis before the plasma infusion were excluded. We used multivariable logistic regression analysis to determine the effect of plasma transfusion before the initiation of urgent hemostasis on in‐hospital mortality. Results We included 47 and 73 patients in the Before and After groups, respectively. Blunt trauma was more common, and the D‐dimer levels and Injury Severity Score were significantly higher in the Before group than in the After group (median D‐dimer, 57.5 versus 38.1 μg/mL; P = 0.040; median Injury Severity Score, 50 versus 34; P

OBJECTIVEThe aim of this study was to show the surgical results of growing rod (GR) surgery with prior foundation surgery (PFS) and sublaminar taping at an apex vertebra.METHODSTwenty-two early-onset scoliosis (EOS) patients underwent dual GR surgery with PFS and sublaminar taping. PFS was performed prior to rod placement, including exposure of distal and proximal anchor areas and anchor instrumentation filled with a local bone graft. After a period of 3–5 months for the anchors to become solid, dual rods were placed for distraction. The apex vertebra was exposed and fastened to the concave side of the rods using sublaminar tape. Preoperative, post–GR placement, and final follow-up radiographic parameters were measured. Complications during the treatment period were evaluated using the patients’ clinical records.RESULTSThe median age at the initial surgery was 55.5 months (range 28–99 months), and the median follow-up duration was 69.5 months (range 25–98 months). The median scoliotic curves were 81.5° (range 39°–126°) preoperatively, 30.5° (range 11°–71°) after GR placement, and 33.5° (range 12°–87°) at the final follow-up. The median thoracic kyphotic curves were 45.5° (range 7°–136°) preoperatively, 32.5° (range 15°–99°) after GR placement, and 42° (range 11°–93°) at the final follow-up. The median T1–S1 lengths were 240.5 mm (range 188–305 mm) preoperatively, 286.5 mm (range 232–340 mm) after GR placement, and 337.5 mm (range 206–423 mm) at the final follow-up. Complications occurred in 6 patients (27%). Three patients had implant-related complications, 2 patients had alignment-related complications, and 1 patient had a wound-related complication.CONCLUSIONSA dual GR technique with PFS and sublaminar taping showed effective correction of scoliotic curves and a lower complication rate than previous reports when a conventional dual GR technique was used.

Aim Despite recent advancements in trauma management following introduction of interventional radiology (IVR) and damage‐control strategies, challenges remain regarding optimal use of resources for severe trauma. Methods In October 2014, we implemented a trauma management system comprising emergency physicians competent in severe trauma management, surgical techniques, and IVR. To evaluate this system, of 5,899 trauma patients admitted to our hospital from January 2011 to January 2018, we selected 107 patients with severe trauma (injury severity score ≥ 16) who presented with persistent hypotension (two or more systolic blood pressure measurements

A pancreaticoduodenal artery (PDA) aneurysm develops due to increased flow through the pancreaticoduodenal arcade in the setting of celiac or superior mesenteric artery occlusion. Additionally, there is no evidence on the computed tomography scan or angiography images that the dissection process extends to the PDA arcade. Moreover, the optimal treatment protocols for PDA aneurysms with celiac artery obstruction and for celiac artery dissection are controversial. We report 2 cases of ruptured PDA aneurysms caused by celiac artery obstruction due to celiac artery dissection in which the aneurysm was excluded, but celiac artery revascularization was not performed successfully. Our cases indicate that endovascular management for ruptured PDA aneurysms and conservative management for celiac artery obstruction due to celiac artery dissection are feasible as first-line treatment in such cases.

Case A 45-year-old man presented to our emergency department with disturbance of consciousness; he had mentioned to his family earlier about a drug overdose. When first responders arrived, he suffered cardiac arrest. Cardiac arrest due to drug overdose was diagnosed.The patient was supported with venoarterial extracorporeal membrane oxygenation. Arterial blood gas showed mixed acidosis, and electrocardiogram showed junctional rhythm and complete right bundle branch block. Outcome The patient's blood pressure gradually decreased, and he died on the third day of hospitalization. After death, his serum diphenhydramine concentration at the time of arrival was found to be 18.7 μg/mL. Conclusion Although diphenhydramine is regarded as a safe medication, it shows dose-dependent toxicity. High intake is associated with death; therefore, caution should be exercised in cases of drug overdose. Developing a procedure for rapid measurement in the emergency department should be a priority.

