Phylogenomic and morphological data reveal hidden patterns of diversity in the national tree of Brazil, Paubrasilia echinata.

PREMISE: Paubrasilia echinata (common names, pau brasil, brazilwood) is the national tree of Brazil and an endangered species endemic to the Brazilian Atlantic Forest. Over its wide distribution of 2000 km, its leaflets morphology exhibits extensive plasticity. Three morphotypes are commonly identified based on leaf size, but it is unclear if they represent distinct taxa or a single polymorphic species. This study aims to clarify the taxonomic position of the three morphotypes to inform conservation decisions. METHODS: A morphometric study of leaf characters of herbarium specimens was coupled with genetic analyses using genotype-by-sequencing data. We used maximum-likelihood and coalescent methods to evaluate the phylogenetic and population structure of the species. We compared these with a morphological dendrogram built from hierarchical clustering. RESULTS: Two of the three morphotypes formed separately evolving lineages, the third morphotype formed two geographically separate lineages, and northern trees with intermediate leaf morphology formed a separate fifth lineage. Leaflet size varied by over 35-fold, and although morphological clustering generally matched the genetic patterns, there were some overlaps, highlighting the cryptic diversity within this group. CONCLUSIONS: Our genetic and morphological results provide some evidence that cultivated trees from different states in Brazil seem to have a limited genetic origin and do not reflect the broader genetic and geographical diversity of the species. As a result, more care is likely needed to preserve the overall genomic diversity of this endangered and iconic species.

Outcomes of endovascular repair of infrarenal penetrating aortic ulcers.

Background: To report technical success as well as perioperative outcomes of patients who underwent endovascular aortic repair (EVAR) of penetrating abdominal aortic ulcers ≤35 mm in diameter (PAU). Patients and methods: The abdominal aortic aneurysm (AAA) quality registry of the German institute for vascular research (DIGG) was used to identify patients with standard EVAR for infrarenal PAU ≤35 mm between 1/1/2019 and 12/31/2021. Infectious, traumatic, inflammatory PAUs, PAUs associated with connective tissue disease, PAUs following aortic dissection as well as true aneurysms were excluded. Demographics, cardiovascular comorbidity, technical success as well as perioperative morbidity and mortality were determined. Results: Amongst 11 537 patients who underwent EVAR during the study period, 405 with PAU ≤35 mm were eligible from 95 participating hospitals across Germany (22% women, 20.5% octogenarians). The median aortic diameter was 30 mm (Interquartile range 27-33). Cardiovascular comorbidities were frequent with coronary artery disease (34.8%), chronic heart failure (30.9%), history of myocardial infarction (19.8%), hypertension (76.8%), diabetes (21.7%), smoking (20.8%), history of stroke (9.4%), symptomatic lower extremity peripheral arterial disease (20%), chronic kidney disease (10.4%) and chronic obstructive pulmonary disease (9.6%). Most patients were asymptomatic (89.9%). Among the symptomatic patients, 13 presented with distal embolization (3.2%) and 3 with contained ruptures (0.7%). Technical success of endovascular repair was 98.3%. Both, percutaneous (37.1%) or femoral cut-down access approaches (58.5%) were registered. Endoleaks of any type were present with type 1 (0.5%), type 2 (6.4%) and type 3 (0.3%) endoleaks. Overall mortality was 0.5%. Perioperative complications occurred in 12 patients (3.0%). Conclusions: According to this registry data, endovascular repair of PAU is technically feasible with acceptable perioperative outcomes, but further studies investigating mid- and long-term data are needed before invasive treatment of PAU disease in an elderly and comorbid patient population should be recommended.

Cellular Antioxidant, Anti-Inflammatory, and Antiproliferative Activities from the Flowers, Leaves and Fruits of Gallesia integrifolia Spreng Harms.

