Changes in coagulation factor XIII activity during resuscitation for hemorrhagic shock.

Objective: Little is known about the coagulation activity of factor XIII (FXIII) during resuscitation for hemorrhagic shock and the effects of plasma transfusions. We performed a single-center observational study to evaluate the changes in FXIII activity during resuscitation for hemorrhagic shock. Patient and Methods: Twenty-three adult patients with hemorrhagic shock were enrolled in this study. Blood samples were drawn upon arrival (T1), at the time of hemostasis completion (T2), and on day 2 (T3). Baseline and changes in FXIII activity and the proportion of patients with adequate levels of FXIII activity (FXIII activity >70%) were evaluated. The effects of plasma transfusion on these parameters were also investigated. Results: At T1, the median (interquartile range) FXIII activity was 53% (47-85%), which did not increase (T1 vs. T3: 53% [47-85%] vs. 63% [52-70%], P=0.8766). The proportion of patients with adequate FXIII activity decreased throughout the resuscitation period (T1, T2, and T3: 30, 34, and 21%, respectively). Plasma transfusion did not affect FXIII activity (T1 vs. T2, 66.4% [23.4] vs. 70.0% [16.2%], P=0.3956; T2 vs. T3, 72.0% [19.5] vs. 63.5% [8.6%], P=0.1161) or the proportion of adequate levels of FXIII activity at 44% at T2 and 27% at T3. Conclusion: FXIII activity is low during the early phase of a hemorrhagic shock. Even with plasma transfusion, FXIII levels were not adequately maintained throughout resuscitation.

Should an emergency physician be a "surgeon" in a rural area? A case of blunt cardiac rupture successfully treated by an emergency physician.

Objective: Blunt cardiac rupture is a life-threatening injury that requires surgical repair by cardiovascular or trauma surgeons. We report a case of blunt cardiac rupture in a rural area in which emergency physicians performed emergency department thoracotomy and surgical repair to save the patient's life. Patient and Methods: This case involved an 18-year-old female who was injured in a traffic accident and underwent emergency thoracotomy and surgical repair. Results: The patient's left thorax was deformed, and sonographic assessment revealed pericardial effusion. She experienced cardiopulmonary arrest 13 min after hospital arrival. An emergency physician performed an emergency department thoracotomy. The clots were removed from the surface of the left ventricle, followed by wound compression to control bleeding from the ruptured left ventricular wall. After the recovery of spontaneous circulation, the emergency physician sutured the ruptured heart. The patient survived with good neurological function. Conclusion: In rural areas, blunt cardiac rupture may require emergency department thoracotomy and cardiac repair by emergency physicians. The establishment of educational systems that include continuous education on trauma surgical procedures and consensus guidelines is needed to assist rural emergency physicians in performing surgical procedures.

Cardiac Tamponade Due to Intrapericardial Hernia Mimicking ST-Segment Elevation Myocardial Infarction.

Intrapericardial hernia is a diaphragmatic hernia that extremely rarely causes cardiac tamponade. We present a case of a cardiac tamponade caused by an intrapericardial hernia in a 78-year-old male patient with a history of coronary artery bypass grafting, mimicking ST-segment elevation myocardial infarction, which was successfully treated by emergent laparotomy.

Successful Treatment of Sepsis-Induced Cardiomyopathy with Intra-Aortic Balloon Pumping: A Case Report and Literature Review.

