Black Arrow Research Articles

A case of inverted serrated polyp that mimics a submucosal tumor

A 68-year-old woman underwent colonoscopy because of abdominal discomfort and changing of bowel movements for half a year. A submucosal protruded lesion, 4 mm × 5 mm, with smooth and intact cover mucosa was found at the rectum 4 cm from the anal margin (A). EUS with a miniprobe revealed a heterogenously hyperechoic lesion with clear margins (B, yellow arrow). The lesion was mainly located between the mucosal and submucosal layers, with a maximum size 3.8 × 4.5 mm in diameter. A thin layer of submucosal structure existed beneath the lesion (B, yellow arrow). The physical examination, laboratory examinations, and abdominal and pelvic CT revealed no remarkable findings. Endoscopic submucosal dissection (ESD) was recommended, and the lesion was removed en bloc. Pathologic examination revealed serrated intestinal mucosa within the muscularis mucosal layer, which was consistent with inverted serrated polyps. The lesion also demonstrated the characteristics of low-grade intraepithelial neoplasia. Genetic testing indicated the existence of a BRAF gene mutation. Histopathologic analysis showed the serrated tubular features (C, black arrows) of this lesion and a small area of defective muscularis mucosae (D, yellow box) on top of the protrusion.

Intimointimal Intussusception in Acute Aortic Dissection.

HomeRadiology: Cardiothoracic ImagingVol. 2, No. 4 PreviousNext Images in Cardiothoracic ImagingFree AccessVascular ImagingIntimointimal Intussusception in Acute Aortic DissectionLucas de Pádua Gomes de Farias , João Manoel Miranda Magalhães Santos, Gustavo Borges da Silva Teles, Luciana de Pádua Silva BaptistaLucas de Pádua Gomes de Farias , João Manoel Miranda Magalhães Santos, Gustavo Borges da Silva Teles, Luciana de Pádua Silva BaptistaAuthor AffiliationsFrom the Hospital Samaritano Paulista, Avenida Brigadeiro Luís Antônio, 1895-Bela Vista, São Paulo, SP, CEP 01317-002, Brazil.Address correspondence to L.d.P.G.d.F. (e-mail: [email protected]).Lucas de Pádua Gomes de Farias João Manoel Miranda Magalhães SantosGustavo Borges da Silva TelesLuciana de Pádua Silva BaptistaPublished Online:Aug 27 2020https://doi.org/10.1148/ryct.2020200023MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In Intimointimal intussusception in aortic dissection is a rare but potentially life-threatening type of complication (1). The intimal tear and delamination process occur circumferentially, and the intimal flap separates from the aorta, partially or totally, with the detached tissue forced downstream. Furthermore, the intussuscepted flap can obstruct the aortic arch and its branches (1–3). Lack of typical imaging findings of type A aortic dissection can be a challenge due to the absence of intimal flap in the ascending aorta (1,3) (Figure).CT angiographic images (A–C, axial multiplanar reformations [MPRs]; D, sagittal oblique; E, MPR extended; F, axial oblique; G, coronal; and H, oblique maximum intensity projection) show Stanford type A aortic dissection with an intimal flap in aortic root (arrowheads) and an intussuscepted intima (white arrow) in aortic arch, with the false lumen wrapped around the true lumen. Furthermore, no intimal flap was seen in ascending aorta (*). Right coronary artery (RCA) originates from true lumen and left main (LM) coronary artery from false lumen. Dissection also extends into the origin of the brachiocephalic trunk (black arrow) and left common carotid artery (image not included). LV = left ventricle.Download as PowerPointOpen in Image Viewer Disclosures of Conflicts of Interest: L.d.P.G.d.F. disclosed no relevant relationships. J.M.M.M.S. disclosed no relevant relationships. G.B.d.S.T. disclosed no relevant relationships. L.d.P.S.B. disclosed no relevant relationships.Keywords: Adults, Aorta, CT-Angiography, Cardiac, Carotid Arteries, Dissection, Thorax, Vascular Authors declared no funding for this work.