Introduction Recently, trauma management has been markedly improved with interventional radiology (IVR) and damage-control strategies. However, the indications for its use in hemodynamically unstable patients with severe trauma remains unclear. In some cases, IVR may be more effective than surgery for damage-control hemostasis; however, performing IVR in life-threatening trauma settings is challenging. To address this, we practiced and evaluated a trauma-management system with emergency physicians who trained for both severe trauma management, and techniques of surgery and IVR. Materials and methods Among the 1822 patients with severe trauma admitted between October 2014 and December 2016, 201 underwent emergency surgery or IVR. Among these, 16 patients whose systolic blood pressure was ≤90 mmHg, without improvement following primary resuscitation, and whose first intervention was IVR, were analyzed. We retrospectively evaluated the admission characteristics, IVR-related characteristics, and prognoses, and compared several parameters before and after IVR. Results This study included 10 men and 6 women (median age: 46 years). IVR was performed for 10 pelvic fractures; five liver-, one splenic-, and one renal injury; and one transection each of the external carotid-, vertebral-, axillosubclavian-, intercostal-, and lumbar arteries. The mean times from the patient arrival, and diagnosis to the start of IVR were 56.3 ± 26.6 and 15.1 ± 3.8 min, respectively. The mean time spent in the angiography suite was 50 min. The systolic blood pressure, pulse rate, base excess/deficit, serum-lactate levels, and D-dimer values were significantly improved after IVR. Although two patients needed additional treatment for morbidities following IVR intervention, all achieved complete recovery. The mortality rate was 25.0%, and no preventable deaths were noted. Eight patients showed unexpected survival. Conclusions In some cases, IVR may be the best first measure for resuscitative hemostasis in potentially lethal multiple injuries, given efficient diagnoses/actions and the ability to deal with complications.

Background Recently, trauma management has been complicated owing to the introduction of damage-control strategies and interventional radiology. Here, we discuss important aspects regarding survival of patients with severe trauma. Case presentation A 74-year-old Japanese woman experienced a traffic accident on a highway. On arrival, paramedics were unable to measure her blood pressure, and her condition deteriorated. The patient was immediately transferred to our hospital in a physician-staffed emergency helicopter, during which she was administered emergency blood transfusions. On admission, her systolic blood pressure was 44 mmHg, and focused assessment with sonography for trauma yielded positive findings at the anterior mediastinum, right thoracic cavity, and intra-abdominal cavity. Plain radiography revealed a partial unstable-type pelvic fracture. Immediately, cardiac tamponade caused by the massive anterior mediastinal hematoma with internal thoracic vessel injuries was diagnosed through a median sternotomy, while a diaphragmatic rupture and hemorrhage from the intra-abdominal cavity were diagnosed through right anterior-lateral thoracotomy. Furthermore, massive bowel and mesenteric vessel injuries were diagnosed through laparotomy; all of these injuries were treated sequentially as a simplified process. The patient then underwent transcatheter arterial embolization for the retroperitoneal hematoma and the pelvic fracture. Reestablishing intestinal continuity was performed after intensive care. All procedures were seamlessly performed by trained emergency physicians, and the postoperative course was uneventful, with the patient recovering completely after rehabilitation. Conclusions The capability to perform complete resuscitative treatments that seamlessly combine surgery and interventional radiology in the appropriate order is important for the survival of patients with multiple traumatic injuries.

要旨 多臓器不全を合併した十二指腸水平脚の腸管気腫，門脈ガスの見られた症例を経験した。57歳の女性。主訴，意識障害。統合失調症にて精神病院入院中に腹痛と頻回な嘔吐後意識障害を生じ当院へ転院搬送となった。来院時Glasgow coma scale E1V1M1，血圧測定不能（頸動脈のみ触知可能）であった。原因精査目的で全身のCTを行うと腹部で十二指腸水平脚中心に腸管気腫・門脈ガス像が認められた。また，急性呼吸促迫症候群，播種性血管内凝固症候群，急性腎障害，敗血症性ショックを呈していた。本病態の原因は不明であったが，腹部理学的所見で汎発性腹膜炎の所見がなく，腹水は漿液性であったため，緊急開腹術を行える体制を整えて非手術的に行った。入院後の上部消化管造影および内視鏡にて十二指腸水平脚に潰瘍性病変を認めた。第20病日に同病変部より消化管出血を来したが，経カテーテル動脈塞栓術にて超選択的に止血できた。さらにその後，十二指腸水平脚全体に狭窄を生じたが経過観察にて徐々に改善し，第60病日軽快転院した。十二指腸水平脚の潰瘍・腸管気腫は非常に稀な病態である。多臓器不全を呈していても，汎発性腹膜炎の所見がなければ保存的治療で救命できる。 ABSTRACT We report a patient with horizontal duodenal ulcer and pneumatosis intestinalis, complicated with hepatic portal venous gas, and multiple organ failure, who made a complete recovery without surgery. A 57–year–old female was admitted to a mental hospital for schizophrenia and developed frequent vomiting. Because her condition did not improve, she was transported to our hospital. Upon admission to our hospital, she was unconsciousness and in shock. However, she recovered slowly via immediate initial medical care. She was diagnosed with duodenal pneumatosis intestinalis, hepatic portal venous gas, and septic shock complicated with acute respiratory distress syndrome, disseminated intravascular coagulation, and acute kidney injury. Because findings from abdominal physical examination were mild at this time and the biopsied ascites was serous, we decided to not perform surgery. Gradually, her vital signs, general condition, and inflammatory signs improved. After that, she experienced massive gastrointestinal hemorrhage from the duodenum, but we were able to stop the bleeding by transcatheter arterial embolization. Additionally, although a duodenal stricture was encountered, it also recovered conservatively. After that there were no complications. Horizontal duodenal ulcer and pneumatosis intestinalis are very rare and the cause of this pathology was unclear. However, we were able to save this patient without surgical treatment.

