Intrahelical Interactions in an α-Helical Coiled Coil Determine the Structural Stability of Tropomyosin.

Tropomyosin (Tpm) is a two-stranded parallel α-helical coiled-coil protein, and studying its structure is crucial for understanding the nature of coiled coils. Previously, we found that the N-terminal half of the human skeletal muscle α-Tpm (α-Tpm 140) was less structurally stable in the presence of phosphate ions than the coiled-coil protein carrier (CCPC) 140 variant with 18 mutated residues, in which all amino acid residues located at the interface between the two α-helices were completely conserved. A classical hypothesis explains that interhelical interactions stabilize the coiled-coil structure. In this study, we tested the hypothesis that the structural stability of Tpm and its variant is governed by the binding of multivalent ions that form a bridge between charged side chains located at positions b, c, and f of the heptad repeat on a single α-helical chain. We found that the structural stability of α-Tpm 140 and CCPC 140 markedly increased upon addition of divalent cations and divalent anions, respectively. We also clarified that the structural stability of the α-Tpm 140/CCPC 140 heteromeric coiled-coil molecule was governed by the stability of a less stable α-helical chain. These results demonstrated that the entire structural stability of Tpm is determined by the stability of a single α-helix. Our findings provide new insights into the study of the structure of coiled-coil proteins.

[Effect of Relative Electron Density and Physical Density Adjustment in Patient-specific Quality Assurance Using PMMA Phantom].

PURPOSE: The purpose of this study was to improve the accuracy of dose-distribution calculations by understanding how the calculated dose varies with the change in the relative electron density replacing polymethyl methacrylate (PMMA) in patient-specific quality assurance. METHOD: We calculated the relative electron density at which dose attenuation in each dose calculation algorithm coincides with the measured value of the dose attenuation of single-field irradiation. Next, the dose change was calculated by changing the relative electron density or physical electron density for substituting PMMA for each X-ray energy and calculation algorithm. Furthermore, using clinical plans, changes in point-dose verification and dose-distribution verification that occurred when the relative electron density or physical electron density was varied were investigated. RESULTS: The dose attenuation varies depending on the dose-calculation algorithm, and the optimum value of the electron density is different for each. After the electron density optimization, the point dose verification using the 97.1% to 98.3% (3%/3 mm), 90.0% to 94.3% (2%/3 mm) and gained a dominant improvement tendency (P<0.001). CONCLUSIONS: We clarified dose change accompanying relative electron density or physical electron density change. We concluded that the accuracy of dose-distribution calculation for verification improves by replacing PMMA with optimal relative electron density or physical electron density.

A Concealed "Natural Orifice": Umbilicus Anatomy for Minimally Invasive Surgery.

INTRODUCTION: A recent development in minimally invasive surgery (MIS) is single-port surgery, where a single large multiport trocar is placed in the umbilicus. All medical schools require that students complete an anatomy course as part of the medical curriculum. However, there is limited instruction regarding the detailed parts of the "umbilicus." In several famous anatomy atlases, the umbilicus is not dissected at all and is merely represented as a button. Until now, the true nature of the umbilicus has not been anatomically demonstrated. METHODS: Five cadavers were obtained from the Osaka Medical College medical student anatomy class. The umbilicus was dissected in the anatomy laboratory, to demonstrate all the layers. A detailed dissection was performed, focusing on the exact center of the umbilicus, in order to ascertain whether there exists a "natural orifice" or a fascial defect. RESULTS: In all cadavers, a small defect of fascia was identified just below the center of the umbilicus. Yellow fatty tissue was present just below the skin in the exact center of the umbilicus. A probe placed exactly in the middle of this defect passes easily through into the abdominal cavity. CONCLUSIONS: With the widespread use of MIS, umbilical incision is commonly used to reduce pain and improve cosmetic results. This study consistently revealed a natural defect of fascia in the center of the umbilicus. Therefore, the umbilicus can be called a concealed "natural orifice." It is important to recognize and utilize this defect effectively to minimize unnecessary tissue trauma during MIS.

Two-Step Assembly of Thermoresponsive Gold Nanorods Coated with a Single Kind of Ligand.

