Search

To evaluate the effect of cryoprecipitate (CRYO) transfusion in women referred for postpartum hemorrhage (PPH). This retrospective cohort study included patients with primary PPH referred to Gifu University Hospital between April 2013 and March 2020. We analyzed the effect of CRYO transfusion on fluid balance 24 h after the initial examination using a multivariable linear regression model adjusted for several confounding variables. To evaluate whether outcomes were modified by active bleeding, an interaction term of CRYO*active bleeding was incorporated into the multivariable model. We identified 157 women: 38 in the CRYO group (cases) and 119 in the control group. Fluid balance in the aforementioned period tended to decrease in the CRYO group compared with that in the control group (coefficient − 398.91; 95% CI − 1298.08 to + 500.26; p = 0.382). Active bleeding on contrast-enhanced computed tomography affected the relationship between CRYO transfusion and fluid balance (p = 0.016). Other outcomes, except for the overall transfusion requirement, were not significantly different; however, the interaction effect of active bleeding was significant (p = 0.016). CRYO transfusion may decrease the fluid balance in the first 24 h in PPH patients, especially in those without active bleeding.

Background: Early use of hemostasis strategies, such as transcatheter arterial embolization (TAE), is critical in cases of pelvic injury because these patients often experience hemorrhagic shock and other fatal injuries. We investigated the influence of delays in TAE administration on mortality.Methods: Patients admitted to the Advanced Critical Care Center at Gifu University with pelvic injury between January 2008 and December 2019 who underwent acute TAE were retrospectively enrolled. The time from when the doctor decided to administer TAE to the start of TAE (needling time) was defined as “decision-TAE time.”Results: We included 159 patients. The median decision-TAE time was 60 min. Twenty-four patients died. Kaplan–Meier curves for overall survival were compared between patients above and below the median cutoff value for decision-TAE time; survival was significantly better for patients below the median cutoff value (p=0.02). Multivariable Cox proportional hazards regression analysis revealed that the longer the decision-TAE time, the higher the risk of mortality (p=0.037). A short TAE duration (procedure time) with a short decision-TAE time was associated with the best survival (p for interaction=0.023).Conclusions: Decision-TAE time may play a key role in establishing resuscitation in pelvic fracture patients, and efforts to shorten this time should be pursued.Trial registration: This observational study used retrospectively collected data.

Background: Stroke has been found to have a seasonally varying incidence; blood pressure, one of its risk factors, is influenced by humidity and temperature. The relationship between the incidence of stroke and meteorological parameters remains controversial. Objective: We investigated whether meteorological conditions are significant risk factors for stroke, focusing on the fluctuation of weather elements that triggers the onset of stroke. Methods: We collected ambulance transportation data recorded by emergency personnel from Gifu Prefecture. We included cases where the cause of the transportation was stroke and excluded cases of trauma. We combined these data with meteorological data as well as data on average temperature, average air pressure, and humidity provided publicly by the Japan Meteorological Agency. Our target period was from January 2012 to December 2016. Results: In the 5-year target period, there were 5,501 occurrences of ambulance transportation due to stroke. A seasonal tendency was confirmed, since ambulance transportation for stroke occurred more frequently at low temperatures (p < 0.001). Temperature (odds ratio: 0.91; p < 0.001) and humidity change (odds ratio: 1.50; p = 0.016) were identified as risk factors for ambulance transportation due to stroke. An increase in temperature incurs a lower risk than a decrease (odds ratio: 0.58; p = 0.09), although there is no statistically significant difference. Conclusions: Meteorological effects on the frequency of ambulance transportation due to stroke were studied. A lower temperature and radical humidity change were identified as risk factors for ambulance transportation due to stroke, and a decrease in temperature was also associated. We speculate on the possibilities of using meteorological data to optimize the assignment of limited medical resources in medical economics.

Early administration of hemostasis strategies, such as transcatheter arterial embolization (TAE), is critical in pelvic injury patients because they often experience hemorrhagic shock and other fatal injuries. We investigated the influence of delays in TAE administration on mortality. Patients admitted to the Advanced Critical Care Center at Gifu University with pelvic injury between January 2008 and December 2019 who underwent acute TAE were retrospectively enrolled. The time from when the doctor decided to administer TAE to the start of TAE (needling time) was defined as “decision-TAE time.” We included 162 patients. The median decision-TAE time was 59.5 min. Twenty-five patients died. Kaplan-Meier curves for overall survival were compared, with a significant difference observed between the patients above and below the median cutoff value for decision-TAE time (p=0.02). The age and sex-adjusted multivariable Cox proportional hazards regression model revealed that the longer the decision-TAE time, the higher the risk of mortality (p=0.01). The interaction between TAE duration (procedure time) and decision-TAE time was statistically significant (p=0.044), indicating that TAE duration modified the effect of decision-TAE time on mortality. Decision-TAE time may play a key role in establishing resuscitation in pelvic fracture patients, and efforts to shorten this time should be pursued.

