The need to suspect tension gastrothorax as a cause of obstructive shock in trauma care: A case report.

INTRODUCTION: Traumatic tension gastrothorax is a type of obstructive shock similar to tension pneumothorax. However, tension gastrothorax is not well known among emergency physicians, and no consensus has yet been reached on management during initial trauma care. We present a case of traumatic tension gastrothorax in which tube thoracostomy was performed based solely on clinical findings very similar to tension pneumothorax, followed by emergency laparotomy. PRESENTATION OF CASE: A 24-year-old male motorcyclist was brought to our emergency medical center after being struck by a motor vehicle. He was in respiratory failure and hypotensive shock with findings suggestive of pneumothorax. Although the physical findings were not fully in line with tension pneumothorax, we immediately performed finger thoracostomy. Subsequent radiography revealed left diaphragmatic rupture with hernia. After unsuccessful attempts to decompress the stomach with a nasogastric tube, immediate emergency laparotomy was performed. During the operation, the stomach, which had prolapsed through the ruptured diaphragm into the thoracic cavity, was manually returned to the abdominal cavity. The ruptured diaphragm was repaired with sutures. DISCUSSION: Although distinguishing between tension pneumothorax and tension gastrothorax based on physical examination alone is difficult, tension gastrothorax requires careful attention to avoid intrapleural contamination from gastric injury. In addition, relying solely on stomach decompression with a nasogastric tube or delaying laparotomy could lead to cardiac arrest. CONCLUSION: When tension pneumothorax is suspected during initial trauma care, tension gastrothorax should also be considered as a differential diagnosis and treated with immediate diaphragmatic repair once identified.

[Pseudo-false Aneurysm of the Left Ventricle after Acute Myocardial Infarction;Report of a Case].

A 77-year-old man was admitted to a regional hospital to undergo investigation of abnormal electrocardiographic findings. Coronary angiography revealed 99% stenosis of the right coronary artery(RCA) segment 3 and 75% stenosis of the left anterior descending artery (LAD)segment 7. Left ventriculography revealed an aneurysm at the inferior wall of the left ventricle. On computed tomography and echocardiography, a saccular aneurysm at the inferior wall, 15 mm in diameter, was observed. Under the suspicion of a ventricular false aneurysm resulting from myocardial infarction, aneurysmectomy, patch closure of the aneurysmal orifice and coronary artery bypass grafting to the LAD and RCA were performed. No pericardial adhesion to the ventricular aneurysm was observed. His postoperative course was uneventful, and he was discharged from the hospital on the 28th postoperative day in good condition. The pathological examination revealed residual cardiomyocytes with the aneurysmal wall.

Paradoxical brain embolism associated with Kimura disease mimics watershed infarction.

Kimura disease (KD) is an uncommon chronic inflammatory disease presenting as subcutaneous lymphadenopathy with eosinophilia. To date, only a single case of brain embolism caused by fibroblastic endocarditis associated with KD has been reported. Watershed infarction was seen in patients with episodes of severe hypotension or cardiac surgery. We here report a young case of KD who developed ischemic stroke and showed multiple small infarcts in the border zones between the territories of major cerebral arteries, mimicking watershed infarction. Transesophageal echocardiography revealed patent foramen ovale and atrial septal aneurysm. Concurrently, deep venous thrombus in the femoral vein was found on duplex ultrasonography. Our case supports the notion that paradoxical brain embolism associated with KD can cause multiple small embolisms and mimic watershed infarction.

Spontaneous resolution of Pneumocystis jirovecii pneumonia on high-resolution computed tomography in a patient with renal cell carcinoma.