BackgroundTrauma management requires a multidisciplinary approach, but coordination of staff and procedures is challenging in patients with severe trauma. In October 2014, we implemented a streamlined trauma management system involving emergency physicians trained in severe trauma management, surgical techniques, and interventional radiology. We evaluated the impact of streamlined trauma management on patient management and outcomes (study 1) and evaluated determinants of mortality in patients with severe trauma (study 2).MethodsWe conducted a retrospective cohort study of 125 patients admitted between January 2011 and 2019 with severe trauma (Injury Severity Score ≥16) and persistent hypotension (≥2 systolic blood pressure measurements ResultsCompared with the Before cohort (n=59), the After cohort (n=66) had a significantly lower in-hospital mortality (36.4% vs. 64.4%); required less time from hospital arrival to initiation of surgery/interventional radiology (median, 41.0 vs. 71.5 minutes); and was more likely to undergo resuscitative endovascular balloon occlusion of the aorta (24.2% vs. 6.8%). Plasma administration before initiating hemostasis (adjusted OR 1.49 (95% CI 1.04 to 2.14)), resuscitative endovascular balloon occlusion of the aorta (9.48 (95% CI 1.25 to 71.96)), and shorter time to initiation of surgery/interventional radiology (0.97 (95% CI 0.96 to 0.99)) were associated with significantly lower mortality.DiscussionImplementing a streamlined trauma management protocol improved outcomes among hemodynamically unstable patients with severe multiple trauma.Level of evidenceLevel III.

Objectives It is controversial whether to stop the fusion at L5 or S1 in adult spinal deformity (ASD) surgery. Our hypothesis is that we can stop long fusion at L5 for selected patients with less severe disability and less complex deformity. Aim was to compare minimum 5-year outcomes between ASD patients with fusion to L5 versus S1. Patients and methods Consecutive 40 patients (≥50 years of age) with ASD underwent spinal fusion from lower thoracic spine to L5 or S1 between 2008 and 2011. 33 patients (82.5 %) had a minimum 5-year follow-up. Lower instrumented vertebra (LIV) was L5 in 12 patients (L5 group) and S1 in 21 (S1 group). Clinical and radiographical parameters were compared between L5 and S1 group. Results There were statistically significant differences between two groups (L5 vs S1) in %male (50 % vs 14 %), %type-N of SRS-Schwab classification (83 % vs 38 %), preop ODI (40.5 vs 56), correction loss of LL (11˚ vs 3˚), final TK (32˚ vs 50˚), correction loss of TK (-1˚ vs 17˚), final improvement of PT (3˚ vs 10˚), final improvement of PI-LL (26˚ vs 39˚), PJK (8% vs 48 %), and revision surgery rate (50 % vs 14 %). Causes of revision surgery in L5 group were distal junctional failure in 5 patients and foraminal stenosis at L5-S1 in 1. All of them underwent additional spinal fusion to the sacrum. Whereas, causes of revision surgery in S1 group were rod fracture in 2 patients and proximal junctional failure in 1. Conclusion Although fusion to L5 was conducted for selected ASD patients with less severe disability (better ODI) and less complex deformity (type N), 50 % of the patients required additional fusion to the pelvis. Decision making to stop the long fusion at L5 for ASD patients ≥50 years of age should be made with careful considerations.