Gold nanorods (GNRs) coated with a single kind of ligand show thermoreponsive two-step assembly to provide a hierarchical structure. The GNRs (33 nm in length × 14 nm in diameter) coated with a hexa(ethylene glycol) (HEG) derivative form side-by-side assemblies at 30 °C (TA1 ) as a steady state through dehydration. By further heating to over 40 °C (TA2 ), larger assemblies, which are composed of the side-by-side assembled units, are formed as hierarchical structures. The dehydration temperature of the HEG derivative varies depending on the free volume of the HEG unit, which corresponds to the curvature of the GNRs. Upon heating, dehydration first occurs from the ligands on the side portions with a lower curvature, and then from the ligands on the edge portions with a higher curvature. The different sized GNRs (33 × 8 and 54 × 15 nm) also show two-step assembly. Both the TA1 and TA2 are dependent on the diameter of the GNRs, but independent of their length. This result supports that the dehydration is dependent on the free volume, which corresponds to the curvature. Anisotropic assembly focusing on differences in curvature provides new guidelines for the fabrication of hierarchical structures.

Spontaneous rupture of the urinary bladder (SRUB): Recovery from cardiopulmonary arrest.

Spontaneous rupture of the urinary bladder (SRUB) is rare and results in a lethal condition, i.e., pan peritonitis. However, early and accurate diagnosis of SRUB is very difficult. A 54-year-old woman was transported to our hospital with suspicion of pan peritonitis after spontaneous return of circulation with pulseless electrical activity. Laboratory investigation seemed to indicate acute renal failure. Namely, her serum urea and creatinine levels were grossly elevated. Exploratory laparotomy showed unexpected rupture of urinary bladder. Her recovery after surgery was relatively smooth. SRUB should be considered in the differential diagnosis of pan peritonitis, because urgent appropriate surgical intervention can rescue patients from this rare lethal disease.

Ileo-ileal knot: a rare case of acute strangulated intestinal obstruction.

Strangulated intestinal obstruction is one of the most common types of acute abdomen and requires urgent surgical treatment. Herein, we report a very rare case of strangulated intestinal obstruction caused by an ileo-ileal knot. An 80-year-old woman was admitted to our hospital with suspicion of strangulation ileus and underwent emergency laparotomy after investigation by exploratory single-port laparoscopy. During surgery, a small bowel gangrene caused by an ileo-ileal knot was found. The gangrenous segment was resected, and primary anastomosis was performed. Post-operative recovery was uneventful except for a minor wound infection. Our extensive search of the literature found only 7 case reports of ileo-ileal knot including ours. An ileo-ileal knot should be considered in the differential diagnosis of acute intestinal obstruction, because this rare phenomenon requires urgent surgical treatment; and some complications should be considered during or after surgery.

Synthesis of Janus-like gold nanoparticles with hydrophilic/hydrophobic faces by surface ligand exchange and their self-assemblies in water.

This study aims at the synthesis of Janus gold nanoparticles (Janus GNPs) with hydrophilic/hydrophobic faces by a simple ligand exchange reaction in an homogeneous system and at the elucidation of the self-assembled structures of the Janus GNPs in water. As hydrophilic surface ligands, we synthesized hexaethylene glycol (E6)-terminated thiolate ligands with C3, C7, or C11 alkyl chains, referred to as E6C3, E6C7, and E6C11, respectively. As a hydrophobic ligand, a butyl-headed thiolate ligand C4-E6C11, in which a C4 alkyl was introduced on the E6C11 terminus, was synthesized. The degree of segregation between the two ligands on the GNPs (5 nm in diameter) was examined by matrix-assisted laser desorption/ionization time-of fright mass spectrometry (MALDI-TOF MS) analysis. We found that the choice of immobilization methods, one-step or two-step addition of the two ligands to the GNP solution, crucially affects the degree of segregation. The two-step addition of a hydrophilic ligand (E6C3) followed by a hydrophobic ligand (C4-E6C11) produced a large degree of segregation on the GNPs, providing Janus-like GNPs. When dispersed in water, these Janus-like GNPs formed assemblies of ∼160 nm in diameter, whereas Domain GNPs, in which the two ligands formed partial domains on the surface, were precipitated even when the molar ratio of the hydrophilic ligand and the hydrophobic ligand on the surface of the NPs was almost 1:1. The assembled structure of the Janus-like GNPs in water was directly observed by pulsed coherent X-ray solution scattering using an X-ray free-electron laser, revealing irregular spherical structures with uneven surfaces.

Age-related changes in rat genioglossus, geniohyoid and masseter muscles.

