[PREVENTION AND CORRECTION OF PULMONARY COMPLICATIONS FOR SEVERE ACUTE PANCREATITIS]

Increased of proinflammatory cytokines levels, including interleukin-8 (IL-8) and tumor necrosis factor-alpha (TNF-alpha) on severe acute pancreatitis causes vasodilatation, increased permeability of the wall, accumulation of fluid in lung tissue and pleural sinuses. Transudate from acute parapancreatyc clusters of hot liquid and abdomen falls into the chest cavity through microscopic defects in the diaphragm due to the formation of pathological pleural-peritoneal connections or the relevant pressure gradient between the abdominal and pleural cavities. Remediation and removal of acute parapancreatyc clusters combined with the use of a multicomponent drug infusion therapy Cytoflavin provide a reduction in the frequency of pulmonary complications of acute pancreatitis from 48.3 to 31.0%. Use of the drug Cytoflavin reduces the severity of endogenous intoxication and mortality from acute lung injury from 12.9 to 6.1%.

Differential involvement of various sources of reactive oxygen species in thyroxin-induced hemodynamic changes and contractile dysfunction of the heart and diaphragm muscles

Thyroid hormones are key regulators of basal metabolic state and oxidative metabolism. Hyperthyroidism has been reported to cause significant alterations in hemodynamics, and in cardiac and diaphragm muscle functions, all of which have been linked to increased oxidative stress. However, the definite source of increased reactive oxygen species (ROS) in each of these phenotypes is still unknown. The goal of the current study was to test the hypothesis that thyroxin (T4) may produce distinct hemodynamic, cardiac, and diaphragm muscle abnormalities by differentially affecting various sources of ROS. Wild-type and T4 mice with and without 2-week treatments with allopurinol (xanthine oxidase inhibitor), apocynin (NADPH oxidase inhibitor), L-NIO (nitric oxide synthase inhibitor), or MitoTEMPO (mitochondria-targeted antioxidant) were studied. Blood pressure and echocardiography were noninvasively evaluated, followed by ex vivo assessments of isolated heart and diaphragm muscle functions. Treatment with L-NIO attenuated the T4-induced hypertension in mice. However, apocynin improved the left-ventricular (LV) dysfunction without preventing the cardiac hypertrophy in these mice. Both allopurinol and MitoTEMPO reduced the T4-induced fatigability of the diaphragm muscles. In conclusion, we show here for the first time that T4 exerts differential effects on various sources of ROS to induce distinct cardiovascular and skeletal muscle phenotypes. Additionally, we find that T4-induced LV dysfunction is independent of cardiac hypertrophy and NADPH oxidase is a key player in this process. Furthermore, we prove the significance of both xanthine oxidase and mitochondrial ROS pathways in T4-induced fatigability of diaphragm muscles. Finally, we confirm the importance of the nitric oxide pathway in T4-induced hypertension.

ToF-SIMS of tissues: "lessons learned" from mice and women

The ability to image cells and tissues with chemical and molecular specificity could greatly expand our understanding of biological processes. The subcellular resolution mass spectral imaging capability of time of flight secondary ion mass spectrometry (ToF-SIMS) has the potential to acquire chemically detailed images. However, the complexities of biological systems combined with the sensitivity of ToF-SIMS require careful planning of experimental methods. Tissue sample preparation methods of formalin fixation followed by paraffin embedding (FFPE) and OCT embedding are compared. Results show that the FFPE can potentially be used as a tissue sample preparation protocol for ToF-SIMS analysis if a cluster ion pre-sputter is used prior to analysis and if nonlipid related tissue features are the features of interest. In contrast, embedding tissue in OCT minimizes contamination and maintains lipid signals. Various data acquisition methodologies and analysis options are discussed and compared using mouse breast and diaphragm muscle tissue. Methodologies for acquiring ToF-SIMS 2D images are highlighted along with applications of multivariate analysis to better identify specific features in a tissue sections when compared to H&E images of serial sections. Identification of tissue features is necessary for researchers to visualize a molecular map that correlates with specific biological features or functions. Finally, lessons learned from sample preparation, data acquisition, and data analysis methods developed using mouse models are applied to a preliminary analysis of human breast tumor tissue sections.