心肺停止で搬送された両側緊張性気胸の14歳男児の1例(A case of 14–year–old boy with cardiopulmonary arrest caused by simultaneous bilateral primary spontaneous pneumothorax)

要旨 自然気胸の多くは片側であり重症例は少ない。しかし緊張性気胸および両側気胸は診断および介入が遅れると致死的となりうる。我々は，発症から1時間も経たないうちに心肺停止となり救急搬送された両側緊張性気胸の14歳男児の症例を経験した。本例では心肺蘇生により自己心拍は再開したが，頻脈・低血圧が遷延し，胸部X線写真で両側緊張性気胸と診断し胸腔ドレナージを行った。しかし，直後に撮影した頭部CTで低酸素脳症を呈し，その後意識障害が遷延し自発呼吸はなく，第12病日に平坦脳波を確認し，最終的にPCPC（pediatric cerebral performance category）6となった。両側気胸は気管支喘息発作と混同されやすく，アナフィラキシーも合わせて鑑別する必要がある。緊張性気胸には片側だけでなく，稀に両側があり，その診断は身体所見のみでは困難なため，近年有用性が報告されている超音波検査を併用し，可及的速やかに胸部X線写真を撮るべきである。

Abstract MP164: Electrophysiologic Conservation of Epicardial Conduction Dynamics After Myocardial Infarction in Newborn Piglets

Introduction: Newborn piglets reportedly exhibit natural heart regeneration after myocardial infarction (MI). However, the electrophysiologic properties of this regenerated muscle have not been examined. We hypothesized that epicardial electrical conduction is preserved after MI in newborn piglets. Methods: Yorkshire-Landrace piglets underwent left anterior descending coronary artery ligation on postnatal day 1 (P1, n=4) or postnatal day 7 (P7, n=7), infarcting the anteroseptal left ventricle through which the Purkinje conduction system passes. After 7 weeks, cardiac magnetic resonance imaging (MRI) was performed with late gadolinium enhancement for fibrosis analysis. Epicardial conduction mapping was performed using custom 3D-printed, 256-channel high-resolution mapping arrays (Fig 1A). Age- and weight-matched healthy pigs served as controls (n=7). Data are expressed as mean±SD. Results: MRI analysis revealed significant differences between the control, P1, and P7 groups in ejection fraction (47.6±3.1% vs 37.6±3.3% vs 30.2±6.6%, p<0.001, Fig 1B) and the degree of transmural anteroseptal LV scar (0.0±0.0% vs 9.1±5.4% vs 15.4±4.2%, p<0.001), respectively. Evidence of infarcted myocardium was identified with high-resolution mapping in the P1 and P7 piglets (black arrows, Fig 1C-F). Epicardial electrical conduction was preserved in control and all P1 pigs (Figs 1C-D), whereas variable conduction block or aberrant propagation were observed in all P7 pigs (Fig 1E-F, p=0.001). Conclusion: P1 piglets exhibited incomplete natural cardiac regeneration after MI but nevertheless demonstrated electrophysiologic conservation of epicardial conduction dynamics.

Left Ventricular Thrombus in a Patient Infected by COVID-19

A 74-year-old woman presented with generalized malaise with nausea and vomiting. The patient had no known systemic disease, history of trauma, or medication. On physical examination, the patient was confused and had abdominal tenderness. The chest roentgenogram showed cardiomegaly and bilateral pleural effusions. Computed tomography (CT) of the chest (Figure 1A) showed bilateral pleural effusions (black asterisks), consolidated areas with air bronchograms in the right hilar region (white arrow) and ground-glass densities in some peripheral locations (black arrows).

