Acute Medicine & Surgery最新文献

A 24-year-old male with autism presented to the emergency department with recurrent vomiting. His mother found crayon fragments in the vomitus. Computed tomography revealed multiple high-density cylindrical objects in the lower esophagus, stomach, and isolated in the ileum (Figure 1A,B). Urgent upper gastrointestinal endoscopy was performed under general anesthesia and 24 crayon fragments were successfully retrieved from the stomach (Figure 1C,D). The crayons in the ileum were defecated without complications.

Although methemoglobinemia induced by colored crayons has been reported previously,^{1, 2} current crayon formulations consist largely of nontoxic wax with an extremely low risk of acute toxicity. Because crayons are not readily digestible enzymatically or thermally in the gastrointestinal tract owing to a melting point of approximately 60°C, they can readily cause complications such as gastrointestinal obstruction or choking on aspirated vomit. Guidelines for the management of foreign bodies in the stomach recommend urgent removal of sharp or long (≧6 cm in length) objects by urgent endoscopy.³ In this case, the crayon fragments were blunt and <6 cm each, but urgent endoscopy under general anesthesia was performed because the patient with autism was concerned about being unable to express discomfort or pain when complications occurred.

The authors declare no conflicts of interest.

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Informed consent: Written informed consent was obtained from the patient's family for the publication of this case report and accompanying images.

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Animal studies: N/A.

We enjoyed reading the article by Kohri et al., titled “Early do-not-attempt resuscitation orders and neurological outcomes in older out-of-hospital cardiac arrest patients: A multicenter observational study” and would like to offer additional commentary on the article.¹ We hope these perspectives may provide insight into areas that may require further research and improvement.

Kohri et al. reported on the association between early DNR orders and neurological outcomes in OHCA patients, highlighting any possible trends between early DNR orders and OHCA patients. They found that those with a DNR order placed received less therapeutic care intervention and had worse neurological outcomes after the same time period, compared to non-DNR patient counterparts. The paper calls for the reconsideration of the implementation of DNR shortly after cardiac arrest in acute care settings.

Kohri et al. had studied the DNR orders and their associated outcomes; however, it lacks the comprehensive assessment of the patient's symptoms leading to the DNR orders, which presents several limitations in the observational study. As a result of this, the conclusion may be misleading as the DNR decision-making may have been impacted by other factors, such as pain management.²

Although the article has a limited level of balancing and confounding through elements such as propensity score analysis, it does not account for subjectivity and biases on the personal level. The clinical judgment or personal biases may vary from individual to individual, and different institutions and hospitals may have their own policies and clinical expertise, resulting in a reduction in the robustness of the conclusion.³

Lastly, the methodology used in the article is quite simplistic and does not capture the overwhelmingly complex reality of healthcare, in which there are a number of different variables that could affect it, such as religion, belief, or socio-economic factors of the family outside the clinical field.⁴

Ultimately, this paper presents a timely and relevant investigation into the correlation between DNR decisions and the neurological outcomes of OHCA patients. By addressing these issues, we can help strengthen the conclusions of essential studies used to improve healthcare globally. We applaud the authors for not only emphasizing the importance of the stress of issuing DNR orders early into care inside an acute care setting. We look forward to reading about future studies that provide insight into these factors.

No funding was received for this study/paper.

The authors declare no conflicts of interest.

Approval of the research protocol: N/A.

Informed consent: N/A.

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

Animal studies: N/A.

A 62-year-old woman was diagnosed with postoperative breast cancer recurrence. While inhaling hydrogen gas through a nasal cannula at home, she used a heat-therapy machine that emitted electromagnetic waves to the breast cancer site. She suddenly experienced explosive sounds in her chest and smelled burning. Subsequently, she experienced several overlapping hemoptysis episodes and was referred to our hospital for further evaluation. Computed tomography revealed an alveolar-centered pulmonary contusion (Figure 1), and the patient was admitted to the hospital with a diagnosis of inhalation combustion lung injury. Arterial blood gas analysis showed no deterioration, and computed tomography revealed no worsening of pulmonary findings or oxygen demand. The hemoptysis resolved spontaneously, and re-evaluation on day 9 confirmed the disappearance of the pulmonary contusion.

Blast lung injuries typically occur during wars or bombing incidents but rarely occur in the home environment.¹ Although the medical efficacy of hydrogen gas remains controversial, several studies have reported the risk of associated explosions.² Our patient was exposed to a small explosion that caused no abnormalities in blood test results, including coagulation function parameters. This case demonstrates that lung injuries caused by the inhalation of combustible gases associated with folk remedies can occur even at home.

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

Animal studies: N/A.