Regulation of memory CD4+ T cell generation by intrinsic and extrinsic IL-27 signaling during malaria infection.

The generation and maintenance of memory T cells are regulated by various factors, including cytokines. Previous studies have shown that IL-27 is produced during the early acute phase of Plasmodium chabaudi chabaudi AS (Pcc) infection and inhibits the development of Th1-type memory CD4+ T cells. However, whether IL-27 acts directly on its receptor on Plasmodium-specific CD4+ T cells or indirectly via its receptor on other immune cells remains unclear. We aimed to determine the role of IL-27 receptor signaling in different immune cell types in regulating the generation and phenotype of memory CD4+ T cells during Plasmodium infection. We utilized Plasmodium-specific TCR transgenic mice, PbT-II, and Il27rα-/- mice to assess the direct and indirect effects of IL-27 signaling on memory CD4+ T-cell generation. Mice were transferred with PbT-II or Il27rα-/- PbT-II cells and infected with Pcc. Conditional knockout mice lacking the IL-27 receptor in T cells or dendritic cells were employed to discern the specific immune cell types involved in IL-27 receptor signaling. High levels of memory in PbT-II cells with Th1-shift occurred only when both PbT-II and host cells lacked the IL-27 receptor, suggesting the predominant inhibitory role of IL-27 signaling in both cell types. Furthermore, IL-27 receptor signaling in T cells limited the number of memory CD4+ T cells, while signaling in both T and dendritic cells contributed to the Th1 dominance of memory CD4+ T cells. These findings underscore the complex cytokine signaling network regulating memory CD4+ T cells during Plasmodium infection.

Interleukin-27-Producing CD4(+) T Cells Regulate Protective Immunity during Malaria Parasite Infection.

Interleukin-27 (IL-27) is a heterodimeric regulatory cytokine of the IL-12 family, which is produced by macrophages, dendritic cells, and B cells upon stimulation through innate immune receptors. Here, we described regulatory CD4(+) T cells that produce IL-27 in response to T cell receptor stimulation during malaria infection, inhibiting IL-2 production and clonal expansion of other T cells in an IL-27-dependent manner. IL-27-producing CD4(+) T cells were Foxp3(-)CD11a(+)CD49d(+) malaria antigen-specific CD4(+) T cells and were distinct from interferon-γ (IFN-γ) producing Th1 or IL-10 producing Tr1 cells. In mice lacking IL-27 in T cells, IL-2 production was restored and clonal expansion and IFN-γ production by specific CD4(+) T cells were improved, culminating in reduced parasite burden. This study highlights a unique population of IL-27 producing regulatory CD4(+) T cells and their critical role in the regulation of the protective immune response against malaria parasites.

Structural Relationships Between Behavioral Problems, Sensory Processing Traits, and Sleep Among Preschoolers.

IMPORTANCE: An association between sensory processing difficulties and behavioral problems among children has been reported in previous studies. Sleep problems among children can lead to both externalizing and internalizing behavioral problems. However, the relationships between sensory processing and sleep among children are not well understood. OBJECTIVE: To develop a structural causal model (SCM) predicated on the hypothesis that sensory processing difficulties and sleep problems are closely related among preschoolers and may contribute to behavioral issues. DESIGN: Cross-sectional study. PARTICIPANTS: A total of 168 children ages 3-5 yr who were enrolled in a preschool or an accredited kindergarten (four facilities in total) in a Japanese prefecture participated in the analysis. OUTCOMES AND MEASURES: After gaining the cooperation of educators, we distributed the following items to the children's parents: an informed consent form, the Short Sensory Profile-Japanese version (SSP-J), the Japanese Sleep Questionnaire for Preschoolers (JSQ-P), and the Child Behavior Checklist for Ages 1.5-5. Through factor analysis of the SSP-J and the JSQ-P, we identified common factors. We developed an SCM using structural equation modeling. RESULTS: Four factors were identified by factor analysis: attention deficit, sensory sensitivity, sleep problems, and restless legs syndrome symptoms. The final structural equation modeling analysis had an acceptable goodness of fit (goodness-of-fit index = .862; root-mean-square error of approximation = .087). CONCLUSIONS AND RELEVANCE: The model suggests that sensory sensitivity and sleep difficulties may contribute to behavioral issues among preschoolers. Plain-Language Summary: The results of this study suggest that relationships exist between behavioral problems, sensory processing, and sleep among preschoolers. The authors developed a model that identified four common factors that contribute to behavioral issues among preschoolers: attention deficit, sensory sensitivity, sleep problems, and restless legs syndrome symptoms. Children's behavioral problems are an important consideration for occupational therapy practitioners working with preschoolers. Sensory processing and sleep must be accurately evaluated to address preschoolers' behavioral issues.