BACKGROUND: Spontaneous resolution of Pneumocystis jirovecii pneumonia has rarely been reported. CASE REPORT: A 59-year-old man presented to our hospital because of pyrexia (38°C) and shaking chills for 2 days. He had a history of right nephrectomy due to renal cell carcinoma and left upper lobectomy for lung metastasis in the last 1.5 years. Two months previously, he was treated with oral prednisolone (20 mg/day) plus the intravenous mTOR inhibitor, temsirolimus (25 mg/week), for brain metastasis. On radiological examination, thoracic computed tomography showed diffuse ground glass opacities spreading in bilateral middle to lower lung fields. Although transbronchial biopsy specimens and bronchoalveolar lavage fluid demonstrated the presence of accumulation of black-colored Pneumocystis jirovecii cysts in the lung, his chief complaints and radiological abnormalities disappeared completely with no treatment. This case demonstrates a unique clinical presentation of Pneumocystis jirovecii pneumonia, in that spontaneous resolution was noted on clinical and sequential radiological evaluations. CONCLUSIONS: Increasing numbers of cytotoxic drugs and biological therapies have emerged, and changes in the immune status due to underlying diseases or administration of immunosuppressive drugs might affect the inflammatory process of Pneumocystis jirovecii pneumonia, as in the present case.

Cerebral small artery diseases may be associated with aortic arch calcification in stroke patients.

AIM: Aortic arch calcification (AoAC) on chest X-rays represents systemic atherosclerosis and it is associated with ischemic cardiovascular diseases. However, the relationship between ischemic stroke and AoAC has yet to be fully elucidated. METHODS: Patients with acute ischemic stroke who were undergoing chest X-ray, blood, and brain magnetic resonance imaging (MRI) examinations were prospectively studied. The extent of AoAC on chest X-ray was divided into four grades (0-3). Clinical characteristics, biochemical findings, white matter lesions on MRI, and AoAC extent were assessed in each stroke subtype, and the factors associated with AoAC were investigated. RESULTS: A total of 175 patients (age, 70 ± 13 years; 115 men) were enrolled in the study. According to the Trial of Org 10172 in Acute Stroke Treatment classification with minor modification, 33 patients (19%) had small artery occlusion (SAO), 42 (24%) had large artery atherosclerosis, 49 (28%) had cardioembolism, 24 (14%) had stroke with other determined etiologies, and 27 (17%) had stroke with undetermined etiologies. Compared to other stroke subtypes, the extent of AoAC was independently correlated with SAO (all p<0.05). Age (odds ratio [OR]: 1.14, 95% confidence interval [CI]: 1.08 to 1.19, p<0.001), hypertension, (OR: 3.44, 95% CI: 1.23 to 9.66, p=0.019), diabetes mellitus (OR: 2.19, 95% CI: 0.99 to 4.85, p=0.054), white matter lesions (OR: 1.54, 95% CI: 1.00 to 2.36, p=0.048), and SAO (OR: 1.38, 95% CI: 1.02 to 1.89, p=0.040) were significantly associated with AoAC. CONCLUSIONS: Age, hypertension, cerebral small artery disease, and possibly diabetes mellitus appear to be closely associated with AoAC in patients with acute ischemic stroke.

Invasive tracheobronchial aspergillosis in a patient with systemic lupus erythematosus-dermatomyositis overlap syndrome.

A 45-year-old man was referred to our hospital with a 3-month history of dyspnea, polyarthralgia, myalgia and weight loss. He was diagnosed with systemic lupus erythematosus/dermatomyositis overlap syndrome with lung involvement, which presented as organizing pneumonia. However, a bronchoscopic examination revealed the presence of multiple plaque-like white lesions with ulcers on the bronchial membrane, located mainly in the central airway. The pathological specimens obtained from bronchoscopy showed numerous filamentous fungal hyphae that were aggressively invading the bronchial walls, suggesting a diagnosis of invasive tracheobronchial aspergillosis. The present case, along with a review of the literature, demonstrates that invasive tracheobronchial aspergillosis can occur in patients who do not appear to be immunosuppressed. This case of aspergillosis should thus be recognized as an extremely rare presentation of an Aspergillus infection.

A case of malignant peritoneal mesothelioma revealed with limitation of PET-CT in the diagnosis of thoracic metastasis.