BACKGROUND Sepsis-induced cardiomyopathy is cardiac dysfunction in sepsis that sometimes results in reduced cardiac output. Inotropic agents are recommended in patients with sepsis and cardiac dysfunction. Here, we present a case of sepsis-induced cardiomyopathy that was resistant to inotropes and was successfully treated with intra-aortic balloon pumping (IABP). We also reviewed the literature on similar cases of sepsis-induced cardiomyopathy treated with IABP. CASE REPORT A 40-year-old woman with fever and hypotension was admitted to a university hospital. Laboratory test results showed elevated inflammatory markers and cardiac markers, such as creatinine kinase-MB and troponin T. Echocardiography revealed severe left ventricular hypokinesis, and cardiac monitoring revealed a low cardiac output. The patient received antimicrobials, vasopressors, and dobutamine; however, her circulatory status did not respond to these treatments. IABP was introduced 7 h after admission and dramatically increased her blood pressure and cardiac output, resulting in the reduction of vasopressor and dobutamine doses. The patient survived without any IABP-related complications. The literature review of 11 cases of sepsis-induced cardiomyopathy treated with IABP shows consistent results with the presented case in terms of positive effects of IABP on circulatory status and cardiac function, resulting in a reduction of inotropes. CONCLUSIONS Some sepsis-induced cardiomyopathy cases with reduced left ventricular function may not respond to inotropes. IABP would be a treatment option for these patients because of its positive effects on cardiac and circulatory functions.

Venous Thoracic Outlet Syndrome with an Upper Extremity Deep Vein Thrombosis Caused by a Dislocated Clavicle Fracture: A Case Report.

BACKGROUND Clavicle fractures are a relatively common injury, and are not problematic when occurring alone. Venous thoracic outlet syndrome (TOS) is generally caused by compression of the subclavian vein between the first rib and oblique muscles, and is often complicated by the presence of upper extremities deep vein thrombosis (UEDVT). Herein, we present a case of venous TOS complicated with UEDVT due to a dislocated clavicle fracture. CASE REPORT A 29-year-old man was injured in a motorcycle accident. The patient's right clavicle was fractured, and the distal part of the fracture had dislocated into his right thorax. Contrast-enhanced computed tomography showed an obstruction of the subclavian vein by the dislocated clavicle and thrombus on the distal side of the obstruction. Anticoagulant therapy was not indicated because of other injuries, such as traumatic subarachnoid hemorrhage. No vena cava filter was placed in the superior vena cava owing to the relatively low volume of the thrombus. Alternatively, intermittent pneumatic compression to the right forearm was initiated. On day 6, surgical reduction of the clavicle was performed. The thrombus remained after the reduction. The patient received anticoagulation therapy with heparin followed by oral anticoagulants. The patient was discharged without any complications of UEDVT or bleeding. CONCLUSIONS Venous TOS with UEDVT caused by trauma is rare. Anticoagulation therapy, pneumatic limb compression, and vena cava filter placement should be considered according to the degree of the obstruction and other associated injuries.

A pediatric case of multiple trauma with impending cardiac arrest due to hemorrhagic shock successfully treated with resuscitative thoracotomy: A case report.

Background: The effectiveness of resuscitative thoracotomy (RT) in pediatric patients with multiple trauma is limited. We present a pediatric case of multiple trauma successfully treated with RT. Case Presentation: A 9-year-old boy was injured after falling down stairs. On arrival, his blood pressure was unmeasurable, and the carotid artery pulse was barely palpable. Sonographic assessment indicated intra-abdominal hemorrhage. RT and aortic cross-clamping were performed, and he received a blood transfusion, after which his circulatory status recovered. Laparotomy indicated an inferior mesenteric vein injury that was sutured. Ten hours after arrival, an acute epidural hematoma was observed and treated with an emergency craniotomy. The patient's condition remained stable and he was discharged on the 101st day. Conclusion: RT may save the life of patients with multiple trauma, even pediatric patients, if performed in a timely manner, based on the diagnosis of hemorrhagic shock, along with rapid transfusion and hemostatic intervention.

Metolachlor Poisoning with Lactic Acidosis Improved by Thiamine Administration: A Case Report.

