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the recognition of noise as a serious health hazard as opposed to a nuisance is a recent development and the health effects of hazardous noise exposure are now considered to be an increasingly important public health problem . noise exposure in the workplace is a common reality in qubec ( province of canada ) and worldwide . in the usa , it is estimated that 22 million workers ( 17 % ) are exposed to hazardous noise . in qubec , two recent surveys have estimated that 7 % and 10 % , respectively , of qubec 's workers reported being currently exposed often or always to loud workplace noise such that it is difficult to maintain a conversation a few feet away , even when shouting . in addition , among them at least 4,300 workers are exposed to daily noise levels of 100 dba or more in over 500 workplaces . the assumption of a causal or contributive impact of occupational noise on the occurrence of occupational accidents has been addressed in several studies . recent publications except one suggest an exposure - response relationship between noise exposure or hearing impairment and accident risk . according to three explanatory models and empirical data , there is a biological plausibility for a causal relationship between noise exposure and occupational accident risk . nevertheless , the extent to which noise does act as a causal or contributive factor in fatal workplace accidents remains unclear and is subject to debate . potential effects of occupational noise on the risk of injuries based on interaction between the worker and his / her workplace [ institut national de sant publique du qubec ( inspq ) , adapted from htu 1993 , wilkins 1981 and le cocq 2010 ] through a review of work - related fatality reports , this study sought to : 1 . determine the number of instances when noise was identified as one of the potential causes and retained as such , 3 . determine the number of instances when noise could have been identified as one of the potential causes , and 4 . though not presented in this paper , the fifth aim was to determine the worth of fatality reports as a potential surveillance data source .

noise exposure in the workplace is a common reality in qubec , canada as it is elsewhere . however , the extent to which noise acts as a causal or contributive factor in industrial work - related accidents has not been studied thoroughly despite its plausibility . this article aims to describe the importance or potential importance , during investigations looking into the specific causes of each work - related fatal accident , of noise as an explanatory factor . the written information contained in the accident reports pertaining to contextual and technical elements were used.the study used multiple case qualitative content analysis . this descriptive study was based on the content analysis of the 788 reports from the commission de la sant et de la scurit du travail du qubec [ workers compensation board ( wcb ) ] investigating the fatal work - related accidents between 1990 and 2005 . the study was descriptive ( number and percentages ) . noise was explicitly stated as one of the explanatory factors for the fatal outcome in 2.2 % ( 17/788 ) of the fatal accidents , particularly when the work involved vehicular movement or the need to communicate between workers . noise was not typically considered a unique cause in the accident , notably because the investigators considered that the accident would have probably occurred due to other risk factors ( for example , disregard of safety rules , shortcomings in work methods , and inadequate training ) . noise is an important risk factor when communication is involved in work . since noise is ubiquitous and may also interfere with vigilance and other risk factors for accidents , it may be a much more important contributing factor to accidents than is currently recognized .

hyponatremia , characterized by a serum sodium level that is less than 135 meq / l , is one of the most commonly diagnosed electrolyte disorders in clinical medicine1 ) . although sodium deficiency leads to hyponatremia , this condition is more commonly caused by solute dilution resulting from excessive consumption of water . severe hyponatremia , where serum sodium level falls below < 125 meq / l , occurs in approximately 3 % of all hospitalized patients2 ) . additionally , a rapid drop in serum sodium levels to 110 - 120 meq / l leads to cerebral edema and brain herniation1 ) . since it is often an indicator of underlying disease , timely diagnosis of hyponatremia is of great importance in preventing potential morbidity and mortality3 ) . approximately one - third of all hyponatremic patients are diagnosed with euvolemic hyponatremia , a condition commonly caused by the syndrome of inappropriate antidiuretic hormone secretion ( siadh ) 4 ) . under normal physiological conditions , antidiuretic hormone ( adh ; also known as vasopressin ) is secreted from the posterior pituitary gland in response to hyperosmolality in a process called osmotic adh secretion . nonosmotic adh secretion , associated with hypovolemia , pain , nausea , and use of certain drugs , also leads to hyponatremia5 ) . although nonosmotic adh secretion can be a normal biological response when caused by hypovolemia or low effective arterial blood volume , it can also be a symptom of siadh3 ) . siadh is characterized by euvolemia , high urinary sodium excretion ( natriuresis ) , and elevated urine osmolality in the absence of diuretics . this syndrome is often associated with pituitary insufficiency , adrenal or renal dysfunctions , thyroid disorders , and edema3 ) . adh binds to the vasopressin-2 receptors in the renal collecting duct and stimulates a cyclic adenosine monophosphate - signaling cascade that leads to the insertion of preformed aquaporin-2 water channels into the apical plasma membrane , thereby resulting in the transcellular movement of water6 ) .

timely diagnosis of hyponatremia is important for preventing potential morbidity and mortality as it is often an indicator of underlying disease . the most common cause of eurvolemic hyponatremia is the syndrome of inappropriate antidiuretic hormone ( siadh ) secretion . recent studies have demonstrated that proinflammatory cytokines such as interleukin ( il ) 1 and il-6 are involved in the development of hyponatremia , a condition that is associated with severe inflammation and is related to antidiuretic hormone ( adh ) secretion . serum sodium levels in hyponatremia are inversely correlated with the percentage of neutrophils , c - reactive protein , and n - terminal - pro brain type natriuretic peptide . additionally , elevated levels of serum il-6 and il-1 are found in inflammatory diseases , and their levels are higher in patients with hyponatremia . because it is significantly correlated with the degree of inflammation in children , hyponatremia could be used as a diagnostic marker of pediatric inflammatory diseases . based on available evidence , we hypothesize that hyponatremia may be associated with inflammatory diseases in general . understanding the mechanisms responsible for augmented adh secretion during inflammation , monitoring patient sodium levels , and selecting the appropriate intravenous fluid treatment are important components that may lower the morbidity and mortality of patients in a critical condition .

severity of disease of hospitalized patients has increased over the past decade , and advanced techniques have allowed such patients to stay alive . it is well - known that advances in medicine and biomedical technology have created the likelihood for medical treatment to be continued beyond a point , of which it offers no advantage to the patient and may lengthen suffering . it is widely recognized that continued care may not always be advantageous , and this concept has given rise to frequent limitation of life support treatment ( lst ) . the concept of limitation of lst which includes do - not - resuscitate ( dnr ) and withdrawal of lst ( wlst ) has examined medical practices to avoid use of treatment which lengthen the patient 's life and does not improve the patient 's outcomes . in north america and europe , 2865 % of all pediatric intensive care unit ( picu ) in contrast to the west , where limitation proceeds up to 90 % of deaths ; the rate in india is 2250 % , in iran 6.7 % , and in saudi arabia 34 % . different cultures , religions , philosophic , legal , and professional attitudes may in part explain these differences . in the context of pakistan , the cost of intensive care is high and affordable only by middle - high income groups . . we could not find any published reports from pakistan on patterns of mortality among critically ill children in picu . therefore , our aim was to conduct a retrospective review on mortality patterns over a 6-year period in a picu and to compare the results with published data from other countries .

background and aim : advances in biomedical technology have made medical treatment to be continued beyond a point , at which it does not confer an advantage but may increase the suffering of patients . in such cases , continuation of care may not always be useful , and this has given rise to the concept of limitation of life - sustaining treatment . our aim was to study mortality patterns over a 6-year period in a pediatric intensive care unit ( picu ) in a developing country and to compare the results with published data from other countries.materials and methods : retrospective cohort study was conducted in a picu of a tertiary care hospital in pakistan . data were drawn from the medical records of children aged 1-month 16 years of age who died in picu , from january 2007 to december 2012.results : a total of 248 ( from an admitted number of 1919 ) patients died over a period of 6 years with a mortality rate 12.9 % . the median age of children who died was 2.8 years , of which 60.5 % ( n = 150 ) were males . the most common source of admission was from the emergency room ( 57.5 % , n = 143 ) . the most common cause of death was limitation of life - sustaining treatment ( 63.7 % , n = 158 ) followed by failed cardiopulmonary resuscitation ( 28.2 % , n = 70 ) and brain death ( 8.1 % , n = 20 ) . we also found an increasing trend of limitation of life - sustaining treatment do - not - resuscitate ( dnr ) over the 6-year reporting period.conclusion : we found limitation of life support treatment ( dnr + withdrawal of life support treatment ) to be the most common cause of death , and parents were always involved in the end - of - life care decision - making .

heart failure ( hf ) is a complex clinical syndrome where the ability of the heart to supply physiological perfusion to organs is impaired , either by acquired or inherited disease . the key biomarker for measuring heart failure is the left ventricular ejection fraction ( lvef ) but a low ejection fraction and hf are not synonymous . common causes are ischemic heart disease , hypertensive heart disease , valvular heart disease , diabetes , myocarditis , cardiomyopathies , tachycardia - induced cardiomyopathy , and systemic diseases with cardiac involvement . in most hf presentations hf represents one of the most important problems for both modern medicine and society with massive impact on individuals and a major annual cost for health systems . the annual costs for hf care exceed $ 40 billions in the us , with the majority spent on hospitalizations for hf [ 13 ] . damage the heart and the whole organism responds upregulated renin - angiotensin system changes , haemodynamic and skeletal muscle changes are the most well known . however , it is the myocardial response that is the most fundamental that of the myocytes and fibroblast ( the most prevalent cells in the myocardium ) , and extracellular space changes . these changes may be initially adaptive but may progress to be maladaptive . common features of this remodelling process are cardiomyocyte hypertrophy , extracellular matrix expansion and composition alteration . calcium handling , energy metabolism , contractile function , vasculature and cell viability may also change . these processes although deeply interwoven may combine into characteristic myocardial phenotypes which , if we can measure them , may permit us to split hf up in a subtypes , opening the door for tailored therapy according to the precise myocardial phenotype . there is no denying the significant advances in treatment strategies for hf , including drug and device therapy , cardiac transplantation , and mechanical circulatory support . however , despite these , the prognosis has not improved in worsening chronic hf , de novo hf and advanced or end - stage hf , which continue to have high mortality and re - admission rates [ 26 ] . whilst the basic biology has pointed to a host of potential therapeutic targets with successful phase 2 trials , few of firstly , we measure the wrong thing the ejection fraction in defining hf , despite the fact that 40 % of hf has a preserved lvef . secondly , we group all types of hf together , thereby ignoring personalised differences in myocardial disease biology . thirdly , our early phase trial surrogate endpoints ( such as short term symptoms improving ) are not well tied to important outcomes such as mortality . what is needed is a better practical understanding and measurement of disease biology fibrosis and myocyte response to split heart failure into different groups , with these biomarkers being tied to specific therapies [ 2 , 3 , 7 ] . this review focuses on a novel technique using standard cardiovascular magnetic ( cmr ) scanner , t1 mapping , to do this and its potential to act as a disease ( rather than syndrome ) biomarker , as a surrogate endpoint in trials and as a way of monitoring and tailoring therapy once implemented for better patient outcomes .

heart failure ( hf ) is a major and growing cause of morbidity and mortality . despite initial successes , there have been few recent therapeutic advances . a better understanding of hf pathophysiology is needed with renewed focus on the myocardium itself . a new imaging technique is now available that holds promise . t1 mapping is a cardiovascular magnetic resonance ( cmr ) technique for non - invasive myocardial tissue characterization . t1 alters with disease . pre - contrast ( native ) t1 changes with a number of processes such as fibrosis , edema and infiltrations . if a post contrast scan is also done , the extracellular volume fraction ( ecv ) can be measured , a direct measure of the interstitium and its reciprocal , the cell volume . this dichotomy is fundamental and now measurable promising more targeted therapy and new insights into disease biology .

while aortic valve replacement ( avr ) is the treatment of choice for several aortic valve disorders ; it is important to recognize some complications post this surgical procedure . most importantly , these include valve dehiscence , conduction abnormalities , thrombosis , infective endocarditis , fistulas , and left ventricular outflow tract ( lvot ) pseudoaneurysms , among others . current imaging modalities such as echocardiography , computed tomography ( ct ) , and magnetic resonance imaging have allowed us to detect these potential complications during follow - up of postoperative patients . in this case report , we present the case of a patient with three previous surgical bioprosthetic avrs who presented to our institution for an additional surgical opinion .

we present a case of a pseudoaneurysm arising from the left ventricular outflow tract / aortic root as a complication of aortic valve surgery . a 45-year - old nigerian female presented to our institution 's emergency department with chest discomfort . she had three bioprosthetic aortic valve replacements in the preceding year at an outside institution for aortic regurgitation and wanted a second opinion on remaining surgical options . the learning points relevant to this case are as follows : ( 1 ) recognizing potential complications postmultiple valve surgeries , ( 2 ) screening patients for chronic infections and rheumatologic conditions that can contribute to failed valve surgeries .

intestinal pseudo - obstruction is a clinical syndrome that involves bowel obstruction without any mechanical cause.1 it can be either acute or chronic and may occur in the small bowel or the colon . chronic intestinal pseudo - obstruction ( cip ) usually exhibits a relapsing clinical course and may either be idiopathic or occur due to other systemic disorders . pregnancy can be a precipitating factor of colonic pseudo - obstruction.2 recently , we experienced a case of a woman with intractable colonic pseudo - obstruction that was aggravated after pregnancy . endoscopic decompression could delay surgical treatment until a gestational age of 21 weeks and finally a full - term delivery could be achieved .

chronic intestinal pseudo - obstruction is a rare clinical syndrome which is characterized by intestinal obstruction without occluding lesions in the intestinal lumen and pregnancy is one of the important aggravating factors . here , we report a case of a woman with intractable intestinal pseudo - obstruction that was precipitated by pregnancy . she could not make any stool passage for more than 4 weeks until a fetal gestational age of 17 weeks was reached . however , the patient could be maintained by repetitive colonoscopic decompressions and finally total colectomy could be performed successfully at a fetal gestational age of 21 weeks .

it s the most common solid tumor and is responsible for 15 % of all cancer - related deaths in childhood . this tumor accounts for more than 7 % of malignancies in patients fewer than 15 years of age . nb tumors from these patients are often characterized by deregulation of many key signaling pathways regulating growth , proliferation , survival , and apoptosis , with concomitant resistance to chemotherapy . the acquisition of multidrug resistance upon treatment with anti - cancer drugs is a common phenomenon for nbs . this is a major reason for the high frequency of fetal outcome of the disease . recently , there are strong epidemiological evidence and laboratory studies that are naturally occurring terpenes may exert cytotoxic effects against nb cells . guaiazulene ( 1,4-dimethyl-7-isopropylazulene gyz , figure 1 ) is a bicyclic sesquiterpene derived from different plants , guaiac wood oil , callis intratropica blue and matricaria chamomilla l and has attracted much attention due to its beneficial biological activities . moreover , previous reports indicated that gyz has antioxidant , antifungal , antimicrobial , anti - inflammatory , anti - spasmodic , anti - ulcer , antitumoral activities and relaxant properties [ 12 - 18 ] . although it has been demonstrated to have interesting biological effects , gyz has been not proven to be cytotoxic , genotoxic and antioxidant / oxidant effects on neuron and nb cell lines . therefore , the aim of the present study was to firstly evaluate the cytotoxic / antiproliferative ( 3- [ 4,5 dimetylthiazol -2-yl ] -2,5 diphenlytetrazolium bromide [ mtt ] assay ) , cytogenetic ( single cell gel electrophoresis [ scge ] assay ) and oxidative effects ( total antioxidant capacity [ tac ] and total oxidative stress [ tos ] analysis ) of gyz on neuron and nb cell cultures for its possible use in the complementary and alternative medicine practices . chemical structure of guaiazulene

aim : neuroblastoma ( nb ) cells are often used in cancer researches such as glioblastoma cells since they have the potential of high mitotic activity , nuclear pleomorphism , and tumor necrosis . guaiazulene ( gyz 1,4-dimethyl-7-isopropylazulene ) is present in several essential oils of medicinal and aromatic plants . many studies have reported the cytotoxic effect of gyz ; however , there are no studies that compare such effects between cancer cell lines and normal human cells after treatment with gyz.materials and methods : in this study , we aimed to describe in vitro antiproliferative and/or cytotoxic properties ( by 3- [ 4,5 dimetylthiazol -2-yl ] -2,5 diphenlytetrazolium bromide [ mtt ] test ) , oxidative effects ( by total antioxidant capacity [ tac ] and total oxidative stress [ tos ] analysis ) and genotoxic damage potentials ( by single cell gel electrophoresis ) of gyz.result : the results indicated that gyz have anti - proliferative activity suppressing the proliferation of neuron and n2a - nb cells at high doses . in addition , gyz treatments at higher doses led to decreases of tac levels and increases of tos levels in neuron and n2a - nb cells . on the other hand , the mean values of the total scores of cells showing dna damage were not found different from the control values.conclusion : from this study , it is observed that gyz has in vitro cytotoxic activity against neuron and n2a - nb cells .