The re-distribution layer (RDL) first type fan out technology is expected to be used for the advanced packages with fine pitch wiring such as side by side die to die interconnection. To demonstrate the fabrication of RDL-first Fan out- Panel level package/wafer level package (FO-PLP/WLP), the actual package was designed. The influences of the material properties of the capillary underfill (CUF) and epoxy molding compound (EMC) on the warpage and the stress on fine patterns for the designed RDL-first FO-PLP were investigated. The numerical analysis was performed. As for the warpage, it was found that warpage can be reduced by using low modulus CUF and EMC. As for the stress on fine patterns, it was revealed that the stress concentrates at the gap between dies, the under part and the tip of the fillet of CUF. By using low Tg CUF, the stress on fine pattern was greatly reduced at 20°C. It was estimates that the low Tg of CUF is effective for the stress reduction. From these results, we selected the optimum combination of CUF and EMC for this designed package. 4 RDL layers, which include line and space of 2/2, 3/3, 5/5 and $5/ 5 \mu \mathrm{m}$ were successfully fabricated with the format size of 320 mm square. The layers were interconnected with small diameter filled Cu vias of $9 \mu \mathrm{m}$. As for the bonding of 8 dies, two bonding methods were carried out with the thermal compression bonder. One was TCB using CUF. The other was the collective bonding by TCB using NCF. Both of the bonding methods could make the solder joints and the solder wetting to the electrode from the bump. Finally the compression mold with granular material was carried out.

要旨 浸水性肺水腫（Immersion Pulmonary Edema，以下IPE）とは潜水や水泳で急性発症する肺水腫であり，多くは速やかに改善するが死亡例の報告もある。IPEの発症機序は不明な点が多く，非心原性肺水腫であると報告されていたが，近年では一過性心筋障害が関与している可能性が報告されている。今回我々は，一過性の心筋トロポニン上昇と心臓壁運動低下を認め，心臓核医学検査で交感神経過亢進と考えられる所見を認めたIPE症例を経験したので報告する。【症例】52歳の女性。水温18°C，最大深度8.4m，平均深度5.5m，潜水時間20分のSCUBAダイビングを行った。潜水中にトラブルはなかったが，浮上後5分程度で呼吸困難が出現したため近医を受診し，減圧症の可能性が考えられ当院に転院搬送となった。来院時の胸部単純レントゲン及び胸部単純CTでは両側肺水腫を認めた。また心筋トロポニンの軽度上昇，心電図検査では非特異的STの変化，心臓超音波検査では軽度の瀰漫性壁運動低下を認めた。肺水腫に伴う低酸素血症の診断で人工呼吸器管理下に集中治療を行った。翌日，肺水腫と低酸素血症は著明に改善し呼吸器を離脱し，第11病日に合併症なく退院となった。入院中の検査では，冠動脈CTで有意狭窄はなく，第2，第3病日の心臓超音波検査は正常であった。また第9病日に行った心筋SPECT MIBGシンチグラフィでは明らかな心筋障害はなかったが，交感神経過亢進と考えられる所見があった。経過，検査結果より減圧症・動脈ガス塞栓・急性冠症候群などは否定的であった。来院時は心筋障害を示す検査結果であったが，症状軽快後の心臓核医学検査では心筋障害はないことから，本症例は交感神経過亢進に伴う一過性心筋障害が関与したIPEと考えた。ダイビングは運動負荷や冷水刺激等により交感神経が刺激されることからIPE発症機序の一つに交感神経過亢進による一過性心筋障害の可能性があると考える。 ABSTRACT Immersion pulmonary edema (IPE) is an acute onset condition occurring due to swimming or diving and it can be potentially fatal. The pathogenesis of IPE is unknown, but reversible myocardial dysfunction is possibly involved. We report a case of IPE wherein transient elevation of cardiac troponin levels, hypokinesis of cardiac left ventricle, and sympathetic over–activation on nuclear cardiology testing were observed. A 52–years–old woman developed dyspnea after scuba diving and was immediately rushed to the hospital. On arrival, radiography showed bilateral pulmonary edema. Her cardiac troponin I level was increased and diffuse hypokinesis of left ventricle was observed. She was diagnosed with hypoxemia and pulmonary edema, admitted to the intensive care unit, and maintained on a ventilator. The next day, her hypoxemia and pulmonary edema improved markedly and extubated. She was discharged on hospital day 11 without any complications. Echocardiogram taken on the second hospital day and coronary artery CT were normal. No myocardial damage was evident on nuclear cardiology testing, but sympathetic over–activation was noted. We believe that the sympathetic nerve is stimulated by cold water and exercise, and reversible myocardial dysfunction may occur due to increased sympathetic over–activation; this could be the pathogenesis of the IPE.