Skeletal muscle fibrosis in the mdx/utrn+/- mouse validates its suitability as a murine model of Duchenne muscular dystrophy

Various therapeutic approaches have been studied for the treatment of Duchenne muscular dystrophy (DMD), but none of these approaches have led to significant long-term effects in patients. One reason for this observed inefficacy may be the use of inappropriate animal models for the testing of therapeutic agents. The mdx mouse is the most widely used murine model of DMD, yet it does not model the fibrotic progression observed in patients. Other murine models of DMD are available that lack one or both alleles of utrophin, a functional analog of dystrophin. The aim of this study was to compare fibrosis and myofiber damage in the mdx, mdx/utrn+/- and double knockout (dko) mouse models. We used Masson’s trichrome stain and percentage of centrally-nucleated myofibers as indicators of fibrosis and myofiber regeneration, respectively, to assess disease progression in diaphragm and gastrocnemius muscles harvested from young and aged wild-type, mdx, mdx/utrn+/- and dko mice. Our results indicated that eight week-old gastrocnemius muscles of both mdx/utrn+/- and dko hind limb developed fibrosis whereas age-matched mdx gastrocnemius muscle did not (p = 0.002). The amount of collagen found in the mdx/utrn+/- diaphragm was significantly higher than that found in the corresponding diaphragm muscles of wild-type animals, but not of mdx animals (p = 0.0003). Aged mdx/utrn+/- mice developed fibrosis in both diaphragm and gastrocnemius muscles compared to wild-type controls (p = 0.003). Mdx diaphragm was fibrotic in aged mice as well (p = 0.0235), whereas the gastrocnemius muscle in these animals was not fibrotic. We did not measure a significant difference in collagen staining between wild-type and mdx gastrocnemius muscles. The results of this study support previous reports that the moderately-affected mdx/utrn+/- mouse is a better model of DMD, and we show here that this difference is apparent by 2 months of age.

GIANT MORGAGNI HERNIA IN A FEMALE WITH MALROTATION SYNDROME AND THORACIC TRANSPOSITION OF SMALL BOWEL, COECUM, ASCENDING AND TRANSVERSE COLON

The sterno-costal hernia of Morgagni is a congenital vice in which is represented unfinished fusion of the transverse septum and the muscular diaphragmal wall. The malrotation syndrome is an embryonic vice as well, with various degree of incomplete and even reverse rotation of the gut, because of disturbed or unfinished development of the midgut. The described case presents a 37 years old female without anamnesis of any previous complains, who was pointed to the clinic after a X-ray photograph because of breathless and asteno-adynamic syndrome. After a precise CT investigation performance was found the presence of the above described anomalities, as well as ectopy of the right kidney and the right liver part. An operative treatment was performed with correction of the hernia and the bowel malrotation. The patient was followed up to the 12th month post-operatively. After a review of the literature in the discussion we inspect the diagnostics and the definition of the right surgical tactics and operative approach in this case with combined malformative pathology.

Surgical treatment of huge hepatocarcinoma with invasion or severe adhesion of diaphragm using the technique of orthotopic liver resection

BACKGROUND/AIMS

To explore the clinical application and significance of the technique of orthotopic liver resection.

METHODOLOGY

From January 2004 to December 2011, five patients with huge hepatocellular carcinoma with invasion or severe adhesion of diaphragm were undergone right semi-liver resection using the technique of orthotopic liver resection. The right hemi-liver was isolated from the first liver portal, second liver portal and third liver portal, then isolated from the normal liver, finally the tumor and the invaded diaphragm were resected or removed from the severe adhesion. The approach to hepatic resection involved routine use of Peng's multifunctional operative dissector, selective control of in and out-flow of liver, control of inferior vena cava (IVC) and liver hanging maneuver, anterior approach, etc.

