Background: Abdominal massage for the resolution of constipation has been reported to be safe and recommended in some studies. It is conventionally performed for the elderly suffering from intractable constipation. Meantime, isolated mesenteric injury after blunt abdominal trauma is uncommon. Here, we report a case of isolated mesenteric injury following self-abdominal massage for constipation. Case presentation: A 68-year-old man consulted a local hospital due to a sudden abdominal pain. He had a history of prostate cancer treated with radiation therapy 3 years ago, and he had been suffering from chronic constipation for many years. A plain computed tomography (CT) revealed a fist-sized homogeneous mass-like lesion located in the left upper abdomen and a moderate amount of ascites. With the initial diagnosis of a malignant tumor accompanied by peritonitis carcinomatosa, he was hospitalized for further examinations. On the next day, his hemoglobin concentration dropped from 11.6 to 6.6 g/dl, and diagnostic paracentesis showed bloody ascites. He was urgently transferred to our tertiary emergency center. An enhanced CT demonstrated a non-enhanced, homogeneous, 8.5 cm in diameter, mass lesion located to the posterior of the stomach with massive bloody ascites. He underwent an emergency exploratory laparotomy, and it showed a 5 cm of laceration in the transverse mesocolon adjacent to Treitz’s ligament and approximately 1.5 l of intraabdominal hemorrhage. Hemostasis of the bleeding from the laceration was achieved by suture ligations, but the gap of the laceration could not be closed by suturing because the tissue was too fragile. Blood transfusion with 4 units of packed red blood cells and 10 units of fresh frozen plasma was performed during operation. He was discharged without any significant complications except for postoperative paralytic ileus. Later on, it turned out that he had a habit of massaging his abdomen for the resolution of intractable constipation and did it hard 1 day before the onset. Conclusions: This is the first report of life-threatening mesenteric injury caused by self-abdominal massage to resolve constipation, though other etiologies such as rupture of small aneurysms could not perfectly be excluded. Abdominal massage is reported to be effective and safe for the resolution of constipation; however, this case demonstrated it could be detrimental.

Disseminated intravascular coagulation (DIC) is a catastrophic systemic disorder of coagulation, resulting in uncontrollable bleeding, multiple organ failure, and death. Sepsis is one of the common causes of DIC. Despite many attempts to correct these coagulation pathologies, no adjunctive treatments have been shown to improve the mortality of DIC associated with sepsis. Although some clinical studies showed a recently developed human recombinant thrombomodulin, ART-123, might be effective in the treatment of DIC, few randomized, placebo-controlled studies have been conducted. In this study, we treated 60 DIC patients associated with systemic inflammatory response syndrome (SIRS) using ART-123 (n = 29) or saline as a placebo (n = 31). The basal clinical characteristics were similar in both groups. We compared clinical severity scores and DIC score in acute phase, and 28 day mortality between the two groups. Our study demonstrated the DIC score improved a few days earlier in the ART-123 group than the placebo group, and there were no major life-threatening adverse events in both groups. The overall survival rate at day 28 was not significantly altered. In conclusion, ART-123 can be used safely in DIC associated with infectious SIRS patients; however, its true efficacy in the treatment of DIC needs to be further investigated.

The impact of the COVID-19 pandemic has been immense, while the epidemiology and pathophysiology remain unclear. Despite many casualties in many countries, there have been less than 1,000 deaths in Japan as of end of June, 2020. In this study, we analyzed the cases of COVID-19 patients admitted to our institution located in the Tokyo metropolitan area where the survival rate is higher than those in other cities in the world. Medical records of COVID-19 patients that were admitted to a single Japanese tertiary university hospital in the Tokyo metropolitan area between March 10th and June 2nd, 2020 were retrospectively reviewed. The identified COVID-19 cases were subdivided into two groups (severe and mild) depending on the need for mechanical ventilation. Those in the severe group required mechanical ventilation as opposed to those in the mild group. The data were analyzed using nonparametric tests expressed by median [interquartile range (IQR)]. A total of 45 COVID-19 patients were included, consisting of 22 severe cases (Group S) and 23 mild cases (Group M). Male sex (Group S, 95.5% vs. Group M, 56.5%, p<0.01), high body mass index (Group S, 24.89 [22.44–27.15] vs. Group M, 21.43 [19.05–23.75], p<0.01), and hyperlipidemia (Group S, 36.4% vs. Group M, 0%, p<0.01) were more seen in Group S. Five (22.7%) cases in Group S underwent extracorporeal membranous oxygenation (ECMO). On admission, lymphopenia, decreased albumin, and elevated fibrinogen, lactate dehydrogenase, transaminases, creatine kinase, C-reactive protein, and procalcitonin were observed in Group S. The median ICU and hospital stay were 13.5 [10.3–22.3] days and 23.0 [16.3–30.5] days, respectively, in Group S. As of June 28th, 2020, in Group S, 19 (86.4%) patients have survived, of which 17 (77.3%) were discharged, and 2 are still in treatments. Three died of multiple organ failure. All 23 patients in Group M have recovered. Male sex, high body mass index, and hyperlipidemia can be risk factors for severe COVID-19 pneumonia, and its overall short-term survival rate was between 77.3% and 86.4% in this study.

