Acute Medicine & Surgery最新文献

Sedation for invasive procedures is given for various clinical purposes to patients of all ages worldwide. However, sedation is a continuum to general anesthesia and contains severe inherent risks leading to mortality. Providing a simulation-based sedation training course (SEDTC) to various medical staff could be an effective strategy to improve patient and medical safety associated with sedation. The SEDTC generally includes basic airway management such as upper airway obstruction release or rapid response action toward excessive sedation, utilizing problem-based learning or simulators. However, participation alone in the SEDTC can only achieve Level 1 (reaction) or 2 (learning) in the Kirkpatrick model. A patient safety improvement of Level 3 (transfer) or 4 (result) of the Kirkpatrick model can be achieved when all members related to sedation undergo experiential learning and reach a consensus. Accordingly, in-hospital interprofessional SEDTC focusing on a resilience approach is essential to achieve effective sedation patient safety in Level 3 or 4 of the Kirkpatrick model.

Tokumaru T, Kurata H, Nakaebisu R, Tomioka J. Aggressive surgery for incisional hernia with necrotizing soft tissue infection highlighting unique abdominal findings. Acute Med Surg. 2023;10(1):e907.

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We would like to apologize for any inconvenience caused. Aside from this, there are no other errors, and the modifications do not change the overall structure or the central thesis of the paper.

A 69-year-old woman with a history of systemic sclerosis was admitted to the emergency department because of vertigo and nausea. She had been prescribed proton pump inhibitors for several years. Physical examination revealed downbeat nystagmus (DBN) in all gaze directions. Laboratory examination revealed hypomagnesemia with a critically low serum magnesium level of 0.1 mg/dL. Head magnetic resonance imaging showed no abnormalities on T1-, T2-, or diffusion-weighted imaging; however, arterial spin labeling (ASL) revealed hyperintensity in the cerebellar nodulus (Figure 1A). She received magnesium supplementation and the proton pump inhibitors were discontinued. After 5 months of follow-up, the DBN disappeared. The magnesium levels normalized to 1.8 mg/dL and hyperintensity improved by ASL imaging (Figure 1B).

Downbeat nystagmus is associated with central vertigo.¹ It occurs due to impairments in the flocculus or nodulus of the cerebellum.^{2, 3} The underlying causes include congenital malformations, tumors, trauma, localized damage from encephalitis, and local functional issues, such as low magnesium levels.^{1, 4} A previous study has highlighted that in patients with paraneoplastic DBN, brain fluoro-d-glucose-positron emission tomography (FDG-PET) can identify increased metabolism in the cerebellar nodulus.⁵ However, FDG-PET is not generally indicated for the diagnosis of DBN. Our case suggests that similar findings can be easily identified using ASL imaging, which is less invasive and more straightforward. Arterial spin labeling imaging should be considered for patients with DBN, even if other radiological investigations do not reveal any abnormalities.

The authors declare no conflicts of interest.

Approval of the research protocol: N/A.

Informed consent: Informed consent was obtained from the patient.

Registry and the registration no. of the study/trial: N/A.

Animal studies: N/A.

An 81-year-old woman presented with swelling and purpuric rash on her right leg lasting for 1 month. She reported no fever or dyspnea but complained of right leg pain. She had hypertension and dyslipidemia. On presentation, her vital signs were not significant. On examination, her right lower limb was swollen with a slightly dark-colored skin and nontender, nonpalpable purpura over her right lower leg (Figure 1A). Laboratory tests showed normal platelet counts and elevated D-dimer levels. Subsequent contrast-enhanced computed tomography revealed venous thrombosis from the right femoral vein to the right popliteal vein but no pulmonary embolism. Intravenous heparin improved her limb swelling and purpura within 7 days (Figure 1B). Then, she was discharged after switching from heparin to apixaban.

Purpura is a clinical manifestation of blood extravasation into the mucosa or skin due to vessel wall damage, vascular occlusion, or coagulopathy.¹ Features of purpura in this case suggest a congestion of the anterior accessory great saphenous vein, which drains into the femoral vein.² Given that purpura is an unusual presentation of deep vein thrombosis,^{1, 3} in addition to venous occlusion by thrombosis, locally incompetent valves and a weakened venous wall, particularly in older women,⁴ might cause purpura at the proximal lower limb.

None.

The authors declare that they have no conflicts of interest.

Approval of the research protocol: N/A.

Informed consent: Informed consent was obtained from the patient.

Registry and the registration no. of the study/trial: N/A.

Animal studies: N/A.

A woman aged in her 80s had multiple comorbidities with congestive heart failure, aortic stenosis, and chronic renal failure. The QTc interval 6 months before admission was normal (454 ms) (Figure 1A). Three days pre-admission, the maximum dose of sitafloxacin was prescribed to treat urinary tract infections. She presented with convulsions, a complete atrioventricular block, a prolonged QTc interval (538 ms) (Figure 1B), and recurrent torsade de pointes (TdP) (Figure 1C). Treatment involved 2 g magnesium sulfate infusion, noninvasive positive pressure ventilation, and emergency pacing. After the heart failure management with discontinuation of sitafloxacin, the QTc interval was improved by 501 and 466 ms on day 7 and 20, respectively (Figure 1D,E). She remained healthy at 6-month follow-up. Oral quinolones are commonly prescribed antibiotics in clinical settings¹; it could induce QT prolongation as hERG gene class effects on potassium channels and causes TdP, especially in the elderly.¹ Treatments are as follows^{2, 3}: external defibrillation, deep sedation with intubation, mechanical circulatory support, eliminating causes, intravenous magnesium sulfate irrelevant to the renal dysfunction, correct serum potassium level, isoproterenol infusion, and temporary overdrive pacing.^{2, 3} The dosage of quinolones should be adjusted according to renal function,¹ and should be prescribed based on age and comorbidities.

The authors have no conflict of interest to declare.

Approval of the research protocol: N/A.

Informed consent: We obtained the informed consent from the patient for the publication of the report.

Registry and the registration no. of the study/trial: N/A.

Animal studies: N/A.