RESULTS

The operations were successfully performed in 5 patients. Operative time was 120, 180, 150, 150 and 160 min, respectively. The amount of blood loss were 350, 350, 400, 450, 600 ml, respectively. Postoperative complications were pleural effusion in 3 cases, and other 2 cases recovered without complications.

CONCLUSIONS

Although the technique of orthotopic liver resection has a high technical requirement for surgeons, it provides a surgical method and operative opportunity for the patients whose tumor has invaded diaphragm or has been severe adhesion with diaphragm and conventional liver resection cannot be performed.

[Bilateral post-traumatic diaphragmatic hernias]

Traumatic diaphragmatic hernias could be clinically apparent and diagnosed after months and years after trauma. Bilateral ruptures of the diaphragm rarely appeared. Patients (46 cases) with diaphragmatic hernias were treated at the period from 1998 to 2010. The rate of diaphragmatic hernias consisted of 41,3%, bilateral post-traumatic hernias was noted in 2.2%. The article presents a follow-up study of bilateral diaphragmatic hernia, which was formed on the left (after 1 year) and on the right after 5 years. Diagnosis was supported by radiographic contrast research and computed tomography data. The stomach and omentum were displaced to the pleural cavity on the left, the transversely colon and omentum had a shift on the right. Thoracotomy and diaphragm plasty were performed in both cases. Hernial orifice was located in the area of esophageal opening and crura of diaphragm. It is necessary to increase clinical suspicion in relation to possibility of diaphragmatic hernia origin after severe closed trauma.

Thoracic endometriosis with a long delay in diagnosis

This paper describes a case of thoracic endometriosis in 36-year-old woman with a long delay in diagnosis. At the admission in the hospital, the patient had a medical history of persistent dysmenorrhea since the age of 13, infertility and an episode of total right pneumothorax two months ago successfully resolved by minimum pleurotomy of the right hemitorax. She came with moderate pain on right hemithorax and dyspnea, which occurred on the first day of menstruation but she did not have any other respiratory symptoms such as hemoptysis, cough. Radiological imaging (chest radiography and computer tomography) at the time of admission confirmed recurrence of the right pneumothorax. She underwent surgical treatment of the right pneumothorax using a single-port video-assisted approach. Intraoperative macroscopic lesions were found catamenial pneumothorax characteristic diagnosis and biopsy material taken (parietal pleura) for histopathology. Immuno-histochemical tests confirmed the diagnosis of thoracic endometriosis. The gonadotropin-releasing hormone analogue was received by the patient early after surgery and there was no clinical or radiological recurrence at a four months follow-up.

Defects in mitochondrial ATP synthesis in dystrophin-deficient mdx skeletal muscles may be caused by complex I insufficiency

Duchenne Muscular Dystrophy is a chronic, progressive and ultimately fatal skeletal muscle wasting disease characterised by sarcolemmal fragility and intracellular Ca2+ dysregulation secondary to the absence of dystrophin. Mounting literature also suggests that the dysfunction of key energy systems within the muscle may contribute to pathological muscle wasting by reducing ATP availability to Ca2+ regulation and fibre regeneration. No study to date has biochemically quantified and contrasted mitochondrial ATP production capacity by dystrophic mitochondria isolated from their pathophysiological environment such to determine whether mitochondria are indeed capable of meeting this heightened cellular ATP demand, or examined the effects of an increasing extramitochondrial Ca2+ environment. Using isolated mitochondria from the diaphragm and tibialis anterior of 12 week-old dystrophin-deficient mdx and healthy control mice (C57BL10/ScSn) we have demonstrated severely depressed Complex I-mediated mitochondrial ATP production rate in mdx mitochondria that occurs irrespective of the macronutrient-derivative substrate combination fed into the Kreb's cycle, and, which is partially, but significantly, ameliorated by inhibition of Complex I with rotenone and stimulation of Complex II-mediated ATP-production with succinate. There was no difference in the MAPR response of mdx mitochondria to increasing extramitochondrial Ca2+ load in comparison to controls, and 400 nM extramitochondrial Ca2+ was generally shown to be inhibitory to MAPR in both groups. Our data suggests that DMD pathology is exacerbated by a Complex I deficiency, which may contribute in part to the severe reductions in ATP production previously observed in dystrophic skeletal muscle.