Background:Some emergency departments use triage scales, such as the Canadian Triage and Acuity Scale and the JUST, to detect the status of life-threatening situations. However, these triage systems have not been used for aeromedical services in Japan. Therefore, we investigated these profiles and conducted a pilot study.Method:We retrospectively evaluated the helicopter emergency medical service cases from 1 April 2015 to 31 March 2020 at Gifu University Hospital using our mission record. In this study, we only evaluated cases that dealt with internal medicine. We excluded cases that were influenced by external factors such as trauma or cases that included hospital-to-hospital transportation, focusing only on prehospital care. We evaluated the validity of medical emergencies such as emergency interventions and the necessity of hospital admission. In addition, we evaluated the validity of the suggested diagnoses and the associated risk factors.Result:A total of 451 cases were suitable for inclusion in the study. In the analysis for all emergency calls, 235 (52.11%) needed emergency intervention and 300 (64.4%) required hospital admission. The suggested diagnosis was valid for 261 (57.87%) cases. After the first assessment by emergency medical technicians (EMTs), 75 cases were removed from the analysis.Therefore, the results of the analysis for all emergency calls requiring emergency intervention were: 52.31%, need admission: 70.26%, and the suggested diagnosis was valid for 69.41% of cases. Results of a multivariate analysis of some key variables identified risk factors for emergency intervention, namely, age, under sports, and gasping. Hospital admission risk factors are being years old only. The suggested diagnosis was only valid in under sports situations.In the first analysis, the risk factors for emergency intervention are years old, being male, under sports, and gasping, and for hospital admission they are years old, being male, detecting stroke symptoms, and disturbance of consciousness. The suggested diagnosis was only valid in under sports situations.Conclusion:There are some “second” keywords/phrases that predict medical emergencies. Therefore, the dispatch commander should gather these keyword/phrases to assess.

Background Using the out-of-hospital cardiac arrest (OHCA) registry in Japan, we evaluated the effectiveness of physicians’ presence in pre-hospital settings after adjusting in-hospital treatments. Methods This was a multicenter cohort study. We registered all consecutive OHCA patients in Japan who, from 1 June 2014 through 31 December 2017, were transported to institutions participating in the Japanese Association for Acute Medicine OHCA registry. We included OHCA patients aged at least 18 years, with medical etiology, and who received resuscitation from emergency medical services (EMS) personnel and medical professionals in hospitals. The primary outcome was one-month favorable neurological survival. We estimated the propensity score by fitting a logistic regression model that was adjusted for several variables before the arrival of EMS personnel and/or pre-hospital physician. A multivariable logistic regression analysis in propensity score-matched patients was used to adjust confounders, including extracorporeal membrane oxygenation, percutaneous coronary intervention, intra-aortic balloon pumping, and targeted temperature management. Results We analyzed 19,247 patients. Among them, 5.4% (N = 1040) had a neurologically favorable outcome. The adjusted odds ratio (AOR) of the physicians’ presence compared with their absence for primary outcome was 1.84 (95% confidence interval (CI): 1.43–2.37). Among first documented non-shockable cardiac rhythm, the AOR was 1.51 (95% CI: 1.04–2.22). Among first documented shockable cardiac rhythm, the AOR of the physicians’ presence for primary outcome was 1.15 (95% CI: 0.83–1.59). Conclusion The improved one-month favorable neurological survival was significantly associated with the physicians’ presence in pre-hospital settings, compared with the physicians’ absence.