Objectives To describe our clinical experiences and recommend a management strategy for spontaneous isolated dissection of a visceral artery. Methods A retrospective study of patients from December 2005 to December 2015 was performed. Thirty-two patients had spontaneous isolated dissection of a visceral artery. Clinical features, computed tomography findings, the treatment method, and follow-up results were evaluated. Results There were 28 men and 4 women (mean age, 54 years). Dissection locations were the celiac artery in 10, superior mesenteric artery in 17, and celiac artery and superior mesenteric artery in 5 patients. Celiac artery stenosis existed with spontaneous isolated dissection of a visceral artery at a high rate. After diagnosis, the blood pressure of all patients was immediately controlled to a lower level. Three patients with arterial rupture and one patient with bowel infarction underwent operations for complications. Overall, the treatment of dissection involved drug therapy alone. The last follow-up computed tomography results of the true lumen residual ratio and the length of the dissected artery improved compared to the values on admission; the maximum diameter of the dissected artery did not enlarge. Eleven patients almost completely improved. No patients had any adverse event. Conclusions Most patients with spontaneous isolated dissection of a visceral artery can be first treated conservatively for dissection with strict blood pressure control and surveillance.

The patient was an emergency transported, 57-year-old man complaining of left thoraco-lateroabdominal pain, with a history of blunt chest trauma 3 months prior. Thoracoabdominal computed tomography (CT) resulted in a diagnosis of diaphragmatic hernia with incarceration and perforation of the stomach, and same-day emergency surgery was performed. The surgery was performed via an abdominal approach, and after manually repositioning the stomach incarceration, the perforated region was resected and the diaphragm sutured closed. Diaphragmatic hernia can be occasionally difficult to diagnose at the time of initial treatment, and may have been overlooked at the initial presentation, 3 months earlier in the present case. When examining a case of blunt force thoracoabdominal trauma, it is important to keep in mind the possibility of diaphragmatic injury. Additionally, during surgery for traumatic diaphragmatic hernia, in cases where manipulation of the abdominal organs is thought necessary, commencing the surgery with an abdominal approach is desirable.

An 86-year-old woman was transported by ambulance after jumping from the second floor of a building. Upon arrival, the blood pressure was stable; however, computed tomography indicated the presence of an anterior mediastinal hematoma. Eight hours after arrival, the patient exhibited shock. The blood pressure increased with rapid infusion. Emergency angiography was performed. Extravasation from the musculophrenic artery, which branches off from the left internal mammary artery, was observed. Transcatheter arterial embolization was performed and bleeding was controlled. This is the first report of musculophrenic artery injury caused by blunt trauma to the best of our knowledge. Findings suggested that if an anterior mediastinal hematoma develops, bleeding must be rapidly controlled. If the patient responds to rapid infusion and injury of the internal mammary artery or one of its branches is suspected, transcatheter arterial embolization is considered appropriate.

Aim Severe caffeine poisoning is rare, but is associated with high mortality. Plasma caffeine concentration is one of the indications of treatment of caffeine poisoning; however, it is not easily measured at most emergency departments. If the plasma lactate concentration and the plasma caffeine concentration were correlated, the plasma lactate concentration may be an indication of caffeine poisoning. In this study, we investigated the correlation between the plasma lactate concentration and the plasma caffeine concentration. Methods From April 2010 to March 2012, 18 patients with severe caffeine poisoning by overdose were admitted at our Emergency Center. The plasma lactate concentration and plasma caffeine concentration of 10 patients were determined at the same time at 12–24 h after admission. These findings were plotted and we analyzed the correlation and trends in these concentrations. Results There were strong correlations between the plasma lactate concentration and the plasma caffeine concentration at admission (n = 18) and at 12–24 h after admission (n = 10) (correlation coefficients, 0.95 and 0.91, respectively). There was a strong positive correlation between the trend of the plasma lactate concentration and the plasma caffeine concentration (n = 10). The correlation coefficient was 0.91. Conclusion These results are extremely beneficial for emergency department clinical physicians because such findings permit the determination of the severe caffeine poisoning patient. Additionally, the plasma lactate concentration might be one of the indicators of hospitalization and discharge.

We provided toxicological analytical support for a fatal case of abuse of α-pyrrolidinovaleorophenone (α-PVP). Solid-phase microextraction (SPME) and capillary gas chromatography coupled to mass spectrometry (GC–MS) was employed to quantify the drug in whole blood. The whole blood concentration of the drug in the heart was 486 ng/ml. This is the first report of α-PVP intoxication as ascertained by mass spectrometric identification of α-PVP in whole blood.