[Diaphragmatic bronchogenic cyst: an exceptional location]

A 64-year-old man complained of persistent dyspnea and bilateral basi-thoracic pain with shoulder irradiation. Chest computed tomography revealed a heterogeneous left diaphragmatic mass, while magnetic resonance imaging showed hypo-T1 and hyper-T2 signal. Positron-emission tomography did not show any hypermetabolism. Video-assisted thoracic surgery was decided. At inspection, tumour appeared within the posterior costal part of the diaphragmatic muscle. Tumour resection was extended to a 8-cm-long portion of the lumbar part of diaphragm. Diaphragm was repaired with non-absorbable interrupted sutures. Postoperative course was uneventful. Final pathology revealed an intra-diaphragmatic bronchogenic cyst, which is an exceptional condition. Primary diaphragmatic tumours are very rare and preoperative diagnosis cannot be affirmed. Embryologic hypotheses (migration along the oesophagus or envelopment within diaphragmatic precursors of an abnormal supernumerary lung bud) including recent molecular findings of deregulated pathways (fibroblast growth factor-10 and NOTCH) are discussed.

Inclusion body myositis masquerading as cardiac dyspnea

Dyspnea in the elderly can be due to a wide array of pathologies. We discuss a case of an elderly gentleman with an extensive cardiovascular history presenting with acute worsening of chronic dyspnea. Because of persistent respiratory distress unresponsive to standard therapy for congestive heart failure, chronotropic insufficiency, and pulmonary hypertension, further evaluation was undertaken which revealed that diaphragmatic weakness was the etiology of his respiratory failure. EMG and muscle biopsy confirmed the diagnosis of inclusion body myositis (IBM).

PO2 cycling reduces diaphragm fatigue by attenuating ROS formation

Prolonged muscle exposure to low PO₂ conditions may cause oxidative stress resulting in severe muscular injuries. We hypothesize that PO₂ cycling preconditioning, which involves brief cycles of diaphragmatic muscle exposure to a low oxygen level (40 Torr) followed by a high oxygen level (550 Torr), can reduce intracellular reactive oxygen species (ROS) as well as attenuate muscle fatigue in mouse diaphragm under low PO₂. Accordingly, dihydrofluorescein (a fluorescent probe) was used to monitor muscular ROS production in real time with confocal microscopy during a lower PO₂ condition. In the control group with no PO₂ cycling, intracellular ROS formation did not appear during the first 15 min of the low PO₂ period. However, after 20 min of low PO₂, ROS levels increased significantly by ∼30% compared to baseline, and this increase continued until the end of the 30 min low PO₂ condition. Conversely, muscles treated with PO₂ cycling showed a complete absence of enhanced fluorescence emission throughout the entire low PO₂ period. Furthermore, PO₂ cycling-treated diaphragm exhibited increased fatigue resistance during prolonged low PO₂ period compared to control. Thus, our data suggest that PO₂ cycling mitigates diaphragm fatigue during prolonged low PO₂. Although the exact mechanism for this protection remains to be elucidated, it is likely that through limiting excessive ROS levels, PO₂ cycling initiates ROS-related antioxidant defenses.