BACKGROUND Metolachlor is a chloroacetamide herbicide that is extensively used worldwide. Ingestion of metolachlor causes acute toxicity via the generation of methemoglobin. Elevated levels of methemoglobin inhibit the transport of oxygen to tissue, causing hypoxia and lactic acidosis. A common treatment approach has been to reduce methemoglobin by administration of methylene blue. Herein, we present a case of metolachlor poisoning causing lactic acidosis that was treatable by thiamine administration, in which the methemoglobin level was not elevated. CASE REPORT A 61-year-old man was admitted to the emergency room with seizures and impaired consciousness after the ingestion of metolachlor (250 mL, 83%) with the intent to commit suicide. The patient's methemoglobin and lactate levels on admission were 0.9% and 11.8 mmol/L, respectively. After admission, the levels of lactate decreased gradually; however, they increased 13 h after admission. There was no evidence of heavy alcohol consumption, hyponutrition, or chronic thiamine deficiency. We initially administered a thiamine bolus (100 mg), which immediately improved his consciousness, followed by continuous administration of the same substance (1500 mg/day). The patient's consciousness improved, and was discharged from the intensive care unit on day 4. CONCLUSIONS Metolachlor can cause metabolic dysfunction and lactic acidosis without an increase in methemoglobin. Moreover, thiamine administration may be beneficial for patients with metolachlor intoxication exhibiting symptoms of elevated lactate levels, impaired consciousness, and lack of elevated methemoglobin levels.

Intraperitoneal Rupture of the Urinary Bladder Mimics an Intra-Abdominal Hemorrhage: A Case Report.

Hemorrhagic shock due to polytrauma is a life-threatening condition, requiring immediate diagnosis of the bleeding site and determination of an appropriate hemostatic procedure. Intra-abdominal injuries and pelvic fractures are major causes of massive hemorrhage, although the appropriate hemostatic procedures are different for each injury. We present a case of intraperitoneal rupture of the urinary bladder associated with pelvic fracture, in which urine extravasation into peritoneal spaces mimics intra-abdominal hemorrhage. A 33-year-old man with a known case of schizophrenia attempted suicide by jumping down from the 4th floor of his apartment (approximately 10 meters in height). He was in a state of shock on arrival. Focused assessment with sonography for trauma (FAST) showed fluid collection around his spleen only but not the perivesical space. Pelvic X-ray showed multiple pelvic fractures. We suspected the patient was in a state of hemorrhagic shock due to intra-abdominal hemorrhage and pelvic fracture. The patient's hemodynamic status did not respond to massive fluid infusion and blood transfusion, including eight units of packed RBCs transfusion. Resuscitative endovascular balloon occlusion of the aorta was performed; however, the patient's hemodynamic status did not recover. We performed an emergency laparotomy to control the suspected intra-abdominal hemorrhage. In peritoneal space, we found a large amount of non-bloody fluid. The liver, spleen, and bowels were not injured, whereas the urinary bladder was ruptured, indicating the correct diagnosis was intraperitoneal rupture of the urinary bladder associated with pelvic fracture. The ruptured urinary bladder wall was sutured, and temporary abdominal closure was performed. A contrast-enhanced CT performed after the laparotomy showed massive hemorrhage around the pelvic fracture. After arrival at the angiography room, the patient became bradycardia, and the pulsation at the carotid artery was not palpable. We performed cardiopulmonary resuscitation; however, the patient died eventually. Intraperitoneal rupture of the urinary bladder would mimic an intra-abdominal hemorrhage. Therefore, a comprehensive diagnostic-treatment approach such as a hybrid ER system would be beneficial for early and accurate diagnosis.

Severe Traumatic Brain Injury in a Patient with von Willebrand Disease Type 2A Successfully Treated with Factor VIII/von Willebrand Factor Concentrates: A Case Report.

BACKGROUND von Willebrand disease (VWD) is characterized by a bleeding tendency due to abnormalities in von Willebrand factor (VWF). Severe traumatic brain injury (TBI) can induce secondary coagulopathy and hemostatic disorders. We herein present a rare case of multiple trauma, including severe TBI, in a patient with VWD who was successfully treated with repeated factor VIII/VWF transfusion in addition to standard critical care. CASE REPORT A 22-year-old man with type 2A VWD sustained head and lower limb injuries in a traffic accident and was comatose. Computed tomography indicated multiple trauma, including severe TBI (left-sided traumatic epidural hematoma, left-sided traumatic subdural hematoma, traumatic subarachnoid hemorrhage, skull fracture, and skull base fracture). The patient underwent emergency craniotomy for hematoma removal, external decompression, and intracranial pressure monitoring along with massive transfusion and repeated perioperative transfusion of factor VIII/VWF concentrates according to the level of bleeding. He recovered consciousness and eventually survived without neurological deficits. CONCLUSIONS Multiple trauma including TBI in patients with VWD is a critical condition. The active transfusion of factor VIII/VWF is essential for controlling hemorrhage early and in the perioperative period.