Unilateral vibration stimulation decreases F-wave persistence and F/M amplitude ratio in contralateral homonymous muscle corresponding to the stimulated muscle during stimulation.

[Purpose] This study aimed to examine the effects of unilateral vibratory stimulation on contralateral homonymous muscle. [Participants and Methods] The study included 14 participants without a history of any disease. Participants were tested under three separate conditions: vibratory stimulation, pressure stimulation, and rest. F-waves were measured at two time points for 15 seconds in the rest position under each of the testing conditions. [Results] The F/M amplitude ratio analysis showed interactions between the vibratory stimulation‒pressure stimulation and vibratory stimulation‒rest conditions. The F-wave persistence analysis demonstrated interactions between the vibratory and pressure stimulation conditions. Vibratory stimulation significantly decreased the F/M amplitude ratio and F-wave persistence at two time points, before and during the stimulation. [Conclusion] The vibratory stimulation used in this study could suppress the contralateral homonymous muscle tone.

Type I interferon production elicits differential CD4+ T-cell responses in mice infected with Plasmodium berghei ANKA and P. chabaudi.

Plasmodium parasites that infect humans are highly polymorphic, and induce various infections ranging from an asymptomatic state to life-threatening diseases. However, how the differences between the parasites affect host immune responses during blood-stage infection remains largely unknown. We investigated the CD4+ T-cell immune responses in mice infected with P. berghei ANKA (PbA) or P. chabaudi chabaudi AS (Pcc) using PbT-II cells, which recognize a common epitope of these parasites. In the acute phase of infection, CD4+ T-cell responses in PbA-infected mice showed a lower involvement of Th1 cells and a lower proportion of Ly6Clo effector CD4+ T cells than those in Pcc-infected mice. Transcriptome analysis of PbT-II cells indicated that type I interferon (IFN)-regulated genes were expressed at higher levels in both Th1- and Tfh-type PbT-II cells from PbA-infected mice than those from Pcc-infected mice. Moreover, IFN-α levels were considerably higher in PbA-infected mice than in Pcc-infected mice. Inhibition of type I IFN signaling increased PbT-II and partially reversed the Th1 over Tfh bias of the PbT-II cells in both PbA- and Pcc-infected mice. In the memory phase, PbT-II cells in PbA-primed mice maintained higher numbers and exhibited a better recall response to the antigen. However, recall responses were not significantly different between the infection groups after re-challenge with PbA, suggesting the effect of the inflammatory environment by the infection. These observations suggest that the differences in Plasmodium-specific CD4+ T-cell responses between PbA- and Pcc-infected mice were associated with the difference in type I IFN production during the early phase of the infection.

Postoperative cerebral infarction and arrhythmia after pulmonary lobectomy in Japan: a retrospective analysis of 77,060 cases in a national clinical database.

PURPOSE: To investigate the incidence of postoperative cerebral infarction after curative lobectomy, its association with the type of lobectomy, and how postoperative new-onset arrhythmia contributes to postoperative cerebral infarction. METHODS: The subjects of this analysis were 77,060 patients who underwent curative lobectomy for lung cancer between 2016 and 2018 according to the National Clinical Database. Incidences of postoperative cerebral infarction and postoperative new-onset arrhythmia were analyzed. Moreover, mediation analysis was performed to evaluate the causal pathway between postoperative new-onset arrhythmia and postoperative cerebral infarction. RESULTS: Postoperative cerebral infarction occurred in 110 (0.7%) patients after left upper lobectomy and in 85 (0.7%) patients after left lower lobectomy. Left upper lobectomy and left lower lobectomy were associated with a higher likelihood of postoperative cerebral infarction than right lower lobectomy. Left upper lobectomy was the strongest independent predictor of postoperative new-onset arrhythmia. However, in the mediation analysis, the odds ratio for cerebral infarction did not change after the addition of the factor of postoperative new-onset arrhythmia. CONCLUSION: Cerebral infarction occurred significantly more often not only after left upper lobectomy, but also after left lower lobectomy. Postoperative new-onset arrhythmia was less likely to be related to cerebral infarction after left upper lobectomy.