Removing top leaves increases yield and nutrient uptake in maize plants

Intraspecific competition for light affects nutrient uptake of maize, especially during the seed filling phase (from the blistering-stage to physiological-maturity). Partial leaf removal only affects the top leaves and improves the light-environment, which could then enhance nutrient uptake during the seed filling phase. However, there is a shortage of quantitative information on the yield effects of such a management measure. A 3-year field trial was conducted to evaluate the impact of different leaf removal treatments (no removal of leaves (D0: control), removal of two leaves (D2), removal of four leaves (D4), and removal of six leaves (D6) from maize-canopy) on total dry matter accumulation, and nitrogen, phosphorus, and potassium uptake at the blistering-stage and physiological-maturity, plus seed number per plant, seed weight, and seed yield at physiological maturity. Compared to D0, at physiological-maturity, D2 significantly increased total dry matter accumulation (by 9%), and uptake of nitrogen (by 5%), phosphorus (by 10%), and potassium (by 4%); while excessive leaf removal treatments considerably reduced dry matter accumulation and nutrient uptake. Importantly, during the seed filling phase of maize, treatment D2 significantly enhanced the uptake of nitrogen, phosphorus, and potassium by 76%, 40%, and 65%, respectively, compared to control. Treatment D2 increased seed number per plant (by 6.4%, from 448 under D0 to 477 in D2) and seed weight (by 5.7%). Relative to control, maize in D2 had 12%, 14%, and 11%, higher seed-yields in 2017, 2018, and 2019, respectively, and it also improved the economic profit when taking into account labor costs. Graphical representation of changes in light transmittance, photosynthesis, nutrient uptake, carbohydrate, and dry matter accumulation in maize plants as affected by different leaf removal treatments. Treatment codes represent no defoliation (D0: control), removal of two leaves (D2), removal of four leaves (D4), and removal of six leaves (D6) from the top of maize canopy. Yellow and green arrows show the light environment and leaf area of maize plants. The black arrows represent the regulating directions of leaf removal treatments on maize growth and development in this paper. The graphical abstract clearly demonstrates the significant improvement of optimum leaf removal treatment (D2) as compared to control (D0). The red and blue arrows show the relevant increase and decrease of the mentioned components between the optimal leaf removal and control.

Tríada de Rigler


 Paciente de 68 años, sin antecedentes quirúrgicos.
 Ingresó a Emergencia con cuadro clínico de oclusión intestinal. Se solicitó radiografía simple de abdomen (solamente se obtuvo en decúbito), observándose la presencia de la tríada radiológica de Rigler, patognomónica del ileo biliar.
 Se señalan los 3 elementos: asas de delgado dilatadas (flecha negra), aerobilia (flecha blanca) y el cálculo calcificado ectópico en la fosa ilíaca derecha (flecha amarilla).
 El íleo biliar es la oclusión intestinal como consecuencia de la migración de un cálculo biliar a través de una fístula bilio-digestiva y su impactación, frecuentemente a nivel de la válvula ileo-cecal. Habitualmente se trata de una fístula colecisto-duodenal, aunque también puede tratarse de una fístula colecisto-colónica.
 El cuadro clínico clásicamente descrito es el de una oclusión intermitente, siendo más frecuente en pacientes añosos, con larga historia de litiasis biliar sintomática.

Oblique versus longitudinal axis/in-plane approaches for ultrasound-guided radial arterial cannulation: A randomised controlled trial.

Oblique versus longitudinal axis/in-plane approaches for ultrasound-guided radial arterial cannulation: A randomised controlled trial.

Blurred vision in a young man: Eyeball fluid cytopathology.

A 23-year-old male presented at the hospital referring progressive blurred vision in his right eye three weeks ago. The ocular examination by a slit-lamp demonstrated an accumulation of a turbid cream-colored material at the bottom of the anterior chamber (AC) of the eyeball (Figure 1, black arrow). An AC paracentesis was carried out, obtaining 0.5 ml of non-transparent fluid. The sample was sent to the Cytology laboratory and the fluid was subjected to cytocentrifugation. The cytological smears were stained with Diff-Quik (Figure 2) and by the Papanicolaou method (Figure 3).

Chiral Magnonics: Reprogrammable Nanoscale Spin Wave Networks Based on Chiral Domain Walls.

