Severe immersion pulmonary edema in a novice elderly scuba diver after heavy alcohol intake.

BACKGROUND: There are no reports of immersion pulmonary edema induced by excessive alcohol intake. We describe the case of a novice scuba diver who developed apnea due to immersion pulmonary edema during scuba diving after heavy alcohol intake. CASE PRESENTATION: A 71-year-old hypertensive man, without regular antihypertensive therapy, performed diving after excessive alcohol intake (total amount, approximately 253 g) until the night before. When swimming at a depth of 12 m, the patient experienced chest discomfort and ascended immediately but became unconscious. Respiratory arrest was confirmed, and he spat pink foamy sputum. On hospital admission, hypoxemia was confirmed, and chest radiography revealed butterfly-shaped shadows. Therefore, mechanical ventilation was initiated. The next day, his blood oxygenation level improved, and the radiographic shadows disappeared. He was discharged on day 7 of hospitalization without sequelae. CONCLUSION: A scuba diver with untreated hypertension might develop immersion pulmonary edema during diving after heavy alcohol intake.

Cardiac auscultation skills among junior doctors: effects of sound simulation lesson.

OBJECTIVES: To evaluate the effect of a sound simulation lesson to improve cardiac auscultation skills among junior doctors. METHODS: This study is based on the design of test comparison before and after educational intervention using a convenient sample. For 50 junior doctors in Japan, diagnostic accuracy before and after a sound simulation lesson for cardiac auscultation skills was compared. There were 15 doctors who experienced cardiology rotation. The lesson used seven abnormal cardiac recordings (third heart sound, double gallop, aortic stenosis, aortic regurgitation, mitral stenosis, mitral regurgitation, and pericardial friction rub). At tests before and after the lesson, the doctors listened to random sound outputs of the same seven recordings, chose diagnostic findings from multiple-choice items, and obtained individual diagnostic accuracy based on the total number of choosing correct findings. Top 10 doctors obtaining the greatest individual accuracy received a commendation. RESULTS: Pre-lesson diagnostic accuracy was not different between doctors with cardiology rotation training (total diagnostic accuracy of the group, 27/105 [26%]) and those without cardiology rotation (70/245 [29%]). Compared to pre-lesson, post-lesson total diagnostic accuracy significantly improved with about two-folds (97/350 [28%] vs 170/350 [61%]; McNemar Test, p<0.0001). The improvement was significant for double gallop (5/50 [10%] vs. 15/50 [30%]), mitral stenosis (0/50 [0%] vs. 6/50 [12%]), and pericardial friction rub (1/50 [2%] vs. 35/50 [70%]). CONCLUSIONS: The use of a simple sound simulation lesson may help junior doctors to learn cardiac auscultation skills. Clinician educators are encouraged to use this strategy in addition to cardiology rotation training.

Impact of rapid response car system on ECMO in out-of-hospital cardiac arrest: A retrospective cohort study.

INTRODUCTION: Extracorporeal life support (ECLS) has been reported to be more effective than conventional cardiopulmonary resuscitation (CPR). In ECLS, a shorter time from arrival to implantation of extracorporeal membrane oxygenation (ECMO; door-to-ECMO) time was predicted to be associated with better survival rates. This study aimed to examine the impact of the physician-based emergency medical services (P-EMS) using a rapid response car (RRC) on door-to-ECMO time in patients with out-of-hospital cardiac arrest (OHCA). METHODS: In this retrospective cohort study, adult patients with OHCA who were admitted to a Japanese tertiary care hospital from April 2012 to December 2016 and underwent venoarterial ECMO were included. Patients were either transferred by emergency medical service (EMS only group) or RRC (RRC group). Primary outcome was door-to-ECMO time. Wilcoxon rank-sum test was used to compare the outcome between the two groups. RESULTS: A total of 34 patients were included in this study, and outcome data were available for all patients. The door-to-ECMO time was significantly shorter in the RRC group than in the EMS only group (median, 23min vs. 36min; P=0.006). Additionally, the RRC was also associated with earlier successful intubation and intravenous adrenaline administration. CONCLUSION: The physician-based RRC system was associated with a shorter door-to-ECMO time and successful advanced procedures in prehospital settings. Combination of the RRC system with ECLS may lead to better outcomes in patients with OHCA.

Streptococcus pneumoniae meningitis without pleocytosis of the cerebrospinal fluid.

Pleocytosis of the cerebrospinal fluid is a key finding for the diagnosis of bacterial meningitis. Bacterial meningitis presenting in normal cerebrospinal fluid is rare in adult patients. We describe the case of a patient with pneumococcal meningitis without cerebrospinal fluid pleocytosis. This case suggests that immediate antibiotic therapy should be started when meningitis is suspected, even with normal cerebrospinal fluid findings. (See Figure.)

Cytokine-dependent but acquired immunity-independent arthritis caused by DNA escaped from degradation.

