Establishment of disaster medical assistance team standards and evaluation of the teams' disaster preparedness: An experience from Taiwan.

BACKGROUND/PURPOSE: Taiwan set up disaster medical assistance teams (DMATs) after the Chi-Chi earthquake, but these teams lack unified standards. METHODS: This study was divided into two phases. Phase I was a Delphi study conducted in 2019 with 26 experts who were invited to establish Taiwan's DMAT standards by modifying the World Health Organization Emergency Medical Team (WHO EMT) type I fixed standards. Phase II was a cross-sectional study conducted in 2020. A questionnaire was used to evaluate the disaster preparedness of DMATs by standards set in phase I. RESULTS: In phase I, Taiwan's DMAT standards were established after three rounds of Delphi consensus, with a response rate of 88.5%. The major departures from the WHO EMT standards were the exclusion of obstetric care, mental health, rehabilitation, and laboratory and blood transfusion standards and the addition of an ultrasound standard. During phase II, a total of 32 teams were invited, and the response rate was 96.9%. The overall standard achievement rate was 56.9%, and the three lowest achievement rates corresponded to sanitation (22.6%), medical malpractice insurance (25.8%), and pharmacy and drug supply (25.8%). The national DMATs, official DMATs, DMATs funded by government, and DMATs with ≥10 years of experience had significantly higher achievement rates for partial or overall standards. CONCLUSION: Using localized standards to evaluate the disaster preparedness of each team, DMATs were found to have many shortcomings mainly due to the lack of unified government announcement standards, legal protection, and adequate financial support.

Midazolam's Effects on Delayed-Rectifier K+ Current and Intermediate-Conductance Ca2+-Activated K+ Channel in Jurkat T-lymphocytes.

Midazolam (MDZ) could affect lymphocyte immune functions. However, the influence of MDZ on cell's K+ currents has never been investigated. Thus, in the present study, the effects of MDZ on Jurkat T lymphocytes were studied using the patch-clamp technique. Results showed that MDZ suppressed the amplitude of delayed-rectifier K+ current (IK(DR)) in concentration-, time-, and state-dependent manners. The IC50 for MDZ-mediated reduction of IK(DR) density was 5.87 µM. Increasing MDZ concentration raised the rate of current-density inactivation and its inhibitory action on IK(DR) density was estimated with a dissociation constant of 5.14 µM. In addition, the inactivation curve of IK(DR) associated with MDZ was shifted to a hyperpolarized potential with no change on the slope factor. MDZ-induced inhibition of IK(DR) was not reversed by flumazenil. In addition, the activity of intermediate-conductance Ca2+-activated K+ (IKCa) channels was suppressed by MDZ. Furthermore, inhibition by MDZ on both IK(DR) and IKCa-channel activity appeared to be independent from GABAA receptors and affected immune-regulating cytokine expression in LPS/PMA-treated human T lymphocytes. In conclusion, MDZ suppressed current density of IK(DR) in concentration-, time-, and state-dependent manners in Jurkat T-lymphocytes and affected immune-regulating cytokine expression in LPS/PMA-treated human T lymphocytes.

Association of injury pattern and entrapment location inside damaged buildings in the 2016 Taiwan earthquake.