SummarySpin waves offer promising perspectives as information carriers for future computational architectures beyond conventional complementary metal-oxide-semiconductor (CMOS) technology, owing to their benefits for device minimizations and low-ohmic losses. Although plenty of magnonic devices have been proposed previously, scalable nanoscale networks based on spin waves are still missing. Here, we demonstrate a reprogrammable two-dimensional spin wave network by combining the chiral exchange spin waves and chiral domain walls. The spin-wave network can be extended to two dimensions and offers unprecedented control of exchange spin waves. Each cell in the network can excite, transmit, and detect spin waves independently in the chiral domain wall, and spin-wave logics are also demonstrated. Our results open up perspectives for integrating spin waves into future logic and computing circuits and networks.

Progressive Weakness and Encephalopathy in a 34-Year-Old Woman

A 34-year-old woman presented because of falls, weakness, and new-onset jaundice. Examination demonstrated mild encephalopathy and scleral icterus. Liver enzymes indicated aspartate aminotransferase (AST) 259 U/L, alanine aminotransferase (ALT) 76 U/L, total bilirubin 9.9 mg/dL, and international normalized ratio 1.6. She underwent a liver biopsy, which revealed macrovesicular steatosis with hepatocyte ballooning (solid black arrow) and Mallory bodies (dashed black arrow) shown in Figures A and B (H&E stain; original magnification, ×100 and ×200, respectively). Masson trichrome staining of the biopsy specimens demonstrated cirrhosis and pericellular fibrosis (black arrows, Figure C; original magnification, ×100). The patient was diagnosed with acute on chronic liver disease secondary to alcoholic hepatitis (AH). The prevalence of AH is difficult to estimate because of the disease spectrum. Alcohol is the strongest risk factor. Laboratory findings in AH reveal an AST/ALT ratio greater than 2. Pathologic findings include hepatic steatosis, Mallory bodies, and fibrosis. The Maddrey discriminant function (MDF) is used to stratify patients and guide treatment. Treatment consists of alcohol cessation and corticosteroids. If treatment is initiated, the Lille model can determine whether corticosteroids should be continued. Our patient had an MDF of 51 and was started on corticosteroids. Alcohol cessation was emphasized, and she remains abstinent.

救急外来での蘇生的開胸術により救命しえた急性心筋梗塞後左室自由壁破裂による心肺停止の1例(A case of successful emergency department thoracotomy for cardiopulmonary arrest due to left ventricular free wall rupture after acute myocardial infarction)

要旨左室自由壁破裂（left ventricular free wall rupture: LVFWR）は急性心筋梗塞の致死的合併症であり，とくに穿孔を伴うblow out型は瞬時に心タンポナーデを来し救命が困難な場合が多い。今回，心肺停止となったLVFWRの１例を救急外来での蘇生的開胸術（emergency department thoracotomy: EDT）により救命することができたので報告する。症例は60歳代の男性。強い胸痛を訴えショック状態で当院へ搬送された。心電図のII，III，aVF誘導でST上昇，心エコーで心嚢液貯留を認めた。急性心筋梗塞によるLVFWRと診断し，心嚢穿刺の準備中に心肺停止となった。救命のため救急外来で左肋間開胸，心嚢内血腫除去，直接心臓マッサージを実施したところ心拍再開を得た。左室下壁に梗塞部と小穿孔を認め，用手圧迫で止血を得，パッチ修復術後に血行動態は安定したため，仮閉胸した後に集中治療室へ入室した。翌日再開胸術を行ったが，接着シートは完全に固着し，穿孔部の止血は十分得られていた。重篤な合併症なく術後56日で自宅退院となり，術後14か月の現在，経過良好である。本邦では心筋梗塞後の左室自由壁破裂に対する，救急外来でのEDT実施による救命例はまだ報告されていない。心肺停止に陥ったLVFWRに対するEDTは救命のための有効な選択肢の1つと思われる。

SERS-based immunocapture and detection of pathogenic bacteria using aboronic acid-functionalized polydopamine-coated Au@Ag nanoprobe.