Aim To describe the registry design of the Japanese Association for Acute Medicine - out-of-hospital cardiac arrest (JAAM-OHCA) Registry as well as its profile on hospital information, patient and emergency medical service characteristics, and in-hospital procedures and outcomes among patients with OHCA who were transported to the participating institutions. Methods The special committee aiming to improve the survival after OHCA by providing evidence-based therapeutic strategies and emergency medical systems from the JAAM has launched a multicenter, prospective registry that enrolled OHCA patients who were transported to critical care medical centers or hospitals with an emergency care department. The primary outcome was a favorable neurological status 1 month after OHCA. Results Between June 2014 and December 2015, a total of 12,024 eligible patients with OHCA were registered in 73 participating institutions. The mean age of the patients was 69.2 years, and 61.0% of them were male. The first documented shockable rhythm on arrival of emergency medical services was 9.0%. After hospital arrival, 9.4% underwent defibrillation, 68.9% tracheal intubation, 3.7% extracorporeal cardiopulmonary resuscitation, 3.0% intra-aortic balloon pumping, 6.4% coronary angiography, 3.0% percutaneous coronary intervention, 6.4% targeted temperature management, and 81.1% adrenaline administration. The proportion of cerebral performance category 1 or 2 at 1 month after OHCA was 3.9% among adult patients and 5.5% among pediatric patients. Conclusions The special committee of the JAAM launched the JAAM-OHCA Registry in June 2014 and continuously gathers data on OHCA patients. This registry can provide valuable information to establish appropriate therapeutic strategies for OHCA patients in the near future.

Background Thyrotoxic crisis and pheochromocytoma multisystem crisis are rare, life-threatening, emergency endocrine diseases with various clinical manifestations. Here we report a case of a patient who simultaneously developed thyrotoxic crisis and pheochromocytoma multisystem crisis and required intensive cardiovascular management. Case presentation A 60-year-old Asian man experienced nausea and vomiting, and subsequently developed dyspnea and cold sweats while farming. His serum free thyroxine, free triiodothyronine, and thyrotropin receptor antibody levels were elevated at 2.9 ng/dL, 7.2 pg/dL, and 4.7 IU/L, respectively. Serum thyrotropin levels were suppressed at less than 0.01 μIU/mL. Thyroid echography demonstrated no thyroid swelling (23 × 43 mm). A whole body computed tomography was performed for systemic evaluation. This revealed exophthalmos and a mass of size 57 × 64 mm in the anterior pararenal space. Based on these findings, we made an initial diagnosis of thyrotoxic crisis secondary to exacerbation of Grave’s hyperthyroidism. Treatment was begun with an iodine agent at a dose of 36 mg/day, thiamazole at a dose of 30 mg/day, and hydrocortisone at a dose of 300 mg daily for 3 consecutive days. To control tachycardia, continuous intravenously administered propranolol and diltiazem infusions were given. At the same time, small doses of doxazosin and carvedilol were used for both alpha and beta adrenergic blockade. On hospital day 5, his blood pressure and serum catecholamine concentrations (adrenalin 42,365 pg/mL, dopamine 6409 pg/mL, noradrenalin 72,212 pg/mL) were still high despite higher beta blocker and calcium channel blocker doses. These findings contributed to the diagnosis of pheochromocytoma multisystem crisis with simultaneous thyrotoxic crisis. We increased the doses of doxazosin and carvedilol, which stabilized his hemodynamic status. On hospital day 16, metaiodobenzylguanidine scintigraphy showed high accumulation in the right adrenal gland tumor. After retroperitoneal laparoscopic adrenalectomy on hospital day 33, his condition stabilized. He was discharged on hospital day 58. Conclusions Since he required more intensive cardiovascular management for thyrotoxic crisis, beta blockade was increased under intensive care unit monitoring even though initial alpha blockade is recommended in pheochromocytoma. When these crises occur simultaneously, cardiovascular management can be very challenging.

Supplemental doses of antithrombin (AT) are widely used to treat sepsis-induced disseminated intravascular coagulation (DIC) in Japan. However, evidence on the benefits of AT supplementation for DIC is insufficient. This multicenter retrospective observational study aimed to clarify the effect of AT supplementation on sepsis-induced DIC using propensity score analyses. Data from 3,195 consecutive adult patients admitted to 42 intensive care units for severe sepsis treatment were retrospectively analyzed; 1,784 patients were diagnosed with DIC (n = 715, AT group; n = 1,069, control group). Inverse probability of treatment-weighted propensity score analysis indicated a statistically significant association between AT supplementation and lower in-hospital all-cause mortality (n = 1,784, odds ratio [95% confidence intervals]: 0.748 [0.572-0.978], P = 0.034). However, quintile-stratified propensity score analysis (n = 1,784, odds ratio: 0.823 [0.646-1.050], P = 0.117) and propensity score matching analysis (461 matching pairs, odds ratio: 0.855 [0.649-1.125], P = 0.263) did not show this association. In the early days after intensive care unit admission, the survival rate was statistically higher in the propensity score-matched AT group than in the propensity score-matched control group (P = 0.007). In DIC patients without concomitant heparin administration, similar results were observed. In conclusion, AT supplementation may be associated with reduced in-hospital all-cause mortality in patients with sepsis-induced DIC. However, the statistical robustness of this connection was not strong. In addition, although the number of transfusions needed in patients with AT supplementation increased, severe bleeding complications did not.