BACKGROUND/PURPOSE: To explore the association of patient injury patterns and entrapped locations inside damaged buildings in the 2016 Taiwan earthquake. METHODS: A retrospective analysis was conducted using the Tainan incident registry system. Residents inside nine conjunctive, 16-story (49.3 m in height) reinforced concrete buildings were categorized as non-injured, injured, and dead. Residents were classified into different groups according to their entrapped locations in height and the severity of building damage. The field triage acuity and trauma severity among groups were compared. Statistical significance was set at the level of 0.05. RESULTS: There were 309 enrollees with 76 (24.6%) non-injured, 118 (38.2%) injured, and 115 (37.2%) dead. Residents either in the high floors (odds ratio [OR] = 2.9, 95% CI: 1.5-5.8, p = 0.003) or in the collapsed buildings (OR = 18.2, 95% CI: 7.6-43.6, p < 0.001) were more likely to be dead. Injured patients who were located in the high floors were more likely to have severe field triage acuities (adjusted OR = 14.7, 95% CI: 1.8-118.0, p = 0.012); intracranial hemorrhage (12.5%), intrathoracic injury (18.8%), or intra-abdominal damage (12.5%) (All p < 0.05); the need for emergency surgical intervention (31.3%, p = 0.035); and major trauma (18.8%, p = 0.001). Residents in the collapsed buildings were more likely to have a crush injury (80.0%, p < 0.001) or crush syndrome (80.0%, p < 0.001). CONCLUSION: People entrapped at different heights of floors or in differently damaged buildings could have a distinct pattern of injury. Our findings may facilitate strategic approaches of patients entrapped in damaged buildings and may contribute to future training for field searches and rescues after earthquakes.

Bisoprolol, Known to Be a Selective ß1-Receptor Antagonist, Differentially but Directly Suppresses IK(M) and IK(erg) in Pituitary Cells and Hippocampal Neurons.

Bisoprolol (BIS) is a selective antagonist of ß1 adrenergic receptors. We examined the effects of BIS on M-type K⁺ currents (IK(M)) or erg-mediated K⁺ currents (IK(erg)) in pituitary GH3, R1220 cells, and hippocampal mHippoE-14 cells. As GH3 cells were exposed to BIS, amplitude of IK(M) was suppressed with an IC50 value of 1.21 µM. The BIS-induced suppression of IK(M) amplitude was not affected by addition of isoproterenol or ractopamine, but attenuated by flupirtine or ivabradine. In cell-attached current, BIS decreased the open probability of M-type K⁺ (KM) channels, along with decreased mean opening time of the channel. BIS decreased IK(erg) amplitude with an IC50 value of 6.42 µM. Further addition of PD-118057 attenuated BIS-mediated inhibition of IK(erg). Under current-clamp conditions, BIS depolarization increased the firing of spontaneous action potentials in GH3 cells; addition of flupirtine, but not ractopamine, reversed BIS-induced firing rate. In R1220 cells, BIS suppressed IK(M); subsequent application of ML-213(Kv7.2 channel activator) reversed BIS-induced suppression of the current. In hippocampal mHippoE-14 neurons, BIS inhibited IK(M) to a greater extent compared to its depressant effect on IK(erg). This demonstrated that in pituitary cells and hippocampal neurons the presence of BIS is capable of directly and differentially suppressing IK(M) and IK(erg), despite its antagonism of ß1-adrenergic receptors.

Clinical Outcome and Safety of Lumboperitoneal Shunt in the Treatment of Non-Obstructive Hydrocephalus.

Objective: This study aimed to evaluate the functional outcomes of lumboperitoneal (LP) shunt for the treatment of non-obstructive hydrocephalus. Methods: We retrospectively studied the clinical surgical results of 172 adult patients with hydrocephalus who underwent LP shunt surgery between June 2014 and June 2019. Data regarding the following were collected: pre- and postoperative symptom status, third ventricle width changes, Evans index, and postoperative complications. Additionally, the baseline and follow-up Glasgow Coma Scale (GCS) score, Glasgow Outcome Scale (GOS), and Modified Rankin Scale (mRS) scores were investigated. All patients were followed up for ≥12 months using clinical interview and braining imaging using computed tomography (CT) scan or magnetic resonance imaging (MRI). Results: Majority of patients presented with normal pressure hydrocephalus as the etiology of their disease (48.8%), followed by cardiovascular accident (28.5%), trauma (19.7%), and brain tumor (3%). The mean GCS, GOS, and mRS improved postoperatively. The average period from symptomatic onset to surgery was 402 days. The average width of the third ventricle on CT scan or MRI was 11.43 mm preoperatively and 10.8 mm postoperatively (P<0.001). The Evans index improved from 0.258 to 0.222 after operation. The symptomatic improvement score was 7.0, with a complication rate of 7%. Conclusion: Significant improvement was observed in the functional score and brain image after LP shunt placement. Moreover, the satisfaction with symptomatic improvement after surgery remains high. LP shunt operation is a viable alternative in the treatment of non-obstructive hydrocephalus due to the low complication rate, fast recovery, and high satisfaction.