Gallesia integrifolia, a notable species in the Atlantic Forest, has been traditionally employed in folk medicine for treating rheumatism, asthma, and worms. This study investigated the cellular antioxidant, antiproliferative, and anti-inflammatory activities of the essential oils (EOs) and crude extracts (CEs) from G. integrifolia flowers, fruits, and leaves. The chemical identification of EOs was performed by GC-MS and CEs by UHPLC-MS. Cellular antioxidant and anti-inflammatory activities were assessed through mouse macrophage cell culture. In addition, the antiproliferative potential was evaluated in gastric, colorectal, breast, and lung tumor cell lines and non-tumor VERO cells. EOs predominantly contained organosulfur compounds in flowers (96.29%), fruits (94.94%), and leaves (90.72%). We found the main compound is 2,2'-Disulfanediyldiethanethiol in the EOs of flowers (47.00%), leaves (41.82%), and fruits (44.39%). Phenolic compounds were identified in CEs. The EOs and CEs demonstrated potential against the tumor cell lines tested (GI50 between 51 and 230 µg/mL). The selectivity index values were greater than 1.0 (1.01 to 3.37), suggesting a relative safety profile. Moreover, the anti-inflammatory activity IC50 ranged from 36.00 to 268 µg/mL, and the cellular oxidation inhibition ranged from 69% to 82%. The results suggest that oils and extracts derived from G. integrifolia have potential for use in various industrial sectors.

Conservative treatment as a therapeutic option for penetrating aortic ulcer of the aortic arch in a patient with bicuspid aortic valve.

Penetrating aortic ulcer (PAU) is ulceration of an aortic atherosclerotic plaque penetrating through the internal lamina into the media. PAU is a rare condition and occurs in 2% - 7% of acute aortic syndromes (AAS); however, the actual incidence is unknown because of asymptomatic patients. One may treat it conservatively as well as surgically. We present a case of a 54-year-old man, who was admitted to hospital due to the exaggeration of exertional chest pain and persistent headaches. During coronary angiography, the suspicion of PAU was raised. Contrast-enhanced computed tomography confirmed the diagnosis. Transesophageal echocardiography showed bicuspid aortic valve with minimal calcification, the dilated ascending aorta, large atherosclerotic plaques in the aortic arch with ulceration (thickness: 5.0 - 5.5mm, diameter: 5 - 6 mm, depth: 3 - 4 mm), without intramural hematoma. Conservative treatment was chosen with uneventful 2-year follow-up. Although surgical management is advocated for patients with PAU type A, we demonstrated that type A PAU can be successfully treated conservatively as well.

Karyotype diversity and 2C DNA content in species of the Caesalpinia group.

BACKGROUND: The Leguminosae family is the third-largest family of angiosperms, and Caesalpinioideae is its second-largest subfamily. A great number of species (approximately 205) are found in the Caesalpinia group within this subfamily; together with these species' phenotypic plasticity and the similarities in their morphological descriptors, make this a complex group for taxonomic and phylogenetic studies. The objective of the present work was to evaluate the karyotypic diversity and the 2C DNA content variation in 10 species of the Caesalpinia group, representing six genera: Paubrasilia, Caesalpinia, Cenostigma, Poincianella, Erythrostemon and Libidibia. The GC-rich heterochromatin and 45S rDNA sites (which are used as chromosome markers) were located to evaluate the karyotype diversity in the clade. The variation in the 2C DNA content was determined through flow cytometry. RESULTS: The fluorochrome banding indicated that the chromomycin A3+/4',6-diamidino-2-phenylindole- blocks were exclusively in the terminal regions of the chromosomes, coinciding with 45S rDNA sites in all analyzed species. Physical mapping of the species (through fluorescence in situ hybridization) revealed variation in the size of the hybridization signals and in the number and distribution of the 45S rDNA sites. All hybridization sites were in the terminal regions of the chromosomes. In addition, all species had a hybridization site in the fourth chromosome pair. The 2C DNA content ranged from 1.54 pg in Erythrostemon calycina to 2.82 pg in the Paubrasilia echinata large-leaf variant. The Pa. echinata small-leaf variant was isolated from the other leaf variants through Scoot-Knott clustering. CONCLUSIONS: The chromosome diversity and the variation in the 2C DNA content reinforce that the actual taxonomy and clustering of the analyzed taxa requires more genera that were previously proposed. This fact indicates that taxonomy, phylogeny and cytoevolutionary inference related to the complex Caesalpinia group have to be done through integrative evaluation.

Pararenal Aortic Ulcer Repair.