Context: α-Pyrrolidinovalerophenone (α-PVP) is a synthetic cathinone that has been abused in recent years. The clinical presentation of acute α-PVP poisoning has not been well characterized. Objective: To elucidate the clinical features of acute α-PVP poisoning. Materials and methods: This retrospective case series included eight subjects that visited our hospital emergency department (ED) between March 2012 and November 2014 and had analytically confirmed blood α-PVP levels. Data related to subject demographics, clinical history, laboratory findings, blood drug levels, and outcome were collected. Results: The median age of the eight study subjects was 27 (range; 21–63) years, and six were male. Drug preparations had been administered by rectal insertion (three subjects) or inhalation (five subjects). The time between drug exposure and presentation at the ED was 8.5 (1–24) h and blood α-PVP concentrations ranged from 1.0 to 52.5 ng/ml. Although psychiatric and neurological findings were reported before arrival at the ED in 5/8 and 7/8 subjects, respectively, these were only observed in 1/8 and 2/8 subjects, respectively, at the ED. Symptoms of high body temperature (3/8), tachycardia (5/8), hypertension (3/8), acid-base balance disorder (5/8), coagulopathy (4/6), blood creatinine phosphokinase >190 U/l (6/8), and a blood lactate level > 1.7 mmol/l (5/7) were observed. All subjects survived and were discharged. Conclusions: This retrospective case series showed that after acute exposure to α-PVP, transient neuropsychiatric findings were accompanied by more persistent sympathomimetic physical findings, disorders of acid-base balance and blood coagulation, high blood creatinine phosphokinase, and hyperlactacidemia.

A rapid, specific, and sensitive method for the simultaneous quantitation of organophosphates (fenitrothion (MEP), malathion, and phenthoate (PAP)), glufosinate (GLUF), and glyphosate (GLYP) in human serum and urine by gas chromatography-mass spectrometry (GC-MS) has been validated. All of the targeted compounds together with the internal standard were extracted from the serum and urine using a mix-mode TiO-C(18) monolithic spin column. The recovery of organophosphates from serum and urine ranged from 12.7 to 49.5%. The recovery of GLUF and GLYP from serum and urine ranged from 1.9 to 7.9%. The intra- and inter-accuracy and precision (expressed as relative standard deviation, %RSD) were within 96.7-107.7% and 4.0-13.8%, respectively. The detection and quantitation limits for serum and urine were 0.1 and 0.1 µg/ml, respectively, for organophosphates, 0.1 and 0.5 µg/ml, respectively for GLUF and GLYP. The method had linear calibration curves ranging from 0.1 to 25.0 µg/ml for organophosphates and 0.5-100.0 µg/ml for GLUF, and GLYP. The validated method was successfully applied to a clinical GLYP poisoning case.

The etiology of a novel cardiac syndrome called "tako-tsubo" cardiomyopathy, otherwise known as "acute onset and reversible left ventricular apical wall motion abnormality (ballooning)," is very similar to that of acute myocardial infarction; however, it may also be associated with emotional or physical stress. We report a case of tako-tsubo-like left ventricular dysfunction with ST-segment elevation after trauma. A 69-year-old man was transferred to our hospital after a fall in which he injured his back. He was diagnosed with a central spinal cord injury and was admitted to our Intensive Care Unit. He complained of a sudden chest pain 12 h after the injury. ST-segment elevation was observed on the electrocardiographic monitor, and subsequent 12-lead electrocardiogram demonstrated ST-segment elevation in leads V(2) through V(5). We considered acute myocardial infarction or cardiac contusion to be the cause of this event; therefore, an emergency coronary angiography was performed. However, the angiography revealed no significant coronary artery stenosis. Furthermore, left ventriculography demonstrated severe hypokinesis of the left ventricular apical region, consistent with tako-tsubo-like left ventricular dysfunction. The patient's cardiac function improved gradually, and he was discharged from our hospital on the 18(th) day after admission. Physicians should recognize the syndrome of tako-tsubo-like left ventricular dysfunction, which may result from traumatic stress or chest injury.