A 47-year-old man was referred to our hospital because of a 2-month history of dry cough, 2-kg weight loss, and a feeling of abdominal fullness. The PET-CT scan depicts the intense standard uptake values (SUVs) of the anterior and subphrenic lymphnodes, and intraperitoneal cavity, especially in the omentum, while, no uptake was found in the pleural cavity. Based on the pathological findings of the open lung biopsy specimens, he was diagnosed with malignant peritoneal mesothelioma of epithelioid type with thoracic metastasis. The present case demonstrated the some of the limitations of PET-CT in the diagnosis of malignant mesothelioma, which failed to detect pleural involvement despite aggressive invasion by this tumor.

Transcriptional repression of Cdc25B by IER5 inhibits the proliferation of leukemic progenitor cells through NF-YB and p300 in acute myeloid leukemia.

The immediately-early response gene 5 (IER5) has been reported to be induced by γ-ray irradiation and to play a role in the induction of cell death caused by radiation. We previously identified IER5 as one of the 2,3,4-tribromo-3-methyl-1-phenylphospholane 1-oxide (TMPP)-induced transcriptional responses in AML cells, using microarrays that encompassed the entire human genome. However, the biochemical pathway and mechanisms of IER5 function in regulation of the cell cycle remain unclear. In this study, we investigated the involvement of IER5 in the cell cycle and in cell proliferation of acute myeloid leukemia (AML) cells. We found that the over-expression of IER5 in AML cell lines and in AML-derived ALDH(hi) (High Aldehyde Dehydrogenase activity)/CD34(+) cells inhibited their proliferation compared to control cells, through induction of G2/M cell cycle arrest and a decrease in Cdc25B expression. Moreover, the over-expression of IER5 reduced colony formation of AML-derived ALDH(hi)/CD34(+) cells due to a decrease in Cdc25B expression. In addition, over-expression of Cdc25B restored TMPP inhibitory effects on colony formation in IER5-suppressed AML-derived ALDH(hi)/CD34(+) cells. Furthermore, the IER5 reduced Cdc25B mRNA expression through direct binding to Cdc25B promoter and mediated its transcriptional attenuation through NF-YB and p300 transcriptinal factors. In summary, we found that transcriptional repression mediated by IER5 regulates Cdc25B expression levels via the release of NF-YB and p300 in AML-derived ALDH(hi)/CD34(+) cells, resulting in inhibition of AML progenitor cell proliferation through modulation of cell cycle. Thus, the induction of IER5 expression represents an attractive target for AML therapy.

Exendin-4, a glucagon-like peptide-1 receptor agonist, provides neuroprotection in mice transient focal cerebral ischemia.

Glucagon-like peptide-1 (GLP-1) is an incretin hormone known to stimulate glucose-dependent insulin secretion. The GLP-1 receptor agonist, exendin-4, has similar properties to GLP-1 and is currently in clinical use for type 2 diabetes mellitus. As GLP-1 and exendin-4 confer cardioprotection after myocardial infarction, this study was designed to assess the neuroprotective effects of exendin-4 against cerebral ischemia-reperfusion injury. Mice received a transvenous injection of exendin-4, after a 60-minute focal cerebral ischemia. Exendin-4-treated vehicle and sham groups were evaluated for infarct volume, neurologic deficit score, various physiologic parameters, and immunohistochemical analyses at several time points after ischemia. Exendin-4 treatment significantly reduced infarct volume and improved functional deficit. It also significantly suppressed oxidative stress, inflammatory response, and cell death after reperfusion. Furthermore, intracellular cyclic AMP (cAMP) levels were slightly higher in the exendin-4 group than in the vehicle group. No serial changes were noted in insulin and glucose levels in both groups. This study suggested that exendin-4 provides neuroprotection against ischemic injury and that this action is probably mediated through increased intracellular cAMP levels. Exendin-4 is potentially useful in the treatment of acute ischemic stroke.

Comparison of clinical backgrounds with anterior versus posterior circulation infarcts.

