Repeated embolization of intercostal arteries after blunt chest injury

To deal with an arterial bleeding from the chest wall after a blunt chest injury, embolization of the bleeding arteries can be a valuable therapeutic option, which is less invasive than a thoracotomy. However, its results are variable, being highly operator-dependent. In the present case, we performed successful emergency embolization of the 4th and 5th intercostal arteries for persistent hemorrhage following blunt trauma to the chest. Several days after the first embolization, secondary embolization was required for treating a pseudoaneurysm that was formed in the 5th intercostal artery. Although the mechanisms underlying pseudoaneurysm formation are not clearly understood, its rupture is potentially fatal. Therefore, it is essential to carefully follow-up patients who experience blunt chest injury to avoid this serious complication.     

Development of takotsubo cardiomyopathy with severe pulmonary edema before a cesarean section

Takotsubo cardiomyopathy is an acute syndrome involving apical ballooning and consequent dysfunction of the left ventricle. Most cases of left ventricular dysfunction resolve within 1 month. We present the case of a 40-year-old woman who developed severe heart failure caused by takotsubo cardiomyopathy with severe left ventricular dysfunction during the perinatal period. Because of the presence of multiple myomas, she was scheduled to undergo a cesarean section under general anesthesia. However, after induction of general anesthesia, she had to be awakened because of the presence of a difficult airway. Because she exhibited insufficient oxygenation, she was transferred to the emergency center. Upon hospital admission, she expectorated large amounts of pink sputum, indicating severe pulmonary edema. Cesarean section was performed immediately. Echocardiography revealed severe left ventricular dysfunction. Full recovery of cardiac function required almost 1 month, after which she was discharged from the hospital without further complications. This is the first reported case of takotsubo cardiomyopathy induced by a failed intubation during a scheduled cesarean section. Takotsubo cardiomyopathy usually shows a good prognosis, but if this myopathy develops during the perinatal period, it can worsen because of excessive preload following the termination of fetoplacental circulation.     

Midurethral autologous fascial sling surgery with reconstruction of the lower abdominal wall using the tensor fascia lata muscle flap for post‐hemipelvectomy stress urinary incontinence

Hemipelvectomy is surgery for pelvic bone neoplasms. In the case of pubic bone osteosarcoma, the distal end of the rectus abdominis muscle is severed from the pubic and ischium bones, and the pelvic floor muscles are resected en bloc with the bone, which leads to stress urinary incontinence. Cancer control is prioritized over complications, and stress urinary incontinence is generally disregarded. A 25‐year‐old woman presented with stress urinary incontinence. She had undergone a hemipelvectomy for left pubic bone osteosarcoma, and stress urinary incontinence appeared and persisted since the surgery. We carried out a reconstruction of the tissue deficit of the rectus abdominis using the tensor fascia lata muscle flap simultaneously with a midurethral autologous fascial sling anchoring to the tensor fascia lata flap. Stress incontinence was successfully improved without morbidity. This is the first reported case of midurethral suspension with reconstruction of the lower abdominal wall with the tensor fascia lata flap for post‐hemipelvectomy stress urinary incontinence.     

The effect of serum in culture on RNAi efficacy through modulation of polyplexes size

Serum in the culture medium is one crucial factor that compromises RNAi efficiency of non-viral vectors. However, mechanistic roles of serum in siRNA delivery remain unknown. In this work, we took one cationic polymer, pullulan chemically modified by spermine (termed as pullulan-spermine, Ps), as a siRNA carrier model to investigate the effects of serum on key steps in siRNA delivery including formation of Ps and siRNA polyplexes (Ps-siRNA), cellular uptake, lysosomal escape, and cytotoxicity. We demonstrate that low serum concentration (1.25% and 2.5%) in culture medium results in large particles of Ps-siRNA, while high serum concentration (10%–40%) leads to small particles of Ps-siRNA. The larger particles initiated the internalization of siRNA more effectively in comparison to the smaller ones. The engulfed Ps-siRNA particles mainly locate in lysosomes. The large particles exhibited stronger abilities of destabilizing lysosomes than that of the small particles as large Ps-siRNA particles contain more amines and subsequently elicit a stronger proton sponge effect which results in more effective lysosomal escape of siRNA. Despite the lower RNAi efficiency, the small particle of Ps-siRNA in the high serum medium generates much lower cytotoxicity. These findings explain why serum significantly affects RNAi and also propose a strategy for improving RNAi efficiency and safety by modulating serum concentration and enhancing lysosomal destabilization.     