Prompt identification of causative pathogenic bacteria is imperative for the treatment of patients suffering from infectious diseases, including sepsis and pneumonia. However, current culture-based methodologies have several drawbacks including their limitation of use to culturable bacterial species. To circumvent these problems, we attempted to detect bacterial DNA in blood using next-generation DNA sequencing (NGS) technology. We conducted metagenomic and 16S ribosomal RNA (rRNA) gene amplicon sequencing of DNA extracted from bacteria-spiked blood using an Ion Personal Genome Machine. NGS data was analyzed using our in-house pipeline Genome Search Toolkit and database GenomeSync. The metagenomic sequencing analysis successfully detected three gram-positive and three gram-negative bacteria spiked in the blood, which was associated with a significant portion of non-bacterial reads, even though human blood cells were separated by low-speed centrifugation prior to DNA extraction. Sequencing analysis of seven variable regions of the 16S rRNA gene amplicon also successfully detected all six bacteria spiked in the blood. The methodology using 16S rRNA gene amplicon analysis was verified using DNA from the blood of six patients with sepsis and four healthy volunteers with potential pathogenic bacteria in the blood being identified at the species level. These findings suggest that our system will be a potential platform for practical diagnosis in the future.

The purpose of this study was to investigate whether resilient denture liners has the potential to decrease problems affecting the alveolar ridge mucosa during the first adjustment session following the initial fitting of the denture. Interventions were complete denture treatment with permanent acrylic resilient denture liner dentures (RLD) in mandibles and conventional heat-activated acrylic resin dentures (ARD) in mandibles. Maxillary dentures were fabricated with conventional heat-activated ARD. Seventy-four subjects were randomly allocated to the RLD and ARD groups by random permuted blocks within the strata method after obtaining written informed consent. A randomized controlled parallel clinical trial with two hospital centres was conducted from April 2004 to July 2006. The problems were comprehensively evaluated by three outcomes with subjective and objective factors as follows: (i) numbers of sore spots, (ii) duration of wearing dentures and (iii) pain perception with 100 mm Visual Analog Scale. The numbers of sore spots in the mandibular support and border areas for the RLD group were significantly less than those for the ARD groups (P < 0.05). The RLD wearers were able to wear their dentures an additional day longer than the ARD wearers (P < 0.05). The maxillary and mandibular pain ratings for the RLD group were significantly lower than those for the ARD group (P < 0.05). Application of resilient denture liners to mandibular complete dentures provided edentulous patients with fewer problems affecting the alveolar during the first adjustment session following the initial fitting of the denture when compared with conventional denture treatments.

We report here the clinical course of a 31-year-old male who recovered from a fulminant form of mitochondrial myopathy with lactic acidosis. The patient was transferred to our hospital with acute dyspnea and a convulsive seizure. On admission, he was in a state of shock, and presented with severe high-output heart failure, acute renal failure, and rhabdomyolysis. Treatment with continuous venovenous hemodiafiltration (CVVHDF) resulted in an excellent response, with no signs of hemodynamic instability. This case suggests that CVVHDF with serial hemodynamic monitoring may be effective in treating hypotensive patients with a life-threatening mitochondrial disorder.

Purpose: The purpose of this study was to demonstrate how a clinician’s experience might affect the complete denture treatment.Methods: A randomized controlled parallel clinical trial at two hospitals was conducted from April 2004 to July 2006. Written informed consent was obtained from the study subjects. Permuted-block randomization was performed with a block size of 4, indicating that not only was the clinician’s experience randomized) but also the denture base materials used (conventional acrylic resin and resilient liner). The chair time required for each step of complete denture treatment was compared between the junior clinician and senior clinician groups. The clinical protocol was carried out as follows: the preliminary impression, final impression, maxillomandibular registration, trial placement, denture delivery, and the number of visits for denture adjustments. Seventy-four subjects were assigned to this trial.Results: Significant differences were observed between the junior clinician and senior clinician groups with regard to chair time required for final impressions and the number of visits required for denture adjustments. There were no differences in chair time required for the other treatment steps.Conclusion: This randomized controlled clinical trial revealed that a clinician’s experience has an obvious influence on the chair time required for a final impression and the number of visits for denture adjustment.

Thin films with average layer thickness 100 nm of poly[( R )-3-hydroxybutyric acid] (P[( R )-3HB]) and poly[( R )-3-hydroxybutyric acid- co -10 mol% 6-hydroxyhexanoic acid] were isothermally crystallized at a given crystallization temperature after melting at 200°C. The spherulitic and lamellar morphologies of polyester thin films were investigated by means of optical microscopy, transmission electron microscopy and atomic force microscopy. After isothermal crystallization, the uniform two-dimensional spherulites which have the stacking texture of flat-on lamellae were developed throughout both polyester thin films. Each flat-on crystal gave a well-resolved electron diffractogram, and all electron diffractograms were identical. Accordingly, the 6-hydroxyhexanoic acid units were rejected from the tightly packed region of lamellar crystals. Both the lamellar periodicity and lamellar width of polyester thin films increased with a rise in the crystallization temperature. At the growth front of crystalline lamellae, microfibril crystals with 30–50 nm width were present. The enzymatic hydrolysis of thin films was carried out at 25°C using an aqueous solution of PHB depolymerase from Alcaligenes faecalis . After enzymatic degradation, the jagged texture along the crystal long-axis could be observed at the ends of crystalline lamellae on the surface of the thin films. These observations suggest that the lamellar crystals of P[( R )-3HB] is composed of both tight molecular packing regions of microfibril crystals and loose molecular packing boundary regions.