, it may be fatal in there is injury caused to the cardiac cavity , an intercostal artery , pulmonary vessels , or intraabdominal organs 2 , 3 . in this situation , invasive management such as emergency surgery and transcatheter arterial embolization ( tae ) may be required 4 , 5 , 6 . however , if there is no severe adverse event immediately after injury of vital organs by the tube insertion , emergency treatment may not be required 7 . here , we describe successful noninvasive management for iatrogenic penetrating splenic injury caused by chest tube insertion .

key clinical messagesplenic injury is one of the most critical complications of chest tube insertion and often requires invasive emergency management . however , noninvasive management such as delayed removal of the malpositioned tube may be considered for a stable patient without severe adverse event .

tracheal intubation with the aid of a rigid laryngoscope , although a gold standard in securing a definitive airway , triggers adverse haemodynamic stress response . in instances when the procedure or the patient need not be subjected to endotracheal intubation , which is an invasive technique , the use of supraglottic airway devices is a superior alternative . the use of supraglottic airway device has also proven to be lifesaving in the management of airway crisis . since the introduction of laryngeal mask airways , an array of supraglottic airway devices have been designed and some of these devices have been modified to be used as conduits for endotracheal intubation . the air - q intubating laryngeal airway ( ila , cookgas llc , mercury medical , clearwater , fl , usa ) was introduced by daniel cook in 2005 as an aid for airway maintenance and as a conduit for tracheal intubation during general anaesthesia . at present , the air - q ila is available in 7 sizes ( 0.5 , 1 , 1.5 , 2 , 2.5 , 3.5 and 4.5 ) in both disposable as well as the reusable form . the aim of this study was to evaluate the efficacy of air - q ila with respect to ease of insertion , characteristics of ventilation , intubating conditions , haemodynamic response to endotracheal intubation and identifying any airway morbidity subsequent to its use .

background and aims : air - q intubating laryngeal mask airway ( ila ) is used as a supraglottic airway device and as a conduit for endotracheal intubation . this study aims to assess the efficacy of the air - q ila regarding ease of insertion , adequacy of ventilation , rate of successful intubation , haemodynamic response and airway morbidity.methods : sixty patients presenting for elective surgery at our medical college hospital were selected . following adequate premedication , baseline vital parameters , pulse rate and blood pressure were recorded . air - q size 3.5 for patients 50 - 70 kg and size 4.5 for 70 - 100 kg was selected . after achieving adequate intubating conditions , air - q ila was introduced . confirming adequate ventilation , appropriate sized endotracheal tube was advanced through the air - q blindly to intubate the trachea . placement of the endotracheal tube in trachea was confirmed.results : air-q ila was successfully inserted in 88.3 % of patients in first attempt and 11.7 % patients in second attempt . ventilation was adequate in 100 % of patients . intubation was successful in 76.7 % of patients with air - q ila . 23.3 % of patients were intubated by direct laryngoscopy following failure with two attempts using air - q ila . post - intubation the change in heart rate was statistically significant ( p < 0.0001 ) . 10 % of patients were noted to have a sore throat and 5 % of patients had mild airway trauma.conclusion : air-q ila is a reliable device as a supraglottic airway ensuring adequate ventilation as well as a conduit for endotracheal intubation . it benefits the patient by avoiding the stress of direct laryngoscopy and is also superior alternative device for use in a difficult airway .

the integration of semiconductor quantum dots ( qd ) as active elements in new quantum optoelectronic devices [ 1 - 4 ] requires a precise control in their shape , size and location over the substrate . in this direction , one of them is the use of patterned substrates [ 5 - 9 ] , in which good results on the growth selectivity and photoluminescence ( pl ) emission of single qd have been obtained [ 5 - 7 ] . another approach based on droplet epitaxy growth technique has recently emerged as an optimal strategy for obtaining different nanostructures complexes with a great control in shape and size . recently , our group has reported the ability to use this technique to obtain low density inas qd with control in size into previously formed gaas nanoholes . in this previous work , we advanced the possibility of using certain capping growth conditions for marking the underneath nanostructures by the formation of mounding features at the top surface . the possibility of top surface localization of buried qd has been studied in the past by the growth of stacked structures and more recently , by evaluating the surface morphology once a single layer of qd is capped . as it is well known , the surface of a thin layer covering nanometric features is not flat , but it shows characteristic mounding features [ 3,14 - 17 ] . however , when the thickness of the cap layer increases , these features enlarge and coalesce discarding any further correspondence of the mounds with the buried nanostructures . the possibility to overcome this problem is of high technological interest for the fabrication of devices , as single photon emitters , where the location of the nanostructures after being buried is a critical issue . in this work , by means of preferential nucleation of inas at the top surface , we demonstrate that mounds formed during the growth of the cap layer unequivocally mark the buried nanostructures . additionally , we show that these surface features can be maintained up to 100-nm thick cap layers by the use of low temperature atomic layer molecular beam epitaxy ( almbe ) growth technique . the different contributions to the surface chemical potential that influence on the selective preferential growth are discussed in the framework of these results .

in this work , we study the top surface localization of inas quantum dots once capped by a gaas layer grown by molecular beam epitaxy . at the used growth conditions , the underneath nanostructures are revealed at the top surface as mounding features that match their density with independence of the cap layer thickness explored ( from 25 to 100 nm ) . the correspondence between these mounds and the buried nanostructures is confirmed by posterior selective strain - driven formation of new nanostructures on top of them , when the distance between the buried and the superficial nanostructures is short enough ( d = 25 nm ) .

maggot therapy is categorised as a debridement for chronic infectious wounds using disinfected live maggots for medical use ( herein referred to as maggots ) . since the 1930s , maggot debridement therapy ( mdt ) has been conducted mainly in north america . in japan , first conducted mdt in 2004 and reported the healing of an ulcerated lesion , leading to the avoidance of major amputation of a limb of a patient with severe cli for whom neither a revascularization procedure nor a transplantation of bone marrow and peripheral mononuclear cells to the lower limb was effective . wound healing is intractable in most cli patients who have reduced blood flow in the skin ; therefore , revascularization is the most important factor for successful management . in addition , the debridement of wounds with no sufficient tissue blood flow may deteriorate ischaemic lesions . treatment decisions are often difficult for cli patients with a reduced cardiac function and surgical intervention or endovascular surgery for revascularization is risky , or not clinically and technically possible . herein , we report a cli patient with severe cardiac dysfunction for whom highly invasive surgery , such as bypass surgery , was impossible due to a history of fulminant myocarditis , but functional limb salvage was achieved after wound bed preparation ( wbp ) with mdt .

abstractischaemic skin ulcer occurred on the foot of a 73-year - old man who had a history of fulminant myocarditis with severe cardiac dysfunction . we attempted wound bed preparation by maggot debridement therapy and salvaged his limb . it can be one of the adjuvant treatment strategies for critical limb ischaemia .

acute pyelonephritis complicates 1 - 2 % of all pregnancies , making it one of the most common medical complications of pregnancy . escherichia coli remains the most common pathogen isolated in acute antepartum pyelonephritis , and ampicillin has been a mainstay of treatment for antepartum pyelonephritis because of efficacy , cost , and minimal risk to both the mother and fetus . because of its concomitant use in the prevention of neonatal group b streptococcal sepsis , there is concern for increasing trends of ampicillin - resistant organisms . in 1984 , duff reported a 22 % incidence of ampicillin - resistant e. coli in acute antepartum pyelonephritis . by 2001 , hart reported a 45 % incidence of ampicillin - resistant e. coli in acute antepartum pyelonephritis [ 2 , 3 ] . globally , there are increasing rates of antibiotic - resistant strains of e. coli . this trend in antibiotic resistance caused the centers for disease control and prevention ( cdc ) to identify investigating the clinical implications of antimicrobial resistance as a priority . moreover , it has been postulated that infections with antibiotic - resistant organisms may increase the risk of treatment failures and morbidity [ 2 , 5 , 6 ] . accordingly , we sought to measure the incidence of ampicillin resistance in uropathogens causing acute pyelonephritis in our pregnant patient population and to determine if resistant organisms resulted in different clinical outcomes .

objective . to measure the incidence of ampicillin - resistant uropathogens in acute antepartum pyelonephritis and to determine if patients with resistant organisms had different clinical outcomes . study design . this was a secondary analysis of a prospective cohort study of pregnant women admitted with pyelonephritis , diagnosed by standard clinical and laboratory criteria . all patients received ampicillin and gentamicin . results . we identified 440 cases of acute pyelonephritis . seventy - two percent ( 316 cases ) had urine cultures with identification of organism and antibiotic sensitivities . fifty - one percent of uropathogens were ampicillin resistant . the patients with ampicillin - resistant organisms were more likely to be older and multiparous . there were no significant differences in hospital course ( length of stay , days of antibiotics , ecu admission , or readmission ) . patients with ampicillin - resistant organisms did not have higher complication rates ( anemia , renal dysfunction , respiratory insufficiency , or preterm birth ) . conclusion . a majority of uropathogens were ampicillin resistant , but no differences in outcomes were observed in these patients .

cranial irradiation has been widely used as a therapeutic method treating a wide variety of lesions , particularly neoplasms . though radiation therapy of central nervous system is usually well - tolerated , it does occasionally cause clinically significant long - term toxicity such as late delayed radiation necrosis and irradiation - related arteriopathy with stroke14 ) . among other complications induction of neoplasm radiosurgery is not free from this problem although there are only a few reported cases14 ) . we report a case of glioblastoma which was developed after gamma knife radiosurgery ( gks ) for meningioma .

we report a patient who underwent gamma knife radiosurgery to treat recurrent meningioma after microsurgery and thereafter developed secondary malignancy adjacent to the original tumor . a 47-year - old woman had underwent resection of the olfactory groove meningioma . then radiosurgery was done three times over 4 year period for the recurrent tumor . after 58 months from the initial radiosurgery , she presented with headache and progressive mental dullness . huge tumor in bifrontal location was revealed in mri . subsequent operation and pathological examination confirmed diagnosis of glioblastoma . this case fits the criteria of radiation - induced tumor and the clinical implication of the issue is discussed .

persistent urogenital sinus ( ugs ) is a complex , challenging , and controversial pathology for the pediatric surgeon . it consists of a persistent communication of the genital and urinary tract with the urethra and vagina joined in a single common channel ( cc ) , with the ugs reaching the perineum.1 it can be an isolated anomaly or associated with external genitalia virilization ( congenital adrenal hyperplasia [ cah ] ) , or included in the cloacal anomaly.2 3 4 surgery should be tailored to the individual patient according to either the length of the cc ( that identifies low and high forms ) or to the associated anomalies . simple flap vaginoplasties are sufficient to treat low ugs , whereas high forms require a more extensive dissection and a subsequent pull - through.3 4 this can be obtained by prior separation of the vagina and urethra ( by the posterior sagittal transanorectal approach [ psta ] or the anterior sagittal transrectal approach [ astra ] ) or by an en bloc procedure ( total urogenital mobilization [ tum ] ) . what we are reporting in this article is a modified technique combining the advantages of these two approaches which was performed on a patient with high ugs related to cah . the aim of opting for this combined approach was to reduce surgical trauma and to provide optimum anatomical visualization , thus simplifying surgery and obtaining good functional and cosmetic results .

persistent urogenital sinus ( ugs ) is a developmental anomaly . it represents one of the most complex problems that a pediatric surgeon may deal with . we report the case of a patient with ugs treated at 3 years of age by anterior sagittal transrectal approach and en bloc sinus mobilization . the procedure was performed with the patient prone with the initial idea of performing an anterior sagittal transrectal approach . the described approach allows an excellent anatomical view with a midline muscle sparing incision , along with an easy identification of the vaginal confluence with the benefit of avoiding dissection between the urethra and vagina .

pathophysiological cycles of denervation and impaired reinnervation , the loss of entire motor units , unloading due to prolonged periods of disuse , and excitation - contraction uncoupling may trigger a substantial loss in skeletal muscle mass and function . although considerable interindividual differences exist in the functional decline of the musculature during aging , most elderly people experience a general loss in skeletal muscle strength . while regular physical activity and a protein - rich diet can partially counteract severe muscle wasting , a sedentary life style and certain medical conditions , such as diabetes , cancer , renal failure , chronic obstructive pulmonary disease , or congestive heart failure [ 57 ] , clearly promote muscle degeneration . skeletal muscle wasting plays a crucial role in physical disability , frailty , and loss of independence in aged people . skeletal muscle wasting in the elderly has been termed sarcopenia of old age , whereby this muscular impairment is probably due to multiple factors , as outlined in figure 1 . on the cellular level , a variety of abnormal structural , physiological , and biochemical processes have been identified that are directly or indirectly associated with age - dependent muscle wasting . this includes a severe decline in contractile efficiency , increased apoptosis , denervation - associated atrophy , bioenergetic changes , impaired ion homeostasis , excitation - contraction uncoupling , decreased capacity for fibre regeneration , a partially diminished cellular stress response , and an altered equilibrium of hormones and growth factors crucial for the maintenance of contractile function , as well as oxidative stress and mitochondrial abnormalities [ 2022 ] . although individual muscles in aged humans and animal models of sarcopenia exhibit alterations in the molecular composition of contractile fibres and changes in their glycolytic and aerobic capacity , findings on distinct shifts in fibre types with aging are highly variable [ 2326 ] . however , since mitochondrial functions are clearly impaired in senescent muscle tissues , it was of interest to summarize the impact of recent mass spectrometry - based proteomic studies on the molecular fate of mitochondrial enzymes in senescent fibres . this paper briefly outlines the proposed role of mitochondria in cellular senescence and recent achievements of mitochondrial proteomics and then focuses on findings from proteomic profiling studies of aged skeletal muscle preparations and the identification of mitochondrial elements as potential markers of fibre aging .