Impact of Personal Protective Equipment on Cardiopulmonary Resuscitation and Rescuer Safety.

Background: High-quality cardiopulmonary resuscitation (CPR) is a key element in the rescue of cardiac arrest patients but is difficult to achieve in circumstances involving aerosol transmission, such as the COVID-19 pandemic. Methods: This prospective randomized crossover trial included 30 experienced health care providers to evaluate the impact of personal protective equipment (PPE) on CPR quality and rescuer safety. Participants were asked to perform continuous CPR for 5 minutes on a manikin with three types of PPE: level D-PPE, level C-PPE, and PAPR. The primary outcome was effective chest compression per minute. Secondary outcomes were the fit factor by PortaCount, vital signs and fatigue scores before and after CPR, and perceptions related to wearing PPE. Repeated-measures ANOVA was used, and a two-tailed test value of 0.05 was considered statistically significant. Results: The rates of effective chest compressions for 5 minutes with level D-PPE, level C-PPE, and PAPRs were 82.0 ± 0.2%, 78.4 ± 0.2%, and 78.0 ± 0.2%, respectively (p = 0.584). The fit-factor test values of level C-PPE and PAPRs were 182.9 ± 39.9 vs. 198.9 ± 9.2 (p < 0.001). The differences in vital signs before and after CPR were not significantly different among the groups. In addition, the fatigue and total perception scores of wearing PPE were significantly higher for level C-PPE than PAPRs: 3.8 ± 1.6 vs. 3.0 ± 1.6 (p < 0.001) and 27.9 ± 5.4 vs. 26.0 ± 5.3 (p < 0.001), respectively. Conclusion: PAPRs are recommended when performing CPR in situations where aerosol transmission is suspected. When PAPRs are in short supply, individual fit-tested N95 masks are an alternative. This trial is registered with NCT04802109.

Unscheduled return visits with and without admission post emergency department discharge.

BACKGROUND: Monitoring unscheduled return visits to the Emergency Department (ED) is useful to identify medical errors. OBJECTIVE: To investigate the differences between unscheduled return visit admissions (URVA) and unscheduled return visit no admissions (URVNA) after ED discharge. METHODS: From January 1, 2008 to March 31, 2008, URVA and URVNA patients who returned within 3 days after ED discharge were enrolled in the study. We compared the clinical characteristics, underlying diseases, ED crowding indicators, staff experience at the patient's first visit, and several other risk factors. We used multivariate logistic regression to evaluate differences between the two groups and to identify predictors of admission from unscheduled return visits. RESULTS: The unscheduled return visit rate was 3.1%. Of the 413 patients included, 147 patients (36%) were admitted, and had a mortality rate of 4.1%. The most common reason for the return visit was an illness-based factor (47.9%). Compared to URVNA patients, unscheduled return visit admissions had higher prevalence rates for old age, non-ambulatory status, high-grade triage, and underlying diseases (e.g., malignancy, diabetes mellitus, hypertension, coronary artery disease, heart failure, and chronic obstructive pulmonary disease). The independent predictors for URVA were: age≥65 years (adjusted odds ratio [OR] 2.2, 95% confidence interval [CI] 1.4-3.5); high-grade triage (adjusted OR 2.1, 95% CI 1.3-3.2); and doctor-based factors (adjusted OR 3.5, 95% CI 2.0-6.1). More advanced staff experience (p=0.490) and ED crowding were not significant predictors (p=0.498 for whole-day number of patients, p=0.095 for whole-shift number of patients). CONCLUSION: Old age, high-grade triage, and doctor-based factors were found to be significant predictors for URVA, whereas advanced staff experience and ED crowding were not.

Intradural lumbar disc herniation: A case report and literature review.