Thrombotic Microangiopathy Secondary to Systemic Sclerosis with Severe Complement Activation Not Responsive to Eculizumab: A Case Report.

BACKGROUND Secondary thrombotic microangiopathies (TMAs) are induced by several underlying conditions and most are resolved by treating the underlying disease. Eculizumab, a human monoclonal antibody, blocks the final stages of the complement system. Several studies have shown that complement C5 monoclonal antibodies are effective in treating secondary TMA. Systemic sclerosis (SSc) is one of the most common causes of secondary TMA, and early diagnosis is important because TMA secondary to SSc has a poor prognosis. We report a case of TMA secondary to SSc that did not respond to eculizumab, despite the presence of severe complement activation. CASE REPORT A 61-year-old previously healthy man was admitted for acute renal failure and thrombocytopenia. TMA was suspected because hemolytic anemia, thrombocytopenia, and organ damage were detected. Based on the physical findings, we suspected SSc as the underlying cause. All tests for specific antibodies, including Scl-70, were negative, and C5b-9 levels were markedly elevated (11 041 ng/mL). We initiated plasma exchange on day 3, followed by eculizumab therapy, but with limited improvement. SSc with secondary TMA was identified upon further testing. After completion of the plasma exchange, the platelet count was maintained above 30 000/µL. Creatinine levels gradually decreased, and the patient was weaned off dialysis. Steroid treatment for SSc was continued, and the patient was eventually discharged. CONCLUSIONS A case of SSc-TMA was ineffectively treated with eculizumab, despite abnormal activation of the complement system. Continuous monitoring and investigation are required, and discontinuation of eculizumab should be determined according to the final diagnosis.

Design, synthesis and biological evaluation of novel indole derivatives as gut-selective NaPi2b inhibitors.

Intestinal sodium-dependent phosphate transport protein 2b (SLC34A2, NaPi2b) inhibitors are expected to be potential new candidates for anti-hyperphosphatemia drugs. However, a risk of on-target side effects based on the inhibition of NaPi2b in the lung and testis has been reported.In this article, we report on our identification of novel indole derivatives as gut-selective NaPi2b inhibitors with good activity, low systemic exposure and moderate hydrophobicity.In particular, gut-selective compound 27, with even lower bioavailability and lower systemic exposure as compared to previously reported pyridine derivatives, demonstrated excellent phosphate absorption-inhibitory effect in SD rats. Compound 27 has an ideal profile and appears to offer promise as a candidate drug for the treatment of hyperphosphatemia, with minimal risk of side effects due to systemic exposure.

Design, synthesis and biological evaluation of novel pyridine derivatives as gut-selective NaPi2b inhibitors.

We previously reported thiophene derivatives as gut-selective (minimally systemic) and potent sodium-dependent phosphate transport protein 2b (SLC34A2, NaPi2b) inhibitors. However, these derivatives did not suppress phosphate absorption form the intestinal tract in Sprague-Dawley (SD) rats. The lack of efficacy in vivo could be due to the high hydrophobicity of these compounds. In this report, we identified novel pyridine derivatives as gut-selective NaPi2b inhibitors with good activity in vitro and relatively low hydrophobicity. Especially, gut-selective compound 20b suppressed phosphate absorption in SD rats. These results suggest that physical properties, such as the hydrophobicity of the compounds, might affect the in vivo efficacy.