mitochondria are of central importance for energy generation in skeletal muscles . expression changes or functional alterations in mitochondrial enzymes play a key role during myogenesis , fibre maturation , and various neuromuscular pathologies , as well as natural fibre aging . mass spectrometry - based proteomics suggests itself as a convenient large - scale and high - throughput approach to catalogue the mitochondrial protein complement and determine global changes during health and disease . this paper gives a brief overview of the relatively new field of mitochondrial proteomics and discusses the findings from recent proteomic surveys of mitochondrial elements in aged skeletal muscles . changes in the abundance , biochemical activity , subcellular localization , and/or posttranslational modifications in key mitochondrial enzymes might be useful as novel biomarkers of aging . in the long term , this may advance diagnostic procedures , improve the monitoring of disease progression , help in the testing of side effects due to new drug regimes , and enhance our molecular understanding of age - related muscle degeneration .

given to a long history of substance abuse disorders in the world , it also has remained as a serious problem in recent years . because of some incorrect beliefs and specific geographical conditions , iran has favorable conditions for youth to crave toward substance abuse . based on a study which has conducted in iran , the subjects experienced the drug use before they were 14 years of age in the 1 time . it seems that drug abuse among youth is spending a progressive trend in the country . hence , finding new ways to deal with this problem is one of the main priorities of iranian government . in many countries , young adults aged 18 - 24 years have become a critical population who need to be addressed . anderson ( 2007 ) noted that the majority ( 85 % ) of relapse occurs among young people when they join together with their peers . research evidences indicate that many psychological factors are involved in drug addiction and subsequent relapse . coping skills is one of these factors has been confirmed their effectiveness in many studies . research has shown that relapse prevention can be some extent predicted by increased the types of cognitive coping responses and coping behaviors . addiction treatment is a complex process that can be handled through addicts desire to quit , family involvement and physical and psychological treatments . coping cognitive behavioral therapy helps individuals to recognize the difficult situation , teaching coping skills , changing reinforcement contingencies , and fostering motivation are the some of the basic tasks in this approach . numerous studies indicate that learning coping skills is associated with a high degree of ability to prevent relapse among addicts . unfortunately , the relapse rates are high among who are not capable to use effectively coping skills in stressful events ( family conflict , peer pressure , financial difficulties or temptations ) . this study aimed to study relapse coping strategies in young adults self - referred to substance abuse treatment centers in the south iran .

background : cognitive - behavioral coping approach is known as an effective strategy to preventing relapse . its goal is to forget incompatible behaviors and replaces them with the compatible answers.objectives : this study examines relapse coping strategies in young adults in selected substance abuse treatment centers in iran.patients and methods : the present is a descriptive cross - sectional study . the sample consisted of 70 self - referred young addicts ( 18 - 24 years ) . adolescence relapse coping questionnaire was used to assess relapse coping strategies . descriptive statistics was used to analyze the data.results : the findings revealed that 71.2 % have experienced a relapse totally . it was hard to control the hypothetical high risk situation and they greatly wanted to use the substance ( mean 7.39 of 10 ) . addicts have used of all three coping skills in definitely would do level.conclusion : enhancing self - efficacy through training coping skills , especially abstinence - focused coping skills to react properly in high risk situation can be useful .

abdominal tb , a common clinical entity in indian sub - continent can infect the gastrointestinal tract , peritoneum , mesentery , lymph nodes , liver , spleen and pancreas . hepatic tb is usually associated with miliary tb or active pulmonary tb . however , isolated liver tb in the absence of miliary tb is very rare restricted to case reports and case series in english literature . the diagnosis is often delayed due to lack of specific symptoms and laboratory findings . here we report a case of synchronous hepatic tb and adenocarcinoma of the colon which is a very rare finding with only a few reports in the literature and none from the indian subcontinent . this case illustrates the diagnostic difficulties of hepatic tb and the need to consider it in the differential diagnosis of hepatic nodular lesions in carcinoma colon patients . increased awareness of this rare association

tuberculosis ( tb ) presenting as isolated liver mass without clinical evidence of tb is difficult to diagnose preoperatively and is usually mimicked by primary or metastatic carcinoma of the liver . hepatic tb associated with carcinoma colon is a rare association which has very rarely been reported in the literature . this case illustrates the diagnostic difficulties of hepatic tb and the need to consider it in the differential diagnosis of hepatic nodular lesions in carcinoma colon patients . here , we report a case of 48-year - old female who presented in the casualty with features of acute intestinal obstruction . preoperatively a mass was seen at the hepatic flexure along with three lesions in the liver presumed to be metastatic in origin . however , histopathology of the mass revealed adenocarcinoma colon and the liver lesion proved to be hepatic tb . we wish to highlight that on encountering a hepatic lesion in a carcinoma colon patient the possibility of hepatic tb should also be kept in mind apart from the obvious possibility of metastasis especially in an endemic country like india .

pancreatic ductal adenocarcinoma ( pdac ) is associated with the worst prognosis of all gastrointestinal malignancies , mainly due to late and unspecific symptoms , an aggressive tumor biology , and resistance to most therapies . , these patients were subjected to primary resection ; however , new data suggest that this group of patients may benefit from perioperative / neoadjuvant systemic chemotherapy . another 3040 % of patients present with borderline resectable or locally advanced / unresectable tumors . here , the risk of occult distant metastasis is higher than in patients with smaller resectable tumors , and perioperative / neoadjuvant treatment is generally recommended to downsize the primary tumor and estimate tumor biology . depending on the patient 's performance status and preferences , more or less aggressive regimens can be chosen . the further course is determined to be neoadjuvant / curative or palliative depending on the radiological and tumor marker response . however , radiological response prediction is difficult , and tumor markers are informative only in a subgroup of patients . the largest group of patients ( 50 % ) with pdac has metastases at the time of diagnosis which is associated with a very limited prognosis of < 1 year . for these patients , this review discusses the current controversy whether patients with pdac should consistently be treated in a perioperative / neoadjuvant setting . further , different treatment approaches for patients with pdac who are resectable or can likely be converted to resectability are briefly addressed .

pancreatic ductal adenocarcinoma is a highly aggressive disease , and medical as well as surgical therapeutic options are limited . this article reviews stage dependent treatment options , with a special focus on the current controversy of perioperative treatment regimens in initially borderline resectable or locally advanced patients . neoadjuvant treatment can potentially increase the rate of complete tumor resection and may be more effective than adjuvant systemic therapy . further , in the case of disease progression during or after neoadjuvant therapy , patients can be spared extensive surgery . today , common therapeutic regimens include gemcitabine / nab - paclitaxel and folfirinox , as well as chemoradiation . however , because of the paucity of evidence from randomized trials , most guidelines do not recommend neoadjuvant therapy in resectable tumors , and for borderline or locally advanced tumors only within clinical trials . importantly , every patient should be discussed in multidisciplinary tumor boards .

primary hyperparathyroidism is rarely a part of multiple endocrine neoplasia type 1 ( men-1 ) syndrome with familial occurrence . the genetic background of this syndrome offers a unique opportunity to review a pathomechanism of tumourigenesis that may be also operative in some sporadic tumours . the classic clinical manifestation of men-1 is a composition of parathyroid hyperplasia , pancreatic endocrine tumour , and pituitary adenoma . all three tumours , however , do not develop in all affected patients during their life span . therefore , the contemporary definition of men-1 is the coincidence of at least two of the above - mentioned tumours . a diagnosis of familial men-1 requires , besides that , a first - degree relative with at least one of the three tumours . in an autopsy series , prevalence of the men-1 syndrome was estimated at 2.2 per 1000 in the general population , but biochemical surveys suggested lower figures0.010.175 per 1000 [ 3 , 4 ] . in patients with primary hyperparathyroidism ( hpt ) approximately 15 % is associated with the men-1 syndrome [ 3 , 5 ] . combining this data with hpt incidence , the prevalence of men-1 can be estimated to be 1030 per 100,000 in the general population . in about 60 % of men-1 patients moreover , it is important to stress that other enteropancreatic tumours usually accompany gastrinoma in men-1 . insulinoma is found in 1030 % of men-1 cases with the classic clinical presentation with recurrent neuroglycopenia , mainly in fasting , similar to that of sporadic cases . other rare enteropancreatic tumours diagnosed in men-1 may secrete somatostatin , glucagon , vasoactive intestinal peptide ( vip ) , growth hormone - releasing factor ( ghrh ) , acth , or parathyroid hormone - related peptide ( pthrp ) . in approximately 30 % of men-1 patients prolactin - secreting microadenomas or tumours secreting growth hormone or acth are less frequent , with the signs and symptoms equivalent to those in sporadic cases . neuroendocrine tumour ( carcinoid ) , found in about 14 % of men-1 cases , originates mainly from the foregut ( thymus , bronchus , stomach , pancreas , duodenum ) , in contrast to sporadic cases originating mainly from midgut . in up to 40 % of men-1 cases the localization of the tumours in the men-1 syndrome can not be explained by the ubiquitous expression pattern of the mutated gene men-1 and its encoded protein , menin . the interaction of menin with mixed - lineage leukaemia protein - containing histone methyl transferase ( mll - hmt ) complex mediates tissue - selective tumour - suppressing and tumour - promoting effects and may be responsible for the tissue susceptibility to tumourigenesis in men-1 .

primary hyperparathyroidism may occur as a part of an inherited syndrome in a combination with pancreatic endocrine tumours and/or pituitary adenoma , which is classified as multiple endocrine neoplasia type 1 ( men-1 ) . this syndrome is caused by a germline mutation in men-1 gene encoding a tumour - suppressor protein , menin . primary hyperparathyroidism is the most frequent clinical presentation of men-1 , which usually appears in the second decade of life as an asymptomatic hypercalcemia and progresses through the next decades . the most frequent clinical presentation of men-1-associated primary hyperparathyroidism is bone demineralisation and recurrent kidney stones rarely followed by chronic kidney disease . the aim of this paper is to present the pathomechanism , screening procedures , diagnosis , and management of primary hyperparathyroidism in the men-1 syndrome . it also summarises the recent advances in the pharmacological therapy with a new group of drugs calcimimetics .

lung cancer is the most common cause of metastasis to the central nervous system ( 1 ) . the brain is also one of the most commonly involved organs in metastases from non - small cell lung cancer ( nsclc ) ( 2 ) . unfortunately , once metastatic brain disease become clinically apparent , the cancer usually has already disseminated widely , which signifies extremely poor prognosis . the median survival duration of patients with brain metastases from nsclc is approximately 1 month without treatment ( 3 ) , 2 - 3 months when treated with steroids alone ( 4 ) , and 3 - 6 months when treated with whole brain radiotherapy ( wbrt ) ( 5 ) . as the survival of patients with brain metastases tends to be so short , quality of life and alleviation of symptoms recently , however , aggressive treatment involving either surgical resection or radiosurgery has been applied , with potential curative intentions . neurosurgical resection of solitary brain metastasis of various origins resulted in a prolongation of median survival to 3.5 - 8 months ( 6 ) . also , in lung cancer cases , several retrospective reviews have suggested that aggressive therapy , such as resection of the lung and isolated synchronous brain lesions , as well as metachronous brain metastases , may be associated with prolonged survival duration ( 7 - 9 ) . under the presumption that low - burden metastatic disease can be effectively surgically resolved in certain subsets of patients , we have treated patients exhibiting primary nsclc and isolated synchronous brain metastases aggressively , by the combined control of lung and brain lesions . this study retrospectively examined our experiences with patients who underwent treatment of isolated synchronous brain metastases coupled with primary nsclc in the last ten years .

this study is a retrospective examination of our experiences with patients who underwent treatment of isolated synchronous brain metastases coupled with primary non - small cell lung cancer . from january 1995 to june 2004 , 12 patients presented with isolated synchronous brain metastases coupled with primary non - small cell lung cancer . the patient was comprised of 8 men and 4 women . the median age was 52 yr , in a range of 32 to 75 yr . median follow - up duration was 10.6 months , in a range of 2 to 55.8 months . recurrence developed in 7 patients , and the median interval from 1st treatment to recurrence was 4.5 months ( 2.8 - 6.5 months ) . the overall 1-yr survival rate was 61.7 % . the 1-yr survival rates for pathologic n0 and n1 cases were 75 % and 66.7 % , respectively . the median survival duration for pathologic n2 was 6.2 months ( 95 % ci , 4.8 - 7.5 months ) . the 1-yr survival rate for cases of single brain metastasis was 75 % . based on our current observations , we could speculate that aggressive management of primary non - small cell lung cancer and isolated synchronous brain metastases was beneficial in a selected group of patients , as long as the brain lesions and pulmonary lesions were limited or resectable .

. clinical features of the disease vary from asymptomatic to symptomatic lymphadenopathy accompanied by fever , malaise and/or weight loss . based on the histological findings cd is divided into two variants the hyaline vascular variant ( hvv ) and the plasma cell variant ( pcv ) . when disease location is considered , cd can be divided further into three types including a unicentric hvv found in 72 % of cases , unicentric pcv accounting for 18 % of cases and multicentric pcv identified in 10 % . the following case has two unique features : ( 1 ) presentation as an obstructive jaundice mimicking acute cholangitis and ( 2 ) presentation as a widespread systemic lymphadenopathy . the final diagnosis was confirmed as multicentric hvv , which is a very rare variant accounting for only 1 % of all cd cases .

castleman disease ( cd ) is a rare lymphoproliferative disorder of unknown etiology with different clinical manifestations . a previous healthy 50 year - old man was hospitalized for right upper quadrant ( ruq ) abdominal pain . he had jaundice and a 1 cm - sized lymph node in the right supraclavicular area . pancreas and biliary computed tomography ( ct ) showed masses at the right renal hilum and peripancreatic areas . positron emission tomography ( pet ) showed widespread systemic lymphadenopathy . excisional biopsy of the right supraclavicular node revealed a hyaline vascular variant of cd . corticosteroid therapy was started and the extent of disease decreased . we here report a case of multicentric cd , the hyaline vascular variant , presenting with jaundice , diagnosed by excisional biopsy and successfully treated with corticosteroids .

trichotillomania is a common impulse control disorder seen in both children and adults characterized by the intense urge to pull out one 's hair which then results in hair loss over the scalp , eyebrows , and/or pubic areas . pulling is often caused or preceded by stress and anxiety which is then relieved after the hair pulling process . there is also a sense of guilt , ridicule , and shame associated with the disorder and patients do not often present on their own for treatment . sometimes , patients may have trichotillomania like symptoms that may extend to them pulling hair from sofa fibers , carpets , soft toys , and even pet animals though its documentation is not as common as the disorder itself . patients with trichotillomania often have insight that they have a disorder and may present to dermatological clinics seeking treatment for alopecia which is patchy and may appear to be alopecia areata . on close scrutiny , however , it may be detected that the alopecia is often due to trichotillomania rather than alopecia areata . here , we present a case of a patient who had trichotillomania and recovered well but then started pulling her child 's hair and in fact brought the child for treatment claiming nonawareness with regards to the cause of the hair loss .

trichotillomania is a disorder of an impulsive hair pulling that occurs in both adults and children alike . trichotillomania is seen in children and often has other psychiatric comorbidity . here , we present an interesting case of a mother who had trichotillomania and recovered with treatment following which she resorted to pulling hair of her child and brought her child for treatment saying that the child too had trichotillomania and that we should help the child recover like her . after interviewing the child , it was revealed that it was , in fact , the mother who used to pull the child 's hair as a release for her hair - pulling urges .