Study design and objection: Intradural disc herniation is a unusual disease associated with spinal surgery. The definitive diagnosis of intradural herniation depends on intraoperative findings. Summary of background data: We present the case of a 63-year-old woman with backache and left sciatica radiation for more than two months. The L2/3 laminectomy and discectomy were performed after magnetic resonance imaging (MRI) study; however, no disc rupture was noted during surgery. Follow-up lumbar spine MRI revealed one large, ruptured disc. The patient underwent revision surgery with durotomy. The large intradural disc was found and removed piece by piece. Methods Results and Conclusions: Intradural disc herniation, especially large herniation, is hard to diagnose specifically despite the progression of neuroradiologic imaging techniques. A durotomy procedure should be considered if there is a missing ruptured disc or a palpable intradural mass during surgery.

Risk of Mortality in Association with Pregnancy in Women Following Motor Vehicle Crashes: A Systematic Review and Meta-Analysis.

The aim of the study was to provide a systematic review and meta-analysis of studies examining the association between mortality risk and motor vehicle crashes (MVCs) in pregnant women compared with nonpregnant women. We used relevant MeSH terms to identify epidemiological studies of mortality risk in relation to MVCs from PubMed, Embase, and MEDLINE databases. The Newcastle-Ottawa Scale (NOS) was used for quality assessment. For comparison of mortality from MVCs between pregnant and nonpregnant women, the pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using a random effects model. The eight studies selected met all inclusion criteria. These studies included 14,120 injured victims who were pregnant at the time of the incident and 207,935 victims who were not pregnant. Compared with nonpregnant women, pregnant women had a moderate but insignificant decrease in mortality risk (pooled OR = 0.68, 95% CI = 0.38-1.22, I2 = 88.71%). Subgroup analysis revealed that the pooled OR significantly increased at 1.64 (95% CI = 1.16-2.33, I2 < 0.01%) for two studies with a similar difference in the mean injury severity score (ISS) between pregnant and nonpregnant women. Future studies should further explore the risk factors associated with MVCs in pregnant women to reduce maternal mortality.

Does CT evidence of a flat inferior vena cava indicate hypovolemia in blunt trauma patients with solid organ injuries?

BACKGROUND: Nonoperative management for selective patients with solid organ injuries from blunt trauma has gained wide acceptance. However, for trauma surgeons, it is often difficult to estimate a patient's circulatory volume. Some authors have proposed that the presence of a collapsed inferior vena cava (IVC) on computed tomography (CT) scan correlates with inadequate circulatory volume. Our aim was to verify whether CT evidence of a flat IVC (FI) is an indicator of hypovolemia in blunt trauma patients with solid organ injuries. METHODS: We conducted a retrospective chart review of all blunt trauma patients with solid organ injuries admitted to our Medical Center from July 2003 to September 2006. Of the 226 patients reviewed, 29 had CT evidence of FI. We compared Injury Severity Scores, hemodynamic parameters, fluid and blood transfusion requirements, mortality rate, and hospital course between patients with (FI group) and without FI (non-FI [NFI] group). RESULTS: The FI group had higher rates of intensive care unit admission and mortality, in addition to longer intensive care unit stays, when compared with the NFI group. In addition, the patients in the FI group needed larger amounts of fluid and blood transfusions and presented lower hemoglobin levels during the first week of admission; furthermore, the majority deteriorated to a state of shock in the emergency department. CONCLUSIONS: CT evidence of FI is a good indicator of hypovolemia and an accurate predictor for prognosis in trauma patients with blunt solid organ injuries.

Will computed tomography (CT) miss something? The characteristics and pitfalls of torso CT in evaluating patients with blunt solid organ trauma.