Background: Stroke has seasonal incidence; blood pressure, one of its risk factors, is influenced by humidity and temperature. The relationship between stroke incidence and meteorological parameters remains controversial. We investigated whether meteorological conditions are stroke risk factors, focusing on fluctuations of weather elements that trigger stroke onset. Methods: We collected the ambulance transportation data of Gifu Prefecture between January 2012 and December 2014. We included cases where the cause of transportation was stroke and excluded trauma cases. We combined these with meteorological data provided publicly by the Japan Meteorological Agency and preformed logistic regression analysis. Findings: In the target period, there were 3314 events of stroke-related ambulance transportation. Seasonal tendency was confirmed, and frequent transportation for stroke occurred at low temperature (p

Background: In basic life support, chest compressions are a very important and basic skill. Acquiring the ability to perform chest compressions is affected by individual characteristics such as physique and physical strength, although all persons can learn to Perform Cardiopulmonary Resuscitation (CPR), including chest compressions. The aim of this study was to examine differences in physique between males and females and Basic Life Support (BLS) skill using a portable manikin with automated corrective feedback.Methods: Participants were 120 fourth-year preclinical dental school students (87 males, 33 females). For skill assessment, students performed chest compressions and single rescuer CPR using a Laerdal Resusci Anne Skill Reporter TM manikin for 2 minutes each before and after CPR. Outcome measures were (1) compression depth (mm), (2) compression rate (number of compressions per minute), (3) compression release depth (recoil, mm), and (4) hand position before and after the BLS course.Results: After the BLS course, compression depth and rate improved significantly. Both before and after the BLS course, male students performed deeper chest compressions than female students. In females, the duration of acceptable chest compressions was significantly shorter than in males.Conclusion: CPR performance was significantly different between males and females, probably due to differences in physique. Therefore, it is necessary for individualized instruction adapted to the learner’s characteristics.

Background The administration of low-dose intravenous immunoglobulin G (IVIgG) (5 g/day for 3 days; approximate total 0.3 g/kg) is widely used as an adjunctive treatment for patients with sepsis in Japan, but its efficacy in the reduction of mortality has not been evaluated. We investigated whether the administration of low-dose IVIgG is associated with clinically important outcomes including intensive care unit (ICU) and in-hospital mortality. Methods This is a post-hoc subgroup analysis of data from a retrospective cohort study, the Japan Septic Disseminated Intravascular Coagulation (JSEPTIC DIC) study. The JSEPTIC DIC study was conducted in 42 ICUs in 40 institutions throughout Japan, and it investigated associations between sepsis-related coagulopathy, anticoagulation therapies, and clinical outcomes of 3195 adult patients with sepsis and septic shock admitted to ICUs from January 2011 through December 2013. To investigate associations between low-dose IVIgG administration and mortalities, propensity score-based matching analysis was used. Results IVIgG was administered to 960 patients (30.8%). Patients who received IVIgG were more severely ill than those who did not (Acute Physiology and Chronic Health Evaluation (APACHE) II score 24.2 ± 8.8 vs 22.6 ± 8.7, p