regional anesthesia is the recommended technique for upper and lower limb surgeries with better postoperative profile . considerable research has been conducted over years in order to determine the ideal local anesthetic ( la ) drug . an ideal drug should have a fast sensory onset , differential offset , with an earlier offset of motor than sensory blockade , enabling early ambulation / movements with prolonged analgesia . several combinations of las and adjuvants such as tramadol , sufentanyl , clonidine , and fentanyl have been employed in the search for near ideal agent , which remains elusive . currently , levobupivacaine ( s ( ) -enantiomer of bupivacaine ) with favorable clinical profile and lesser cardiotoxicity when compared with racemic bupivacaine is being favored la for regional block . dexmedetomidine , an 2-receptor agonist , with 2/1 selectivity 8 times than that of clonidine has also been reported to improve the quality of intrathecal and epidural anesthesia when used along with la as adjuvant . in our current prospective , randomized , double - blind study we evaluated the effectiveness of the addition of dexmedetomidine to levobupivacaine for supraclavicular brachial plexus block . it was hypothesized that addition of dexmedetomidine 1 g / kg to levobupivacaine will help to reduce the total dose of levobupivacaine required for supraclavicular brachial plexus block . other primary objectives were to asses : onset and duration of sensory blockade ; onset and duration of motor blockade ; duration of postoperative analgesia ; and patient satisfaction score ( pss ) . secondary objectives assessed included : intraoperative narcotic requirement ; hemodynamic changes ; and any side - effects or complications .

background and aims : regional anesthesia is a recommended technique for upper and lower limb surgeries with better postoperative profile . in this , randomized , double - blind study , we evaluated the effectiveness of the addition of dexmedetomidine to varying concentration of levobupivacaine for supra clavicular brachial plexus block.material and methods : after obtaining ethical committee approval , a double - blind , randomized prospective clinical study was conducted on 90 american society of anesthesiologist grade i and ii patients in the age group of 18 - 55 years , divided randomly into two groups : group a received 40 ml of solution containing 30 ml 0.5 % levobupivacaine and 10 ml 1 % lignocaine and group b received 40 ml of solution containing 30 ml 0.25 % levobupivacaine and 10 ml 1 % lignocaine with dexmedetomidine 1 microg / kg for supraclavicular brachial plexus block . besides effectiveness , other parameters observed were : duration of sensory blockade ; onset and duration of motor blockade ; duration of postoperative analgesia ; and patient satisfaction score.results : onset of sensory and motor blockade was 7.6 1.006 min and 8.3 0.877 min in group a , while it was 6.96 1.077 min an 7.6 1.1 min in group b , respectively . the difference was statistically significant ( p < 0.05 ) . duration of sensory block was 8.5 0.77 h in group a and 8.5 0.98 in group b ( p > 0.05 ) . duration of motor block was 8.45 0.75 h in group a and 5.6 0.98 in group b ( p < 0.05 ) . duration of analgesia was 8.5 0.77 h in group a and 9.2 1.05 in group b ( p < 0.05 ) .conclusion : addition of 1 microg / kg dexmedetomidine to 0.25 % levobupivacaine for supraclaviclar plexus block shortens sensory , motor block onset time and motor block durations , extends sensory block , and analgesia durations . reduction in total levobupivacaine dose also increases the safety margin of the block .

the first case of hiv was reported in nepal in 1988 , thereafter , there was a trend for increasing numbers of infections being recorded among specific groups of the population and in the low - risk general population for 20 years . although nepal 's hiv control programme has achieved some progress in reducing the incidence of hiv infections , it needs to be implemented effectively and efficiently to achieve the targets set . hiv in nepal is characterised as a concentrated epidemic in specific groups of the population , for example people who inject drugs ( pwid ) , men who have sex with men ( msm ) and female sex workers ( fsw ) . male migrants who work particularly in india , where migrant labourers often visit female sex workers , are considered a bridging population that transfers infections to the general population . forty - eight per cent of nepal 's population are between the age of 15 and 49 years , and are vulnerable for acquiring and transmitting hiv infection . the global health sector strategy on hiv 20162021 has proposed the vision of zero new infections , zero new deaths and zero hiv - related discrimination in a world where people living with hiv are able to live long and healthy lives . nepal 's national hiv / aids strategy 20112016 has adopted strengthening of the second generation surveillance ( sgs ) system . however , before starting sgs , it is important to know the status and progress made in hiv / aids control so as to further strengthen control programmes based on identified intervention gaps . the epidemiology of hiv in nepal has changed due to evolutions in policies over the last 10 years , particularly in diagnosis and treatment , and the various efforts to control hiv in the different population groups . therefore , this review aims to improve knowledge on the effectiveness of the interventions / policies in different sub - populations at risk .

abstractbackground and objectivesnepal has made progress with the control of hiv infection in recent years . there have been changes in epidemiology , programme interventions in different population groups , and changes in policies over the last 10 years , particularly in diagnosis and treatment . therefore , this review was conducted to identify the effectiveness of different interventions / policies in different sub - populations at risk , targeted towards epidemiology and treatment outcomes for those with hiv infection in nepal.methodsthis review was prepared based on a review of published and unpublished documents from the nepalese hiv infection control programme , published articles in different journals , different survey reports including integrated bio - behavioural surveillance ( ibbs ) survey reports.resultsthe prevalence of hiv infection among adults in 2014 was 0.20 % with a progressive decreasing trend from 2005 . the prevalence of hiv infection among injecting drug users ( 51.7 % in 2005 and 6.4 % in 2015 in kathmandu valley ) was relatively high in all years as compared to other risk groups . hiv infection prevalence among women attending antenatal clinics was higher in the year 2006 ( 0.25 % ) but there was a decreasing trend in the following years to 2015 , when prevalence was 0.077 % . although different interventions were conducted to cover key populations at risk , the coverage in some risk population was very low . hiv testing status among the general population was very low ( 7.5 % among males and 2.9 % among females ) in 2011 . only one - third of hiv - infected individuals were on art in 2015 , although this proportion has increased since 2005 . the share of domestic budget among the total expenditure on hiv control program is below 15 % .conclusionsthere is the need for implementation of control programmes more efficiently and effectively with expanding geographical and population coverage . surveillance systems should be strengthened to get up - to - date information for evidence - based planning and developing strategies . the domestic budget for hiv control programme should be increased to improve their sustainability .

the term acute coronary syndrome ( acs ) encompasses a range of thrombotic coronary artery diseases , including unstable angina ( ua ) , and both st segment elevation ( stemi ) and non - st segment elevation myocardial infarction ( nstemi ) , mostly induced by local coronary thrombosis as an acute complication of atherosclerosis . patients with an acute coronary syndrome have a high risk of suffering subsequent cardiac events . [ 24 ] coronary plaque disruption , with consequent platelet aggregation and thrombosis , is the most important mechanism by which atherosclerosis leads to the acute ischemic syndromes of unstable angina , acute myocardial infarction , and sudden death . with growing evidence that atherosclerosis is an inflammatory process , several plasma markers of inflammation have been evaluated as potential tools for the prediction of coronary events . these markers of inflammation include serum amyloid a , interleukin 6 , homocysteines , fibrinogen levels , fibrinolytic capacity , apolipoprotein a , apolipoprotein b-100 , lipoprotein ( a ) and c - reactive protein ( crp ) . increased concentrations of crp have been reported in unstable angina and in acute myocardial infarction . liuzzo and associates have shown that concentrations of crp and serum amyloid a in unstable angina increase independently of myocardial cell injury . they also reported that higher concentrations of crp at the time of hospital admission ( > 3.0 mg / l ) were predictive of a poor outcome in unstable angina . crp has been shown to predict risk in a wide variety of clinical settings ; it has incremental value in addition to standard lipid screening for primary prevention . [ 1113 ] a recent analysis by chew et al . shows that crp predicts the risk of death or myocardial infarction at 30 days among patients undergoing percutaneous coronary intervention . crp was found to be independently associated with the recurrence of cardiovascular events and with death in the mid to long term . it has been suggested that crp may not only be a marker of generalized inflammation but directly and actively participates in both atherogenesis and atheromatous plaque disruption . the aim of the present study was to evaluate the prognostic value of crp in predicting cardiovascular outcome in patients presenting with acute coronary syndromes .

background and objectives : the acute - phase reactant c - reactive protein ( crp ) has been shown to reflect systemic and vascular inflammation and to predict future cardiovascular events . the objective of this study was to evaluate the prognostic value of crp in predicting cardiovascular outcome in patients presenting with acute coronary syndromes.patients and methods : this prospective , single - centered study was carried out by the department of pathology in collaboration with the department of cardiology , bolan medical college complex quetta , balochistan , pakistan from january 2009 to december 2009 . we studied 963 consecutive patients presenting with chest pain to accident and emergency department . patients were divided into four groups . group-1 comprised patients with unstable angina ; group-2 included patients with acute st elevation myocardial infarction ( stemi ) ; group-3 comprised patients with non - st elevation myocardial infarction ( non - stemi ) and group-4 was the control group . all four groups were followed - up for 90 days for occurrence of cardiovascular events.results : the crp was elevated ( > 3 mg / l ) among 27.6 % patients in group-1 ; 70.9 % in group- 2 ; 77.9 % in group-3 and 5.3 % in the control group . among cases with elevated crp , 92.1 % had a cardiac event compared to 34.3 % among patients with crp 3 mg / l ( p < 0.0001 ) . the mortality was significantly higher ( p < 0.0001 ) in group-2 ( 8.9 % ) and group-3 ( 11.9 % ) as compared to group-1 ( 2.1 % ) . there was no cardiac event or mortality in group-4.conclusions : elevated crp is a predictor of adverse outcome in patients with acute coronary syndromes and helps in identifying patients who may be at risk of cardiovascular complications .

osteonecrosis of the knee , first reported by ahlback et al.1 ) is characterized by severe pain of sudden onset on the medial side of the knee . the etiology of osteonecrosis has not yet been clearly elucidated , but possible causative factors include sickle cell anemia , gaucher disease , caisson disease , corticosteroid treatment , systemic lupus erythematous , and alcohol abuse . thus , the two major theories of etiology are related to trauma and vascular diseases2 ) . the trauma theory implies that repetitive microtrauma in osteoporotic bones results in stress fracture and osteonecrosis . on the other hand , the vascular disease theory explains that an alteration in microcirculation increases bone marrow pressure and microthrombosis disrupts normal blood flow , which leads to the development of osteonecrosis . osteonecrosis after arthroscopic meniscectomy is very rare and only about a score of cases has been reported since first described by brahme et al.3 ) in 1991 . santori et al.4 ) suggested that abnormal load transfer after meniscectomy that results in chondral damage , inflammation , edema , and increased bone marrow pressure is the major cause of osteonecrosis . in spite of the rarity , osteonecrosis of the knee after arthroscopic meniscectomy requires early diagnosis and proper treatment to prevent it from developing into a serious complication . in this report , we present a case of osteonecrosis after partial medial meniscectomy that exhibited rapid progression with a review of the literature .

osteonecrosis of the femoral condyle is known as an uncommon complication after arthroscopic meniscectomy . the lesion of osteonecrosis can be irreversible , thus early detection of the disease is crucial for treatment . a 50-year - old male patient without known risk factors of osteonecrosis developed increasing knee pain after arthroscopic partial meniscectomy . magnetic resonance imaging showed rapid progression of osteonecrosis of the medial femoral condyle . unicompartmental knee arthroplasty was performed after 9 months of conservative therapy . the patient is now free from pain during daily activities . it might be important to remind that if the patient 's pain after arthroscopic partial meniscectomy is severe than expected , clinical doctors should pay attention to the possibility of ongoing osteonecrosis of the femoral condyle .

in postmortem studies , dementia with lewy bodies ( dlb ) accounts for 1020 % of all cases of dementia and can therefore be regarded as the second most common cause of dementia after alzheimer 's disease ( ad ) . for a definite diagnosis , autopsy is required . however , confirmation of the diagnosis during the patient 's lifetime is both reasonable and important , since patients with dlb respond to acetylcholine esterase inhibitors and furthermore demonstrate a hypersensitivity to antipsychotic treatment . clinical consensus criteria from 1996 possess a fairly high specificity with 8090 % , but only a low sensitivity , decreasing to 30 % according to some studies . an improvement in clinical accuracy particularly when ad is part of the differential diagnosis seems to be worthwhile . in postmortem studies , a 5790 % loss of presynaptic dopamine transporters could be demonstrated in dlb but not in ad . the presence a dopaminergic abnormality in dlb including striatal dopaminergic transporter loss was outlined in vivo with positron ( pet ) and single - photon emission computed tomography ( spect ) . on the grounds of these observations , a positive , i.e . abnormal , fp - cit - spect was included as a feature suggestive of dlb in the revised clinical consensus criteria from 2005 . sensitivity could thereby be increased up to 81.3 % . moreover , in a follow - up study over a period of 1 year , it was shown that in case of clinical suspicion , an fp - cit scan may be helpful . of 19 patients initially diagnosed as having possible and after 1 year as having probable dlb , 12 patients ( 63.2 % ) had pathological fp - cit - spect , while the remaining 7 cases that were assessed as non - dlb at the 1-year follow - up had normal datscan ( 100 % specificity ) . another challenge in differential diagnosis resides in the distinction between parkinson 's disease and dementia ( pdd ) . it is still an open question whether the underlying neurobiological changes result from one and the same mechanism in both entities . fp - cit - spect is abnormal in both dlb and pdd , possibly with a lower dopamine transporter uptake in pdd than in dlb . regarding the current clinical criteria , an agreement was reached that the diagnosis of dlb is not possible when extrapyramidal features are present for > 12 months before the diagnosis of dementia . in the following , we describe 3 cases who had no extrapyramidal signs , and thus dlb was the only possible diagnosis ( table 1 ) .

clinically , alzheimer 's disease ( ad ) is by far the most common cause of dementia . criteria for the diagnosis of dementia with lewy bodies ( dlb ) are highly specific but not at all sensitive , which is reflected by the higher number of dlb cases detected histopathologically at autopsy . imaging of dopamine transporter with fp - cit spect is one possibility to increase sensitivity . pathological confirmation was also included in the revised consensus criteria for the diagnosis of dlb . however , in the absence of parkinsonism , one of the core features , a clinical diagnosis of ad is more likely . the role of fp - cit spect in dlb diagnosis remains to be clarified . based on our 3 case reports and a review of the literature , the utility of this imaging method in the differential diagnosis of ad and dlb is highlighted .

highly active antiretroviral therapy ( haart ) has improved the prognosis of patients with human immunodeficiency virus ( hiv ) infection by significantly reducing related morbidity and mortality.1,2 early treatment protocols , many of which are still recommended , contain two nucleoside reverse transcriptase inhibitors ( nrti ) and one nonnucleoside reverse transcriptase inhibitor ( nnrti ) or a protease inhibitor ( pi ) .35 nnrtis currently included in treatment regimens comprise nevirapine ( npv ) , efavirenz , and rilpivirine . although npv is used mostly to substitute pis in patients with high cardiovascular risk in developed countries,5 it is still included in first - line treatment regimens in low - income countries.3 given its short plasma half - life , nvp immediate - release ( nvp - ir ) must be administered twice a day to achieve a 24-hour effective plasma level.6 in order to simplify art regimens and improve adherence to prescribed medications , the extended - release formulation of nvp ( nvp - xr ) , which allows a single daily intake , has been developed and tested in two phase iii clinical trials . the aim of the current review is twofold : ( 1 ) to highlight the clinical utility and efficacy of nvp - xr ; ( 2 ) to assess the impact of nvp - xr on patients safety by shedding light on the main side effects of nvp - xr and the expected gain in term of treatment adherence .