BACKGROUND: Selective nonoperative management has become the Standard care for blunt solid organ trauma patients, and torso computed tomography (CT) provides useful therapeutic clues. We conducted this study to determine the frequency and character of missed diagnoses in blunt solid organ trauma patients. METHODS: We reviewed the medical records of all blunt trauma patients who underwent torso CT and who were admitted for solid organ injuries (liver, spleen and kidney) at the Chi- Mei Medical Center from August 2003 to October 2006. RESULTS: The patients were divided into the Missed Group (24 patients) and the Unaltered Group (262 patients) according to the presence or absence of a missed diagnosis. The overall missed diagnosis rate was 8.4%. Only one unidentified bowel injury was disclosed by follow-up CT, and all of the missed injuries were revealed by laparotomy. The Missed Group had a higher Injury Severity Score, lower Glasgow Coma Scale, more Intensive Care Unit (ICU) care, and longer duration of hospitalization. CONCLUSION: Discovery of missed diagnoses is not uncommon in patients who sustain severe trauma. Laparotomy revealed all of the missed diagnoses, and follow-up CT demonstrated a poor ability to detect unidentified injuries. We suggest laparotomy instead of follow-up CT in the nonoperative management of patients with blunt solid organ injuries if clinical deterioration occurs.

Fabrication of 3D Printed Poly(lactic acid)/Polycaprolactone Scaffolds Using TGF-ß1 for Promoting Bone Regeneration.

Our research was designed to evaluate the effect on bone regeneration with 3-dimensional (3D) printed polylactic acid (PLA) and 3D printed polycaprolactone (PCL) scaffolds, determine the more effective option for enhancing bone regeneration, and offer tentative evidence for further research and clinical application. Employing the 3D printing technique, the PLA and PCL scaffolds showed similar morphologies, as confirmed via scanning electron microscopy (SEM). Mechanical strength was significantly higher in the PLA group (63.4 MPa) than in the PCL group (29.1 MPa) (p < 0.01). Average porosity, swelling ratio, and degeneration rate in the PCL scaffold were higher than those in the PLA scaffold. SEM observation after cell coculture showed improved cell attachment and activity in the PCL scaffolds. A functional study revealed the best outcome in the 3D printed PCL-TGF-ß1 scaffold compared with the 3D printed PCL and the 3D printed PCL-Polydopamine (PDA) scaffold (p < 0.001). As confirmed via SEM, the 3D printed PCL- transforming growth factor beta 1 (TGF-ß1) scaffold also exhibited improved cell adhesion after 6 h of cell coculture. The 3D printed PCL scaffold showed better physical properties and biocompatibility than the 3D printed PLA scaffold. Based on the data of TGF-ß1, this study confirms that the 3D printed PCL scaffold may offer stronger osteogenesis.

Pediatric Nuclear Medicine Examinations and Subsequent Risk of Neoplasm: A Nationwide Population-Based Cohort Study.

Objective: To evaluate the association between radiation exposure from repeated nuclear medicine (NM) examinations and the subsequent risk of neoplasm in pediatric patients. Methods: From 2000 to 2017, participants under 18 years of age who underwent NM scanning were identified using the Health and Welfare Data Science Center (HWDC) dataset, which was extracted from the Taiwan National Health Insurance Research Database (NHIRD). Both the exposed cohort and unexposed subjects were followed up with until the presence of any malignancy arose, including malignant brain, lymphoid and hematopoietic tumors and benign brain or other central nervous tumors. Results: There were 35,292 patients in the exposed cohort and 141,152 matched subjects in the non-exposed group. The exposed cohort had an overall higher IR (IR: incidence rate, per 100,000 person-years) of any malignancy and benign central nervous tumor than the non-exposed group [IR, 16.9 vs. 1.54; adjusted hazard ratio (HR), 10.9; 95% CI, 6.53-18.2]. Further stratifying the number of NM examinations into 1-2, 3-4, and 5 or more times revealed that the IR of pediatric neoplasms increased gradually with the increased frequency of NM examinations (IR, 11.5; adjusted HR, 7.5; 95% CI, 4.29-13.1; IR, 25.8; adjusted HR, 15.9; 95% CI, 7.00-36.1; IR, 93.8; adjusted HR, 56.4; 95% CI, 28.8-110.3). Conclusion: NM examination is significantly associated with a higher risk of pediatric neoplasms, according to our population-based data. Thorough radiation protection and dose reduction in pediatric NM procedures should be an issue of concern.