OBJECTIVES: The aim of this study was to elucidate age-related changes from adult to middle age in the contractile properties of the masseter, genioglossus and geniohyoid muscles of the rat. MATERIALS AND METHODS: We analysed the expressions of myosin heavy chain (MyHC) mRNAs and proteins as indicators of the contractile properties in these muscles obtained from rats at 6, 12, 18 and 24 months of age using real-time PCR and SDS-PAGE. RESULTS: We found no marked age-related changes in the expressions of MyHC mRNAs and proteins in rat masseter and geniohyoid muscles, suggesting that the biological ageing process does not affect contractile properties in these muscles. However, we found a decrease in the expression of MyHC IIb mRNA with ageing in the rat genioglossus muscle, suggesting that biological ageing process induces at least some fast-to-slow myofibre phenotype transition. CONCLUSION: The biological ageing process from adult to middle age appears to differentially affect different types of craniofacial muscles.

IGF and myostatin pathways are respectively induced during the earlier and the later stages of skeletal muscle hypertrophy induced by clenbuterol, a ß2-adrenergic agonist.

Clenbuterol, a ß2-adrenergic agonist, increases the hypertrophy of skeletal muscle. Insulin-like growth factor (IGF) is reported to work as a potent positive regulator in the clenbuterol-induced hypertrophy of skeletal muscles. However, the precise regulatory mechanism for the hypertrophy of skeletal muscle induced by clenbuterol is unknown. Myostatin, a member of the TGFß super family, is a negative regulator of muscle growth. The aim of the present study is to elucidate the function of myostatin and IGF in the hypertrophy of rat masseter muscle induced by clenbuterol. To investigate the function of myostatin and IGF in regulatory mechanism for the clenbuterol-induced hypertrophy of skeletal muscles, we analysed the expression of myostatin and phosphorylation levels of myostatin and IGF signaling components in the masseter muscle of rat to which clenbuterol was orally administered for 21 days. Hypertrophy of the rat masseter muscle was induced between 3 and 14 days of oral administration of clenbuterol and was terminated at 21 days. The expression of myostatin and the phosphorylation of smad2/3 were elevated at 21 days. The phosphorylation of IGF receptor 1 (IGFR1) and akt1 was elevated at 3 and 7 days. These results suggest that myostatin functions as a negative regulator in the later stages in the hypertrophy of rat masseter muscle induced by clenbuterol, whereas IGF works as a positive regulator in the earlier stages.

[Impact of Irradiation Field Aperture Controller Settings on Patient-specific Quality Assurance].

PURPOSE: The aperture shape controller (ASC) is a tool on a radiation therapy planning system to reduce complexity by increasing the aperture size of multileaf collimator (MLC). The purposes of this study were to clarify the effect of the dose index on the treatment plan when the intensity of ASC is changed and then to clarify the effect on the verification result in the individual patient-specific quality assurance (QA) using the verification phantom. METHODS: For four types of mock structures presented at AAPM TG-119, volumetric modulated arc therapy (VMAT) treatment plans with three dose levels were set without using the ASC for each of these four types. ASC settings were changed to very low, low, moderate, high and very high for the treatment plan, and the treatment plan was recreated without changing the planning target volume (PTV) and/or OAR dose constraints. The dose index of the treatment plan was then evaluated. The plan was also transferred by the true composite method to the assessment phantom, and patient-specific QA was evaluated. RESULTS: The frequency of dose constraint deviation by changing the ASC was 3.6% (2/55). In patient-specific QA, when the ASC setting was set to moderate, the γ analysis passing rate increased by 1.5% compared to the case without the ASC. In the treatment plan with a γ analysis pass rate of 95% or less without ASC, a 2.7% increase in the γ analysis pass rate was observed by setting the ASC to moderate. CONCLUSION: We found that setting the ASC tended to improve patient-specific QA. Compared to when the ASC was not set, the evaluation result of patient-specific QA was improved without violating the dose constraints of the PTV and/or organ at risk (OAR). In particular, the improvement was notable for the case where the evaluation result of patient-specific QA was 95% or less when the ASC was not used.

Successful treatment for sports hernia by total extraperitoneal repair with intraperitoneal examination: Report a case.