DNase II digests the chromosomal DNA in macrophages after apoptotic cells and nuclei from erythroid precursors are engulfed. The DNase II-null mice develop a polyarthritis that resembles rheumatoid arthritis. Here, we showed that when bone marrow cells from the DNase II-deficient mice were transferred to the wild-type mice, they developed arthritis. A deficiency of Rag2 or a lack of lymphocytes accelerated arthritis of the DNase II-null mice, suggesting that the DNase II(-/-) macrophages were responsible for triggering arthritis, and their lymphocytes worked protectively. A high level of TNFα, IL-1ß, and IL-6 was found in the affected joints of the DNase II-null mice, suggesting an inflammatory-skewed cytokine storm was established in the joints. A lack of TNFα, IL-1ß, or IL-6 gene blocked the expression of the other cytokine genes as well and inhibited the development of arthritis. Neutralization of TNFα, IL-1ß, or IL-6 had a therapeutic effect on the developed arthritis of the DNase II-null mice, indicating that the cytokine storm was essential for the maintenance of arthritis in the DNase II-deficient mice. Methotrexate, an antimetabolite that is often used to treat patients with rheumatoid arthritis, had a therapeutic effect with the DNase II-null mice. These properties of arthritis in the DNase II-null mice were similar to those found in human systemic-onset juvenile idiopathic arthritis or Still's disease, indicating that the DNase II-null mice are a good animal model of this type of arthritis.

Interferon-induced TRAIL-independent cell death in DNase II-/- embryos.

The chromosomal DNA of apoptotic cells and the nuclear DNA expelled from erythroid precursors is cleaved by DNase II in lysosomes after the cells or nuclei are engulfed by macrophages. DNase II(-/-) embryos suffer from lethal anemia due to IFN-beta produced in the macrophages carrying undigested DNA. Here, we show that Type I IFN induced a caspase-dependent cell death in human epithelial cells that were transformed to express a high level of IFN type I receptor. During this death process, a set of genes was strongly activated, one of which encoded TRAIL, a death ligand. A high level of TRAIL mRNA was also found in the fetal liver of the lethally anemic DNase II(-/-) embryos, and a lack of IFN type I receptor in the DNase II(-/-) IFN-IR(-/-) embryos blocked the expression of TRAIL mRNA. However, a null mutation in TRAIL did not rescue the lethal anemia of the DNase II(-/-) embryos, indicating that TRAIL is dispensable for inducing the apoptosis of erythroid cells in DNase II(-/-) embryos, and therefore, that there is a TRAIL-independent mechanism for the IFN-induced apoptosis.

[Usefulness of transesophageal echocardiography to evaluate the completeness of pediatric patent ductus arteriosus ligation].

Transesophageal echocardiography (TEE) is being utilized with increasing frequency in the operating room both as a monitor and as a diagnostic tool, and its usefulness for determining the adequacy of congenital heart disease repair intraoperatively and postoperatively has been addressed previously. This report describes TEE monitoring in a 4-month-old baby undergoing patent ductus arteriosus (PDA) re-operation. After application of a first double ligation to the ductus via thoracotomy, several investigations in intensive care unit including chest X-ray, transthoracic echocardiography and TEE, detected incomplete ligation, and reoperation was scheduled immediately. Re-operation, a clipping to the ductus, was successfully performed under real-time TEE monitoring. We conclude that the use of intraoperative TEE monitoring during a PDA ligation enables us to avoid residual ductal flows.

Comparison of antagonizing potencies of dodecane analogues to isoflurane in goldfish.

PURPOSE: We reported previously that long-chain fatty acids (carbon atoms > or =12) antagonize volatile anesthetics in goldfish. To examine the contribution of the carboxyl group to the antagonizing potency of fatty acids in vivo, we compared antagonizing potencies to isoflurane in goldfish among terminally substituted dodecane analogues. METHODS: Dodecane (carbon atoms = 12) analogues [fatty acid (DoAC), alcohol (DoAL), alkane (DoAK), sulfate (DoSF), trimethylammonium (DoTA)] were examined. We determined the EC50 (the anesthetic concentration producing a 50% effect) values of isoflurane in the absence or presence of these chemical compounds in goldfish by observing the escape reaction of goldfish from an electrical stimulus. RESULTS: DoAC at higher than 10 microM and DoAL at higher than 20 microM increased the EC50 values of isoflurane in a concentration-dependent manner compared with the control (P < 0.05). DoAC at 50 microM and DoAL at 100 microM increased the EC50 1.7- and 1.6 fold, respectively. DoAK, DoSF, and DoTA showed no significant differences from the control. In the comparison of DoAC and DoAL at the same concentration, DoAC was more effective than DoAL (P < 0.001). CONCLUSION: DoAC and DoAL showed antagonizing potencies to isoflurane, whereas DoAK, DoSF, and DoTA had no effect. DoAC was more effective than DoAL. The findings suggest that polarity of the chemical compounds may be necessary to exert antagonizing potency to isoflurane. Furthermore, a highly negative charge density of the carboxyl group may be responsible for the effective antagonization of DoAC to isoflurane.