A surface-enhanced Raman scattering (SERS)-based immunocapture nanoprobe is described for the detection of pathogenic bacteria. The probe uses boronic acid-functionalized polydopamine-coated Au@Ag nanoparticles as an advanced SERS nanotag. Modified magnetic IgG@Fe3O4 nanoparticles are used for magnetic separation. Au@Ag@PDA nanoparticles, where PDA stands for polydopamine, were functionalized with boronic acid to bind to pathogenic bacteria and induce signal amplification. The Raman signal is amplified 108 times when the SERS tag binds the surface of bacteria. The SERS spectra exhibit fingerprint-like patterns that enable bacterial classification. The results of principal component analysis (PCA) and hierarchical cluster analysis (HCA) of the spectral regions were compared. The bacterial surface protein and glycan signals (1300-1450cm-1) were the best regions for bacterial classification. Staphylococcus aureus, Escherichia coli, Shigella dysenteriae, Pseudomonas aeruginosa, and Klebsiella pneumonia were successfully classified by this method. The lowest detection limit was 10 colonies/mL (CFU·mL). The assay can be completed within 30min. Conceivably, this method may be extended to the quantitative detection or classification of bacteria under various other conditions. Graphical abstract Schematic representation of immunocapture and detection of pathogenic bacteria using boronic acid-functionalized polydopamine-coated Au@Ag nanoprobe through the bacterial surface protein and glycan signals. Green arrow: laser; black arrow: SERS; red ball: bacteria; grey ball: IgG@Fe3O4; golden ball: boronic acid-functionalized Au@Ag@PDA.

A wide QRS complex tachycardia: What is the mechanism?

A 20-year-old man with Loeys-Dietz syndrome with familial TGFBR2 mutation and Wolff-Parkinson-White syndrome presented with palpitations. His transthoracic echocardiogram revealed normal left ventricular systolic function and an enlarged aortic root based on his age and size. The baseline electrocardiogram during rapid atrial pacing revealed preexcitation with a pattern suggestive of a left posterolateral accessory pathway (AP) (Figure 1A). There was no evidence of decremental AP conduction. A wide complex tachycardia was induced during programmed stimulation. Intracardiac electrograms showed variable His bundle depolarization (black arrows) (Figure 1B). What is the mechanism of the tachycardia and its varying His bundle activation?

Intraventricular Flow Patterns in Patients Treated with Left Ventricular Assist Devices.

The success of left ventricular assist device (LVAD) therapy is hampered by complications such as thrombosis and bleeding. Understanding blood flow interactions between the heart and the LVAD might help optimize treatment and decrease complication rates. We hypothesized that LVADs modify shear stresses and blood transit in the left ventricle (LV) by changing flow patterns and that these changes can be characterized using 2D echo color Doppler velocimetry (echo-CDV). We used echo-CDV and custom postprocessing methods to map blood flow inside the LV in patients with ongoing LVAD support (Heartmate II, N = 7). We compared it to healthy controls (N = 20) and patients with dilated cardiomyopathy (DCM, N = 20). We also analyzed intraventricular flow changes during LVAD ramp tests (baseline ± 400 rpm). LVAD support reversed the increase in blood stasis associated with DCM, but it did not reduce intraventricular shear exposure. Within the narrow range studied, the ventricular flow was mostly insensitive to changes in pump speed. Patients with significant aortic insufficiency showed abnormalities in blood stasis and shear indices. Overall, this study suggests that noninvasive flow imaging could potentially be used in combination with standard clinical methods for adjusting LVAD settings to optimize flow transport and minimize stasis on an individual basis.

Platelet-rich fibrin membrane nerve guidance conduit: a potentially promising method for peripheral nerve injuries.

Platelet-rich fibrin membrane nerve guidance conduit: a potentially promising method for peripheral nerve injuries.

