Primary aortoduodenal fistula caused by tuberculous aortitis presenting as recurrent massive gastrointestinal bleeding

Upper gastrointestinal bleeding from primary aortoduodenal fistula (PADF) is unusual and fatal. The etiology of PADF from tuberculous aortitis is rare. We report a 69-year-old male patient who suffered recurrent hematemesis and hematochezia with hypovolemic shock of unknown origin. Initial endoscopy failed to lead to a diagnosis. A bleeder over the third portion of the duodenum was found after the third endoscopy. Exploratory laparotomy showed a ruptured aortic pseudoaneurysm with an aortoduodenal fistula. Dacron graft repair of the aorta and simple closure of the duodenal fistula were carried out. Pathologic examination revealed tuberculous aortitis. The patient survived and was symptom-free following operation and antituberculous therapy. Review of the literature revealed that the clinical presentations in this disorder are insidious. The endoscopic findings are atypical. We conclude that so-called "herald bleeding", a history of tuberculous infection or aortic aneurysm and a high degree of suspicion are critical for successful diagnosis. Early diagnosis and surgical exploration are needed for timely and successful management.     

Correlation between Serum 25-Hydroxyvitamin D Level and Peripheral Arterial Stiffness in Chronic Kidney Disease Stage 3–5 Patients

Vitamin D deficiency and high brachial-ankle pulse wave velocity (baPWV) are each independently associated with higher incidence of mortality and cardiovascular (CV) disease or CV events, respectively. This study aimed to evaluate the relationship between serum 25-hydroxyvitamin D levels and baPWV in non-dialysis patients with stage 3–5 chronic kidney disease (CKD). We enrolled 180 CKD patients. A commercial enzyme-linked immunosorbent assay was used to measure 25-hydroxyvitamin D levels. BaPWV values were measured using an automatic pulse wave analyzer. Either left or right baPWV > 18.0 m/s was considered indicative of peripheral arterial stiffness (PAS). In this study, 73 (40.6%) patients were found to have PAS. Compared to those without PAS (control group), patients with PAS were older and had higher incidence of diabetes mellitus, higher systolic and diastolic blood pressure, higher levels of intact parathyroid hormone, and C-reactive protein, and lower levels of 25-hydroxyvitamin D. Multivariate logistic regression analysis found 25-hydroxyvitamin D levels (odds ratio [OR]: 0.895, 95% confidence interval [CI] 0.828–0.968, p = 0.005) and old age (OR: 1.140, 95% CI 1.088–1.194, p < 0.001) to be independently associated with PAS in patients with stage 3–5 CKD. Lower serum 25-hydroxyvitamin D levels and older age were associated with PAS in these patients.     

Development of a Flexible Metamaterial Film with High EM Wave Absorptivity by Numerical and Experimental Methods

The present study is intended to develop and test a cost-effective and efficient printing method for fabricating flexible metamaterial film with high electromagnetic wave absorptivity. The film can be easily applied to the surfaces with curved aspects. Firstly, numerical parametric study of the absorption characteristics of the film is performed for the range of frequency varying from 2.0 to 9.0 GHz based on commercial software package. Secondly, the flexible metamaterial films are fabricated, and experiments are conducted. The flexible metamaterial film consists of a flexible dielectric film made of polyimide (PI) and an array of split-ring resonators. The split-ring resonators of different geometric dimensions are fabricated on the PI film surface by using a silver nanoparticles ink jet printer. The performance of the flexible structure is then measured and dependence of operation frequency with higher absorptivity on the dimensions of the split-ring resonators is investigated. A comparison between the numerical and experimental data shows that the numerical predictions of the operation frequency with higher absorptivity closely agree with the experimental data.     

Acute rheumatic fever in adult patients

Acute rheumatic fever (ARF) is considered as a disorder of children, and attacks in adults are usually a recurrence of disease acquired in the child’s life. Although the incidence of ARF in children has a decreasing trend in developed countries, resurgent and sporadic epidemics still occur in adults. The first attacks of ARF in adult patients without a childhood history can lead to a diagnostic dilemma.A medical record review in adults at least 18 years of age with an arthralgia complaint fulfilling 2015 revised Jones criteria was performed from January 1, 2000 to December 31, 2019.Eleven ARF patients were identified, including 8 with initial attacks (6 females aged 26–42 years, 33.9 ± 5.3) and 3 pre-existing valvular heart disease with recurrent attacks (2 females aged 38–52 years, 45.0 ± 7.0). In addition to febrile pharyngitis and migratory polyarthritis in initial attacks, pericarditis was encountered in 1, valvulitis in 2, prolong PR interval in 3 and skin involvement in 2 patients with erythema marginatum and IgA vasculitis. All responded to antibiotics and nonsteroidal anti-inflammatory drugs therapy with normalized clinical and laboratory abnormalities, no new-onset carditis, and no recurrent disease during a long-term follow-up (3.8–19.8 years, 12.7 ± 5.4).A sporadic occurrence of adult ARF is observed in southern Taiwan. This disease should be considered by physicians for the differential diagnosis of febrile pharyngitis with arthritis and/or carditis in adults, even in areas with a low incidence of ARF.