A 66-year-old man was admitted to our intensive care unit because of severe pneumonia. He was treated with mechanical ventilation, antibiotics, and corticosteroids, but muscle weakness developed rapidly. His muscle strength declined to a Medical Research Council scale sum score of 18/60；thus, a diagnosis of intensive care unit-acquired weakness (ICU-AW) was made. The results of nerve conduction studies were compatible with critical illness polyneuropathy. Mechanical ventilation was required for 95 days because of continuous respiratory failure. Rehabilitation began at 48 hours after hospitalization and was continued to prevent immobilization even when he was mechanically ventilated. However, orthostatic hypotension developed and inhibited mobility training. Physical and occupational therapies provided muscle strengthening exercises followed by a progressive mobility program that assisted him to raise his head, sit on the edge of the bed, and stand up. The intervention was performed within safety criteria of vital signs and the rating of perceived exertion (RPE) Borg scale between 11 and 13. It resulted in the attenuation of orthostatic hypotension and the recovery of muscle strength. He finally achieved independence in activities of daily living and the ability to walk without help after 271 days of admission. This case report suggests that long-term rehabilitation within safety criteria of vital signs and RPE Borg scale between 11 and 13 is safe and feasible without overuse weakness for ICU-AW with orthostatic hypotension.

　　From 2008 to 2014, we experienced 40 respiratory failure cases which required long-term ventilation in the post-ICU in Kakeyu Hospital. They had been referred to our hospital from acute care hospitals and most of them had been transferred on our regional medical cooperation system. Initially, we used long-term care beds for them, but as the number of serious cases increased, we moved them to acute care beds. As regards main causes of respiratory failure, post cardiac arrest syndrome topped the list with 12 cases, followed by chronic obstructive pulmonary disease, intractable neurological diseases and cervical cord injury. All these cases combined, the number came to 30 cases, accounting for 75% of all. The shortest stay in hospital was made by a patient with brain stem lymphoma. It was only 12 days, but the longest was made by a patient with post meningoencephalitis 6 years. Our care consisted not only ventilation and medical care but also giving a bath, walking with a type of wheelchair, and sunbathing at the rooftop of our hospital. In May 2014, we renovated the post-ICU from an acute care division to a physical disability patient ward. As the elderly population will increase, it is expected that the need for acute care will augment in parallel with an increase to the number of post cardiac arrest syndrome and the demand of long-term ventilation. Therefore, the community care system will need the post-ICU for cooperation with acute care hospitals.

STUDY DESIGN: A retrospective study. PURPOSE: To compare clinical and radiological outcomes between bilateral C2 pedicle screwing (C2PS) and unilateral C2PS, combined with contralateral C2 laminar screwing (LS), for posterior atlantoaxial fixation. OVERVIEW OF LITERATURE: Posterior fixation with C1 lateral mass screwing (C1LMS) and C2PS (C1LMS-C2PS method) is an accepted procedure for rigid atlantoaxial stabilization. However, conventional bilateral C2PS is not always allowed in this method due to anatomical variations of C2 pedicles and/or asymmetry of the vertebral artery. Although unilateral C2PS plus contralateral LS (C2PS+LS) is an alternative in such cases, the efficacy of this procedure has not been evaluated in controlled studies (i.e., with bilateral C2PS as a control). METHODS: Clinical and radiological records of patients who underwent the C1LMS-C2PS method, using unilateral C2PS+LS (n=9), and those treated using conventional bilateral C2PS (n=10) were compared, with a minimum two years follow-up. RESULTS: Postoperative complications related to the unilateral C2PS+LS technique included one case of spontaneous spinous process fracture of C2. A C1 anterior arch fracture occurred after a fall in one patient, who underwent bilateral C2PS and C1 laminectomy. No significant differences were seen between the groups in reduction of neck pain after surgery or improvement of neurological status, as evaluated using the Japanese Orthopaedic Association score. A delayed union occurred in one patient each of the groups, with the final fusion rate being 100% in both groups. CONCLUSIONS: Clinical and radiological outcomes of unilateral C2PS+LS were comparable with those of the bilateral C2PS fixation technique for the C1LMS-C2PS method.
Asian Continental Ancestry Group ; Follow-Up Studies ; Humans ; Laminectomy ; Neck Pain ; Postoperative Complications ; Retrospective Studies ; Vertebral Artery

An 83-year-old man had acute type B aortic dissection combined with a large athelosclerotic abdominal aortic aneurysm (AAA) over 8cm in diameter. The dissection advanced into the wall of the AAA. The patient was treated with strict medical therapy for two months and successfully underwent an early elective abdominal aortic repair concomitant with off-pump aortocoronary bypass grafting. This strategy of meticulous medical management may improve clinical outcome for the acute phase in such rare cases.