an extended - release formulation of nevirapine ( nvp - xr ) has been developed with the aim of simplifying antiretroviral treatment regimens and improving patients adherence with a single daily intake . the verxve and tranxition clinical trials have demonstrated the noninferiority of nvp - xr compared with nevirapine immediate - release ( nvp - ir ) on viral load after 24 and 48 months of treatment . the tolerance profiles of nvp - xr and nvp - ir are similar . simplifying the treatment dosage for nvp would likely improve adherence to antiretroviral treatments .

exaggerated innate immune / inflammatory responses in the brain are now thought to be a common core in the etiology of numerous psychiatric disorders such as depression , ptsd and bipolar disorder ( jones and thomsen , 2013 ) . seemingly unrelated to neuroinflammation , the experience of life stressors is a predisposing factor in the development of psychiatric disorders ( kessler , 1997 ) . however , the clinical literature contains numerous instances in which stress predisposes individuals to inflammatory disorders such as cardiovascular disease ( albus , 2010 ) , which have a high comorbidity with psychiatric conditions that include depression ( sansone and sansone , 2008 ) . indeed , recent evidence from several laboratories , including our own , suggests that stressors sensitize or prime the neuroinflammatory response to subsequent pro - inflammatory challenges , thereby providing a mechanism that can link the impact of stressors and a pivotal role for neuroinflammatory processes in the development of psychiatric disorders . the central notion explored here is that exposure to stressors can induce a vulnerable phenotype characterized , in part , by a sensitized neuroimmune microenvironment . thus , prior stress can lead to a potentiated neuroinflammatory cascade upon exposure to pro - inflammatory challenges that include bacterial or viral infection and sterile injury . this exaggerated neuroinflammatory response can then manifest as changes in cognitive ( e.g . memory ) , affective ( e.g . mood ) , sensory ( e.g . pain ) and vegetative ( e.g . sleep and eating ) endophenotypes , typically observed in a spectrum of psychiatric disorders . several neuroimmune mechanisms , by which stress sensitizes / primes the neuroinflammatory response to pro - inflammatory challenges , have been characterized in recent years . first , a brief overview of neuroinflammatory processes will be provided as a basis for exploring mechanisms of neuroinflammatory priming .

stress and glucocorticoids ( gcs ) have universally been considered to be anti - inflammatory , however in recent years , stress and gcs have been found to exert permissive effects ( immunological priming ) on neuroinflammatory processes . this phenomenon of priming is characterized by prior stress or gc exposure potentiating the neuroinflammatory response to a subsequent immune challenge . a considerable body of evidence is discussed here that supports this permissive effect of stress and gcs.in light of this evidence , a mechanism of neuroinflammatory priming is proposed involving a signal cascade in the brain involving danger - associated molecular patterns ( hmgb-1 ) and inflammasomes ( nlrp3 ) , which results in an exaggerated or amplified neuroinflammatory response and subsequently , the amplification of the physiological and behavioral sequelae of this response ( i.e . sickness ) . finally , we explore the notion that stressor - induced sensitization of the neuroimmune microenvironment may predispose individuals to psychiatric disorders , in which exaggerated innate immune / inflammatory responses in the brain are now thought to play a key role .

the -adrenergic receptor ( -ar ) plays an essential role in normal physiologic functions and consists of catecholamines and their corresponding receptors , including the - and -ar families . the sympathetic nervous system regulates the body 's fight or flee response through the -adrenergic pathway . increasing evidence suggests that -ar signaling is crucial in cancer progression and metastasis and regulates tumor growth , invasiveness , migration , angiogenesis , apoptosis , and anoikis . the nonselective -ar blocker propranolol has exhibited anticancer effects in cancer cell lines and animal models . the association between -ar - blocker usage and cancer outcomes has been widely studied in breast cancer , prostate cancer , ovarian cancer , melanoma , and colon cancer . the use of -ar - blockers has been demonstrated to reduce the recurrence of metastasis and mortality in most studies ; however , several population - based cohort studies have yielded inconsistent findings . whether a -adrenergic pathway is involved in the initiation of cancer several retrospective studies have demonstrated that a -ar blocker can reduce cancer risk , whereas other studies have yielded conflicting results . to clarify the association between the nonselective -ar blocker propranolol and cancer incidence , we conducted a nationwide population - based cohort study , using a substantial dataset available in taiwan .

abstract-blockers have been reported to exhibit potential anticancer effects in cancer cell lines and animal models . however , clinical studies have yielded inconsistent results regarding cancer outcomes and cancer risk when -blockers were used . this study investigated the association between propranolol and cancer risk.between january 1 , 2000 and december 31 , 2011 , a patient cohort was extracted from the longitudinal health insurance database 2000 , a subset of the taiwan national health insurance research database . a propranolol cohort ( propranolol usage > 6 months ) and nonpropranolol cohort were matched using a propensity score . cox proportional hazard models were used to estimate the hazard ratio ( hr ) and 95 % confidence intervals ( cis ) of cancer associated with propranolol treatment.the study sample comprised 24,238 patients . after a 12-year follow - up period , the cumulative incidence for developing cancer was low in the propranolol cohort ( hr : 0.75 ; 95 % ci : 0.670.85 ; p < 0.001 ) . patients with propranolol treatment exhibited significantly lower risks of cancers in head and neck ( hr : 0.58 ; 95 % ci : 0.350.95 ) , esophagus ( hr : 0.35 ; 95 % ci : 0.130.96 ) , stomach ( hr : 0.54 ; 95 % ci : 0.300.98 ) , colon ( hr : 0.68 ; 95 % ci : 0.490.93 ) , and prostate cancers ( hr : 0.52 ; 95 % ci : 0.330.83 ) . the protective effect of propranolol for head and neck , stomach , colon , and prostate cancers was most substantial when exposure duration exceeded 1000 days.this study supports the proposition that propranolol can reduce the risk of head and neck , esophagus , stomach , colon , and prostate cancers . further prospective study is necessary to confirm these findings .

copd is associated with significant morbidity and health care costs , and though current pharmacologic treatments have modest benefits , adjunctive pulmonary rehabilitation ( pr ) has been shown to substantially impact patient outcomes.1,2 the minimum recommended duration of therapy for pr is 8 weeks , and successful completion of pr is associated with improvements in quality of life and dyspnea , exercise tolerance , and a decrease in the rates of exacerbations and hospitalizations.35 despite these benefits , recent studies have highlighted very poor referral rates for pr overall and as low as 10 % post - hospitalization.6 of those who do attend pr , a significant percentage of patients do not complete the program with attrition rates as high as 60 % .79 the documented benefits of pr necessitate accurate identification of factors associated with non - completion . prior studies have linked non - completion of pr to multiple factors including patients perceptions of their illness and attitudes toward treatment options , time constraints , and transportation problems.10,11 in addition , while pr has been shown to reduce the rate of exacerbation , one study found that individuals frequently withdrew or missed pr appointments due to copd exacerbations or hospitalizations occurring during their enrolment.4,11 while previous smaller studies have documented socioeconomic and psychosocial factors associated with non - completion , many of these are not modifiable . in addition , prior reports have not adequately examined the impact of common copd comorbidities on pr attendance.7,9,1217 we analyzed data from a large , prospective cohort of copd patients at a tertiary care hospital to systematically examine factors associated with pr attendance . specifically , we hypothesized that several modifiable factors including smoking status as well as comorbid depression and anxiety would predict completion of pr . we also hypothesized that completion of pr at our center would result in improvements in exercise capacity and quality of life comparable to prior reports .

backgrounddespite known benefits , a significant proportion of patients with copd do not complete pulmonary rehabilitation ( pr ) . little is known regarding which factors promote successful completion of pr.methodswe analyzed data from a prospectively maintained database of subjects with copd who attended a pr program at the university of alabama at birmingham , from 1996 to 2013 . subjects were categorized as either completers or non - completers , based on successful completion of at least 8 weeks of pr . demographics and comorbidities were recorded . short form 36 health survey , beck depression inventory - ii , and san diego shortness of breath questionnaire were administered to all participants at baseline and on completion of pr to assess participants perception of their health status , severity of depression , and dyspnea with performance of activities of daily living . univariate and multivariable analyses were performed to identify predictors of successful completion of pr.resultsfour hundred and forty subjects were included , of whom 229 completed pr . forty - one percent were female , and 17 % were african american . compared with non - completers , completers had greater short form 36 health survey pain score , lower forced expiratory volume in the first second , and lower beck depression inventory score , and included a lower percentage of current smokers . on multivariate analysis , cigarette smoking at enrollment was associated with lower likelihood of completion of pr ( adjusted odds ratio 0.38 , 95 % confidence interval 0.160.90 ; p=0.02 ) .conclusioncigarette smoking was the sole independent predictor of pr dropout , and smoking cessation may warrant greater emphasis prior to enrollment .

shivering , a common post - anaesthesia occurrence is defined as an involuntary , repetitive activity of skeletal muscles . the incidence of shivering has been found to be quite high , approximately 40 - 50 % in different studies . shivering also increases intraocular and intracranial pressure , and may contribute to increased wound pain , delayed wound healing , and delayed discharge from post - anaesthetic care . apart from being an uncomfortable experience , its deleterious effects deserve primary prevention and rapid control on occurrence . shivering is a physiological response to core hypothermia in an attempt to raise the metabolic heat production . the main causes of intra / post - operative shivering are temperature loss , increased sympathetic tone , pain , and systemic release of pyrogens . spinal anaesthesia significantly impairs the thermoregulation system by inhibiting tonic vasoconstriction , which plays a significant role in temperature regulation . it also causes a redistribution of core heat from the trunk ( below the block level ) to the peripheral tissues . the non - pharmacological management is by external heating like the use of forced air warming , warming blankets , warmed fluids etc . , according to the results of a meta - analysis , the most frequently reported pharmacological interventions include clonidine , pethidine , tramadol , nefopam and ketamine . unfortunately , no gold standard treatment is known for shivering as the administration of all the available drugs is associated with various adverse effects . during the last decade , tramadol has become a favoured and commonly used drug for post - spinal anaesthesia shivering . however , it has many adverse effects like nausea , vomiting , dizziness etc . , which cause further discomfort to the patient . various studies , which have been conducted to compare them have concluded that clonidine has better efficacy and less adverse effects as compared to tramadol . it has been used as a sedative agent and is known to reduce the shivering threshold . few studies which have explored its anti - shivering potential have inferred that dexmedetomidine is an effective drug without any major adverse effect and provides good haemodynamic stability . hence , we planned to do a comparative study of the efficacy , haemodynamic , and adverse effects of tramadol and dexmedetomidine when used for the control of post - spinal anaesthesia shivering .

background and aims : dexmedetomidine ( 2 adrenergic agonist ) has been used for prevention of post anaesthesia shivering . its use for the treatment of post - spinal anaesthesia shivering has not been evaluated . the aim of this study was to evaluate and compare the efficacy , haemodynamic and adverse effects of dexmedetomidine with those of tramadol , when used for control of post - spinal anaesthesia shivering.methods : a prospective , randomised , and double - blind study was conducted in 50 american society of anaesthesiologists grade i and ii patients of either gender , aged between 18 and 65 years , scheduled for various surgical procedures under spinal anaesthesia . the patients were randomised in two groups of 25 patients each to receive either dexmedetomidine 0.5 g / kg or tramadol 0.5 mg / kg as a slow intravenous bolus . grade of shivering , onset of shivering , time for cessation of shivering , recurrence , response rate , and adverse effects were observed at scheduled intervals . unpaired t - test was used for analysing the data.results : time taken for cessation of shivering was significantly less with dexmedetomidine when compared to tramadol . nausea and vomiting was observed only in tramadol group ( 28 % and ; 20 % respectively ) . there was not much difference in the sedation profile of both the drugs.conclusion : we conclude that although both drugs are effective , the time taken for cessation of shivering is less with dexmedetomidine when compared to tramadol . moreover , dexmedetomidine has negligible adverse effects , whereas tramadol is associated with significant nausea and vomiting .

type 2 diabetes ( t2d ) mellitus is a chronic metabolic disease with epidemic proportions . its global prevalence was estimated to be 6.4 % worldwide ( 285 million adults in 2010 ) and is predicted to rise to approximately 7.7 % ( 439 million ) by 2030 . t2d is a multifactorial disorder resulting from an interaction between genetic and environmental conditions ( sedentary lifestyle and western diet ) and characterized by a peripheral insulin resistance , hyperglycaemia , and pancreatic cell dysfunctions . two defects have been reported during diabetes development , a gradual deterioration of cell functions and a reduction in pancreatic cells mass . cell failure is not limited to t2d but is rather a common feature of all forms of diabetes , including the autoimmune type 1 diabetes ( t1d ) , autosomal dominant onset diabetes of young ( mody ) , wolfram syndrome , and wolcott - rallison syndrome ( wrs ) . in the early stage of diabetes development , the response of pancreatic islets challenged by nutrients and/or insulin resistance is a hypersecretion of insulin to maintain normoglycaemia . to this end , the process of cell compensation is a combination of cell mass expansion and an increase of acute glucose - stimulated insulin secretion . postmortem analyses of pancreas of nondiabetic obese patients show an increase of cell volume , implying postnatal plasticity of cell mass . moreover the cell compensation process is associated with an improved capacity of the secretory machinery to support increased insulin production . subsequently , the production of large amounts of insulin by compensating islet cells places a continuous demand on the er for proper protein synthesis , folding , trafficking , and secretion . when the folding capacity of the er is exceeded , misfolded or unfolded proteins accumulate in the er lumen , resulting in er stress . paradoxically , upr signalling activation leads to opposite cell fates , that is , adaptation / survival versus death . increasing evidence links the endoplasmic reticulum ( er ) stress to cell deterioration and apoptosis [ 2 , 3 ] . recent experiments performed in db / db mice and ob / ob mice models at different times of disease progression revealed that the maintenance ( or suppression ) of adaptive upr is associated with cell compensation ( or failure ) in obese mice . moreover , engin et al . recently showed a progressive loss of upr mediator expression before the onset of diabetes in nod mice . the administration of the chemical chaperone tauroursodeoxycholic acid to rescue the deleterious er stress response improved pathophysiological signs of diabetes with a recovery of cell survival and adaptation to stress . in addition , the authors showed a decline of the upr mediator in both experimental models and t2d human islets , suggesting that decreased expression of cell upr actors can play a central role in cell compensation and subsequently t2d occurrence .

pancreatic cell failure leads to diabetes development . during disease progression , cells adapt their secretory capacity to compensate the elevated glycaemia and the peripheral insulin resistance . this compensatory mechanism involves a fine - tuned regulation to modulate the endoplasmic reticulum ( er ) capacity and quality control to prevent unfolded proinsulin accumulation , a major protein synthetized within the cell . these signalling pathways are collectively termed unfolded protein response ( upr ) . the upr machinery is required to preserve er homeostasis and cell integrity . moreover , upr actors play a key role by regulating er folding capacity , increasing the degradation of misfolded proteins , and limiting the mrna translation rate . recent genetic and biochemical studies on mouse models and human upr sensor mutations demonstrate a clear requirement of the upr machinery to prevent cell failure and increase cell mass and adaptation throughout the progression of diabetes . in this review we will highlight the specific role of upr actors in cell compensation and failure during diabetes .