Background: There are few reports on long-term convalescence with regard to cardiac injury caused by blunt chest trauma. Nuclear medicine study of the heart (NMSH) in the early stages of injury is reportedly superior to detect the correlation between injury and fatal arrhythmia. Therefore, we prospectively performed NMSH and Holter electrocardiogram (ECG) in the early and chronic stages for a cardiac injury patient, and we longitudinally examined the recovery process and the occurrence of fatal arrhythmia. Methods and Results: A total of 202 patients with blunt chest trauma were admitted to our hospital between April 2006 and January 2007. Of 65 patients who were diagnosed with cardiac injury by ECG, a myocardial enzyme, or cardiac ultrasonography, 11 were enrolled in this study because they agreed to outpatient visiting for regular examinations for 1 year. NMSH showed positive findings in 6 of the 11 patients in the acute period of < 1 month. Twelve months later, five patients improved but still exhibited protracted cardiac damage without complete recovery. Among the six patients in whom NMSH showed positive findings, Holter ECG indicated an abnormal finding in two patients in the acute period and in four patients in the chronic period, and detected one patient with a nonsustained ventricular tachycardia in the chronic period. Conclusion: Cardiac injuries may exacerbate cardiac functions and lead to fatal arrhythmia during the chronic period. Therefore, evaluating recovery for at least 12 months after myocardial damage is necessary to prevent sudden cardiac death.

Melt-crystallized films of poly[( R )-3-hydroxybutyric acid- co -10mol% 6-hydroxyhexanoic acid] (P[( R )-3HB- co -6HH]) were prepared by isothermal crystallization at various temperatures for 3 days, and subsequently stored at room temperature after the films formed well-developed and volume-filled spherulites. The lamellar morphologies and properties of melt-crystallized films were characterized by means of wide-angle X-ray diffraction, small-angle X-ray scattering, differential scanning calorimetry, transmission electron microscopy, and atomic force microscopy. The melting endotherm of P[( R )-3HB- co -6HH] films was composed of a broad peak starting around room temperature and of a sharper peak starting above the isothermal crystallization temperature. The stacking of flat-on lamellae with lamellar periodicity of 8–10 nm was detected on the surface of P[( R )-3HB- co -6HH] films after the primary crystallization at 110°C. On storage at room temperature above the T g (−5°C) of copolyester, thin crystals of 1–4 nm thickness appeared on the surface of P[( R )-3HB- co -6HH] films crystallized at 110°C. These results suggest that long sequences of ( R )-3HB units in a random copolyester form relatively thick P[( R )-3HB] crystalline lamellae during the primary crystallization process at a given crystallization temperature, while shorter sequences of ( R )-3HB units, which are incapable of crystallizing at a given crystallization temperature, form relatively thin crystalline lamellae during the subsequent crystallization process at room temperature.

Purpose: This study investigated the inhibitory effect of acrylic resin incorporating FAp-TiO2 against the adhesion of C. albicans.Materials and methods: FAp-TiO2 was added at 1, 5, 10 wt% to acrylic resin to form specimen disks of 7 mm diameter, and the surface roughness was measured. Then, C. albicans was cultured aerobically at 37 °C for 24 hours in glucose peptone yeast extract (GPY) broth, and adjusted to OD=1 at 550 nm with a KCl-buffer. The disks were immersed in the C. albicans suspension for 2 hours at 37 °C with UVA from a black light source. After the incubation, the disks were washed gently with phosphate buffer saline (PBS), and the luminescent signal derived from the viable cells on the disks was determined using a bioluminescence adenosine triphosphate (ATP) assay.Results: In the measurement of surface roughness, no significant difference was observed between any of the specimens. The adhesion assay of C. albicans revealed that a statistically significant decrease was observed in FAp-TiO2 when compared with the control (p‹0.01).Conclusion: We suggest that acrylic resin incorporating FAp-TiO2 prevents the adhesion of C. albicans, indicating a wide range of possibilities for the practical use of new photocatalysts in acrylic resin.