Double Microballoon-occluded Ethanol Embolization for Pelvic Arteriovenous Malformation: A Case Report.

A 40-year-old man was incidentally found to have right-sided pelvic arteriovenous malformation (AVM) with an aneurysmal dominant outflow vein (DOV). The AVM had two main feeding arteries forming a cluster of fine vessels shunt to the DOV. As transvenous approach was impossible due to anatomical difficulty, transarterial ethanol embolization was performed under simultaneous double microballoon occlusion of the two feeding arteries in combination with protective coil embolization of the prostatic branches. Ethanol (13 mL) was intermittently injected from both microballoon catheters until the AV shunt was completely occluded. At 1-year follow-up, contrast-enhanced CT revealed shrinkage of the thrombosed DOV without any symptom. Our case demonstrated the usefulness of simultaneous double microballoon-occluded ethanol embolization for treating a localized pelvic AVM with a few feeding arteries.

The left ventricular "lining" technique for repair of ischemic ventricular septal rupture.

We describe a technique to repair ischemic ventricular septal rupture via a left ventriculotomy. It employs a large endoventricular patch as a "lining" over the locally patched septal defect and the free wall defect which is going to be roofed with an external patch. Both defects are then closed in double layers, holding a single continuous patch. The technique enhances the advantage of the left ventriculotomy in the repair and minimizes ventriculotomy-related morbidity.

Isolated left hepatic vein draining into the coronary sinus: a rare anomaly encountered during mitral valve surgery.

A left hepatic vein draining into the coronary sinus is an extremely rare congenital abnormality as a solitary cardiovascular malformation. We encountered the anomaly during the mitral valve surgery in a 72-year-old woman. The operation was successfully carried out using an additional suction directly in the left hepatic vein.

Distal aortic replacement followed by endovascular repair for the management of severe intra-pleural adhesions accidentally detected during open surgery for chronic type B aortic dissection: a report of two cases.

BACKGROUND: Open repair is the most promising curative treatment option for patients with chronic type B aortic dissection. However, based on our experience, following the accidental detection of intra-pleural adhesions during open surgery for chronic type B aortic dissection, complete replacement of the diseased aorta cannot be accomplished. To overcome this problem, we switched the procedure to create a distal landing zone for subsequent endovascular repair by replacing the distal aorta with a vascular graft. CASE PRESENTATION: We report two cases in which open repair was attempted; however, the proximal descending thoracic aorta could not be exposed due to the presence of severe adhesion in the pleural cavity. In these patients, we accessed the lower descending thoracic aorta or thoracoabdominal aorta and created a distal landing zone for subsequent endovascular repair by replacing the aorta with a vascular graft. Thereafter, endovascular repair was performed with good outcomes. CONCLUSIONS: Replacement of the distal aorta, which is typically easy to access despite the presence of intra-pleural adhesions, with a vascular graft serves as a reliable distal landing zone for subsequent endovascular repair. This method may be a viable option for the management of severe adhesions accidentally detected in the pleural cavity during open repair for chronic type B aortic dissection.

Complications of cerebral air embolism associated with pleural lavage for empyema.

Standard initial treatment for acute empyema involves antibiotic administration and chest tube drainage; however, pleural lavage with saline is another treatment that mitigates the need for surgical drainage. Although this treatment is recognised as non-invasive and safe, the complications of cerebral air embolism are less recognised.In this case, a man in his late 40s was diagnosed with acute empyema and treated with chest tube (28 Fr) drainage and antibiotics. Empyema remained on follow-up chest imaging; thus intrapleural fibrinolytic therapy (urokinase 120 000 units/day for a total of 3 days) and pleural lavage (0.9% saline 1000 mL/day daily) were administered. During the 10th pleural lavage, the patient suddenly became unconscious. Head imaging revealed a cerebral air embolism. Consequently, he received urgent hyperbaric oxygen therapy and improved without any neurological sequelae.Clinicians should be aware of the complications of sudden cerebral air embolism due to pleural lavage for empyema.

A case report of an elderly male with isolated coronary sinus atrial septal defect.