due to worldwide occurrence , substantial morbidity and mortality rates , respiratory viral infection which swiftly and easily spread , pose a serious public health problem ( 1 ) . human metapneumovirus ( hmpv ) is one of the etiological agents of acute respiratory tract infections ( artis ) which can infect people in all age groups ( 2 ) . it induces clinical symptoms ranging from upper to lower respiratory tract illnesses such as bronchiolitis , bronchitis and pneumonia ( 35 ) . in 2001 , hmpv was identified in samples from children with respiratory tract disease for the first time ( 6 ) . in addition , it is a new member of the family paramyxoviridae , subfamily pneumovirus , genus metapneumovirus ( 7 ) . rsv is one of the most important respiratory pathogens of childhood , with detection rates reaching 7085 % in hospitalized infants during seasonal winter epidemics worldwide ( 1 , 8 ) . rsv causes severe lower respiratory infections like bronchiolitis or pneumonia in infants and young children ( 9 ) . coinfection of hmpv with rsv in infants has been suggested to be a factor that influences the severity of bronchiolitis ( 9 ) . phylogenetically , rsv is the closest human virus related to hmpv , and the clinical manifestations of hmpv may share an overlapping spectrum with rsv , so that these two viruses can not be distinguished by clinical manifestations ( 4 , 7 , 9 , 10 ) . rsv and hmpv might have similar seasonal patterns , so co - infection is possible ( 6 , 9 ) . this report describes a case who did not have the respiratory sign and symptoms , while was actually infected with rsv and hmpv simultaneously .

background : respiratory virus infections in children are a leading cause of morbidity and mortality worldwide.methods : a total of 897 clinical specimens were collected from february 2007 to january 2008 and transported to the national influenza center . two hundred and two samples belonged to children under the age of six from 897 specimens , described above , were selected . then they were tested for influenza virus types and subtypes by real time pcr assay subsequently , the specimens were tested for rsv and hmpv by hemi - nested multiplex pcr and parainfluenza viruses type 14 by hemi - nested multiplex pcr and adenovirus by hemi - nested pcr.results : the throat swab was taken from the kawasaki case with the history of chicken s contact . the specimen was tested for all influenza subtypes especially h5n1 and the results were negative . meanwhile pcr was done for screening of other respiratory viruses that results came out positive for rsv and hmpv.conclusion : in the present study , we demonstrated the possibility to detect dual infection caused by rsv and hmpv , but because of the extravagant pattern of this case , more investigation is suggested specially on kawasaki patients .

sino - nasal undifferentiated carcinoma ( snuc ) is a rare malignancy first described by frierson et al . , as an aggressive neoplasm that was clinico - pathologically distinct from other poorly differentiated malignancies of the nasal cavity and sinuses . snuc is believed to originate from schneiderian epithelium or from the nasal ectoderm of the paranasal sinuses . snuc typically presents as a rapidly enlarging tumor mass involving multiple ( sinonasal tract ) sites , often with an evidence of extension beyond the anatomic confines of the sinonasal tract . given the undifferentiated nature of this malignancy , however , immunohistochemical analysis is extremely helpful . with the use of a panel of markers , positive staining for neuron - specific enolase and chromogranin , cytokeratins 7 , 8 and 19 , nonreactive to s-100 and non - expression of vimentin . these findings suggest that the tumor is of epithelial origin and lacks any evidence of neuroendocrine , muscle , melanocyte or leukocyte differentiation . this allows proper classification of the tumor as an snuc - a malignant tumor of the sinus ( sinonasal ) that is of epithelial origin ( carcinoma ) , but lacks evidence of keratin production ( undifferentiated ) . since the initial recognition of snuc as a distinct clinicopathological entity , treatment regimens have evolved to include the current recommendation of combined radial resection , radiotherapy and chemotherapy . despite this aggressive therapy , outcome has remained dismal , with the mean survival time being less than a year after diagnosis .

malignant neoplasms of the paranasal sinuses and nasal cavity are rare , comprising only 3 % of all head and neck malignancies . this includes both primary sinonasal neoplasms and metastatic disease . we present the case of a patient with a maxillary soft tissue swelling , which proved to be a rare malignant tumor of maxillary sinus origin , a sinonasal undifferentiated carcinoma

lichen striatus ( ls ) is an uncommon , asymptomatic , self - limiting dermatosis which lasts an average of nine months and usually occurs in children , although it is also rarely seen in adults . it often arises without a clear trigger , but some cases would appear to be related to several possible precipitating events such as infections and , more rarely , cutaneous injury , trauma , hypersensitivity , or other unspecified factors . ls typically presents as a continuous or interrupted linear band of pink , tan , red , or skin - colored papules that follow blaschko 's lines , which represent the pathways of cutaneous cell migration during embryonic development . the lesions are generally solitary and unilateral , but unusual cases with multiple and bilateral lesions have been rarely reported . however , this therapy is not always effective and its prolonged use may be associated with certain adverse effects including cutaneous atrophy . other anecdotal therapies include oral corticosteroid , photodynamic therapy , topical calcineurin inhibitors , and oral acitretin . we report a case of ls unresponsive to topical steroid therapy associated with psoriasis vulgaris , successfully treated with oral acitretin .

lichen striatus ( ls ) is an uncommon dermatosis of unknown etiology that presents as a continuous or interrupted linear band of pink , tan , red or skin - colored papules in a blaschkoid distribution . the lesions are generally solitary and unilateral , but unusual extensive cases with multiple and bilateral lesions have been also described . albeit ls is typically an asymptomatic and self - limited dermatosis , it may cause a significant psychological distress in some patients , thus requiring an appropriate therapy . topical steroid is the most commonly used treatment but it is not always effective . we report a case of ls unresponsive to topical steroid therapy associated with psoriasis vulgaris successfully treated with oral acitretin .

gastrinomas are neuroendocrine tumors ( net ) , primarily located in the duodenum or pancreas . gastrin overproduction causes the zollinger - ellison syndrome , which includes ulceration of the gastrointestinal tract , mainly the jejunum , resulting in abdominal pain and diarrhea . the incidence of gastrinomas is 0.52 per million per year and therefore very rare [ 2 , 3 ] . gastrinomas are classified according to a grading system , similar to other pancreatic neuroendocrine tumors ( pnets ) . this grading is based on histopathology and subdivided into immunostaining for tumor markers and proliferation markers ( table 1 ) . using the current who criteria , grades 1 and 2 are well - differentiated pnets with increased expression of the tumor markers , chromogranin a , and synaptophysin . grade 3 tumors are poorly differentiated with areas of necrosis and decreased expression of chromogranin a [ 3 , 5 ] . up to 25 % of the gastrinomas liver metastases are the most important prognostic factor for survival [ 2 , 6 ] . ten - year survival of patients with diffuse liver metastases is 16 % compared to 90 % 10-year survival in patients who underwent a curative gastrinoma resection . for patients with unresectable liver metastases , patients with liver metastases may experience symptoms such as weight loss , pain , and anorexia , particularly caused by tumor load . liver metastases derive the majority of their blood supply from the hepatic artery , compared with normal liver parenchyma , which derive the majority of the blood supply from the portal venous circulation . postembolization syndrome is the most important complication after embolization , characterized by symptoms of fever , unremitting nausea , general malaise , loss of appetite , and abdominal pain . the exact cause is not yet entirely clarified ; however , it may be a result of tumor ischemia and inflammation of the liver tissue [ 8 , 9 ] . only a small series describes the effect of hepatic embolization of liver metastases from gastrinomas . the aim of this study is to present our single - centre experience of the effect of selective arterial embolization for gastrinomas in symptoms reduction , complications , and response rate . these results are compared to the literature results , and a protocol for patients care during embolization is presented .

background . gastrinomas are rare functional neuroendocrine tumors causing the zollinger - ellison syndrome ( zes ) . at presentation , up to 25 % of gastrinomas are metastasized , predominantly to the liver . embolization of liver metastases might reduce symptoms of zes although a postembolization syndrome can occur . in this study , the results of embolization are presented , and the literature results are described . methods . from a prospective database of pancreatic neuroendocrine tumors , all patients with liver metastatic gastrinomas were selected if treated with arterial embolization . primary outcome parameters were symptom reduction , complications , and response rate . the literature search was performed with these items . results . three patients were identified ; two presented with synchronous liver metastases . all the three patients had symptoms of zes before embolization . postembolization syndrome occurred in two patients . six months after embolization , all the 3 patients had a clinical and complete radiological response ; a biochemical response was seen in 2/3 patients . from the literature , only a small number of gastrinoma patients treated with liver embolization for liver metastases were found , and similar results were described . conclusion . selective liver embolization is an effective and safe therapy for the treatment of liver metastatic gastrinomas in the reduction of zes . individual treatment strategies must be made for the optimal success rate .

mucinous cystic tumors of the ovary rarely contain one or more solid mural nodules in which the histological features differ markedly from the background of benign , borderline or malignant mucinous neoplasms . four varieties of mural nodules have been described , including true sarcomas , sarcoma - like mural nodules ( slmn ) , foci of anaplastic carcinoma and mixed type . slmn stend to occur in younger women and are characterized by smaller size , sharp demarcation , a heterogeneous cell population , and no serious impact on the prognosis . it should be differentiated from true sarcomatous mural nodules and foci of anaplastic carcinoma with areas of sarcomatoid differentiation since both of these lesions carry a graver prognosis . we report a very rare case of slmn in a borderline mucinous tumor of the ovary .

sarcoma - like mural nodule ( slmn ) is a very uncommon and misleading benign entity which may be associated with benign , borderline or malignant mucinous neoplasm of the ovary . it should be distinguished from other malignant mural nodules with sarcoma , carcinosarcoma or anaplastic carcinoma for proper management . we report a rare case of slmn in a borderline mucinous tumor of the ovary in a 30-year - old lady . in spite of having confusing histopathological features the final diagnosis was made depending on the younger age of the patient , well circumscription of the nodule , absence of vascular invasion and immunohistochemical profile .

by the end of 20 century , hepatitis c virus ( hcv ) started to emerge as a global threat with around 170 million people infected worldwide1 . the virus is a blood borne pathogen and the high risk group includes patients undergoing blood transfusions , intravenous drug users , renal patients undergoing frequent dialysis , people involved with tattooing and unsafe sexual activity . the infection with virus can follow either an acute and/or subsequently in majority of the cases a chronic clinical profile . while the acute infection is resolved spontaneously in a few weeks time without any therapeutic intervention , the most disturbing aspect of this infection is that the spontaneous viral clearance is atypical , with nearly 54 - 86 per cent of the infected individuals progressing to chronic hepatitis234 . chronic hcv infection is defined as the persistence of hcv rna in the blood for at least 6 months and in its more aggressive form in about 5 - 10 per cent cases progressing to cirrhosis and hepatocellular carcinoma ( hcc ) 3 this virus has a single - stranded rna of positive polarity of 9.6 kb nucleotides . the rna contains one long open reading frame , encoding a polyprotein of approximately 3000 amino acids flanked by un - translated regions ( utrs ) on both 3 and 5 ends . owing to high mutability due to error prone reverse - transcription , the hcv genome , has high degree of genetic variability . to date , at least six genotypes and more than 120 subtypes of the virus have been identified , and more are in the process of being characterized . genotypes 1a ( hcv-1a ) , 1b , 2a , 2b , and 3a are distributed globally and account for the majority of hcv infections worldwide5 . hcv-1b , the most common genotype worldwide , is also the dominant genotype in asia - pacific , particularly in japan , south korea , china and taiwan . hcv-2a and 2b are also commonly distributed , particularly in japan , south korea and southern taiwan6 . while genotype-3 of hcv is more prevalent in many countries of asia oceania78 , the genotype-4 is predominantly found in north africa and middle east . genotypes 7 - 11 appear to be the variants of hcv-3 ( genotype 10a ) and hcv-6a ( genotypes 7 , 8 , 9 , 11 ) , and have been re - classified as subtypes of genotypes 3 and 66 . in india , genotype 3 predominates in the north , east and west india while genotype 1 is more common in southern parts of india8101112 .

chronic hepatitis c infection poses a major global health predicament and appears to be potent threat to mankind . the treatment in wide use is interferon / ribavirin combination therapy which is generally effective in about 60 - 70 per cent of patients carrying genotype 3 and causes significant morbidity . the response to therapy is largely guided by limited number of factors such as genotype of virus , rapid virological response , ethnicity , pre - therapy viral load , etc . while involvement of host genetic factors has been a major focus of research in playing an important role in the outcome of disease , the role of immune system can not be marginalized . poor cellular trafficking and suboptimal t cell responses in liver , the hall marks of chronic hepatitis c virus infection , might be attributed to defective antigen presentation . various immunological factors , both innate and adaptive , play role in the pathogenesis of the disease and become dysfunctional in active disease . recent reports suggest the major impact of functional and numerical status of dendritic cells in deciding the fate of antiviral therapy . in this review we take a look at the involvement of dendritic cells in playing an important role in the response to therapy .

laparoendoscopic single - site surgery ( less ) in urology was first described by rane et al . . the less approach has been utilized for various indications in adults , including donor nephrectomy , simple nephrectomy , and reconstructions such ureteral reimplantation and pyeloplasty . the safety and efficacy of the standard laparoscopic approach has also been described in pediatric populations , in which studies have compared outcomes between the laparoscopic and open approaches . however , there is a paucity of literature regarding application of the less approach in children . concerns regarding the application of less in children are the smaller working space and the need for specialized instrumentation . in this article , we review our experience with less in children . we detail the intraoperative outcomes and the measures taken to reduce the level of difficulty .

purposewe report our experience with laparoendoscopic single - site ( less ) urological procedures in children less than 5 years of age.materials and methodsten patients ( 11 procedures ) underwent less through the umbilicus . seven patients underwent nephrectomy and three patients underwent pyeloplasty ( one simultaneous bilateral ) . r - port port ( advanced surgical concepts , ireland ) was used in nine cases , in one case , the gelpoint access port ( applied medical , rancho santa margarita , ca , usa ) was used . the olympus endoeye camera with coaxial light cable was used . the hilum was secured in all cases with hem - o - lok clips ( teleflex medical , research triangle park , nc , usa ) except in one case in which an endo gia stapler ( covidien surgical , norwalk , ct , usa ) was used.resultsall procedures were technically successful . accessory port ( 3 mm ) was used in 3 patients . mean age in nephrectomized patients was 3.141.7 years , the mean operative room time ( ort ) was 97.512.54 minutes . in the pyeloplasty group , mean ort was 19247.16 minutes and mean age was 2.432.3 years . bilateral pyeloplasty was done in a 4-month - old infant . the ort in this case was 180 minutes . a follow - up renogram done in the pyeloplasty patients ( n=2 ) showed good drainage . mean length of stay was 3.6 days ( range , 3 to 6 days ) .the analgesic requirement was 23.86 mg ( range , 12.5 to 50 mg ) of diclofenac sodium.conclusionsless is technically feasible in patients as young as 4 months of age . it has the potential to offer better cosmesis . this needs to be proved in further comparative studies . development of miniature instruments will further the growth of less in this age group .

the anastomotic complications after primary repair of esophageal atresia ( ea ) are well recognized and can significantly increase the morbidity . the management options for an anastomotic leak ( al ) vary from conservative management to reoperation . a major al may require esophageal diversion that leads to discarding of the native esophagus . to retain the native esophagus , a redo anastomosis with or without vascularized flaps or a conservative approach with adequate nutritional supplementation have all been described in the literature , however , the reported success of conservative treatment is quite variable . there is no controversy regarding the conservative management of minor leaks , but the management strategies for major anastomotic disruptions are still not standardized . gastroesophageal reflux is associated with a significant number in patients of ea and is one of the factors preventing the closure of al leading to failure of conservative treatment . we performed transgastric feeding jejunostomy ( fj ) with decompressing gastrostomy in patients of ea with anastomotic dehiscence and studied its effect on healing .