Introduction: and importance: TEP might be one of options for treating such a sports hernia. Case presentation: An 18-year-old Japanese male presented with right groin pain for approximately two years. The pain was initially felt on the right side only, especially on kicking. We assessed the patient using laparoscopic examination with an intra-abdominal scope and subsequently diagnosed a sports hernia with a bilateral internal inguinal hernia. We then performed total extraperitoneal repair (TEP) for its treatment. The patient had a good postoperative course and was discharged from our hospital in remission after 3 days. Finally, the patient was able to play soccer without groin pain. Clinical discussion: Chronic groin pain in athletes can be caused by a bulge in the posterior inguinal wall, consistent with an incipient direct inguinal hernia. Conclusion: We show that intraperitoneal examination with TEP might be one of options for treating such a sports hernia. Endoscopic placement of the retropubic mesh must be considered an important option for this type of hernia.

Laparoscopic intraperitoneal mesh repair of an incisional hernia after transverse rectus abdominis myocutaneous flap reconstruction for breast cancer.

Breast reconstruction with transverse rectus abdominis myocutaneous (TRAM) flap is performed for the treatment of large defects of the breast. However, this may result in an abdominal wall hernia or bulging. A 53-year-old Japanese woman with left breast cancer underwent left skin-sparing mastectomy, sentinel node lymph node dissection, and immediate reconstruction with a contralateral pedicled TRAM flap. Thirty-two months following surgery, right lower abdominal wall hernia (15.5 × 12 cm) and bulging were observed at the suprapubic region. The patient was diagnosed with an incisional hernia and was scheduled for laparoscopic intraperitoneal mesh repair. The mesh was coated with an absorbable hydrogel barrier and was trimmed to 26 × 22 cm, with a 5 cm overlap around the defect. The patient demonstrated a good postoperative course. In conclusion, intraperitoneal onlay mesh with hernia repair closure (IPOM-Plus) is a simple and useful method for hernia repair following TRAM flap reconstruction.

A case report of the transanal lateral lymph node dissection with a combined abdominal assisted approach for the lower rectal cancer.

INTRODUCTION: Low and mid rectal cancer cells have the tendency to spread in the lateral pelvic lymph node (LPLN). The Japanese guidelines recommend systematic lymph node dissection when a positive LPLN is suspected or in stages II-III rectal cancer. However, laparoscopic lymph node dissection is complex and challenging. We introduce transanal LPLN dissection using an abdominal approach. PRESENTATION OF CASE: A 78-year-old man was diagnosed with advanced rectal cancer. Computed tomography and magnetic resonance imaging showed lower rectal wall thickening and bilateral lateral lymph node swelling. We performed laparoscopic abdominal peritoneal resection with combined bilateral LPLN dissection using abdominal and transanal approaches. He had an uneventful postoperative course with no signs of recurrence at the 5-month follow-up. DISCUSSION: LPLN metastases for low rectal cancer especially occur at the bottom of the deep pelvic spaces. As laparoscopic LPLND for low rectal cancer can be complicated, we adopted abdominal and transanal approaches, which provide the advantage of an anatomical view. This procedure may improve lateral pelvic anatomical structure viewing, and may offer advantages over laparoscopic abdominal approaches for visualizing and dissecting LPLNs. CONCLUSION: Curative resection has become available for rectal cancer with transanal LPLN dissection. LPLN dissection with combined abdominal and transanal approaches is a feasible treatment for advanced rectal cancer.

Autophagic-lysosomal pathway functions in the masseter and tongue muscles in the klotho mouse, a mouse model for aging.

Klotho mutant (kl/kl) mice, a type of short-lived mouse models, display several aging-related phenotypes. To investigate whether the atrophy of skeletal muscles is induced in these mice via activation of the ubiquitin-proteasomal pathway and/or the autophagic-lysosomal pathway through an alteration of insulin/IGF-I signaling, we analyzed the activity of the two pathways for protein degradation and components of the insulin/IGF signaling pathway in their skeletal muscles. The masseter, tongue, and gastrocnemius muscles in kl/kl showed marked reductions in muscle weight and in myofiber diameter compared with +/+. The autophagic-lysosomal pathway in kl/kl was activated in the masseter and tongue, but not in the gastrocnemius, compared with that in +/+, whereas the ubiquitin-proteasomal pathway in these three muscles of kl/kl was not altered. No marked difference in the phosphorylation levels of insulin/IGF-I signaling components, such as insulin/IGF-I receptor, Akt, and FoxO in three muscles studied were found between kl/kl and +/+, but the phosphorylation levels of signaling component at the downstream of mTOR such as 4E-BP1 and p70 S6K were suppressed in the masseter and tongue of kl/kl compared with +/+. Deficiency of essential amino acids is reported to activate the autophagy-lysosomal pathway through the down-regulation of mTOR, not through IGF-Akt-FoxO. The masseter and tongue seem to be more actively moved than limb muscles in kl/kl, because they are essential for survival activities such as mastication, swallowing, and respiration. Thus, the deficiency of amino acid by the active movement of the masseter and tongue seems to stimulate the autophagic-lysosomal pathway via the down-regulation of mTOR signalling pathway.