BACKGROUND: Isolated coronary sinus atrial septal defect (CSASD) is a rare congenital cardiac anomaly, comprising <1% of atrial septal defects. Elderly patients with this anomaly are even more uncommon and sometimes overlooked. CASE SUMMARY: A 73-year-old man with a history of electrical defibrillation therapy for atrial flutter presented with worsening exertional dyspnoea. Cardiac examination revealed CSASD without persistent left superior vena cava, showing only moderate tricuspid regurgitation. Surgical repair of the defect and regurgitant valve improved symptoms dramatically. DISCUSSION: Elderly patients with atrial arrhythmias might show uncommon presentations of congenital heart disease. Cardiologists should pay attention to enlarged right ventricle, pulmonary artery, and, in particular, enlarged coronary sinus. Direct closure with interrupted sutures secured with pledgets is effective in some case of terminal type of CSASD.

Fusobacterium necrophorum pelvic peritonitis and bacteremia mimicking intestinal necrosis.

Fusobacterium necrophorum infection is known to cause Lemierre's syndrome, not pelvic peritonitis. Herein, we report a case of Fusobacterium necrophorum pelvic peritonitis and bacteremia, without Lemierre's syndrome, mimicking intestinal necrosis. A 28-year-old woman with peritoneal irritation and shock was suspected of having intestinal necrosis due to the presence of hepatoportal venous gas and pneumatosis intestinalis. Intestinal necrosis was ruled out by emergency laparotomy. However, massive opaque ascites and inflammatory changes in the uterus and fallopian tubes were observed. Fusobacterium necrophorum and Gardnerella vaginalis were found in ascetic fluid cultures. Moreover, Fusobacterium necrophorum was also found in blood culture. Systemic management of septic shock and antibiotic treatment improved the patient's general condition and abnormal gas on imaging. The patient had untreated bacterial vaginosis prior to admission. Pelvic peritonitis caused by Fusobacterium necrophorum is extremely rare. However, it must be recognized to avoid its rapid development into severe onset mimicking intestinal necrosis.

[Cavernous Hemangioma Originating in the Left Atrial Appendage:Report of a Case].

A 66-year-old male with hypertension was referred for evaluation of abnormal find chest X-ray. A computed tomography (CT) scan revealed a solitary pericardial mass with a diameter of 5 cm, located in the left atrioventricular groove. It showed solid but unevenly enhanced contents suggesting a well vascularized tumor originating in either a part of the left heart or the pericardium. As magnetic resonance imaging showed a clear boundary between the tumor and the pericardium, cardiac origin was suspected. Surgical removal of the tumor was performed via median sternotomy. The tumor originated from the lateral aspect of the left atrial appendage, having a base of 10 mm in diameter. The tumor was fully excised with an associated left atrial cuff under cardiopulmonary bypass. The postoperative course was uneventful. The tumor was histopathologically diagnosed as cavernous hemangioma originating in the left atrial wall. There has been no sign of recurrence for four years following surgery.

Ecthyma gangrenosum mimicking cellulitis.

This report has strong implications for carefully examining the common skin signs of cancer patients receiving chemotherapy. These signs can warn clinicians of the potential for severe infections such as fatal sepsis.

A surgical case of primary perivascular epithelioid cell tumor of the heart.

BACKGROUND: We encountered an extremely rare case of perivascular epithelioid cell tumor (PEComa) of the heart. CASE REPORT: A 54-year-old woman was admitted to our hospital because a solid mass developing in the left atrioventricular groove by computed tomography scans of the chest. Histologic examination of the resected tumor revealed that the tumor had proliferating fusiform or spheroid cells with clear cytoplasm. Immunostaining showed positive results for α-smooth muscle actin, a myogenic marker, and human melanin black-45 (HMB-45), leading to a diagnosis of PEComa. The patient was discharged uneventfully, and there was no recurrence for the last thirteen years postoperatively. CONCLUSIONS: We experienced a surgical case of PEComa primarily occurring in the heart. Although no sign of a recurrence is observed to date, we consider it necessary to follow up the case carefully.

Lemierre's syndrome complicating influenza A virus infection.