Background Cardiac trauma is associated with a much higher mortality rate than injuries to other organ systems, even though cardiac trauma is identified in less than 10% of all trauma admissions. Here we report blunt trauma of the left atrium due to snowboarding trauma. Case presentation A 45-year-old Asian man collided with a tree while he was snowboarding and drinking. He lost consciousness temporarily. An air ambulance was requested and he was transported to an advanced critical care center. On arrival, a pericardial effusion was detected by a focused assessment with sonography for trauma. His presenting electrocardiogram revealed normal sinus rhythm and complete right bundle branch block. Laboratory findings included a white blood cell count of 13.5 × 103/μl, serum creatine kinase level of 459 IU/l, and creatine kinase–myocardial band level of 185 IU/l. Enhanced computed tomography showed a large pericardial effusion and bleeding from his left adrenal gland. There were no pelvic fractures. A diagnosis of cardiac tamponade due to blunt cardiac injury and left adrenal injury due to blunt trauma was made. Subsequently, emergency thoracic surgery and transcatheter arterial embolization of his left adrenal artery were performed simultaneously. A laceration of the left atrial appendage in the lateral wall of his left ventricle was detected intraoperatively and repaired. His postoperative course progressed favorably, although a pericardial effusion was still detected on chest computed tomography on hospital day 35. His electrocardiogram showed normal sinus rhythm and the complete right bundle branch block pattern changed to a narrow QRS wave pattern. He was discharged on hospital day 40. Conclusions The present case report illustrates two points: (1) severe injuries resulted from snowboarding, and (2) complete right bundle branch block was caused by blunt cardiac injury. The present report showed blunt trauma of the left atrium with complete right bundle branch block as an electrocardiogram change due to snowboarding trauma. To detect cardiac trauma in snowboarding accidents, an examination of an electrocardiogram is required in all patients who might have a bruised chest.

Severe sepsis is a major concern in the intensive care unit (ICU), although there is very little epidemiological information regarding severe sepsis in Japan. This study evaluated 3195 patients with severe sepsis in 42 ICUs throughout Japan. The patients with severe sepsis had a mean age of 70 ± 15 years and a mean Acute Physiology and Chronic Health Evaluation II score of 23 ± 9. The estimated survival rates at 28 and 90 days after ICU admission were 73.6 and 56.3 %, respectively. Electronic supplementary material The online version of this article (doi:10.1186/s40560-016-0169-9) contains supplementary material, which is available to authorized users.

We herein report a rare case of ectopic pancreatic acinar cell carcinoma (ACC) which presented as a submucosal tumor of the pylorus. A 73-year-old man came to our hospital presenting with epigastralgia. Esophago-gastroduodenal endoscopy showed no mucosal lesions, but a submucosal tumor was observed around the pylorus. Abdominal computed tomography revealed two round masses. One was located in the pylorus, while the other was found between the portal vein and the inferior vena cava. An examination of a biopsy specimen was inconclusive. We diagnosed a gastrointestinal stromal tumor or malignant lymphoma preoperatively, and decided to perform an operation in order to confirm the diagnosis and select the optimal treatment. Intraoperatively, the mass in the pylorus invaded the pancreatic head, and the lymph node in the hepatoduodenal ligament was swollen. We performed a pancreaticoduodenectomy as a radical excision. The resected specimen showed the 7.6 x 4.9-cm size tumor to mainly originate from the pylorus. Histopathologically, the tumor was identified as pancreatic ACC with lymph node metastasis. The tumor cells were labeled by immunohistochemical staining for alpha1-antitrypsin. Because of the tumor location, we considered the tumor to have originated from the ectopic pancreatic tissue in the stomach. This is only the second case of ACC originating from an ectopic pancreas reported in the literature.

Flail chest is a rare complication in pediatric patients with blunt chest trauma. There is no general consensus on which treatment is most appropriate for flail chest in pediatric patients, although it has been reported that surgical fixation is associated with beneficial outcomes for flail chest in adults. The present report described two pediatric cases of flail chest, which was rare in pediatric blunt trauma. In small children, functional residual capacity is smaller, and the thorax is pliable due to high thoracic compliance. Therefore, it is only advisable to select intubation and mechanical ventilation treatment. Likewise, in pediatric flail chest, the available evidence does not suggest that ventilator management protocols should be adopted routinely, and the treatment for pediatric flail chest was not established completely. There were not huge different between the described patients, including injury severity and ventilation setting. However, one had a relapse of flail chest after extubation and chest taping was required, while the other patient's condition was stable after decannulation. As described above, it is difficult to predict a recurrence of flail chest in pediatric patients even if treatment goes well. Therefore, T-piece trial should be considered prior to extubation.