OBJECTIVE/BACKGROUND: In order to investigate techniques and outcomes of pararenal penetrating aortic ulcer (PAU) repair, a retrospective cohort study was performed. METHODS: Over the 6 year study period, 12 patients treated for a pararenal PAU were included. Outcome measures included technical success, survival, and peri-operative complications, as well as stent patency. RESULTS: Treatment modalities included hybrid procedures with endovascular aneurysm repair (EVAR) and bypass grafting, chimney EVAR (Ch-EVAR), and fenestrated EVAR (FEVAR). Four of the 12 patients were symptomatic, and eight patients underwent elective surgery. The technical success rate was 100%. Symptom resolution was recorded in all symptomatic patients immediately post-operatively. Complications encountered included one type I endoleak in a patient who underwent Ch-EVAR, and one case of post-operative stroke, paralysis, and death in a patient who underwent FEVAR. No adverse events were recorded in the remaining 10 patients. The PAU protrusion distance was significantly greater in symptomatic patients. Perforation and leakage were more prevalent in patients with pre-operative abdominal or back pain. CONCLUSION: Encouraging results of endovascular treatment of pararenal PAUs were observed. One major and fatal complication was encountered, which underlines the complexity and risks of the techniques. Another patient required re-intervention owing to an endoleak following off label use of covered stents for Ch-EVAR. FEVAR, which generally requires a custom made graft, was increasingly applied over the study period, potentially because of an increased awareness of this distinct pathology allowing for elective procedure planning. Ch-EVAR and hybrid procedures were predominantly used in symptomatic patients, whereas FEVAR was the preferred elective treatment option.

Construction of a novel twin-arginine translocation (Tat)-dependent type expression vector for secretory production of heterologous proteins in Corynebacterium glutamicum.

Corynebacterium glutamicum is recognized as a favorable host for the secretory production of heterologous proteins. However, there are few secretion-type expression vectors available for protein production in C. glutamicum. In this study, we constructed a shuttle expression vector pAU3, which harbors the strong promoter tac-M for constitutive gene transcription, the consensus RBS sequence for protein translation, and the strong cgR_0949 signal sequence for protein secretion via the Tat pathway in C. glutamicum. The applicability of pAU3 was confirmed by the highly efficient expression and secretion of the CAT protein in C. glutamicum. The vector pAU3 is highly useful for secretory production of heterologous proteins in C. glutamicum.

Damage Detection in FRP-Reinforced Concrete Elements.

Fiber-Reinforced Polymer (FRP) composites have emerged as a promising alternative to conventional steel reinforcements in concrete structures owing to their benefits of corrosion resistance, higher strength-to-weight ratio, reduced maintenance cost, extended service life, and superior durability. However, there has been limited research on non-destructive testing (NDT) methods applicable for identifying damage in FRP-reinforced concrete (FRP-RC) elements. This knowledge gap has often limited its application in the construction industry. Engineers and owners often lack confidence in utilizing this relatively new construction material due to the challenge of assessing its condition. Thus, the main objective of this study is to determine the applicability of two of the most common NDT methods: the Ground-Penetrating Radar (GPR) and Phased Array Ultrasonic (PAU) methods for the detection of damage in FRP-RC elements. Three slab specimens with variations in FRP type (glass-, carbon- and basalt-FRP, i.e., GFRP, CFRP, and BFRP, respectively), bar diameter, bar depths, and defect types were investigated to determine the limitations and detection capabilities of these two NDT methods. The results show that GPR could detect damage in GFRP bars and CFRP strands, but PAU was limited to damage detection in CFRP strands. The findings of this study show the applicability of conventional NDT methods to FRP-RC and at the same time identify the areas with a need for further research.

Surgical or endovascular therapy of abdominal penetrating aortic ulcers and their natural history: a systematic review.

Little is known regarding the outcomes of endovascular and surgical treatment of penetrating ulcers in the abdominal aorta. The potential benefit of conservative management of asymptomatic disease is also debatable. A systematic review of the literature was undertaken to investigate these issues.

Unusual presentation of acute ruptured penetrating aortic ulcer of descending thoracic aorta with right hemothorax.

Right-sided hemothorax is a rare presentation of ruptured penetrating aortic ulcers. A 72-year-old female presented to the hospital with a penetrating aortic ulcer of the mid-thoracic aorta and a right-sided hemothorax. The patient was taken for thoracic endovascular aortic repair and right-sided tube thoracostomy. The diagnosis was complicated by the patient's history of pacemaker placement causing prominent venous collaterals in the mediastinum. The postoperative course was complicated by lower extremity weakness, requiring lumbar cerebrospinal fluid drain placement. The patient regained full function of her lower extremities. This case illustrates that patients with ruptured acute aortic syndromes may present with right hemothorax, so index of suspicion should remain high in this population.

PAU-SA: a synthetic aperture interferometric radiometer test bed for potential improvements in future missions.