[Diaphragmatic lipoma needed to distinguish from Bochdalek hernia; report of a case]

A 69-year-old woman had been followed up for an abnormal shadow on the left diaphragm at a nearby hospital, which showed gradual increase in size and she was referred to our hospital for treatment. Chest computed tomography(CT) showed a dome-shaped and homogeneous mass with smooth surface on the left diaphragm. CT showed 50×60 mm hypodense mass and partly interrupted diaphragm. Magnetic resonance imaging( MRI) revealed fat signal intensity on both T1 and T2 weighted image and fat suppressed T1 image. Bochdalek hernia or diaphragm lipoma was suggested and surgery was done. Yellowish round tumor on the diaphragm was resected. The omentum was easily separated from the tumor. Histopathological finding revealed the lipoma cell invading into striated muscle of diaphragm, and the tumor was diagnosed as a mature lipoma originated from diaphragm.

Perihepatic adhesions: An unusual complication of hemolysis, elevated liver enzymes and low platelet syndrome

We present a case of symptomatic perihepatic adhesions, which developed after a pregnancy complicated by hemolysis, elevated liver enzymes and low platelet (HELLP) syndrome, in which a subcapsular liver hematoma occurred. Our patient presented with complaints of persistent, severe right-sided upper abdominal pain. The complaints developed gradually, one year after a pregnancy that had been complicated by HELLP syndrome with a subcapsular liver hematoma. The hematoma had resolved spontaneously. An upper-abdominal magnetic resonance imaging revealed a density between liver and diaphragm at the site of the former subcapsular hematoma, suspect of perihepatic adhesions. The presence of perihepatic adhesions was confirmed during a laparoscopy and treated by adhesiolysis in the same session. The adhesions may have developed in response to the degradation process of the subcapsular liver hematoma during conservative treatment. This case of perihepatic adhesions may therefor be the first presentation of a long term sequel of subcapsular liver hematoma in HELLP syndrome.

Widespread sequence variations in VAMP1 across vertebrates suggest a potential selective pressure from botulinum neurotoxins

Botulinum neurotoxins (BoNT/A-G), the most potent toxins known, act by cleaving three SNARE proteins required for synaptic vesicle exocytosis. Previous studies on BoNTs have generally utilized the major SNARE homologues expressed in brain (VAMP2, syntaxin 1, and SNAP-25). However, BoNTs target peripheral motor neurons and cause death by paralyzing respiratory muscles such as the diaphragm. Here we report that VAMP1, but not VAMP2, is the SNARE homologue predominantly expressed in adult rodent diaphragm motor nerve terminals and in differentiated human motor neurons. In contrast to the highly conserved VAMP2, BoNT-resistant variations in VAMP1 are widespread across vertebrates. In particular, we identified a polymorphism at position 48 of VAMP1 in rats, which renders VAMP1 either resistant (I48) or sensitive (M48) to BoNT/D. Taking advantage of this finding, we showed that rat diaphragms with I48 in VAMP1 are insensitive to BoNT/D compared to rat diaphragms with M48 in VAMP1. This unique intra-species comparison establishes VAMP1 as a physiological toxin target in diaphragm motor nerve terminals, and demonstrates that the resistance of VAMP1 to BoNTs can underlie the insensitivity of a species to members of BoNTs. Consistently, human VAMP1 contains I48, which may explain why humans are insensitive to BoNT/D. Finally, we report that residue 48 of VAMP1 varies frequently between M and I across seventeen closely related primate species, suggesting a potential selective pressure from members of BoNTs for resistance in vertebrates.