BACKGROUND: The aim of this study was to identify the relevant clinical backgrounds for anterior circulation territory infarctions (ACTI) and posterior circulation territory infarctions (PCTI). METHODS: Data were obtained from April 1995 to May 2005 discharge statistics of the neurologic service in our hospital. The infarctions were divided into anterior circulation territory and posterior circulation territory by computed tomography and magnetic resonance imaging, and we examined clinical backgrounds for small vessel disease, large artery disease, and cardioembolism (CE). RESULTS: A total of 1089 cases were ACTI and 430 were PCTI. Male/female ratio was 1.75 for ACTI and 2.67 for PCTI (P < .05). The mean age was 69.1 years for ACTI and 65.9 years for PCTI (P < .001). Multiple logistic regression analysis showed that significant contributed clinical backgrounds for small vessel disease were age and hyperlipidemia in ACTI. Those for large artery disease were male sex and history of cerebrovascular disease in PCTI. Those for CE were age and atrial fibrillation in ACTI; and diabetes, hypertension, hyperlipidemia, and smoking in PCTI. Those for all cerebral infarctions were age and atrial fibrillation in ACTI; and male sex, diabetes, and hypertension in PCTI. CONCLUSION: This study showed differences in clinical backgrounds between ACTI and PCTI. Moreover, PCTI were closely related to the conventional vascular risk factors even in CE.

Synthesis, in vitro and in vivo studies of Gd-DTPA-XDA-D1-Glc(OH) complex as a new potential MRI contrast agent.

A new type of dendritic molecules Gd-DTPA-XDA-D1-Glc(OH), which work as a functionalized ligand coordinating gadolinium(III) ion at the center of their frameworks with two glucose moieties on the molecular surfaces, were readily synthesized with high yield. The structures were established by IR, (1)H, (13)C NMR, and mass spectral studies. Its bio-distribution patterns were evaluated on rats.

Self-assembled light-harvesting systems: Ru(II) complexes assembled about Rh-Rh cores.

Ru(II) polypyridine species have been assembled about dirhodium(II, II) tetracarboxylate cores. The complexes prepared have general formulas [{(terpy)Ru(La)}n{Rh2(CH3COO)4-n(CH3CN)2}]2n+ (a-type compounds: terpy = 2,2':6',2' '-terpyridine; La = 4'-(p-carboxyphenyl)-2,2':6',2' '-terpyridine; n = 1, 1a; n = 2, cis-2a and trans-2a-cis and trans refer to the arrangement of the Ru(II) species around the dirhodium core; n = 3, 3a), [{(Lb)Ru(La)}n{Rh2(CH3COO)4-n(CH3CN)2}]2n+ (b-type compounds: Lb = 6-phenyl-2,4-di(2-pyridyl)-s-triazine; n = 1, 1b; n = 2, an inseparable mixture of cis-2b and trans-2b; n = 3, 3b; n = 4, 4b), and [{(terpy)Ru(Lc)}{Rh2(CH3COO)3(CH3CN)2}]2+ (1c; Lc = 6-(p-carboxyphenyl)-2,4-di(2-pyridyl)-s-triazine). As model species, also the mononuclear [(terpy)Ru(La)]2+ (5a), [(La)Ru(Lb)]2+ (5b), and [(terpy)Ru(Lc)]2+ (5c) have been prepared. All of the complexes have been characterized by several techniques, including NMR and mass spectra, and the stability of the various species is discussed. The absorption spectra of all of the compounds are dominated by the Ru(II) polypyridine moieties, showing intense ligand-centered (LC) bands in the UV region and intense metal-to-ligand charge-transfer (MLCT) bands in the visible. The compounds exhibit several metal-centered oxidation and ligand-centered reduction processes, which have been assigned to specific subunits. Both absorption and redox data indicate a supramolecular nature of the assembled systems. Efficient energy transfer from the MLCT triplet state of the Ru-based components to the lowest-energy excited state of the dirhodium core takes place for the a-type compounds at 298 K in acetonitrile solution, whereas such a process is inefficient for the b-type and c-type species, which exhibit the typical MLCT emission. At 77 K in butyronitrile matrix, Ru-to-Rh2 energy transfer is partly efficient for both the a-type and the b-type compounds and is inefficient for 1c. The reasons for such behavior are discussed by taking into account arguments concerning the driving force and reorganization energy of the complexes.