Mental Status and Feasibility of an Intravitreal Ranibizumab Treat-and-Extend Regimen in Patients with Neovascular Age-Related Macular Degeneration.

INTRODUCTION: Anti-vascular endothelial growth factor (VEGF) therapy is the first-choice treatment for neovascular age-related macular degeneration (nvAMD); however, patients often are burdened physically, financially, and mentally. We investigated the relationship between mental status and feasibility of an intravitreal ranibizumab treat-and-extend (TAE) regimen for nvAMD. METHODS: In this prospective, multicenter study, 75 patients with nvAMD received ranibizumab intravitreally in a TAE regimen. After two monthly injections, the injection intervals were extended step-by-step to 6, 8, 12, and 16 weeks in eyes with dry maculas on optical coherence tomography (OCT) and, if exudation persisted or relapsed, shortened by one step. The best corrected visual acuity (BCVA) measurement and OCT were performed at baseline and on the same days of the scheduled injections. At baseline, all patients completed a survey, the Hospital Anxiety and Depression Scale (HADS), regarding mental burden. At week 52, patients on the TAE regimen for 1 year completed the HADS and a questionnaire designated to assess treatment-associated mental status. RESULTS: Fifty-one patients (68%) completed the 1-year TAE regimen; 24 eyes (32%) discontinued the TAE regimen because of the rescue treatment, difficulty in completing clinical visits, or financial burden. In 51 eyes on the TAE regimen for 1 year, the mean BCVAs improved from 64.3 letters at baseline to 71.6 letters at week 52. The mean anxiety and depression scores on HADS decreased significantly (p < 0.01) after the 1-year treatment. Women tended to have higher anxiety scores, possibly associated with fear of injection and recurrence, while some men had higher depression scores potentially associated with financial burden, difficulty in completing clinical visits, and subsequent interruption of the TAE regimen especially in eyes with low treatment efficacy. CONCLUSIONS: A TAE regimen of intravitreal ranibizumab injections preserves vision in eyes with nvAMD and reduces mental burden associated with disease relapse. TRIAL REGISTRATION: This clinical study was registered retrospectively on December 22, 2014 with the ClinicalTrials.gov identifier NCT02321839.

Physician-Staffed Emergency Vehicle Crash: A Case Report.

Physician-staffed vehicles are widely operated in many countries. There is a paucity of literature regarding physician-staffed emergency vehicle accidents. On an evening in January 2016, at the request of the fire department, a physician-staffed vehicle was dispatched with two physicians, a nurse, and a driver from the base hospital to the scene of a patient with cardiopulmonary arrest. The vehicle ran with the alerting siren and warning lights. On its way, the vehicle struck a car and the mission was canceled. The patient was transported to another hospital by the ambulance staff only. No passengers were injured. One physician and a nurse examined the driver of the struck car and transported the driver to the base hospital by additional ambulance units. Because there were no manuals or guidelines, the staff responses were not systematic. After the repair of the crashed vehicle and preparation of operation manuals for two months, the physician-staffed vehicle returned to service, and it has worked without any accident since then. The physician-staffed vehicle is of benefit to critical victims and it rarely crashes. When the vehicle is involved in an accident, it results in multiple victims as well as additional emergency demands. Warning lights and sirens in the dark at a four-point crossroads might increase the risk of crashing. Information influx from the emergency scenes might distract the physicians' attention and put stress on the driver, leading to dangerous high-speed emergency driving. Educational training and manuals in each hospital and a nationwide framework regarding safety operations and accidents are needed.

A 48-Year-Old Man Presenting as an Emergency with Severe Back Pain, a Large Anterior Paravertebral Hematoma, and Spontaneous Rupture of the Right 9th Intercostal Artery Successfully Managed by Transcatheter Arterial Embolization: A Case Report.