Background: Abnormal cardiac repolarization is observed in patients with epilepsy and can be associated with sudden death. We investigated whether structural brain abnormalities are correlated with abnormal cardiac repolarizations in patients with seizure or epilepsy. Methods and Results: We retrospectively analyzed and compared 12‐lead ECG parameters following seizures between patients with and without structural brain abnormalities. A total of 96 patients were included: 33 women (17 with and 16 without brain abnormality) and 63 men (44 with and 19 without brain abnormality). Brain abnormalities included past stroke, chronic hematoma, remote bleeding, tumor, trauma, and postsurgical state. ECG parameters were comparable for heart rate, PR interval, and QRS duration between groups. In contrast, corrected QT intervals evaluated by Fridericia, Framingham, and Bazett formulas were prolonged in patients with brain abnormality compared with those without (women: Fridericia [normal versus abnormal], 397.4±32.7 versus 470.9±48.9; P =0.002; Framingham, 351.0±40.1 versus 406.2±46.1; P =0.002; Bazett, 423.8±38.3 versus 507.7±56.6; P <0.0001; men: Fridericia, 403.8±30.4 versus 471.0±47.1; P <0.0001; Framingham, 342.7±36.4 versus 409.4±45.8; P <0.0001; Bazett, 439.3±38.6 versus 506.2±56.8; P <0.0001). QT dispersion and T _peak −T _end intervals were comparable between groups. We also observed abnormal ST‐segment elevation in 5 patients. Importantly, no patients showed fatal arrhythmias during or after seizures. Conclusions: Our study demonstrated that brain abnormalities can be associated with abnormal cardiac repolarization after seizures, which might be a manifestation of electrophysiological remodeling in the brain.

Case: Pica is common among patients with psychiatric disorders, but only a few cases regarding coin pica have been reported. A 51‐year‐old man with depression complaining of fatigue was found to have numerous coins in the esophagus and the stomach on X‐rays. He had a peritoneal sign and underwent an emergency laparotomy.Outcome: The surgical findings showed perforation on the anterior wall of the gastric body and coins in the stomach, which were removed manually, followed by an omental patch. Residual coins in the esophagus were removed by endoscopy. The coins totaled 1,894, weighing 8,076 grams. The patient was then diagnosed as schizophrenic. He was asymptomatic for metal toxicity and was finally transferred to a psychiatric hospital.Conclusion: This pica case is the first to show coin pica can lead to gastric perforation, and also reports the largest amounts of coins ingested by a person to date.

Background: Splenic rupture by diffuse large B‐cell lymphoma (DLBCL), which usually progresses insidiously, is extremely rare.Case Presentation: A 60‐year‐old man presented with paralysis in his lower left extremity. A magnetic resonance imaging suggested transverse myelitis. No lymphadenopathy or organomegaly was noted. Two months after remission, he was referred to the emergency department complaining of presyncope. He was in preshock due to splenic rupture, and underwent laparotomy after attempts of transcatheter arterial embolization. Splenomegaly, hepatomegaly, and disseminated enlarged lymph nodes were observed. Histological examinations of the resected spleen showed DLBCL. He died of multiple organ failure associated with intractable bleeding. His autopsy revealed diffuse systemic invasions of lymphoma cells except for the brain and spinal cord. Microscopically, the spinal cord showed macular incomplete necrosis and histiocytic infiltration, suggestive of hemophagocytic syndrome.Conclusion: The progression of DLBCL in our case is drastically rapid. Undiagnosed transverse myelitis preceded the onset.