症例は62歳の男性. 2004年3月17日より突然腹痛が出現し, 3月18日に近医を受診した.内服薬の処方を受けたが症状軽快せず,また腹部X線でイレウスと診断されたため, 3月23日に当院を紹介受診し入院となった.入院後,イレウス管を留置し保存的療法を行ったが症状の軽快を認めず,イレウス管からの小腸造影検査では左下腹部に先細り状の小腸閉塞を認めた.このため何らかの内ヘルニアによるイレウスと診断し, 4月12日に開腹手術を施行した.手術所見ではS状結腸間膜右葉に径2.5cm大の欠損を認め,回盲部から約200cm口側の小腸が約10cm嵌入していた.嵌入した小腸を用手的に整復して内ヘルニアを解除し,S状結腸間膜の欠損部を縫合閉鎖して手術を終了した.術後経過は良好で術後11日目に退院した. S状結腸間膜内ヘルニアは稀な疾患であり,若干の文献的考察を加えて報告する.

Background: Public access defibrillation (PAD) with automated external defibrillator (AED) is a widely available and beneficial intervention for cardiac arrest. The quality of chest compressions (CC) is an important determinant of the outcome of cardiopulmonary resuscitation (CPR). In Japan, AED with real-time audiovisual feedback is being implemented, and has been available to bystanders since 2011. However, the benefit of CC feedback systems for laypersons remains unclear. In this study, we sought to determine the effects of audiovisual feedback system on the quality of CC in bystanders with different medical backgrounds. Methods: A total of 478 individuals (151 healthcare professionals [mean age, 31.3 years], 76 medical students [mean age, 23.6 years], and 251 non-healthcare professionals [mean age, 40.1 years]) participated in a CPR quality improvement challenge. Participants performed two 2-min trials of CC on a training manikin equipped with an accelerometer-based system for measuring both rate and depth of CC. Real-time audiovisual feedback was disabled during first trial, but activated during the second trial. The quality of CC was evaluated by counting the number of compressions with the appropriate depth (5.0-10 cm) and rate (100-120 cpm) in each trial. Results: Among all participants, mean depth of CC was higher (6.35 vs. 5.87 cm), and mean rate was lower (102.4 vs. 112.2 cpm) when the feedback system was activated than when it was disabled (p < 0.05). When real-time feedback was activated, non-healthcare professional participants performed CC of greater depth (6.41 vs. 5.63 cm) than healthcare professionals (6.25 vs. 6.09 cm) and medical students (6.34 vs. 6.19 cm) (p < 0.05). The quality index of CC, which the percentage of adequate depth and rate, was also significantly improved regardless medical backgrounds (p < 0.05). Conclusions: The use of real-time CPR feedback systems improves the quality of CC performed by individuals of all backgrounds, especially non-healthcare personnel. PAD with AED providing CPR feedback technologies may elevate the survival rate of out-of-hospital cardiac arrest and increase the likelihood of favorable outcomes.

Patients with simple pneumopericardium due to blunt thoracic trauma occasionally progressed to tension pneumopericardium, although pneumopericardium is believed to be benign in general. A 65-year-old man had both arms caught in a grinding machine and his face struck hard at work. He was diagnosed with bilateral degloving injuries of both arms and mediastinal emphysema on computed tomography. He required transfer to an advanced emergency medical service center for treatment. Although he was hemodynamically stable then, the patient's condition deteriorated during transportation. The patient returned to the local hospital as cardiopulmonary resuscitation continued, repeat computed tomography was performed, which showed a substantial pneumopericardium and exacerbation of mediastinal and subcutaneous emphysema. After then, cardiopulmonary resuscitation was discontinued because there was no response. For the patient to be rescued in this situation, thoracotomy is required, although it should be reserved for patients with evidence of hemodynamic compromise attributable to cardiac tamponade.

A 71-year-old man presented with hemoptysis due to chronic contained rupture of the descending thoracic aorta after sepsis by Escherichia coli complicated with transrectal biopsy of the prostate, and underwent urgent graft replacement. The aorta had an almost normal caliber and ruptured into the left lung without abscess. The perforated site of the lung was filled with gelatin-resorcinol-formaldehyde glue, and the defect of the aortic wall was closed. Without graft infection, lung abscess, or sepsis, the patient was discharged followed by 1 month’s intravenous administration of cefazolin and piperacillin sensitive to Escherichia coli after the surgery.

Vilacosta and associates have recently described the pathology of a new cardiovascular syndrome, acute aortic syndrome. This syndrome embraces a heterogeneous group of patients with a similar clinical profile that includes penetrating atherosclerotic aortic ulcer, intramural aortic haematoma, and classic aortic dissection. The authors describe progressive acute abdominal aortic syndrome, in which the penetration of the ulcer occurred at the dorsal end of the abdominal aorta and progressed rapidly and cranially.