BACKGROUND The rupture of an intercostal artery is rare and is usually associated with trauma, neurofibromatosis type 1, or coarctation of the aorta. Transcatheter arterial embolization is a minimally invasive vascular surgical procedure used to control hemorrhage of an intercostal artery. This report describes a case of a 48-year-old man who presented with severe back pain. This was due to a large anterior paravertebral hematoma following the spontaneous rupture of the right 9th intercostal artery. The rupture was successfully managed by transcatheter arterial embolization. CASE REPORT A 48-year-old man suddenly felt severe back pain while walking. He had no previous medical history and he had not experienced any external injury. On arrival, he was tachycardic and hypertensive. He did not have abnormal physical findings. His chest radiograph, 12-lead electrocardiogram, ultrasonography, and blood test findings were unremarkable. A chest computed tomography scan with contrast media was performed, which revealed a 4.3×2.7×7.0 cm mass, enhanced with contrast media, anterior to the 9th vertebral body. The patient was diagnosed with spontaneous rupture of the right ninth intercostal artery. The lesion was embolized with 8 microcoils. The patient was discharged on the 8th hospital day without complications. CONCLUSIONS This report presents a rare case of the rupture of an intercostal artery in which no cause was identified. It highlights the role of imaging as an important diagnostic tool. Furthermore, this report shows the benefits of the timely use of emergency transcatheter arterial embolization, which in this instance resulted in a successful outcome.

Nicardipine versus nitroglycerin for hypertensive acute heart failure syndrome: a single-center observational study.

Objective: Nitroglycerin is a first-line treatment for hypertensive acute heart failure syndrome (AHFS). However, nicardipine is frequently used to treat hypertensive emergencies, including AHFS. In this study, we compared the effectiveness of nicardipine and nitroglycerin in patients with hypertensive AHFS. Patients and Methods: This single-center, retrospective, observational study was conducted at the intensive care unit of a Japanese hospital. Patients diagnosed with AHFS and systolic blood pressure 140 mmHg on arrival between April 2013 and March 2021 were included. The outcomes were the time to optimal blood pressure control, duration of continuous infusion of antihypertensive agents, duration of positive pressure ventilation, need for additional antihypertensive agents, length of hospital stay, and body weight changes. Outcomes were compared between the nicardipine and nitroglycerin groups. We also compared these outcomes between the groups after excluding patients who received renal replacement therapy. Results: Fifty-eight patients were enrolled (26 and 32 patients were treated with nitroglycerin and nicardipine, respectively). The nicardipine group had a shorter time to optimal blood pressure control (2.0 [interquartile range, 2.0-8.5] h vs. 1.0 [0.5-2.0] h), shorter duration of continuous anti-hypertensive agent infusion (3.0 [2.0-5.0] days vs. 2.0 [1.0-2.0] days), less frequent need for additional anti-hypertensive agents (1 patients [3.1%] vs. 11 patients [42.3%]), and shorter length of hospital stay (17.5 [10.0-33.0] days vs. 9.0 [5.0-15.0] days) than the nitroglycerin group. The duration of positive pressure ventilation and body weight changes were similar between the groups. The outcomes were similar after excluding patients who received renal replacement therapy. Conclusion: Nicardipine may be more effective than nitroglycerin for treating hypertensive AHFS.

Design, synthesis and biological evaluation of novel 1H-pyrazole-4-carbonyl-4,5,6,7-tetrahydrobenzo [b]thiophene derivatives as gut-selective NaPi2b inhibitors.

Intestinal sodium-dependent phosphate transport protein 2b (SLC34A2, NaPi2b) inhibitors are expected to be potential new candidates for anti-hyperphosphatemia drugs. However, a risk of on-target side effects based on the inhibition of NaPi2b in the lung and testis has been reported. To identify gut-selective (minimally systemic) NaPi2b inhibitors, we prepared and evaluated 1H-pyrazole-4-carbonyl-4,5,6,7-tetrahydrobenzo[b]thiophene derivatives with highly polar functional groups to reduce systemic exposure. As a result, compounds 36a and 36b showed a good activity in vitro and a low bioavailability in Sprague-Dawley (SD) rats. However, these compounds did not suppress phosphate absorption in SD rats. This lack of in vivo efficacy could be due to the high hydrophobicity of these compounds. The results of further investigations of other classes of compounds with appropriate physical properties will be reported in due course.