Botulinum neurotoxins (BoNTs) target peripheral motor neurons and act by cleaving SNARE proteins, which are essential for neurotransmitter release from nerve terminals. SNARE proteins occur in multiple homologues and it has been difficult to determine which one is the physiologically relevant toxin target in motor nerve terminals among closely related SNARE homologues such as VAMP1 and VAMP2. Here we report that, in contrast to the highly conserved VAMP2, sequence variations in VAMP1 that confer resistance to BoNTs are widespread across vertebrates. In particular, residue 48 of VAMP1 is polymorphic between BoNT/D-sensitive residue M and BoNT/D-resistant residue I in rats. Taking advantage of this finding, we carried out an intra-species comparison, which showed that diaphragm motor nerve terminals from rats with I48 in VAMP1 were insensitive to BoNT/D as compared to those with M48. Since VAMP2 is conserved in rats, these data demonstrate that VAMP1 is the physiologically relevant toxin target in motor neurons. Interestingly, human VAMP1 encodes the BoNT/D-resistant residue I48, which may explain why humans are insensitive to BoNT/D. Finally, we found that residue 48 of VAMP1 switches frequently between M and I among 17 primate species, suggesting a potential selective pressure from BoNT/D for resistance in primates.

[Computed tomography-guided percutaneous microwave ablation for diaphragm-abutting liver tumors: assessments of safety and short-term therapeutic efficacies]

OBJECTIVE

To assess the safety and short-term therapeutic efficacies of computed tomography (CT)-guided percutaneous microwave ablation (PMA) for diaphragm-abutting liver tumors.

METHODS

A total of 69 patients with 75 diaphragm-abutting liver tumors (tumor from diaphragmc ≤ 5 mm) underwent CT-guided PMA. According to the site of diaphragm-abutting lesions, they were divided into neighboring muscle group (group A) and neighboring aponeurosis group (group B); According to the size of lesions, they were divided into <2.5 cm group (group I) and ≥ 2.5 cm group (group II). The complications of intra and post-ablation within 2 weeks were recorded. They underwent contrast enhanced CT (CECT) or contrast enhanced MRI (CEMRI) at Month 1, 3 and 6 post-ablation. Then CEMRI or CECT was re-checked every 3-6 months. All patients were followed up for 12-30 months. Comparative analyses were performed for short-term therapeutic efficacies.

RESULTS

At Month 1 post-PMA, complete response (CR) rate was 86.7% (65/75) and incomplete response (ICR) rate 13.3% (10/75). After additional ablation, 5 lesions transformed into CR.No statistical difference in CR rate existed between groups A and B (95.0% vs 77.1%). The CR rate of group I was obviously higher than that of group II (95.0% vs 77.1%). The 1-year survival rate was 97.1%. The occurring rate of minor complications was 42.0% (29/69) and that of serious complications 2.9% (2/69).No statistical difference of occurring rates of minor complications existed between groups A and B(38.1%vs 45.5%). But the occurring rates of diaphragmatic burns, pulmonary exudation and pneumothorax had obvious statistical differences between two groups. The occurring rate of minor complications in group I was obviously lower than that of group II (30.0% vs 54.3%) and serious complications occurred in group II. Minor complications were reversible and recovered after non-special or symptomatic treatment. Two cases of serious complications improved after standard clinical treatment.

CONCLUSION

CT-guided PMA for diaphragm-abutting liver tumors is both safe and effective.However puncture route and power/time should be optimized according to tumor size and location.

Recovery of diaphragm function following mechanical ventilation in a rodent model

BACKGROUND

Mechanical ventilation (MV) induces diaphragmatic muscle fiber atrophy and contractile dysfunction (ventilator induced diaphragmatic dysfunction, VIDD). It is unknown how rapidly diaphragm muscle recovers from VIDD once spontaneous breathing is restored. We hypothesized that following extubation, the return to voluntary breathing would restore diaphragm muscle fiber size and contractile function using an established rodent model.

METHODS

Following 12 hours of MV, animals were either euthanized or, after full wake up, extubated and returned to voluntary breathing for 12 hours or 24 hours. Acutely euthanized animals served as controls (each n = 8/group). Diaphragmatic contractility, fiber size, protease activation, and biomarkers of oxidative damage in the diaphragm were assessed.