CD49d marks Th1 and Tfh-like antigen-specific CD4+ T cells during Plasmodium chabaudi infection.

Upon activation, specific CD4+ T cells up-regulate the expression of CD11a and CD49d, surrogate markers of pathogen-specific CD4+ T cells. However, using T-cell receptor transgenic mice specific for a Plasmodium antigen, termed PbT-II, we found that activated CD4+ T cells develop not only to CD11ahiCD49dhi cells, but also to CD11ahiCD49dlo cells during acute Plasmodium infection. CD49dhi PbT-II cells, localized in the red pulp of spleens, expressed transcription factor T-bet and produced IFN-γ, indicating that they were type 1 helper T (Th1)-type cells. In contrast, CD49dlo PbT-II cells resided in the white pulp/marginal zones and were a heterogeneous population, with approximately half of them expressing CXCR5 and a third expressing Bcl-6, a master regulator of follicular helper T (Tfh) cells. In adoptive transfer experiments, both CD49dhi and CD49dlo PbT-II cells differentiated into CD49dhi Th1-type cells after stimulation with antigen-pulsed dendritic cells, while CD49dhi and CD49dlo phenotypes were generally maintained in mice infected with Plasmodium chabaudi. These results suggest that CD49d is expressed on Th1-type Plasmodium-specific CD4+ T cells, which are localized in the red pulp of the spleen, and can be used as a marker of antigen-specific Th1 CD4+ T cells, rather than that of all pathogen-specific CD4+ T cells.

Strong Photoluminescence Enhancement in Molybdenum Disulfide in Aqueous Media.

The interface between conventional semiconductors and aqueous ionic solutions is an important target in chemistry and materials science. Recently, a wide variety of research has been done on transition-metal dichalcogenides (TMDCs) for use as 2D layered semiconductors, and their optoelectronic properties have been widely explored. One representative TMDC, monolayer (1L) MoS2, is known to show a photoluminescence (PL) signal of a direct band gap nature, and the PL intensity is dependent on the carrier concentration. Various methods of 1L MoS2 carrier modulation have been shown to enhance the PL intensity in dry environments. In contrast, enhancement in an aqueous environment is limited, and a strategy to design an interface with aqueous media has not yet been established. One proposed idea was an aqueous acid interface; however, the enhancement of the PL with this method was usually minimal, about 1 order of magnitude. In this study, we demonstrate a method to achieve strong PL enhancement in 1L MoS2 in an aqueous media by incorporating bis(trifluoromethane)sulfonyl anion (TFSI- ion) in an acidic environment. With the addition of the TFSI- ion in an acidic environment, the enhancement factor of the PL in 1L MoS2 is more than 100 times greater than its PL intensity in water. The molecular anion is the key factor, as the TFSI- ion facilitates the oxidation of MoS2. This anionic effect is the additional factor needed to modulate the optoelectronic properties of 2D semiconductors in aqueous media. The proposed idea could have potential applications for biochemical sensors in aqueous situations.

Generation of germ cell-deficient pigs by NANOS3 knockout.

NANOS3 is an evolutionarily conserved gene expressed in primordial germ cells that is important for germ cell development. Germ cell deletion by NANOS3 knockout has been reported in several mammalian species, but its function in pigs is unclear. In the present study, we investigated the germline effects of NANOS3 knockout in pigs using CRISPR/Cas9. Embryo transfer of CRISPR/Cas9-modified embryos produced ten offspring, of which one showed wild-type NANOS3 alleles, eight had two mutant NANOS3 alleles, and the other exhibited mosaicism (four mutant alleles). Histological analysis revealed no germ cells in the testes or ovaries of any of the nine mutant pigs. These results demonstrated that NANOS3 is crucial for porcine germ cell production.

[Surgical Resection of the Rib Fragment to Prevent Lung Injury in a Patient with Chest Trauma:Report of a Case].

An 82-year old man was admitted for a left fifth rib fracture with traumatic pneumothorax. Computed tomography showed a sharp rib fragment protruding into the thoracic cavity. Thoracic drainage was not performed before surgery to avoid lung injury by the rib fragment. At surgery, fifth rib fragment protruding into the thoracic cavity was found, but lung injury was not present. The bone fragment was removed, and the patient's postoperative course was uneventful.