Acquired Thrombotic Thrombocytopenic Purpura Without Anti-ADAMTS13 Antibody Caused by Influenza A (H1N1) Virus Successfully Treated by Plasma Exchange: A Case Report.

BACKGROUND Thrombotic microangiopathy, characterized by microangiopathic hemolytic anemia, thrombocytopenia, and organ damage by microvascular thrombosis, has a high mortality rate; therefore, early diagnosis and treatment are important. Thrombotic thrombocytopenic purpura is caused by a deficiency of a disintegrin-like and metalloproteinase with thrombospondin type 1 motifs 13 (ADAMTS13), and results in thrombotic microangiopathy. Influenza virus causes thrombotic thrombocytopenic purpura by inducing immunoglobulin G autoantibodies against ADAMTS13. We report a rare case of thrombotic thrombocytopenic purpura caused by influenza A without anti-ADAMTS13 antibody that was treated by plasma exchange. CASE REPORT A 57-year-old woman was admitted to our hospital because of hypoxemia. We diagnosed pneumonia and disseminated intravascular coagulation. Despite treatment, she developed thrombocytopenia, and we diagnosed thrombotic microangiopathy and started plasma exchange. With a PLASMIC score of 6 points and neuropsychiatric symptoms, we strongly suspected thrombotic thrombocytopenic purpura and started rituximab. However, ADAMTS13 activity by FRETS-VWF73 assay was 65%, and anti-ADAMTS13 antibody was negative. After 4 plasma exchanges and 2 rounds of rituximab, platelet numbers and lactate dehydrogenase and creatinine concentrations normalized on the 16th day of hospitalization. Subsequently, influenza A (H1N1) was identified in a nasopharyngeal swab collected on admission. Plasma enzyme-linked immunosorbent assay testing for chromogenic ADAMTS13 activity showed a significant decrease (<0.5%). Therefore, we diagnosed thrombotic thrombocytopenic purpura caused by influenza A without anti-ADAMTS13 antibody. CONCLUSIONS We present a rare case of thrombotic thrombocytopenic purpura without anti-ADAMTS13 antibody caused by influenza A virus successfully treated by plasma exchange. Influenza A may reduce ADAMTS13 activity without inducing autoantibodies.

Successful covered stent-graft treatment of superficial femoral arterial injury due to blunt trauma.

BACKGROUND: Endovascular treatment is used for traumatic arterial injuries in the torso. However, the effectiveness of endovascular covered stent-graft treatment for peripheral artery injury is unclear. We present a case of superficial femoral artery (SFA) injury successfully treated with a covered stent-graft. CASE REPORT: A 68-year-old man presented with traumatic lower limb injury and shock. Computed tomography angiography revealed left subtrochanteric fracture and hematoma with extravasation. Digital subtraction angiography revealed extravasation from a left SFA branch, and a pseudoaneurysm at the SFA trunk. We coil embolized the SFA branch, and treated the pseudoaneurysm with a covered stent-graft. Computed tomography carried out 22 days later showed complete pseudoaneurysm exclusion and sufficient stent patency. CONCLUSION: We successfully used a covered stent-graft to treat SFA injury due to blunt trauma. A covered stent-graft could be effective for peripheral artery injury.

Refractory Duodenal Bleeding Ulcers Successfully Treated with Factor XIII Transfusion.

A 67-year-old woman with a history of autoimmune hepatitis was admitted for fever, acute hepatic dysfunction, and acute kidney injury. She was diagnosed with multiple duodenal ulcers. Despite the administration of proton pump inhibitor and red blood cells, her black stool and anemia progressed, and she was therefore transferred to our hospital. Despite hemostatic treatments, she continued to bleed. On the 21st day of admission, an endoscopic examination showed the oozing of blood from the duodenal mucosa. A low factor XIII (FXIII) activity level was detected, and she was administered FXIII concentrate. The bleeding stopped and she was thereafter discharged.