Immune checkpoint inhibitor-induced refractory polyarthritis rapidly improved by sarilumab and monitoring with joint ultrasonography: A case report

Rationale:Immune checkpoint inhibitors (ICIs) have shown efficacy for the treatment of various kinds of malignant tumors. However, ICIs can cause immune-related adverse events, such as arthritis. Nevertheless, the treatment of ICI-induced arthritis has not been established yet. Here we report a case of ICI-induced polyarthritis successfully treated using sarilumab and monitored using joint ultrasonography.Patient concerns:A 61-year-old man presented with polyarthritis. He had been treated with nivolumab for recurrent renal cell carcinoma 11 months before. He developed ICI-induced nephritis (proteinuria and elevated serum creatinine) 3 months before, which resolved after discontinuing nivolumab for 1 month. Two months after resuming nivolumab, he developed polyarthralgia and joint swelling, which were suspected to be associated with nivolumab administration, and hence we discontinued nivolumab again. Laboratory tests revealed elevated C-reactive protein level and erythrocyte sedimentation rate, but were negative for rheumatoid factor and anti-cyclic citrullinated peptide antibody. Joint ultrasonography revealed active synovitis in several joints, but a joint X-ray revealed no bone erosion.Diagnoses:We diagnosed polyarthritis as ICI-induced arthritis because the findings were not typical of rheumatoid arthritis (no bone erosion and seronegativity) and the patient had already developed other immune-related adverse events (ICI-induced nephritis).Interventions:After discontinuation of nivolumab, we started treatment with 15 mg daily prednisolone and 1000 mg daily sulfasalazine, although it was ineffective. Hence, we initiated 200 mg biweekly sarilumab.Outcomes:Following sarilumab administration, polyarthritis improved rapidly, and joint ultrasonography confirmed the rapid improvement of synovitis. Hence, we tapered off the glucocorticoid treatment. No recurrence of renal cell carcinoma was noted for 2 years after the initiation of sarilumab despite no anti-tumor therapy.Lessons:Sarilumab may serve as a good treatment option for treating refractory ICI-induced polyarthritis. Joint ultrasonography may contribute to the evaluation of ICI-induced polyarthritis and monitoring the effects of treatments.     

Synthesis of surface-modified iron oxide nanocrystals using supercritical carbon dioxide as the reaction field

In the synthesis of surface-modified nanocrystals (NCs), a simple and green chemistry approach to reduce liquid waste, particularly a solventless process, has been desired. In this study, we applied the supercritical CO₂ technology, which is an excellent solventless process, to the synthesis of surface-modified iron oxide NCs. The synthesis was performed at 30.0 ± 0.8 MPa of CO₂, 18 h and 100 °C, where iron(iii) acetylacetonate, pure water and decanoic acid were used as starting materials. As a result, the supercritical CO₂ medium gave the NCs of α-Fe₂O₃ and γ-Fe₂O₃ with unimodal size distribution, where the mean size was 7.8 ± 2.0 nm. In addition, they were self-assembled on the TEM substrate and the mean nearest-neighbor spacing was close to the chain length of decanoic acid. Furthermore, FT-IR and TG analyses indicate that decanoic acid chemically attaches to the surface of iron oxide NCs that are dispersed in cyclohexane. These results suggest that the supercritical CO₂ medium could be the new appealing reaction field to fabricate densely modified NCs without liquid waste.

We applied the supercritical CO₂ technology, which is an excellent solventless process, to the synthesis of surface-modified iron oxide nanocrystals.     

Young woman with repeated late stent thrombosis: a case report

A 34-year-old woman with hypertension, obesity, and history of smoking presented with unstable angina and severe stenosis of the proximal left anterior descending artery. Percutaneous coronary intervention was performed with stent implantation resulting in adequate expansion. She was treated with aspirin and ticlopidine for 1 month, then only aspirin for 1 month. One year after stenting, she presented with acute myocardial infarction and total occlusion at the stent. Balloon angioplasty was performed. She took ticlopidine and aspirin for 9 months. Two months later, she presented with acute myocardial infarction with reocclusion at the stent. Blood examination showed no manifest collagen disease or thrombophilia. This case of repeated late stent thrombosis occurred in a young woman not treated by brachytherapy.