A 36-Hour Unplugged Full-Scale Exercise: Closing the Gaps in Interagency Collaboration between the Disaster Medical Assistance Team and Urban Search and Rescue Team in Disaster Preparedness in Taiwan.

INTRODUCTION: Disaster medical assistance team (DMAT) and urban search and rescue team (USAR) need to cooperate seamlessly to save lives in disasters, but related research is limited. OBJECTIVES: To estimate the disaster preparedness of the DMAT and the barriers affecting interagency cooperation between the DMAT and the USAR team. METHODS: This was an observational study of a full-scale exercise conducted in Taiwan from November 16 to 18, 2018. The exercise scenario simulated a magnitude 7 earthquake in Tainan City. DMATs from other counties were deployed and cooperated with local USAR teams to carry out disaster relief. Our study invited 7 experts to evaluate DMATs on disaster preparedness capabilities and the interagency collaboration between DMATs and USAR. RESULTS: A total of eight DMATs, consisting of 30 physicians, 65 nurses, 74 logisticians, 5 health bureau personnel, and 85 USAR teams, participated in this exercise. During the mission, 176 patients were treated. The capabilities of each team were generally consistent with the basic technical standards for type I emergency medical teams, but the compliance rates for basic local anesthesia, cold chain equipment for medication, rapid blood test tools, and sterilization devices were only 50%, 12.5%, 12.5%, and 9%, respectively. In addition, 53% of participants reported abnormal vital signs, indicating that it was a high-stress situation. Moreover, the main barriers to interagency collaboration were differing perspectives and poor mutual understanding. CONCLUSION: A full-scale exercise carried out jointly with DMATs and USAR teams was valuable for disaster preparedness, particularly in terms of understanding the weaknesses of those teams and the barriers to interagency collaboration.

Characteristics of pyogenic liver abscess patients with and without diabetes mellitus.

OBJECTIVES: Pyogenic liver abscess (PLA) is relatively common in patients with diabetes mellitus (DM), but it is unclear whether there are differences between patients with and without DM. We conducted a study to identify the possible differences and factors that affect fatality. METHODS: We included PLA patients treated at a medical center from April 2001 to March 2004 and compared the clinical characteristics of patients with and without DM. We applied chi-square, Fisher's exact, and t-tests to evaluate the differences between the two groups and used logistic regressions to identify predictors of fatality. RESULTS: Of the 377 patients included, 182 (48.3%) had DM. Patients with DM had higher prevalence rates of cryptogenic etiology, gas-forming nature, thrombocytopenia, hyperglycemia, growth of Klebsiella pneumonia in blood cultures, metastatic infection, and bacteremia, but lower prevalence rates of biliary origin, right upper quadrant pain, and growth of Escherichia coli in pus cultures. Whereas creatinine >1.3 mg/dl (adjusted odds ratio (OR) 7.3, 95% confidence interval (CI) 2.2-24.5) and gas-forming nature (adjusted OR 9.4, 95% CI 3.0-24.5) were predictors of fatality, DM was not. We discovered that C-reactive protein and neutrophil were good biomarkers of PLA, but not asparate aminotransferase and alanine aminotransferase. CONCLUSIONS: PLA patients with and without DM have different clinical characteristics, but DM is not a predictor of fatality. We have identified several biomarkers that might help reduce the misdiagnosis of PLA.

Arsenic compounds activate the MAPK and caspase pathways to induce apoptosis in OEC­M1 gingival epidermal carcinoma.