We report a 24-year-old previously healthy woman with Lemierre's syndrome following influenza A virus infection. One week after influenza A was diagnosed by rapid antigen test and treated by oseltamivir, she developed multiple cavitary lung lesions, and a left internal jugular vein thrombosis. The blood culture grew Fusobacterium necrophorum. We administered ampicillin-sulbactam and unfractionated heparin to which she responded very well. Although viral infections have been related to Lemierre's syndrome, influenza virus rarely implicated. Lemierre's syndrome should be included in the differential diagnoses of rare complications of influenza virus infection.

Usefulness of next-generation DNA sequencing for the diagnosis of urinary tract infection.

Acute urinary tract infection (UTI) is a highly common clinical condition. Although bacterial culture is the gold standard diagnostic test, false negative results may be possible, leading to the pathogen being unidentified. In recent years, bacterial DNA sequencing analysis has garnered much attention, but clinical studies are rare in Japan. In this study, we assessed the usefulness of next-generation DNA sequencing (NGS) analysis for acute UTI patients. We thus performed an observational, retrospective case series study. Urine and blood samples were collected from ten acute UTI patients, of whom four had also been diagnosed with urosepsis. Seven variable regions of bacterial 16S rRNA genes were amplified by PCR and then sequenced by IonPGM. The identified bacterial species were compared with those identified using the culture tests and the clinical parameters were analyzed. As a result, the NGS method effectively identified predominant culture-positive bacteria in urine samples. The urine NGS also detected several culture-negative species, which have been reported to be potentially pathogenic. Out of four urosepsis cases, three were pathogen-positive in blood NGS results, while two were pathogen-negative in blood culture. In one sepsis case, although blood culture was negative for Escherichia coli, this species was detected by blood NGS. For non-sepsis cases, however, blood NGS, as well as blood culture, was less effective in detecting bacterial signals. In conclusion, NGS is potentially useful for identifying pathogenic bacteria in urine from acute UTI patients but is less applicable in patients who do not meet clinical criteria for sepsis.

Spatial adiabatic passage of massive quantum particles in an optical Lieb lattice.

Quantum interference lies at the heart of quantum mechanics. By utilizing destructive interference, it is possible to transfer a physical object between two states without populating an intermediate state which is necessary to connect the initial and final states. A famous application is a technique of stimulated Raman adiabatic passage, where atomic internal states can be transfered with high efficiency regardless of lossy intermediate states. One interesting situation is a case where the initial and final states are spatially well separated. Quantum mechanics allows a particle to move without practical possibility of being found at the intermediate area. Here we demonstrate this spatial adiabatic passage with ultracold atoms in an optical lattice. Key to this is the existence of dark eigenstates forming a flat energy band, with effective transfer between two sublattices being observed. This work sheds light on a study of coherent control of trapped cold atoms.

IgG4-Positive Plasmacytic Infiltration in Aortic Wall and Aortic Valve Surgical Samples and Its Relation to Preoperative Serum IgG4 Levels.

The prevalence and extent of immunoglobulin G4 (IgG4)-positive cell infiltration were investigated in 282 surgical samples of aortic wall and aortic valve. Tissue infiltration of IgG4-positive cells was observed in 24 (17.3%) of 139 aortic valve samples and 46 (32%) of 143 aortic wall samples, and the condition of IgG4-positive cell infiltration > 30/hpf together with IgG4/CD138 ratio > 40% was observed in 2 (1.4%) of aortic valve samples and 14 (9.8%) of aortic wall samples. Among 275 patients, preoperative serum IgG4 level was available in 48 patients (50 samples), and it was > 135 mg/dL in only one patient. Of these 48 patients with serum IgG4 measurement, 29 patients had aortic valve stenosis and 12 had aortic aneurysm. Compared with 23 aortic stenosis patients without tissue infiltration of IgG4-positive cells in the aortic valve, six patients with IgG4-positive cell infiltration had a more prevalent smoking history (26% versus 83%) and borderline significantly higher serum IgG4 (median, 24.5 mg/dL versus 55.5 mg/dL), although either preoperative peak pressure gradient between left ventriculum and aorta or aortic valve area did not differ significantly between groups. Compared with six aortic aneurysm patients without tissue infiltration of IgG4-positive cells in the aortic wall, six patients with IgG4-positive cell infiltration had borderline significantly higher serum IgG4 (median, 28.9 mg/dL versus 68.2 mg/dL). The current study showed that tissue IgG4-positive infiltration is not a rare occurrence in the aortic stenosis and aortic aneurysm. Clinical significance of tissue IgG4-postive cell infiltration in these patients requires further investigation.

