Co-infection with Neisseria mucosa in a patient with tuberculous otitis media.

Tuberculous otitis media (TOM) is a rare manifestation caused by Mycobacterium tuberculosis with low incidence rates among extrapulmonary tuberculosis cases. Diagnosis is often delayed because of the presence of several clinical manifestations and the high prevalence of secondary bacterial infections. Few reports have attributed secondary bacterial infections in patients with TOM to commensal Neisseria. Thus, understanding the pathogenic mechanisms and clinical features of commensal Neisseria is important, considering its recent presentation as an infection-causing pathogen. Neisseria mucosa is a commensal inhabitant in humans and is generally considered non-pathogenic but can cause infection in rare cases. Here, we report an atypical secondary infection caused by Neisseria mucosa in an 81-year-old woman with TOM being treated for pulmonary tuberculosis. Direct purulent otorrhea smear microscopy revealed no acid-fast bacilli using Ziehl-Neelsen staining, whereas the phagocytosis of gram-negative cocci by white blood cells was confirmed using Gram staining. Otorrhea culture revealed the growth of N. mucosa. Subsequently, M. tuberculosis infection in the otorrhea was identified using a culture-based method. Vigilance is critical for the early detection of TOM to prevent further complications. This report raises awareness regarding TOM and provides insight into the pathogenicity of N. mucosa in otitis media.

Non-A Blood Type Is a Risk Factor for Poor Cardio-Cerebrovascular Outcomes in Patients Undergoing Dialysis.

The clinical impact of ABO blood type on cardio-cerebrovascular outcomes in patients undergoing dialysis has not been clarified. A total of 365 hemodialysis patients participated in the current study. The primary endpoint was defined as a composite including cardio-cerebrovascular events and cardio-cerebrovascular death. The primary endpoint was observed in 73 patients during a median follow-up period of 1182 days, including 16/149 (11%) with blood type A, 22/81 (27%) with blood type B, 26/99 (26%) with blood type O, and 9/36 (25%) with blood type AB. At baseline, no difference was found in the echocardiographic parameters. Multivariable Cox regression analyses revealed that blood type (type A vs. non-A type; hazard ratio (HR): 0.46, 95% confidence interval (95% CI): 0.26-0.81, p = 0.007), age (per 10-year increase; HR: 1.47, 95% CI: 1.18-1.84), antiplatelet or anticoagulation therapy (HR: 1.91, 95% CI: 1.07-3.41), LVEF (per 10% increase; HR: 0.78, 95% CI: 0.63-0.96), and LV mass index (per 10 g/m2 increase; HR: 1.07, 95% CI: 1.01-1.13) were the independent determinants of the primary endpoint. Kaplan-Meier curves also showed a higher incidence of the primary endpoint in the non-A type than type A (Log-rank p = 0.001). Dialysis patients with blood type A developed cardio-cerebrovascular events more frequently than non-A type patients.

[A case of proximal-type Hirayama disease associated with neck axial rotation].

Hirayama disease is characterized by juvenile onset of unilateral muscular atrophy of a distal upper extremity. The pathogenic mechanism of Hirayama disease is cervical cord compression by the posterior dura with forward displacement in the neck flexion position. A few cases of 'proximal-type Hirayama disease' have been described as showing muscular weakness and atrophy of the proximal upper extremities caused by the pathogenic mechanism similar to that of Hirayama disease. We report herein the case of a 16-year-old boy with proximal-type Hirayama disease, who developed symptoms after he began kyudo (Japanese traditional archery). Neurological examination revealed bilateral weakness of the muscles innervated by C5 and C6 segments (the deltoid, biceps brachii, brachioradialis), bilateral mild sensory disturbance in the radial side of the forearm, absent tendon reflexes of the biceps brachii and brachioradialis with preserved triceps reflex, pyramidal signs of the bilateral lower extremities (pathologically brisk reflexes of lower extremities, Babinski's signs). MR images in the neck flexion position showing expansion of the posterior extradural space and forward displacement of the spinal cord at the C3/4, C4/5, C5/6 and C6/7 disk levels. CT myelogram revealed spinal cord compression not only in neck flexion but also in neck left axial rotation. His symptoms improved after the restriction of neck flexion and axial rotation. Weakness of the upper extremities improved after 2 months. Pyramidal signs of the lower extremities disappeared after 18 months. The pathogenic mechanism in this case may be associated with not only neck flexion but also neck axial rotation.

[Current Status of Clinical Ethics and Creation of Ethical Organizational Culture].

When an ethical problem arises in clinical practice, the process of discussion aimed towards a solution is important. The decision should be made by a multidisciplinary team rather than by an individual clinician. In clinical practice, highly feasible solutions are required. Clinical ethics consultation is useful as a service that supports the decision-making process. A future issue is to foster an organizational culture of openness that enables professionals to solve the problem in practice.

[A Case Report of Spontaneous Cerebrospinal Fluid Otorrhea].