The Soil Moisture and Ocean Salinity (SMOS) mission is an Earth Explorer Opportunity mission from the European Space Agency (ESA). Its goal is to produce global maps of soil moisture and ocean salinity using the Microwave Imaging Radiometer by Aperture Synthesis (MIRAS). The purpose of the Passive Advanced Unit Synthetic Aperture (PAU-SA) instrument is to study and test some potential improvements that could eventually be implemented in future missions using interferometric radiometers such as the Geoestacionary Atmosferic Sounder (GAS), the Precipitation and All-weather Temperature and Humidity (PATH) and the Geostationary Interferometric Microwave Sounder (GIMS). Both MIRAS and PAU-SA are Y-shaped arrays with uniformly distributed antennas, but the receiver topology and the processing unit are quite different. The purpose of this work is to identify the elements in the MIRAS's design susceptible of improvement and apply them in the PAU-SA instrument demonstrator, to test them in view of these future interferometric radiometer missions.

Cytotoxicity and anti-inflammatory activities of Gallesia integrifolia (Phytolaccaceae) fruit essential oil.

The chemical composition of Gallesia integrifolia fruits essential oil was obtained by hydrodistillation using a modified Clevenger apparatus was investigated by gas chromatography coupled to mass spectrometry (GC/MS). In addition, the cytotoxicity activity against human tumor cell lines MCF-7 (breast adenocarcinoma), NCI-H460 (large cell lung carcinoma), HeLa (cervical carcinoma), and HepG2 (hepatocellular carcinoma), and non-tumor PLP2 (porcine liver primary cells) as well as the anti-inflammatory action was proposal. The compounds were predominantly organosulfates (2,8-dithianonane, dimethyl trisulfide, and lenthionine). Anti-inflammatory activity that provides 50% inhibition of nitric oxide production (55 µg/mL) of essential oil of the fruits. It also presents cytotoxic activity against MCF-7 (GI50 = 66 µg/mL), NCI-H-460 (GI50 = 147 µg/mL), HeLa (GI50 = 182 µg/mL) and HepG2 (GI50 = 240 µg/mL). The essential oil is more active in tumor cells than in non-tumor cells and the GI50 values for essential oil reported in our work support future studies.

Natural history and clinical significance of aortic focal intimal flaps.

Objective: Focal intimal flaps (FIF) are a variety of defects of the aorta that result in a short, flap-like projection into the lumen, and are often encountered in asymptomatic patients undergoing computed tomography angiography (CTA) surveillance for aortic aneurysm, but the natural history and clinical significance of such lesions has not yet been studied. Methods: We retrospectively identified patients with an asymptomatic FIF and available imaging follow-up (>1 year). FIF was defined as flap-like intimal irregularity < 4 cm in length involving the thoracic aorta (TA), abdominal aorta (AA) or common iliac arteries (CIA). FIF characteristics included length and circumferential extent as well as the presence and size (width and depth) of associated penetrating aortic ulcers (PAUs). Patient characteristics, adverse events and history of surgical repair was determined by chart review. FIFs and associated PAUs were assessed for progression by comparing baseline and follow-up CTA studies. Results: A total of 84 FIFs were identified in 77 patients. Average age was 69.2 ± 10.1 years, and 81% were male (81%). Common co-morbidities included: hypertension (78%), hyperlipidemia (68%), smoking (60%), coronary artery disease (41%), aortic aneurysm (34%), type II diabetes mellitus (27%) and prior cardiovascular surgery (25%). FIFs were most commonly located in the abdominal aorta (n = 50, 60%). Nearly all FIFs were associated with local atherosclerotic plaque (93%). Mean follow-up interval was 3.5 ± 2.6 years (259 cumulative follow-up years). Change in FIF length and local aortic diameter over follow-up were 0.7 ± 2.3 mm and 0.8 ± 1.1 mm, respectively. Nearly half (47%) of FIFs were associated with penetrating aortic ulcers (PAU) with baseline depth of 7.3 mm (IQR: 6.1-10.2) and change in depth of 0.5 ± 1.4 mm. Only 12% of FIFs and 0% of associated PAUs demonstrated growth (≥3 mm) at follow-up. No acute pathology developed in the location of FIFs and no aortic interventions were performed specifically to treat FIFs. Conclusion: Focal intimal flaps identified in asymptomatic patients with aortic disease were co-localized with atherosclerotic plaque and PAUs, and demonstrated indolent behavior, not leading to significant growth or acute aortic events, supporting a conservative management approach.