Arsenic is a well­documented environmental toxicant that can induce neurotoxicity and peripheral vascular diseases. In fact, arsenic trioxide has been used to treat various cancer types. Oral cancer has been in the top ten common cancers for decades in Taiwan, and the incidence rate is continuously increasing. The majority of oral cancers are associated with excessive tobacco, alcohol consumption and betel chewing. To the best of our knowledge, no study has revealed the effect of arsenic compounds on oral cancers. Thus, the present study used OEC­M1 oral squamous carcinoma cells treated with sodium arsenite (NaAsO2) and dimethylarsenic acid (DMA) to determine whether both arsenic compounds could exert anticancer effects on oral cancer. The results demonstrated that NaAsO2 and DMA induced rounding up and membrane blebbing in OEC­M1 cells, which are morphological characteristics of apoptosis. Annexin V/PI double staining analysis further confirmed that both arsenic compounds induced apoptosis of OEC­M1 cells. In addition, NaAsO2 and DMA significantly decreased the survival rate and increased the percentage of OEC­M1 cells in the subG1 and G2/M phases (P<0.05). Furthermore, both arsenic compounds significantly activated the cleavage of caspase­8, ­9, ­3 and PARP, and the phosphorylation of JNK, ERK1/2 and p38 in OEC­M1 cells (P<0.05). Collectively, the findings of the present study indicated that NaAsO2 and DMA stimulate extrinsic and intrinsic apoptotic pathways through the activation of the MAPK pathways to induce apoptosis of OEC­M1 cells, suggesting that NaAsO2 and DMA may be used as novel anticancer drugs for oral cancers.

Acute spontaneous cervical spinal epidural hematoma with hemiparesis as the initial presentation.

Acute onset of hemiparesis is a common initial presentation of cerebral vascular accidents, but many differential diagnoses should be considered. Hemiparesis results from an upper motor neuron lesion above the midcervical spinal cord, and the absence of cranial nerve signs or facial palsy suggests a lesion in the high cervical spinal cord. Most spinal cord lesions, however, result in quadriparesis or paraparesis, but not hemiparesis. We present a rare case of acute spontaneous cervical spinal epidural hematoma, with initial presentation of right hemiparesis and mild neck pain.

Delayed perforation of right ventricle with cardiac tamponade: a complication of pacemaker implantation.

We report a case of delayed cardiac tamponade that resulted from pacemaker implantation in the emergency room of a large urban hospital. A 19-year-old male patient with a pacemaker implanted 10 days earlier suffered from delayed perforation of the right ventricle with cardiac tamponade. A review of the literature revealed that cardiac tamponade is a rare complication of pacemaker implantation. Pacemakers should only be implanted by physicians with relevant experience, and emergency room physicians should be aware of the possibility of the associated complications and be prepared to treat them.

Arsenic trioxide induces programmed cell death through stimulation of ER stress and inhibition of the ubiquitin-proteasome system in human sarcoma cells.

Sarcoma is a rare form of cancer that differs from the much more common carcinomas because it occurs in a distinct type of tissue. Many patients of sarcoma have poor response to chemotherapy and an increased risk for local recurrence. Arsenic trioxide (ATO) is used to treat certain types of leukemia. Recently, data have revealed that ATO induces sarcoma cell death in several types of solid tumor cell lines. In the present study, we investigated whether ATO induces cancer cell death and elucidated the underlying anti-cancer mechanisms. Our results showed that ATO caused concentration- and time-dependent cell death in human osteosarcoma and fibrosarcoma cells. The types of cell death that were induced by ATO were primarily autophagy and apoptosis. Furthermore, ATO activated p38, JNK and AMPK and inhibited the Akt/mTOR signaling pathways. Specifically, we found that ATO induced endoplasmic reticulum (ER) stress and suppressed proteasome activation in two types of sarcoma cell lines. However, the level of proteasome inhibition in osteosarcoma cells was lower than in fibrosarcoma cells. Thus, we used combined treatment with ATO and a proteasome inhibitor to examine the antitumor activity in fibrosarcoma cells. The data indicated showed that the combination treatment of ATO and MG132 (a proteasome inhibitor) resulted in synergistic cytotoxicity. In a fibrosarcoma xenograft mouse model, the combined treatment significantly reduced tumor progression. Immunohistochemical studies revealed that combined treatment induced autophagy and apoptosis. In summary, our results suggest a potential clinical application of ATO in sarcoma therapy and that combined treatment with a proteasome inhibitor can increase the therapeutic efficacy.