Spontaneous cerebrospinal fluid(CSF)otorrhea is less common than CSF leakage caused by trauma, and rarely occurs in adults. We report an adult case of CSF otorrhea. A 71-year-old woman with no traumatic or otologic history was hospitalized due to bacterial meningitis. After hospitalization, CSF leakage started suddenly from the left external ear canal. A high resolution CT scan with intrathecal administration of contrast material revealed CSF leakage in the left ear canal and multiple bone erosions in both the tegmen mastoideum and the posterior fossa aspect of the petrous bone. We performed closure and surgery via the middle fossa approach. We identified a bone defect in the tegmen mastoideum but could not detect any obvious abnormality in the dura mater. We placed both a pericranial flap and a free abdominal fat on the middle base of the skull as sealing materials. There was no recurrence of CSF otorrhea following surgery. In this surgery, the use of a multilayered closure technique is very important to avoid the recurrence of CSF leakage.

Extremely rare persistent primitive artery passing through the jugular foramen with symptomatic ipsilateral carotid artery stenosis.

Primitive arteries are persistent fetal anastomoses between the carotid and vertebral-basilar circulation. Although rare, persistent primitive arteries can remain at birth. A 73-year-old woman presented with cerebral infarction to the posterior circulation caused by symptomatic common carotid artery stenosis with an unnamed and extremely rare persistent primitive artery. This anomalous vessel branched from the extracranial internal carotid artery and passed through the ipsilateral jugular foramen into the posterior cranial fossa and merged into the basilar artery. To our knowledge, this is the first case of a persistent primitive artery passing through the jugular foramen with symptomatic common carotid artery stenosis.

New Sesquiterpene Lactone Dimer, Uvedafolin, Extracted from Eight Yacon Leaf Varieties (Smallanthus sonchifolius): Cytotoxicity in HeLa, HL-60, and Murine B16-F10 Melanoma Cell Lines.

Uvedafolin, 1, a new sesquiterpene lactone dimer, was isolated from the leaves of Smallanthus sonchifolius with five related compounds, 2-6, and their cytotoxicity was assessed against three tumor cell lines (HeLa, HL-60, B16-F10 melanoma). The stereostructure of 1 was newly elucidated by ESI-TOF-MS, 1D/2D NMR, and single-crystal X-ray diffraction. Dimers 1 and 2 had the most effective IC50 values, 0.2-1.9 µM, against the three tumor cell lines when compared with monomers 3-6 (IC50 values 0.7-9.9 µM) and etoposide (IC50 values 0.8-114 µM). The ester linkages of two sets of monomers, uvedalin, 5, and sonchifolin, 6, for 1, and enhydrin, 4, and sonchifolin, 6, for 2, as well as the acetyl group at the C-9 position, were essential for the high cytotoxicity. Dimers 1 and 2 would have potential as anticancer agents.

Case of Rapid Progression of Hemiatrophy on the Face: A New Clinical Entity?

A lot of diseases, including lupus profundus, morphea, lipodystrophy, and Parry-Romberg syndrome, may manifest progressive hemifacial atrophy. These diseases usually progress slowly and rapid progression of atrophy is extremely rare. We report a case of elderly-onset rapid progression of hemifacial atrophy only in three weeks. Our case did not meet variable differential diagnoses. We discuss the clinical character of the patient against the past of literature and suppose it may be a new clinical entity.

False-positive serology following intravenous immunoglobulin and plasma exchange through transfusion of fresh frozen plasma in a patient with pemphigus vulgaris.

Intravenous immunoglobulin therapy and plasma exchange through transfusion of fresh frozen plasma are therapeutic options for patients with refractory pemphigus vulgaris. Passive acquisition of various clinically important antibodies through these therapies can occur, leading to false serology and negatively affecting patients' clinical care. It is recommended that dermatologists recognize the possibility of these phenomena and interpret them appropriately. Here, we report false-positive serology following intravenous immunoglobulin therapy and plasma exchange through transfusion of fresh frozen plasma in a patient with refractory pemphigus vulgaris. We also discuss the measure for misinterpretation and unnecessary clinical intervention.

Effects of controlled-release fertilizer on leaf area index and fruit yield in high-density soilless tomato culture using low node-order pinching.

To further development of a simplified fertigation system using controlled-release fertilizers (CRF), we investigated the effects of differing levels of fertilizers and plant density on leaf area index (LAI), fruit yields, and nutrient use in soilless tomato cultures with low node-order pinching and high plant density during spring-summer (SS), summer-fall (SF), and fall-winter (FW) seasons. Plants were treated with 1 of 3 levels of CRF in a closed system, or with liquid fertilizer (LF) with constant electrical conductivity (EC) in a drip-draining system. Two plant densities were examined for each fertilizer treatment. In CRF treatments, LAI at pinching increased linearly with increasing nutrient supply for all cropping seasons. In SS, both light interception by plant canopy at pinching and total marketable fruit yield increased linearly with increasing LAI up to 6 m(2) · m(-2); the maximization point was not reached for any of the treatments. In FW, both light interception and yield were maximized at an LAI of approximately 4. These results suggest that maximizing the LAI in SS and FW to the saturation point for light interception is important for increasing yield. In SF, however, the yield maximized at an LAI of approximately 3, although the light interception linearly increased with increasing LAI, up to 4.5. According to our results, the optimal LAI at pinching may be 6 in SS, 3 in SF, and 4 in FW. In comparing LAI values with similar fruit yield, we found that nutrient supply was 32-46% lower with the CRF method than with LF. In conclusion, CRF application in a closed system enables growers to achieve a desirable LAI to maximize fruit yield with a regulated amount of nutrient supply per unit area. Further, the CRF method greatly reduced nutrient use without decreasing fruit yield at similar LAIs, as compared to the LF method.