Safety and tolerability of Pau d' Arco (Tabebuia avellanedae) for primary dysmenorrhea: A single-arm, open-label trial on adults ages 18-45.

Objectives: To evaluate the safety and tolerability of encapsulated Tabebuia avellanedae in generally healthy women aged 18-45 with primary dysmenorrhea. Methods: A single arm, open-label trial was conducted in which 1050 mg/day of encapsulated Tabebuia avellanedae (Pau d'Arco) was administered to twelve healthy women aged 18-45 for eight weeks. The primary outcome was safety and tolerability as measured by standardized adverse events scales and serial collection of laboratory markers to assess general health, prothrombin times, and the presence or absence of anemia. Secondary outcomes included pain intensity, quality of life, and pain interference measured by the Visual Analog Scale (VAS), the Patient-Reported Outcomes Measurement Information System (PROMIS) 29 survey, and the PROMIS Visual Sexual Function and Satisfaction: Interfering Factors survey, respectively. Exploratory outcomes included serum concentration of high-sensitivity C-reactive protein as a marker of systemic inflammation. Results: Seventy-five percent of participants (n = 9/12) completed the study. Seventy-five percent of study participants (n = 9/12) reported an adverse event, most of which were characterized as mild, and none were determined to be a Food and Drug Administration (FDA) serious adverse event. Most laboratory markers stayed within normal limits throughout the study period with a few clinically mild abnormalities. There was a significant decrease in pain intensity compared to baseline after the first dose (p < .01), after 4 weeks of treatment (p < .01), and after 8 weeks of treatment (p < .01). Over the 8-week intervention period, pain interference, quality of life, and sexual function and satisfaction scores improved nonsignificantly and hs-CRP decreased nonsignificantly. Conclusions: Tabebuia avellanedae supplementation of 1050 mg/day dose for eight weeks in generally healthy women aged 18-45 with primary dysmenorrhea was generally safe, associated with moderate tolerability, and associated with significant improvements in pain intensity scores. Future studies examining the safety and efficacy of Tabebuia avellanedae on primary dysmenorrhea are warranted.

Coronary Artery Bypass Salvage With Branched Aortic Endograft in a Patient With Aortic Arch Ulcer.

Treatment of multiple penetrating aortic ulcers becomes troublesome if they involve the aortic arch. We report a percutaneous aortic repair using a unibody design endoprosthesis with a precannulated side component for the left subclavian artery to manage a large aortic arch ulcer and preserve the patency of previous coronary artery bypass graft. (Level of Difficulty: Advanced.).

A single-center experience in the use of hybrid techniques for thoracic aortic pathology.

The hybrid method of treating thoracic aortic pathology is devoid of the disadvantages of traditional open surgery and, at the same time, has a broader range of applications than the endovascular method. From 2014 to 2019, we researched 122 patients with thoracic aortic pathology treated with the hybrid method (open surgery with thoracic endovascular aortic repair (TEVAR) at the National M. Amosov Institute of Cardiovascular Surgery National Academy of Medical Science of Ukraine. In the general group, 34 patients had a descending aortic aneurysm without dissection or rupture; 71 patients had an aortic dissection (10 - acute, 9 - subacute, 52 - chronic), penetrating aortic ulcer (PAU) - 7, thoracoabdominal aneurysm (Crawford I-II) - 4, isolated aortic arch aneurysm - 2, residual enlargement aorta after previous ascending aortic grafting causing type A acute aortic dissection (TAAD) - 3, primary aortic thrombosis - 1. Patients admitted as elective surgery candidates had switched aortic arch vessels (debranching) in the first stage and TEVAR in the second stage. For emergencies (aortic rupture with uncontrolled bleeding, malperfusion syndrome), TEVAR operation was performed first. Long-term results of treatment after three and six months are satisfactory. The hybrid technique of aortic arch treatment using modern minimally invasive technologies can eliminate the pathology in the most dangerous segment of the main artery of the body, providing a reasonable level of hospital mortality - 4.2%, and a small number of neurological complications.

The Management of Patients With Penetrating Aortic Ulcers: A Systematic Review.

