Seizure and delayed emergence from anesthesia resulting from remote cerebellar hemorrhage after lumbar spine surgery -A case report-
A patient with remote cerebellar hemorrhage (RCH) who was presented at the authors' hospital with seizure and delayed emergence from anesthesia after loss of cerebrospinal fluid (CSF) through a dural tear during lumbar spine surgery is described. RCH is a rare and unpredictable complication after spinal surgery. Its most common clinical features are diminished consciousness, headache, and seizure. Its mechanism is still disputed, but is probably venous bleeding secondary to significant intra- or post-operative loss of CSF. Therefore, RCH must be considered in patients with unexplained mental deterioration or disturbance upon emergence and seizure from general anesthesia after spine surgery.

title: Hydrocortisone for refractory hypotension of very low birth weight infant with patent ductus arteriosus: a case report
abstract: A male infant weighing 1,090 g, 28 weeks of gestation, was scheduled to take a ligation of a patent ductus arteriosus (PDA). Eight days after birth, mean arterial pressure (MAP) has fall to \30 mmHg. We started with dopamine (5–10 lg/kg/min), to maintain the blood pressure, but this was not successful. Although we did not confirm an adrenal insufficiency (AI), we decided to start medication of hydrocortisone, 3 mg/kg/day, which resulted in over 50/35 mmHg. The hydrocortisone was tapered for 3 days because MBP was maintained at[40 mmHg, and 5 lg/kg/min of dopamine was maintained until the day of surgery. At 31 days after birth, we induced anesthesia with 2 mg/kg of ketamine, 20 lg/kg of fentanyl, and 0.9 mg/kg of rocuronium without premedication. Anesthesia was maintained by a continuous infusion of ketamine (1 mg/kg/h) and intermittent rocuronium in 50% O2 with air. After ligation of a PDA, MAP was decreased to 30 mmHg by degrees which required an increase to 10 lg/kg/ min of dopamine and the addition of 5 lg/kg/min of dobutamine to maintain over 30 mmHg. An echocardiogram showed globally normal contractility without a PDA. In spite of our efforts, mean blood pressure had fallen to 24 mmHg at 6 h after ligation. The patient was commenced on intravenous hydrocortisone (3 mg/kg/day), which increased MAP to above 30 mmHg and heart rate to 172 bpm after 90 min. After 4 h, MAP was maintained over 50 mmHg and heart rate was 190 bpm. Two days after surgery, the dopamine, dobutamine, and hydrocortisone were tapered and the blood pressure was maintained until discharge. Hypotension of very low birth weight (VLBW) premature infants is a major factor of morbidity, and mortality. Inotropes such as dopamine and dobutamine are widely used to normalize blood pressure but more than 50% of hypotensive VLBW infants requiring dopamine at doses[10 mg/kg/min develop refractory hypotension (RH) that is resistant to vasopressor . Hydrocortisone is beneficial in treatment of RH, but the mechanisms are not completely understood. Down-regulation of cardiovascular adrenergic receptors and the development of relative adrenal insufficiency are thought to be the factors that may explain the corticosteroid responsiveness of RH [2, 3]. Cardiovascular response to catechol amines is attenuated due to down-regulation of the cardiovascular adrenergic receptors in VLBW infants with critical illness . Moreover, VLBW infants have low adrenal reserves and reach a relatively adrenal insufficiency (AI) state in stressed situations . Watterberg et al.  has reported hydrocortisone (1 mg/kg every 8 h) was effective for VLBW infants with AI. In this case, the infant had RH in spite of the treatment with inotropes after birth and PDA ligation, and we successfully treated him with hydrocortisone. Thus, we recommend that early hydrocortisone therapy be administered to VLBW premature infants for perioperative RH resistant to inotropes..

title: Fibrosarcoma of the ovary arising in a fibrothecomatous tumor with minor sex cord elements. A Case report and review of the literature.
abstract: We report the case of a 69-year-old woman who presented with postmenopausal bleeding. Endometrial curettings showed complex atypical hyperplasia with focal well-differentiated adenocarcinoma. A computed tomographic scan of the abdomen revealed a right ovarian mass. Histologically, the right ovarian tumor was a fibrothecoma with minor sex cord elements showing focal fibrosarcomatous change. Fibrosarcoma of the ovary is a rare tumor that is considered to arise de novo or secondary to benign fibromatous tumors. Fibrothecoma of the ovary with minor sex cord elements is also a rare entity. To the best of our knowledge, this is the first reported case of a fibrosarcoma arising in a fibrothecoma with minor sex cord elements.

title: Clinical features of echovirus 6 and 9 infections in children.
abstract: Clinical features of echovirus 6 and 9 infections in children have not been comprehensively evaluated, particularly for sporadic cases.



To describe the clinical features of children with echovirus 6 or 9 infections.



From 2000 to 2008, 199 children with culture-proven echovirus 6 or 9 infections identified in a university-affiliated hospital were included. Data extracted from 174 inpatients were further analyzed.