Neuroleptic malignant syndrome as part of an akinetic crisis associated with sepsis in a patient with Lewy body disease.

A 65-year-old Japanese woman with Parkinson's disease, later diagnosed with Lewy body disease, presented with a 2-day history of systemic tremors. She also had fever without rigidity or creatine kinase (CK) elevation. She was diagnosed with sepsis caused by pyelonephritis with acute kidney injury and parkinsonism exacerbation. Although antibiotic and fluid therapy improved her pyuria and renal function, her fever and tremors persisted. On the fourth day, her symptoms worsened and resulted in cardiopulmonary arrest; however, quick resuscitation allowed the return of spontaneous circulation. Simultaneously, hyperthermia, altered consciousness, extrapyramidal symptoms, dysautonomia and CK elevation were noted. Thus, dantrolene administration was initiated with a tentative diagnosis of neuroleptic malignant syndrome (NMS). This caused her fever to subside, and her symptoms gradually improved. It was difficult to distinguish between parkinsonism exacerbation associated with sepsis and NMS. Physicians should consider NMS early on, even if the patient does not fulfil the diagnostic criteria.

Antiferromagnetic Spin Correlation of SU(N) Fermi Gas in an Optical Superlattice.

Large-spin cold atomic systems can exhibit unique phenomena that do not appear in spin-1/2 systems. We report the observation of nearest-neighbor antiferromagnetic spin correlations of a Fermi gas with SU(N) symmetry trapped in an optical lattice. The precise control of the spin degrees of freedom provided by an optical pumping technique enables us a straightforward comparison between the cases of SU(2) and SU(4). Our important finding is that the antiferromagnetic correlation is enhanced for the SU(4)-spin system compared with SU(2) as a consequence of a Pomeranchuk cooling effect. This work is an important step towards the realization of novel SU(N>2) quantum magnetism.

Severe herpes simplex virus pneumonia in an elderly, immunocompetent patient.

Although not common, herpes simplex virus (HSV) pneumonia can occur in immunocompromised patients. However, HSV pneumonia in immunocompetent hosts is very rare. The authors encountered a very rare case of severe HSV pneumonia in an immunocompetent host. The patient was an 85-year-old Japanese woman who presented with severe intractable pneumonia refractory to empirical antimicrobial therapy. Furthermore, the causative microorganisms remained unknown. Therefore, cytological examination of bronchoalveolar lavage fluid and protected brush biopsy of the lower respiratory tract were performed, which indicated herpes virus-infected cells with nuclear inclusions; PCR assay was positive for HSV DNA. Accordingly, the patient was diagnosed with HSV pneumonia. Her respiratory condition improved immediately after initiation of acyclovir monotherapy. In selected cases of intractable pneumonia refractory to standard antimicrobial therapy, the possibility of HSV pneumonia should be pursued.

Helicobacter pylori-negative Advanced Gastric Cancer with Massive Eosinophilia.

The incidence of Helicobacter pylori-negative gastric cancer is very low. A 60-year-old man was referred to Tokai University Hospital from a local clinic because of eosinophilia. The laboratory data revealed prominent eosinophilia, with a white blood cell count of 7,900 /µL and increased eosinophil granulocyte level of 1,659 /µL. After an examination for secondary eosinophilia, esophagogastroduodenoscopy showed an enlarged gastric fold in the corpus, suggesting type 4 gastric cancer. Repeated esophagogastroduodenoscopy (EGD) and a re-biopsy demonstrated poorly differentiated adenocarcinoma and signet ring cell carcinoma. The patient was negative for Helicobacter pylori infection according to the serum anti-Helicobacter pylori antibody, culture and histopathological findings.