Emergency laparoscopic cholecystectomy for hemorrhagic cholecystitis: A case report.

INTRODUCTION: Hemorrhagic cholecystitis (HC) is a rare but specific complication of acute cholecystitis. HC progression often leads to fatal and severe outcomes. PRESENTATION OF CASE: We describe the case of a 64-year-old man who was diagnosed with HC. Intraoperatively, the gallbladder surface was congested. The resected specimen had no gallstones and showed basophilic degenerate material toward the mucosal surface. In addition, vascular congestion and red cell extravasation were noted at the bottom of the layer. The patient's postoperative course was good, and he was discharged with remission 4 days following the operation. DISCUSSION: Diagnosis and treatment during early stages are the most critical aspects of HC management and may lead to improved outcomes. We successfully performed timely laparoscopic cholecystectomy for the treatment of HC. CONCLUSION: In cases where HC occurs, appropriate treatment should be chosen by experiential judgment and consideration of the current literature.

Clinical outcome of the Gant-Miwa-Thiersch procedure for colonic mucosal prolapse after intersphincteric resection-a single-center report from Japan.

INTRODUCTION: Dysfunctions such as mucosal prolapse occur after intersphincteric resection (ISR) to treat lower rectal cancer, even when it is possible to preserve the anus. METHOD: We analyzed the data of 12 patients with rectal or colonic prolapse who underwent the Gant-Miwa-Thiersch procedure between March 2017 and May 2021. RESULT: There were no severe postoperative complications or recurrences. CASE PRESENTATION: A 75-year-old Japanese man initially underwent ISR and had mucosal prolapse nine months after his initial operation. We performed the Gant-Miwa-Thiersch procedure for colonic mucosal prolapse after ISR. SURGICAL PROCEDURE: Our procedure is a perineal plication method of prolapsed colonic mucosa with nylon wiring (The Gant-Miwa procedure), using a 1-nylon wire encircled three times to straighten the anal canal, with a cord inserted above the internal sphincter muscle (Thiersch procedure). DISCUSSION: Mucosal plication is performed via the Gant-Mowa or Delorme procedure to reduce the risk of recurrence. However, mucosal plication can be performed many times. Our Thiersch procedure involves encircling and straightening the anal canal with a 1-nylon wire to fix the new internal anal sphincter. In conclusion, the Gant-Miwa-Thiersch procedure for rectal and colonic mucosal prolapse, especially after ISR, is a viable treatment option.

Laparoscopic cholecystectomy following extended totally extraperitoneal repair of a ventral hernia: A case report.

INTRODUCTION AND IMPORTANCE: Ventral hernial repair extensively requires the use of surgical meshes to cover the abdominal wall. Patients with a history of laparoscopic ventral hernial repair are predisposed to secondary mesh infections. However, strategies to avoid these mesh infections have not yet been reported. Herein, we report the safety of laparoscopic cholecystectomy in a patient with cholecystitis following extended totally extraperitoneal repair of a ventral hernia. CASE PRESENTATION: A 69-year-old man presented with a five-day history of right hypochondrial pain and severe epigastric pain since the previous day. He had undergone ventral hernial repair. With a diagnosis of acute cholecystitis, laparoscopic cholecystectomy was performed. During laparoscopic cholecystectomy, we inserted the first trocar from the right lower quadrant of the abdomen. Subsequently, we completed the surgery without penetrating the mesh by the ports and observing the other ports in the abdominal cavity. The patient recovered without any complications or short-term mesh infections. CLINICAL DISCUSSION: When performing abdominal surgery in a patient after ventral hernial repair, the presence of the mesh limits the approachability of the abdominal cavity without mesh penetration. Although it remains unclear whether mesh damage during abdominal surgery causes secondary mesh infection, avoiding any damage to the mesh may be recommended, especially in patients who are highly susceptible to intra-abdominal infection. CONCLUSION: We concluded that if the surgery is completed without damaging the mesh site, mesh infection after abdominal contamination surgery may be avoided.

Diagnostic accuracy of presepsin in predicting bacteraemia in elderly patients admitted to the emergency department: prospective study in Japan.