RESULTS

12 hours of MV induced VIDD. Compared to controls diaphragm contractility remained significantly depressed at 12 h after extubation but rebounded at 24 h to near control levels. Diaphragmatic levels of oxidized proteins were significantly elevated after MV (p = 0.002) and normalized at 24 hours after extubation.

CONCLUSIONS

These findings indicate that diaphragm recovery from VIDD, as indexed by fiber size and contractile properties, returns to near control levels within 24 hours after returning to spontaneous breathing. Besides the down-regulation of proteolytic pathways and oxidative stress at 24 hours after extubation further repairing mechanisms have to be determined.

[Thoracic endometriosis and catamenial pneumothorax]

It was analyzed own experience of diagnosis and treatment of catamenial (menstrual) pneumothorax and thoracic endometriosis and literature review. It is shown that catamenial pneumothorax has specific clinical and instrumental signs allowing to establish the diagnosis before surgery. It was proposed surgical treatment including the removal of trans diaphragmatic way of pneumothorax development, removal of thoracic endometriosis and the establishment of reliable pleurodesis. It was demonstrated that this volume of surgery can be successfully implemented by using of thoracoscopic access. Relapse prevention includes hormonal therapy for the 6 months after surgery under the supervision of an obstetrician-gynecologist.

The effect of theophylline on the prevention of mechanical ventilation-induced diaphragm atrophy in rats

BACKGROUND

Movement disorders and atrophy occur in the diaphragm, the most important muscle of respiration, because of mechanical ventilation (MV).

OBJECTIVES

In this animal model, we aimed to evaluate the effect of intravenous theophylline administration on the prevention of mechanical ventilation-induced diaphragmatic atrophy.

MATERIAL AND METHODS

In our study, 30 healthy male Sprague-dawley rats were used. They were divided into 3 equal groups. Group 1: the control group (no MV); group 2: the placebo group that received MV; Group 3: the theophylline group composed of rats that received both MV and theophylline therapy. In all 3 groups, the diaphragmatic atrophy was evaluated histopathologically.

RESULTS

In the histopathological examination, no macroscopic thickening and microscopic atrophy were observed in the diaphragm in the control group. In the placebo group (group 2), macroscopically definite thickening was observed in all rats, and microscopically, heavy (+++) atrophy was observed. In the theophylline group (group 3), there was no atrophy in one rat. In 8 rats, light (+), and in 1 rat medium (++) atrophy was observed.

CONCLUSIONS

In our study, it was shown that atrophy occurred in the diaphragms of rats after MV, and the atrophy was decreased after theophylline administration.

Pancreatic herniation: a rare cause of acute pancreatitis?

Acute pancreatitis is a common and potentially fatal condition, with several well-known causes including gallstones, excessive alcohol consumption and specific medications. We report a case of an 89-year-old man presenting with acute pancreatitis, which we believe to be secondary to a diaphragmatic herniation of the pancreas. This extremely rare anatomical abnormality can be found incidentally in the asymptomatic patient or may present with a variety of acute symptoms. However, there have been only isolated reports of these cases presenting as acute pancreatitis. While the majority of acute pancreatitis cases can be explained by common causes, it is important that clinicians be aware of and should consider investigating for other more unusual possibilities, such as pancreatic herniation, before labelling an episode as 'idiopathic'.

Complex suicide by self-stabbing with subsequent drowning in the sea

The paper presents a unique case of a complex suicide committed by a young man, mostly probably triggered by a disappointment in love. The uniqueness of the suicide lies in the fact that the victim inflicted several deep stab wounds on himself, in the chest and abdomen, while standing partly submerged in the sea and, having done so, he dropped and disappeared in the water. The postmortem examination showed, apart from deep wounds in the trunk, characteristics of drowning that manifested itself in the form of aqueous emphysema of the lungs. Suicide was clearly determined on the basis of the circumstances preceding death, the location, and arrangement of the trunk wounds and the testimony given by a witness of the incident. The circumstances preceding the suicidal act clearly suggest an underlying undiagnosed mental disorder.