Age ranged from 4 days to 15 years with a mean of 4.7 years. 123 (62%) were male. The disease spectrums were similar for echovirus 6 (n=100) and 9 (n=74) infections, with aseptic meningitis (49% and 51%, respectively) being the most common syndrome, followed by meningismus, upper respiratory tract infection, pneumonia, and herpangina. All 174 inpatients had fever but the duration of fever was significantly longer in patient with echovirus 9 infection than those with echovirus 6 infections (6.0 days vs. 3.8 days, p<0.001). The rate of leukocytosis (leukocyte count>15,000/μL) were significantly higher in patients with echovirus 6 infections than those with echovirus 9 infection (p<0.001). One neonate with echovirus 6 infection died from hepatic necrosis with coagulopathy, and one infant with echovirus 6 infection and one child with echovirus 9 infection died from brain involvement. Two children had long-term sequelae of seizure disorder. The remaining 169 children (97%) recovered uneventfully.



For children with echovirus 6 or 9 infections requiring hospitalization, aseptic meningitis was the most common manifestation and fatal outcome or long-term sequel, though rare, might occur.

title: Forkhead factor, FOXO3a, induces apoptosis of endothelial cells through activation of matrix metalloproteinases.
abstract: The forkhead factor, FOXO3a, is known to induce apoptosis in endothelial cells (ECs). However, its effects on extracellular matrices (ECM), which are important in EC survival, remained unknown. Here, we evaluated the role of FOXO3a on EC-ECM interaction.



Constitutively active FOXO3a was transduced to human umbilical vein endothelial cells by adenoviral vector (Ad-TM-FOXO3a). Ad-TM-FOXO3a transfection led to dehiscence of ECs from fibronectin-coated plates, resulting in anoikis, which was significantly reversed by matrix metalloproteinase (MMP) inhibitor, GM6001. FOXO3a increased the expression of MMP-3 (stromelysin-1) but decreased the expression of tissue inhibitors of metalloproteinases-1 (TIMP-1), which was associated with increased MMP enzymatic activity in zymography. Pathophysiologic conditions such as serum starvation or heat shock also induced activation of endogenous FOXO3a, leading to activation of MMP-3 and apoptosis, which was reversed by GM6001. Delivery of Ad-TM-FOXO3a to the intraluminal surface in vivo led to EC denudation, disrupted vascular integrity, and impaired endothelium-dependent vasorelaxation.



Activation of MMPs and possible ECM disruption represent novel mechanisms of FOXO3a-mediated apoptosis in ECs.

title: Wide spread of Tn2006 in an AbaR4-type resistance island among carbapenem-resistant Acinetobacter baumannii clinical isolates in Taiwan.
abstract: Carbapenem resistance in Acinetobacter baumannii is a global problem. The purpose of this study was to elucidate current resistance mechanisms of imipenem-resistant A. baumannii (IRAB) in Taiwan and their correlation with patient outcomes. Acinetobacter baumannii clinical isolates from two teaching hospitals in Taiwan were collected in 2009 and were examined by Etest for determination of the minimum inhibitory concentrations (MICs) of imipenem, ceftazidime and ceftriaxone. Primers specific for carbapenemase genes and upstream regions were designed for PCR amplification. Bacterial isolates were genotyped by pulsed-field gel electrophoresis (PFGE). Clinical presentations of patients were analysed retrospectively. Upstream insertion sequence ISAba1 was found in 34 isolates that carried bla(OXA-23), including 28 with transposon Tn2006 (ISAba1-bla(OXA-23)-ISAba1) in an AbaR4-type resistance island and 6 with Tn2008 (ISAba1-bla(OXA-23)), as well as in 8 isolates carrying ISAba1-bla(OXA-51-like). All of these isolates expressed full resistance to imipenem (MIC>32 mg/L). Forty-one different PFGE genotypes were found among 62 isolates. Tn2006 was found in 19 genotypes (46.3%), which is more common than ISAba1-bla(OXA-51-like) (12.2%) (P=0.001). Prior use of carbapenems or extended-spectrum cephalosporins for ≥5 days was the only independent risk factor significantly associated with IRAB infection (odds ratio=361.175). Higher mortality was significantly associated with infection caused by IRAB and ISAba1-bla(OXA-23)-carrying strains compared with infection caused by imipenem-susceptible A. baumannii and ISAba1-bla(OXA-51-like)-carrying strains (P=0.009 and 0.027, respectively). Tn2006 is currently the most common imipenem resistance determinant, which showed a higher ability to spread among A. baumannii and was associated with a higher mortality in IRAB-infected patients.

title: Reconstitution and characterization of a new desosaminyl transferase, EryCIII, from the erythromycin biosynthetic pathway.
abstract: EryCIII converts alpha-mycarosyl erythronolide B into erythromycin D using TDP-d-desosamine as the glycosyl donor. We report the heterologous expression, purification, in vitro reconstitution, and preliminary characterization of EryCIII. Coexpression of EryCIII with the GroEL/ES chaperone complex was found to enhance greatly the expression of soluble EryCIII protein. The enzyme was found to be highly active with a kcat greater than 100 min-1. EryCIII was quite selective for the natural nucleotide sugar donor and macrolide acceptor substrates, unlike several other antibiotic glycosyl transferases with broad specificity such as desVII, oleG2, and UrdGT2. Within detectable limits, neither 6-deoxyerythronolide B nor 10-deoxymethynolide were found to be glycosylated by EryCIII. Furthermore, TDP-d-mycaminose, which only differs from TDP-d-desosamine at the C4 position, could not be transferred to alphaMEB. These studies lay the groundwork for detailed structural and mechanistic analysis of an important member of the desosaminyl transferase family of enzymes.