OBJECTIVE: Early prediction of bacteraemia in the elederly is needed in the emergency department (ED). DESIGN, SETTING AND PARTICIPANTS: A prospective study in Japan; single-centre trial in patients who satisfied the sepsis criteria was conducted between September 2014 and March 2016. Forty-six elderly patients aged ≥70 years were included. The study protocol was approved by the ethics committee of Osaka Medical College. Ethics Committee approval number was 1585. INTERVENTIONS: Blood sampling to evaluate C-reactive protein (CRP), procalcitonin (PCT) and presepsin plasma levels; two sets of blood sampling for bacterial cultures; and evaluations of the Sequential Organ Failure Assessment and Acute Physiology and Chronic Health Evaluation scores were performed on arrival at the ED. The results were compared between patients with bacteraemia and those without bacteraemia. MAIN OUTCOME MEASURE: The accuracy of detecting bacteraemia. RESULTS: The presepsin value was significantly higher in the bacteraemia group than in the non-bacteraemia group (866.6±184.6 vs 639.9±137.1 pg/mL, p=0.03). The PCT and CRP did not significantly differ between the groups. The area under the receiver operating characteristic curve values were not significantly different among presepsin (0.69), PCT (0.61) and CRP (0.53). Multivariate analysis showed that presepsin was independently associated with bacteraemia (OR 8.84; 95% CI 0.95 to 81.79; p=0.02). CONCLUSION: Presepsin could be a good biomarker to predict bacteraemia in elderly patients with sepsis criteria admitted to the ED.

Single-port surgery (SPS) strategy for small bowel obstruction (SBO) caused by postoperative internal hernia: A series case report.

RATIONALE: Internal hernia due to postoperative adhesions sometimes causes small bowel obstruction (SBO) and requires emergency surgery. The difficulties in the management of SBO with internal hernia include accurate diagnosis and estimation of its ischemic degree and of the risk of SBO recurrences following the surgical procedure. Laparoscopic surgery is a noninvasive to reduce postoperative adhesions and therefore has been widely used recently. However, surgeons often tend to hesitate in applying laparoscopic surgery for SBO because of some situational disadvantages such as poor operating space or iatrogenic bowel injury. Hence, laparoscopic surgery is still not yet the standard procedure for SBO caused by internal hernia. Thus, the establishment of an appropriate procedure for SBO due to internal hernia is required. PATIENT CONCERNS: We experienced 3 SBO cases caused by postoperative internal hernia. The first patient was a 59-year-old man who had temporary loop-ileostomy for a perforated sigmoid colon due to diverticulitis. Severe hypogastralgia and vomiting occurred suddenly on the 33rd postoperative day. The second patient was an 81-year-old man who had been hospitalized due to epigastralgia of unknown origin. He had a surgical history of omentum patching for a perforated duodenum 20 years ago. The third patient was a 72-year-old female who presented at our hospital after sudden and severe hypogastralgia. She had a surgical history of sigmoidectomy for her sigmoid colon cancer 22 years ago. DIAGNOSIS: A contrast computed tomography (CT) revealed a suspected closed loop obstruction of their bowels and immediate surgical treatments were required. INTERVENTION: We tried SPS using the surgical glove method as an initial approach for their SBO caused by postoperative internal hernia. OUTCOMES: Two of these 3 cases completely underwent SPS treatment, which afforded accurate diagnosis of SBO. Laparotomy following SPS, which allowed accurate diagnosis, was judged to be appropriate and was performed in the third case. All the patients were discharged without any complications and SBO have not recurred after their discharge. Finally, we established a new strategy using SPS for SBO with internal hernia. LESSONS: Our experience suggests that SPS is a promising strategy as an initial surgical approach for SBO with internal hernia.

An atypical case of atypical pneumonia.

Atypical pneumonia has been thought to account for 7%-20% of community-acquired pneumonia (CAP). The treatment for the pathogens that cause atypical pneumonia is different from that of other bacterial pneumonia. Therefore, identification of the causative pathogen in a primary care situation is crucial for adequate treatment of CAP. Mycoplasma infection is prevalent in the general population, but Mycoplasma pneumoniae with extrapulmonary symptoms is relatively rare. Herein, we report a case of CAP because of M. pneumoniae that presented with a wide variety of extrapulmonary diseases. Delayed administration of appropriate antibiotics may contribute to development of extrapulmonary manifestations.