Differential requirements for IRF4 in the clonal expansion and homeostatic proliferation of naive and memory murine CD8+ T cells.

Interferon regulatory factor 4 (IRF4) has critical roles in immune cell differentiation and function and is indispensable for clonal expansion and effector function in T cells. Here, we demonstrate that the AKT pathway is impaired in murine CD8+ T cells lacking IRF4. The expression of phosphatase and tensin homolog (PTEN), a negative regulator of the AKT pathway, was elevated in Irf4-/- CD8+ T cells. Inhibition of PTEN partially rescued downstream events, suggesting that PTEN constitutes a checkpoint in the IRF4-mediated regulation of cell signaling. Despite the clonal expansion defect, in the absence of IRF4, memory-like CD8+ T cells could be generated and maintained, although unable to expand in recall responses. The homeostatic proliferation of naïve Irf4-/- CD8+ T cells was impaired, whereas their number eventually reached a level similar to that of wild-type CD8+ T cells. Conversely, memory-like Irf4-/- CD8+ T cells underwent homeostatic proliferation in a manner similar to that of wild-type memory CD8+ T cells. These results suggest that IRF4 regulates the clonal expansion of CD8+ T cells at least in part via the AKT signaling pathway. Moreover, IRF4 regulates the homeostatic proliferation of naïve CD8+ T cells, whereas the maintenance of memory CD8+ T cells is IRF4-independent.

Nonspecific CD8+ T Cells and Dendritic Cells/Macrophages Participate in Formation of CD8+ T Cell-Mediated Clusters against Malaria Liver-Stage Infection.

CD8+ T cells are the major effector cells that protect against malaria liver-stage infection, forming clusters around Plasmodium-infected hepatocytes and eliminating parasites after a prolonged interaction with these hepatocytes. We aimed to investigate the roles of specific and nonspecific CD8+ T cells in cluster formation and protective immunity. To this end, we used Plasmodium berghei ANKA expressing ovalbumin as well as CD8+ T cells from transgenic mice expressing a T cell receptor specific for ovalbumin (OT-I) and CD8+ T cells specific for an unrelated antigen, respectively. While antigen-specific CD8+ T cells were essential for cluster formation, both antigen-specific and nonspecific CD8+ T cells joined the clusters. However, nonspecific CD8+ T cells did not significantly contribute to protective immunity. In the livers of infected mice, specific CD8+ T cells expressed high levels of CD25, compatible with a local, activated effector phenotype. In vivo imaging of the liver revealed that specific CD8+ T cells interact with CD11c+ cells around infected hepatocytes. The depletion of CD11c+ cells virtually eliminated the clusters in the liver, leading to a significant decrease in protection. These experiments reveal an essential role of hepatic CD11c+ dendritic cells and presumably macrophages in the formation of CD8+ T cell clusters around Plasmodium-infected hepatocytes. Once cluster formation is triggered by parasite-specific CD8+ T cells, specific and unrelated activated CD8+ T cells join the clusters in a chemokine- and dendritic cell-dependent manner. Nonspecific CD8+ T cells seem to play a limited role in protective immunity against Plasmodium parasites.

The influence of seawater properties on toxicity of copper pyrithione and its degradation product to brine shrimp Artemia salina.

Copper pyrithione (CuPT) is a biocide, used worldwide to prevent biofouling on submerged surfaces. In aquatic environments it rapidly degrades, however, one of the degradation products (HPT) is known to react with cupric ion back to its parent compound. Not much is known about the behavior and toxicity of CuPT and its degradation product HPT in different water systems. Hence, our aim was to investigate the ecotoxicity of CuPT, HPT as well as Cu2+ to the brine shrimp Artemia salina in natural seawater and organic matter-free artificial seawater. Moreover, in order to elucidate the influence of ionic strength of water on CuPT toxicity, tests were performed in water media with modified salinity. The results showed that CuPT was the most toxic to the exposed crustaceans in a seawater media with the highest salinity and with no organic matter content. HPT in a presence of cupric ion converted to CuPT, but the measured CuPT concentrations and the mortality of A. salina in natural water were lower than in artificial water. The toxicity of CuPT to A. salina was significantly influenced by the organic matter content, salinity, and proportions of constituent salts in water. In a combination with cupric ion, non-hazardous degradation product HPT exhibits increased toxicity due to its rapid transformation to its parent compound.