Ca2+ signalling is important for loss of keratinocyte adhesion in pemphigus vulgaris

Pemphigus vulgaris (PV) is a severe blistering skin disease caused by autoantibodies (PV‐IgG) against desmogleins (Dsg)1 and 3. Ca2+ release in response to PV‐IgG has been reported. However, its contribution to loss of keratinocyte adhesion is largely unknown. Phosphatidylinositol‐4‐kinase‐a (PI4K) and phospholipase‐C‐γ1 (PLC) release inositol‐3‐phos‐phate (IP3) activating the IP3‐receptor (IP3R) and thereby causing Ca2+ flux from the endoplasmic reticulum (ER) into the cytoplasm. Low Ca2+ in the ER activates the Ca2+ release‐activated‐channel (CRAC) to replenish the Ca2+ store. Inhibitors against PI4K, PLC, IP3R or CRAC were applied under conditions under which they effectively blocked Ca2+ influx. All inhibitors ameliorated PV‐IgG‐induced alterations of Dsg1 and Dsg3 localization, keratin filament retraction and loss of cell adhesion in dissociation assays. Inhibition of PLC completely abolished PV‐IgG‐induced and also ameliorated AK23‐mediated loss of adhesion. These data demonstrate that Ca2+ signalling is important for loss of cell adhesion in PV but independent from antibodies against Dsg3 supporting the hypothesis that autoantibodies engage different signalling mechanisms to reduce cell adhesion.Support or Funding InformationFunded by the DFGCa‐dependendent interacellular signalling in pemphigus vulgaris. Black arrows indicate calcium‐flux.Figure 1

Muscle and Joint Evolution in Crocodyliforms

Modern crocodylians employ immense forces during feeding relative to other clades. Many characters that enable crocodylians to generate and resist these forces are not found in their ancestors, and thus the evolution of crocodylians involved a substantial reorganization of the feeding apparatus. This transformation saw changes to many cranial joints: the expansion of the pterygoid buttress, reshaping and reorienting of the articular surface of the jaw joint, and the suturing of the quadrate and palate to the braincase, closing the primitive and potentially‐kinetic otic and palatobasal joints. The jaw muscles that loaded cranial joints also experienced reorganization: the flatter skull of crocodylians led to mediolateral orientations, the pterygoideus ventralis muscle began attaching laterally on the mandible, and the retroarticular process enlarged caudally, expanding the size of the depressor mandibulae muscle. Once this suite of changes was in place, crocodyliforms radiated into forms with derived diets and craniodental modifications. However, the biomechanical effects of these morphological character shifts on feeding performance have not been explicitly evaluated, obscuring coevolutionary patterns of morphology and function. Here, we use select crocodylians and fossil relatives that characterize the evolution of the clade to reconstruct jaw muscle anatomy and estimate biomechanical loading of cranial joints. We hypothesize that crocodylians will be characterized by successive increases in jaw muscle mass relative to body size. We used CT data to create 3D models of extant and fossil suchians that demonstrate the evolution of the crocodylian skull, using osteological correlates to reconstruct muscles. Muscle forces were distributed with the computational package Boneload and used as input for finite element analysis and 3D lever analyses. We found that jaw muscles expanded and shifted attachments throughout suchian evolution: muscle orientations became more mediolateral as the skull flattened, the pterygoideus ventralis muscle began inserting on the lateral mandible, and the depressor mandibulae muscle expanded its attachment on the enlarged retroarticular process. Changes to cranial joints accompanied muscular changes: the pterygoid buttress expanded, the articular surfaces of the jaw joint changed, and the quadrate and palate sutured to the braincase. Our results showed that joint force orientation tracks with articular surface metrics. We found that as bite location moves caudally, working side joint force decreases in magnitude; it is likely that in feeding events such as shaking bites or death roll, the jaw joint is loaded in tension. This study depicts a feeding apparatus that defies traditional understanding. The combination of dual craniomandibular joints and jaw joints loaded in tension is unknown from other tetrapods.Support or Funding InformationNSF‐EAR 1631684Cladogram of representative crocodiles included in the study. The black arrows represent the orientation of joint reaction force; note that joint reaction force becomes more horizontally oriented in later specimens.Figure 1

Identification of novel PKD1 mutations in two Chinese families with autosomal dominant polycystic kidney disease by targeted next generation sequencing.

Identification of novel PKD1 mutations in two Chinese families with autosomal dominant polycystic kidney disease by targeted next generation sequencing.

Afebrile and Leukopenic Sweet's Syndrome Following Partial Ileectomy in an Elderly Woman

Afebrile and Leukopenic Sweet's Syndrome Following Partial Ileectomy in an Elderly Woman