aims : to investigate the role of feeding jejunostomy ( fj ) in patients of esophageal atresia with anastomotic leak ( al ) to decrease the degree of gastroesophageal reflux ( ger ) and its effect on anastomotic healing.materials and methods : twenty neonates , with major al and severe ger after primary repair were managed with decompressing gastrostomy and transgastric fj and analyzed prospectively.results : male to female ratio was 1.7:1 . mean birth weight was 2.2 kg . anastomotic gap ranged from 0 to 4 cm . the amount of leak was more than 20 % of nasogastric feeds . gastrostomy and fj was done on an average of the 12th postoperative day , after observing the general condition , chest tube output , lung expansion , and ventilatory requirement . there was a drastic reduction in chest tube output and lung expanded in all patients . average hospital stay was 36 days ( 8 - 80 days ) . sixty percentage patients were discharged successfully on fj . esophagogram demonstrated healing and leak free patency after an average of 1.5 months . ger was noted in seven patients , four developed stricture , and one had pseudodiverticulum in follow-up.conclusion : decompressing gastrostomy and fj can be an alternative to managing major als . it helps in healing of anastomotic dehiscence and in preserving the native esophagus .

collision cancers are malignancies in the same organ or anatomical site that comprises at least two different tumor components , with no mixed or transitional area between the two components . , it is known that the prognosis of collision cancer is very poor even after radical resection . herein , we present a case of coexisting neuroendocrine carcinoma and conventional adenocarcinoma ( collision tumor ) in the ampulla of vater , which has seldom been reported in literature .

herein , we present a case of coexisting neuroendocrine carcinoma and conventional adenocarcinoma ( collision tumor ) in the ampulla of vater , which has seldom been reported in the literature . a 51-year - old man presented with a month history of jaundice . mrcp disclosed about 1.91.8 cm sized heterogeneously enhancing mass in ampulla of vater , causing obstructions of distal common bile duct . he underwent pylorus - preserving pancreaticoduodenectomy under the diagnosis on ampulla of vater cancer . pathologically , sections on the ampulla of vater showed conventional ductal adenocarcinoma extended and collided with poorly differentiated neuroendocrine carcinoma . in conclusion , we hereby presented a case of coexisting neuroendocrine carcinoma and conventional adenocarcinoma in the ampulla of vater .

urate ( uric acid ) is the major inert end product of purine degradation in humans and higher primates in contrast to most other mammals because of the genetic silencing of hepatic enzyme uricase , which is oxidized to water soluble allantoin1 ) , and serum urate concentration is determined by the balance between production and elimination2 ) . the kidney plays a dominant role in urate elimination because it excretes approximately 70 % of the daily urate production . particularly , the renal proximal tubule has an important role in transport of organic anions including urate3 ) . renal handling of uric acid in the proximal tubule seems bidirectional , apical absorption via the urate / anion exchanger and basolateral uptake via organic anion transporters4 ) . the organic anion transporter type 1 ( oat1 ) is expressed at the basolateral membrane of proximal tubular cells and functions as an organic anion / dicarboxylate exchanger that takes up organic anions from the plasma into proximal tubular cells . the organic anion transporter type 3 ( oat3 ) is also localized at the basolateral membrane of the proximal tubular cells , and may be involved in the transport of endogenous and exogenous organic anions5 ) . also , oat3 has been identified as an organic anion / dicarboxylate exchanger similarly to oat16 ) . in addition , urat1 is a urate - anion exchanger regulating blood urate levels and has been reported to be expressed in the apical membrane of proximal tubular cells . . however , the physiologic roles of these urate transporters in regulation of uric acid transport in the kidney are not clearly defined8 ) . hyperuricemia and gout in humans have important clinical implications because of their pathogenic roles in atherosclerosis and other cardiovascular diseases9 ) . this study was undertaken to investigate in rat kidneys whether the protein abundance of urat1 , oat1 and oat3 is affected by the increase in uric acid intake .

renal handling of uric acid mainly occurs in the proximal tubule , and bidirectional transport of urate may involve apical absorption via the urate - anion exchanger ( urat1 ) and basolateral uptake via organic anion transporters ( oat1 and oat3 ) . in rat kidneys , we investigated whether the protein abundance of urat1 , oat1 , and oat3 is affected by the increase in uric acid intake . male sprague - dawley rats were randomly divided into control and uric acid - supplemented groups , and uric acid - supplemented rats were given 0.75 g of uric acid per 180 g body weight per day for 8 days . after the animal experiment , kidneys were harvested and semi - quantitative immunoblotting was carried out from cortical homogenates using polyclonal peptide - derived antibodies to urat1 , oat1 , and oat3 . serum uric acid level showed an increasing tendency in the uric acid - supplemented rats compared with control rats , whereas urinary uric acid excretion was not significantly different between the uric acid - supplemented rats and control rats . urat1 protein abundance in cortical homogenates was not significantly different between the uric acid - supplemented rats and control rats . however , oat1 protein abundance was significantly increased in the uric acid - supplemented rats compared with the control rats . oat3 protein abundance was not significantly different between the uric acid - supplemented rats and control rats . in conclusion , oat1 may have a regulatory role in response to the increase in uric acid intake in the rat kidney . the up - regulation of oat1 would exert stimulation of urinary uric acid excretion and might contribute to protection from hyperuricemia .

one woman is sexually assaulted in canada every minute ( 1 ) . sexual assault is any form of sexual contact without voluntary consent andthat violates a person 's sense of autonomy , control and mastery over their body ( 2 ) . at the university of alberta , recovery from sexual- assault- related posttraumatic stress disorder ( ptsd ) is not solely measured by eliminating symptoms or achieving specific outcomes . healing from this trauma does not mean that the survivor will forget the experience or never again experience any symptoms . rather , successful recovery is subjective and measured by whether the survivor increases his or her involvement in the present , acquires skills and attitudes to regain control of his of her life , forgive him or herself for guilt , shame and other negative cognitions , and gain stress reduction skills for overall better functioning ( 4 ) . there are many factors involved in successful recovery , including the degree of support received , previous self - concept , personal strength , and professional treatment provided by the medical and justice systems ( 5 ) . ptsd is one of the problems that may result from failure of the recovery process . ptsd is caused by exposure to a traumatic event and intense psychological distress occurs as a result of re - experiencing the event ( 6 ) . ptsd is diagnosed when symptoms last longer than one month ( 7 ) . to prevent the distressing reactions , survivors will avoid stimuli that provoke these feelings and this avoidance behaviour can be severe enough to significantly impair daily life ( 8 ) . the consequences of a sexual assault may be manifested biologically , psychologically , and sociologically . by gaining a better appreciation of the repercussions of sexual assault , a holistic and individualized therapy can be developed to ameliorate the physical and emotional pain following the trauma . the issues facing individuals who have experienced sexual assault will be discussed and improvements in current treatments will be suggested , with hopes to develop more effective and holistic therapies in the future .

sexual assault occurs with alarming frequency in canada . the prevalence of posttraumatic stress disorder ( ptsd ) in assault survivors is drastically higher than the national prevalence of the disorder , which is a strong indication that the current therapies for sexual - assault - related ptsd are in need of improvement . increasing knowledge and understanding of the pathologies associated with rape trauma in biological , psychological and sociological domains will help to develop more effective treatments for survivors . a dysregulation of the hypothalamic - pituitary - adrenal ( hpa ) axis is observed in survivors of sexual assault and this may be a fundamental cause of the structural and functional abnormalities contributing to ptsd symptoms . pharmacotherapies are available to treat ptsd ; however , they are often inadequate or unwanted by the survivor . psychological health is compromised following interpersonal trauma and many psychological therapies are available , but with varying efficacy . a person 's cognitions have a dramatic effect on the onset , severity , and progress of ptsd following sexual assault . sociological impacts of assault influence the development of ptsd through victim - blaming attitudes and the perpetuation of rape myths . perceived positive regard and early social support is shown to be important to successful recovery . education is vital in rape prevention and to foster a supportive environment for survivors . the biological , psychological and sociological impacts and treatments should not remain mutually exclusive . a better appreciation of the biopsychosocial repercussions of sexual assault will aid in developing a more holistic and individualized therapy to help alleviate the physical and emotional pain following the trauma of rape .

born of the prophet muhammad s favorite daughter , fatimah , al - hasan was declared as the legitimate successor of his father , ali ibn - abi - talib ( the last of the caliphs known to arab historians as orthodox ) , in 661 . faced by his rival , muawiyah ibn - abi - sufyan , who had been proclaimed caliph in 660 in jerusalem , al - hasan abdicated in the same year and reasoned as follows : i have deemed it right to make peace with him and have pledged allegiance to him , since i considered whatever spares blood as better than whatever causes it to be shed . after living in retirement in al - madinah ( in present - day saudi arabia ) for eight years , al - hasan died in 669 , when he was just 45 years of age . the belief that al - hasan died peacefully has not been ruled out by all the experts on muslim history . however , in general , muslim theologians commonly believe that his death was caused by a fatal act of poisoning . with autopsy information unavailable , historical documents are the only available evidence in order to investigate cases such as al - hasan s death scientifically . a few traditions , such as the one containing the following quote , mention that when al - hasan was about to die , he was asked by his younger brother al - husayn to identify his poisoner but refused to do so ( as he wanted no innocent person to be falsely accused and killed ) : if he / she [ the poisoner ] is not [ i.e . , not the one whom i suspect ] , i would like no innocent person to be killed because of me.still , the following tradition addresses two concurrent acts of poisoning , which resulted in two victims : al - hasan and a survivor . jadah daughter of al - ashath ibn - qays al - kindi poisoned al - hasan ibn-ali , peace be upon both of them , and poisoned a freedwoman of his ; however , the freedwoman of his vomited the poison while al - hasan kept it in his stomach . this tradition says that a freedwoman of al - hasan who had also been poisoned vomited the poison and survived , which means that she could have served as forensic evidence for the murder of al - hasan . but are there any historical reports in which the poison is qualitatively described and can lead to a forensic hypothesis for the murder of al - hasan ? if he / she [ the poisoner ] is not [ i.e . , not the one whom i suspect ] , i would like no innocent person to be killed because of me . jadah daughter of al - ashath ibn - qays al - kindi poisoned al - hasan ibn-ali , peace be upon both of them , and poisoned a freedwoman of his ; however , the freedwoman of his vomited the poison while al - hasan kept it in his stomach .

the puzzle of a mysterious death in the middle ages has been hypothesized in terms of contemporary forensic legal and scientific methods . that al - hasan ibn-ali died in 669 aged just 45 has been forensically analyzed based on written sources that dictate eyewitness accounts of historical events . the report of the contemporaneous poisoning of another individual who resided under the same household as al - hasan s and experienced similar , yet non - lethal , symptoms has served as the beginning of the analysis . in light of ancient ( medieval ) documents and through using mineralogical , medical , and chemical facts , it has been hypothesized that mineral calomel ( mercury ( i ) chloride , hg2cl2 ) from a certain region in the byzantine empire ( present - day western turkey ) was the substance primarily responsible for the murder of al - hasan .

bronchodilator drugs significantly decrease airway resistance in patients with obstructive lung disease , as well as in patients with acute lung injury [ 2**,3**,4 ] . in patients with obstructive lung disease ( chronic obstructive pulmonary disease [ copd ] or asthma ) , these drugs are part of the standard therapy and play an important role in patient management [ 5**,6 * * ] . by reducing the resistance to airflow , dynamic hyperinflation , this leads to improved synchrony between the patient and ventilator , less risk of barotrauma and cardiovascular compromise , and enhancement of respiratory muscle performance [ 5**,6 * * ] . in mechanically ventilated patients bronchodilators may be administered either by the systemic route ( ie intravenously ) or directly to the target site in the endobronchial tree by inhalation [ 2**,3**,6 * * ] . similar to the situation with ambulatory patients , the inhaled route is preferable during mechanical ventilation because the drug efficacy is comparable or even greater than that of the intravenous drug , but the side effects are minimized because of the smaller dose and minimal systemic absorption [ 2**,3**,6 * * ] . inhaled bronchodilators in mechanically ventilated patients may be delivered either by a nebulizer or by a mdi [ 2 * * ] . however , the delivery of bronchodilators with mdi in mechanically ventilated patients has received considerable interest in recent years [ 2**,3 * * ] . this is because the use of mdi has several advantages over the nebulizer , such as reduced cost , ease of administration , less personnel time , reliability of dosing and a lower risk of contamination . particularly , in the present era of limited financial resources , the cost of therapy is an important issue . indeed , it has been estimated that substitution of nebulizers with mdis in a 700-bed hospital could potentially reduce the cost of aerosol therapy by us $ 300 000 a year . moreover , the use of nebulizers under certain circumstances may lead to patient / ventilator dyssynchrony . ineffective efforts have been identified in patients ventilated on assisted modes of support whenever the flow rate of continuous inline nebulizer exceeded the patient 's inspiratory flow rate . this may lead to serious episodes of hypoventilation , which may not be detected by the alarm function because the bias flow introduced into the system by the continuous flow is falsely interpreted by the ventilator as representing minute ventilation . finally , nebulizers may damage the expiratory transducer of some ventilators , rendering the expiratory volume measurement unreliable . although bronchodilator delivery with mdi in mechanically ventilated patients has several advantages over nebulizers , the use of mdis in this group of patients has not gained widespread acceptance among intensive care unit physicians . indeed , bronchodilator delivery with mdi is considered to be relatively ineffective due to drug deposition in the ventilator circuit and endotracheal tube [ 13 * ] . this consideration , however , is not supported by recent scientific data . provided that a proper technique of administration is used , bronchodilator therapy with mdi is clearly effective [ 2**,3 * * ] . in this brief review we present data regarding the efficacy of mdi in mechanically ventilated patients , and provide guidelines for proper use of this mode of bronchodilator therapy .

the delivery of bronchodilators with metered - dose inhaler ( mdi ) in mechanically ventilated patients has attracted considerable interest in recent years . this is because the use of the mdi has several advantages over the nebulizer , such as reduced cost , ease of administration , less personnel time , reliability of dosing and a lower risk of contamination . a spacer device is fundamental in order to demonstrate the efficacy of the bronchodilatory therapy delivered by mdi . provided that the technique of administration is appropriate , mdis are as effective as nebulizers , despite a significantly lower dose of bronchodilator given by the mdi .

extramammary paget 's disease ( empd ) is a rare cutaneous , intraepithelial adenocarcinoma involving primarily the epidermis but occasionally extending into the underlying dermis which accounts for < 1 % of carcinomas in vulva and majority of the patients are postmenopausal females . it presents with a long - standing history of pruritic , erythematous , scaly , or velvety patches . the most frequent site is the vulva , but perineal , scrotal , perianal , and penile skin are also common areas . the cancer cells in the neoplasm usually stay in situ and only rarely invade into the dermis to be metastatic through the lymphatic system .

extramammary paget 's disease is a rare cutaneous , intraepithelial adenocarcinoma involving primarily the epidermis but occasionally extending into the underlying dermis . the condition typically presents as a red , velvety , pruritic skin rash of the vulva region which closely mimics a multitude of other , more common conditions . as a result , vulvar paget 's disease is frequently misdiagnosed , leading to an often lengthy lag time ( an average of about 23 years ) between the onset of symptoms and diagnosis .