[Using Super Resolution to Denoise on PET Images].

A high-resolution display panel comes to practical use, but the resolution of the indicated contents does not change. The up-sampling processing is applied to indication of the low-resolution contents. In the up-sampling process, the super resolution enables an up-sampling process which estimates information of high frequency components lost by sampling while analyzing input images is noticed. In this paper, we aimed at reconstructing an image of normal resolution in which the influence of statistical noise is reduced by applying super resolution after down-sampling processing is applied to positron emission tomography (PET) image with many statistical noises. To evaluate the noise reduction effect, we compared it with the Gaussian filter which is frequently used to reduce the influence of the statistical noise of the PET image. A 3D Hoffman brain phantom was used to evaluate objectively by peak signal-to-noise ratio and power spectral density. The objective index of the PET image applying super resolution is positive results, suggesting the possibility of being useful as compared with the conventional method.

Evaluation of facilitative factors for preventing cognitive decline: A 3-year cohort study of community intervention.

AIM: We conducted a cohort study to elucidate paticipants' facilitative factors that may help to prevent cognitive decline. METHODS: This study followed 100 participants (average age: 74.1 ± 5.8; 10 men, 90 women) for 3 years; participants had previously been part of the Taketoyo Project (n = 366) in 2007-2011. The end-point was defined as reduced cognitive function in elderly community residents participating in a preventive intervention for dementia. The presence or absence of reduced cognitive function at the end of the third year of intervention was the dependent variable, and all evaluation items were considered explanatory variables. After Fisher's exact test (P < 0.15), stepwise multiple logistic regression analysis (P < 0.05) was performed, and facilitative factors for prevention of cognitive decline were extracted. RESULTS: Items with a significant adjusted odds ratio (OR) based on multiple logistic regression analysis were the three-word delayed recall test (OR: 0.330, 95% confidence interval (CI): 0.142-0.767; P < 0.05), word fluency (OR: 0.565, 95%CI: 0.359-0.891; P < 0.05), frequency of going out (OR: 2.790, 95%CI: 0.803-6.380; P < 0.05) and number of friends with whom they engaged in activities (OR:0.344, 95%CI: 0.127-0.932; P < 0.05). CONCLUSION: Subjects who had maintained a certain level of cognitive function, engaged in activities with friends, and went out frequently at baseline were extracted. In other words, the results suggested that enhancement of social networks and leisure activities prompted by recreational centre participation had a positive effect on maintaining cognitive function. The results also suggest that to improve the effectiveness of preventive interventions for cognitive dysfunction, support for social factors and leisure activities, in addition to cognitive function, may improve the long-term effectiveness of maintaining cognitive function.

[Primary Lung Cancer Associated with Dilated Phase of Hypertrophic Cardiomyopathy;Report of a Case].

A 66-year-old man diagnosed as dilated phase of hypertrophic cardiomyopathy (D-HCM) was pointed out an abnormal shadow on routine chest radiography. The patient had past medical history of hypertension, congestive heart failure and chronic obstructive pulmonary disease. The computed tomography showed a 3.8 cm-sized tumor in the left lower lobe of the lung, and histopathological examination revealed squamous cell carcinoma (cT2aN0-1M0, cStage I B-II A). Cardiosonography showed diffuse hypokinesis from basal to mid area, and ejection fraction was 36.3%. Sporadic ventricular premature contraction was seen by the Holter electrocardiogram. The patient underwent left lower lobectomy with node lymph node dissection (ND1b). The circulatory condition of the patient was stable during surgery. After surgery, careful management of electrolytes and fluid infusion, and the regular medication was started again on the next day of surgery.

Nutritional status and management of risks due to physical therapy in patients hospitalized for long periods.