BACKGROUND: Penetrating aortic ulcers (PAUs) are an entity within acute aortic syndrome. They often remain undiagnosed and are found incidentally or when they become symptomatic. Management is currently guided by clinical judgment. This review aims to identify indications for treatment and inform management. METHODS: We searched PubMed for studies on the management of PAUs. The outcome measures were mortality, progression and resolution of symptoms. RESULTS: This review incorporates 27 studies involving 1356 patients with PAU. Data was available regarding symptoms for 1213 patients (494 symptomatic, 719 asymptomatic). Overall late mortality for PAUs was found to be higher than 30-day mortality. Early mortality was higher for symptomatic patients as compared to those with asymptomatic PAUs. Early mortality was lowest for PAUs treated with endovascular interventions (5%), followed by PAUs managed medically and highest following open surgical management. Indications for treatment included symptoms, progression/instability, aortic diameter >5 cm, concomitant aortic pathology or pleural effusion. 13% of patients managed conservatively at initial presentation demonstrated progression and were considered for intervention subsequently. 9% of patients required reintervention after initial endovascular surgery. CONCLUSION: Endovascular treatment, if anatomically suitable, should be considered as first line treatment for symptomatic PAUs. Patients with asymptomatic PAUs, if associated with high-risk features such as PAU diameter >20 mm, PAU depth >10 mm, aortic diameter >42 mm, concomitant pathology, morphological change or an infective etiology, should also be considered for intervention. Small asymptomatic PAUs with no high-risk features may be managed conservatively but must undergo regular surveillance.

Inflammasomes in the Pathophysiology of Aortic Disease.

Aortic diseases comprise aneurysms, dissections, and several other pathologies. In general, aging is associated with a slow but progressive dilation of the aorta, along with increased stiffness and pulse pressure. The progression of aortic disease is characterized by subclinical development or acute presentation. Recent evidence suggests that inflammation participates causally in different clinical manifestations of aortic diseases. As of yet, diagnostic imaging and surveillance is mainly based on ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI). Little medical therapy is available so far to prevent or treat the majority of aortic diseases. Endovascular therapy by the introduction of covered stentgrafts provides the main treatment option, although open surgery and implantation of synthetic grafts remain necessary in many situations. Because of the risks associated with surgery, there is a need for identification of pharmaceutical targets interfering with the pathophysiology of aortic remodeling. The participation of innate immunity and inflammasome activation in different cell types is common in aortic diseases. This review will thus focus on inflammasome activities in vascular cells of different chronic and acute aortic diseases and discuss their role in development and progression. We will also identify research gaps and suggest promising therapeutic targets, which may be used for future medical interventions.

Mid-back pain due to a penetrating atherosclerotic aortic ulcer: do not miss the diagnosis-a case report.

In clinical practice, clinicians often meet patients suffering from mid-back pain. One of the possible causes of mid-back pain is penetrating atherosclerotic aortic ulcer (PAU), but the diagnosis is often delayed owing to its low incidence. Here, we report a patient with mid-back pain due to a PAU, who was diagnosed after receiving several procedures for reducing musculoskeletal pain. A 65-year-old man visited our pain clinic for mid-back pain [numeric rating scale (NRS): 7] experienced for 2 months. The pain was radiated to the lateral chest area and was aggravated when in the supine and standing positions. Trigger point injection, medial branch block, and pulsed radiofrequency were ineffective. The cardiac evaluation and abdominal computed tomography (CT) results showed no abnormalities. On CT aortography at 3 months after pain onset, intraluminal thrombus, multiple ruptured PAUs, and aneurysmal change of the descending thoracic aorta were found. Accordingly, PAU was diagnosed as the origin of the patient's pain. We administered nicardipine with a rate of 1.15 mcg/kg/min and esmolol with a rate of 100 mcg/kg/min for controlling the systolic blood pressure. In addition, an anticoagulant was administered orally. To alleviate the pain, we further administered intravenous opioid. Approximately 6 h after, the systolic blood pressure decreased to 100-120 mmHg, and the pain rating decreased to NRS 1. Two weeks after the discharge, the patient's pain rating was sustained at NRS 1. Clinicians should be aware of the fact that PAU can be a cause of mid-back or chest pain.

Sudden Cardiac Arrest Due to Ascending Aortic Thrombus Originating From Penetrating Aortic Ulcer.

Penetrating aortic ulcers typically occur in severely diseased vessels. We present the case of a 46-year-old woman, without extensive atherosclerosis, who had sudden cardiac arrest related to ischemia from a mobile intraluminal aortic thrombus adherent to a penetrating ulcer in the ascending aorta. (Level of Difficulty: Intermediate.).