[Purpose] This study aimed to understand the nutritional status of patients hospitalized for long periods and the risk of physical therapy (PT) for such patients. [Subjects and Methods] Participants were selected from patients who were hospitalized at a designated medical long-term care sanatorium. The participants were divided into 5 groups (A-E) depending on their mode of energy intake and ambulatory ability during PT. The serum albumin level, energy intake, total daily energy expenditure, and total daily energy expenditure per session of PT (EEPT) were evaluated for each group. [Results] Protein-energy malnutrition was observed in 69.6% of the participants. No significant association was identified between the serum albumin level and body mass index. Energy intake was significantly higher in Groups D and E, whose energy intake was via ingestion, than in Groups A and B, whose intake was via tube feeding. EEPT was highest in patients of Group E who had gait independence different from the ability of those in groups A-D. [Conclusion] The actual energy intake is lower with tube feeding than with ingestion. Risk management and energy intake should be revisited in elderly patients who have been hospitalized for long periods and subsequently obtain gait independence.

Expression of PD-1/LAG-3 and cytokine production by CD4(+) T cells during infection with Plasmodium parasites.

CD4(+) T cells play critical roles in protection against the blood stage of malarial infection; however, their uncontrolled activation can be harmful to the host. In this study, in which rodent models of Plasmodium parasites were used, the expression of inhibitory receptors on activated CD4(+) T cells and their cytokine production was compared with their expression in a bacterial and another protozoan infection. CD4(+) T cells from mice infected with P. yoelii 17XL, P yoelii 17XNL, P. chabaudi, P. vinckei and P. berghei expressed the inhibitory receptors, PD-1 and LAG-3, as early as 6 days after infection, whereas those from either Listeria monocytogenes- or Leishmania major-infected mice did not. In response to T-cell receptor stimulation, CD4(+) T cells from mice infected with all the pathogens under study produced high concentrations of IFN-γ. IL-2 production was reduced in mice infected with Plasmodium species, but not in those infected with Listeria or Leishmania. In vitro blockade of the interaction between PD-1 and its ligands resulted in increased IFN-γ production in response to Plasmodium antigens, implying that PD-1 expressed on activated CD4(+) T cells actively inhibits T cell immune responses. Studies using Myd88(-/-), Trif(-/-) and Irf3(-/-) mice showed that induction of these CD4(+) T cells and their ability to produce cytokines is largely independent of TLR signaling. These studies suggest that expression of the inhibitory receptors PD-1 and LAG-3 on CD4(+) T cells and their reduced IL-2 production are common characteristic features of Plasmodium infection.

IRF4 in dendritic cells inhibits IL-12 production and controls Th1 immune responses against Leishmania major.

IRF4 is a transcription factor from the IRF factor family that plays pivotal roles in the differentiation and function of T and B lymphocytes. Although IRF4 is also expressed in dendritic cells (DCs) and macrophages, its roles in these cells in vivo are not clearly understood. In this study, conditional knockout mice that lack IRF4 in DCs or macrophages were generated and infected with Leishmania major. Mice lacking DC expression of IRF4 showed reduced footpad swelling compared with C57BL/6 mice, whereas those lacking IRF4 in macrophages did not. Mice with IRF4-deficient DCs also showed reduced parasite burden, and their CD4(+) T cells produced higher levels of IFN-γ in response to L. major Ag. In the draining lymph nodes, the proportion of activated CD4(+) T cells in these mice was similar to that in the control, but the proportion of IFN-γ-producing cells was increased, suggesting a Th1 bias in the immune response. Moreover, the numbers of migrating Langerhans cells and other migratory DCs in the draining lymph nodes were reduced both before and postinfection in mice with IRF4 defects in DCs, but higher levels of IL-12 were observed in IRF4-deficient DCs. These results imply that IRF4 expression in DCs inhibits their ability to produce IL-12 while promoting their migratory behavior, thus regulating CD4(+) T cell responses against local infection with L. major.

[Tension Pneumothorax Developing Hemothorax after Chest Tube Drainage].

A 61-year-old man visited a physician complaining of progressive chest pain and dyspnea. The chest radiography showed complete collapse of the right lung suggesting tension pneumothorax. The patient was transferred to our hospital. A small amount of the right pleural effusion was also seen in addition to pulmonary collapse on the chest radiography. Chest drainage was performed, and continuous air leakage was seen. At 2 hours later, air leakage was disappeared but the bloody effusion was noted. The chest radiography revealed massive effusion and the enhanced computed tomography showed active bleeding. The emergency surgery was conducted. The bleeding point was a ruptured vessel between the apical parietal pleura and the pulmonary bulla. Hemostasis and the resection of the bullae was performed. Careful observation after chest drainage is necessary to prepare unexpected hemothorax in case of tension pneumothorax with pleural effusion.