vascular endothelial growth factor ( vegf ) and its receptors are thought to play a pivotal role in tumor angiogenesis . bevacizumab is a humanized monoclonal antibody designed to block vegf - a and has proved to be effective in colorectal cancer , nonsmall cell lung cancer , renal cell carcinoma , ovarian carcinoma , and glioblastoma multiforme [ 28 ] . in the field of breast cancer , bevacizumab has generated more controversies and discussions than any other targeted therapy . in february 2008 , the fda granted accelerated approval to bevacizumab in combination with paclitaxel for the first - line treatment of metastatic , her2-negative metastatic breast cancer ( mbc ) , based on promising results of the eastern cooperative oncology group ( ecog ) 2100 trial . on july 20th 2010 , the oncologic drugs advisory committee ( odac ) of the fda 's center for drug evaluation and research voted 12 to 1 against the use of bevacizumab in combination with chemotherapy for the first - line treatment of advanced breast cancer . this was followed by a definitive announcement by the fda revoking approval of bevacizumab for this indication . nonetheless bevacizumab is still approved by different regulatory agencies across several countries as a standard antiangiogenic drug for the treatment of first - line advanced breast cancer . with more than 20,000 breast cancer patients currently being randomized into bevacizumab studies , it is crucial to define which magnitude of endpoint or risk / benefit ratio is expected . in this study , we performed a meta - analysis of randomized phase iii studies evaluating bevacizumab for the first - line treatment of metastatic breast cancer [ 1113 ] . the magnitude of risks and benefits of adding bevacizumab to the standard treatment of advanced cancer are discussed in the context of recent controversies and ongoing randomized phase iii clinical trials .

background . randomized studies have shown different magnitude of bevacizumab benefit in the treatment of advanced breast cancer . regulatory agencies have modified bevacizumab treatment indications across different regions . in this study , we perform a meta - analysis of phase iii studies aiming to interrogate the magnitude of bevacizumab benefit for the treatment of first - line her2-negative metastatic breast cancer ( mbc ) . methods . data from studies e2100 , avado and ribbon-1 were used to calculate the benefit of bevacizumab in terms of tumor overall response rate ( orr ) , progression - free survival ( pfs ) , overall survival ( os ) , and toxicities . combined statistical estimates of hazard ratios ( hr ) and odds ratios were calculated using fixed - effects or random - effects models . results . a total of 2,695 patients were evaluated . combining bevacizumab with different chemotherapy backbones resulted in a 30 % risk reduction of pfs events ( hr = 0.70 ; 95 % confidence interval [ ci ] , 0.570.86 ) and increased orr ( odds ratio 1.81 ; 95 % ci , 1.532.14 ) . no os benefit could be demonstrated ( hr = 0.95 ; 95 % ci , 0.851.06 ) . bevacizumab significantly increased the incidence of adverse events such as proteinuria , hypertension and cardiovascular events . conclusions . bevacizumab combined with chemotherapy in the first - line treatment of mbc significantly improved orr and pfs , but also increased grade 3 - 4 toxicities . no significant os advantage was observed .

achalasia cardia is a primary motility disorder of the esophagus characterized by aperistalsis of the body of the esophagus and failure of relaxation of the lower esophageal sphincter ( les ) appropriately in response to swallowing.1 it is a chronic , benign disease of unknown etiology and is a common cause of dysphagia . the first case of this condition was reported by sir thomas willis in 1674 in which he described esophageal dilation with whalebone in a patient who had dysphagia and a dilated esophagus . the term achalasia was coined by hurst in the year of 1927 , which means absence of relaxation , more specifically , inadequate les relaxation in the absence of distal mechanical obstruction.2 the mainstay of treatment of achalasia cardia is the relief of the functional obstruction at the level of the gastroesophageal junction . about 5 % of all cases occur in children ; while only a few are reported in infants.3 here we present our experience in two infants suffering from achalasia cardia , and both cases were treated successfully .

achalasia cardia is a neuromuscular disorder of unknown etiology involving the body of the esophagus and lower esophageal sphincter ( les ) . it is characterized by aperistalsis of the body of the esophagus and failure of relaxation of lower esophageal sphincter . it usually affects patients between the ages of 30 and 60 years . it is unusual in childhood and extremely rare in infants . we report two cases of achalasia cardia in infants . both cases were treated with open heller s esophagocardiomyotomy with anti - reflux procedure .

children and adolescents with gerd usually have a history of vomiting and spitting up as an infant . if gerd is left untreated , it can lead to dysphagia , odynophagia , esophageal stricture , chronic hoarseness , laryngitis or respiratory problems such as coughing or reactive airway disease in children and non - cardiac chest pain or barrett s esophagus in adults . proper evaluation and appropriate therapy may result in better long - term outcomes , such as improved quality of life and reduction in the overall health - care burden . traditional catheter - based esophageal ph monitoring is uncomfortable and cumbersome ; many parents may forego testing for their children , leaving them undiagnosed and consequently untreated or under treated for this disorder . in gastric juices have been detected in the middle ear , which this indicates that gerd can cause chronic otitis media with fluid collection . testing with a ph probe can cause nasal and throat irritation in some , impairing the ability to maintain a normal diet . the catheter itself remains visible , causing many patients to alter their exercise and activity routines during the test period . these changes in the patient s routine may provide false negative findings and adversely affect the reliability of the results . parents are also unhappy with these limitations . some of our patients have refused to eat and drink properly and some missed school days while the ph probe catheter was in place . shoreview , mn ) may offer a more desirable diagnostic option for ph monitoring for pediatric patients and their parents in terms of comfort and convenience . the purpose of this retrospective study is to analyze the efficacy , safety and reliability of the bravo capsule placement procedure and its related complications .

backgroundgastroesophageal reflux disease ( gerd ) is a common problem seen in pediatrics and adolescents . the bravo ph monitoring system is a capsule that detects and quantifies the severity of reflux disease . this test is also valuable for evaluation of patients with extra - gastrointestinal manifestations of gerd such as asthma , chronic cough , hoarseness , aspiration pneumonia , and pre / post fundoplication surgery . this study evaluates the safety and reliability of this procedure in children.methodsfrom january 2002 to december 2010 , 219 patients ( 85 males and 134 females ) , ages 6 - 18 years underwent upper endoscopy with biopsies and placement of the bravo capsule.resultsin 201 out of 219 patients , the bravo ph monitoring procedure completed within 48 hours without any complaints . in 3 out of 219 patients , the ph dropped to less than 2 after 30 minutes . this indicated that the capsule moved from the esophagus to the stomach . one other patient deleted all data while playing with the recorder at home . in another patient , there was recorder malfunction . three patients presented with chest pain , one with chest and back pain and nine patients had a mild sensation of sub - sternal pain for two hours or less . none of the patients needed to retrieve the capsule.conclusionbravo capsule ph monitoring of the esophagus is reliable , safe , well tolerated and free from significant complications , and preferred by young adolescents . with the bravo capsule , adolescents can attend school and continue their normal physical activities without interruption .

the underwater environment produces some pathophysiological problems due to the fast changing of its bounded pressure which may cause various illnesses that might be difficult to detect and treat . our nervous system is an organ which is very sensitive to underwater pressure changes , and a damaged nervous system can lead to hazardous disorders . hyperbaric condition can be considered as a risk factor for cerebral ischemic events and strokes in divers ( 1 - 4 ) . the trembling of hands , postural instability , gastrointestinal problems , somnolence and cognitive dysfunction are some of the diving related disorders developed by a hyperbaric condition called high pressure neurological syndrome ( hpns ) ( 5 ) . clinical symptoms of nitrogen narcosis are similar to alcohol intoxication which leads to a temporary dysfunction of neuromuscular and intellectual activity and the disturbance of behavior and personality . this condition generally occurs in depths of deeper than 30 meters ( 100 ft ) . nitrogen narcosis leads to hallucinations , unconsciousness and even death at a depth of 90 to 100 meters ( 5 ) . zeba et al showed that the cases of diving cns barotraumas are rare but its symptoms are diverse and include dysesthesias , complete quadriplegia and encephalopathy ( 6 ) . moreover , long term diving may cause various problems , the most common of them being the lack of concentration and numbness of hands and feet ( 7 ) . although there is much evidence emphasizing neurological effect of barotraumas in divers , there is not any data about the effect of high pressure condition on intracranial pressure . in some studies ultrasound ( us ) has been called as a noninvasive technique to detect increased intracranial pressure ( icp ) ( 8 ) in conditions such as hydrocephalus ( 9,10 ) and trauma ( 11 , 12 ) . however , in this study we investigated the effect of long term diving practice upon optic nerve and sheath diameters as a non - invasive indicator of intracranial pressure changes in professional divers .

background : there is not any data available about the effect of high bar pressure condition on intracranial pressure . in this study , the effect of diving on the optic nerve and sheath diameters as non - invasive markers of intracranial pressure has been investigated . methods : twenty professional male divers from twenty one volunteers were chosen for this cross - sectional study . only one person who had a history of barotraumas was excluded . each diver then completed a questionnaire on demographic data , medical and diving history . nineteen other volunteers were selected to represent a control group . a 10-mhz linear ultrasonic probe was used to measure the optic nerve sheath diameters of both eyes in closed and supine position and its relationship with diving history of divers was determined . results : it was found that divers have a higher mean optic nerve sheath diameter compared to the normal population as previously reported by other studies . the mean diameter of the left and right optic nerve sheaths were 6.40.7 , 6.50.9 mm respectively and a significant relationship between optic nerve sheath diameter and diving history was found . conclusion : results showed that divers have a higher optic nerve diameter than the general population . however , our result can not yet be considered as a marker of intracranial pressure in divers as it was conducted on an limited number of subjects and so a bigger study should be undertaken for this purpose .

it is usually controlled by cis - acting factors , such as au - rich elements ( ares ) in the 3utr , and transacting factors , such as rna - binding proteins , mirna , and ribonucleases ( reviewed in refs . traditionally , the 3utr has been viewed as the region most recognized by rna - binding proteins such as tristetraprolin ( ttp / zfp36 ) and hur , and that exoribonucleases largely mediate mrna decay . conversely , very few mammalian endoribonucleases are known and they were shown to cleave at ua di - ribonucleotides . rnase l has a substrate cleavage preference at uu and ua in single - stranded viral mrnas during acute viral infections and possibly in cellular mrnas under certain conditions . another endoribonuclease has been described that preferentially cleaves single - stranded mrna - coding regions inside ua and ug in several mrnas , including c - myc , mdr1 , and -globin . since ua and uu dinucleotides are common targets for these known endoribonucleases , we sought to eliminate , or at least reduce , uw ( w = a or u ) dinucleotides in the coding region of several genes , without affecting the protein code . the ua dinucleotides are generally under - represented in human and other vertebrate genomes and are further deficient in the mrna when compared to nontranscribed dna . deficiency of uw frequency in coding regions may impose a selection against endoribonuclease - mediated mrna decay inside ua dinucleotides . in this report , we showed that mrna stability increased as a result of reduction in uw frequency , leading to increased protein production . this observation suggests a general approach for rational design of synthetic genes to yield robust protein expression .

uu and ua dinucleotides are rare in mammalian genes and may offer natural selection against endoribonuclease - mediated mrna decay . this study hypothesized that reducing uu and ua ( uw ) dinucleotides in the mrna - coding sequence , including the codons and the dicodon boundaries , may promote resistance to mrna decay , thereby increasing protein production . indeed , protein expression from uw - reduced coding regions of enhanced green fluorescent protein ( egfp ) , luciferase , interferon- , and hepatitis b surface antigen ( hbsag ) was higher when compared to the wild - type protein expression . the steady - state level of uw - reduced egfp mrna was higher and the mrna half - life was also longer . ectopic expression of the endoribonuclease , rnase l , did not reduce the wild type or uw - reduced mrna . a mutant form of the mrna decay - promoting protein , tristetraprolin ( ttp / zfp36 ) , which has a point mutation in the zinc - finger domain ( c124r ) , was used . the wild - type egfp mrna but not the uw - reduced mrna responded to the dominant negative action of the c124r zfp36/ttp mutant . the results indicate the efficacy of the described rational approach to formulate a general scheme for boosting recombinant protein production in mammalian cells .

small cell carcinoma is a malignancy that occurs mainly in the lung , and primary lesions in the head and neck are very rare . extrapulmonary small cell carcinoma ( epscc ) shows a fair response to either chemotherapy or chemoradiotherapy , similar to small cell lung carcinoma ( sclc ) ; however , poor prognosis has been reported due to its high metastatic potential . irinotecan hydrochloride ( cpt-11 ) , a topoisomerase i inhibitor , has been reported to be effective against sclc . here , we report a rare case of epscc of the tonsil , treated with cpt-11 and cisplatin ( cddp ) , which is the recent treatment protocol for sclc . the present case represents the first report of cpt-11 usage for epscc of the oropharynx . our case suggests that cpt-11 and cddp may become an effective treatment option for epscc of the oropharynx .

we report a rare case of extrapulmonary small cell carcinoma arising in the palatine tonsil treated by combined chemotherapy with irinotecan / cisplatin following irradiation therapy . this chemotherapy regimen was recently found to be effective for small cell lung carcinoma . our case is the first report of combined irinotecan / cisplatin chemotherapy to treat extrapulmonary small cell carcinoma of the oropharynx .

hiv is a preventable chronic , life - threatening illness affecting fetal and maternal health , increasing both morbidity and mortality in both infected and noninfected children worldwide [ 13 ] . given the lack of an effective vaccine and the complexity of life - long treatment , prevention of maternal to child transmission ( pmtct ) continues to be a crucial public health need globally . it has been well established that pregnant women have a significantly higher risk of hiv acquisition during gestation and while breastfeeding than their nonpregnant counterparts , due to behavioral factors , such as decreased condom use , and biological factors such as immunosuppression [ 4 , 5 ] . prior research in england , in african countries , in the united states , and by our own group in brazil demonstrates that despite universal antenatal testing of women , hiv infected babies are born to women who had negative hiv tests during early prenatal care , implicating seroconversion during pregnancy and breastfeeding [ 611 ] . furthermore , studies conducted at our institution in porto alegre , brazil , demonstrated that women known to seroconvert during pregnancy have a much higher hiv mtct rate , than those with an unknown seroconversion time ( transmission rate of 33 % in the first group versus 8.2 % in the latter ) . in fact , recent evidence indicates that infant hiv infection related to new maternal hiv-1 infection after antenatal hiv screening could account for up to 40 % of all ongoing mother - to - child transmission in low and middle income countries [ 9 , 12 ] . the source of these new infections during pregnancy is likely the mother 's sexual partner . therefore , there is a renewed interest in expanding pmtct efforts to include the mother 's sexual partner . with the goal of trying to expand pmtct to the entire family unit including the male partners , we performed this initial study to determine the proportion of pregnant women who have knowledge of their sexual partner 's hiv status results at the time of labor and delivery and their comfort in discussing hiv testing with their sexual partners during prenatal care and/or labor and delivery as well as to evaluate their risk factors for hiv acquisition . we decided to perform the study in porto alegre because the prevalence of hiv in pregnant women there rose from 0.5 % in 1997 to 6.5 % in 2002 . at hospital conceiao , a large tertiary county medical center providing care to a large sector of the low to middle income population of the metropolitan area , the hiv seroprevalence rates range from 3 to 5 % in pregnant women receiving prenatal care , and 5 to 10 % among pregnant women without prenatal care . prior to study initiation , we hypothesized that women continue to participate in high risk behavior during pregnancy and will agree to discuss hiv testing with partners in order to optimize their infant 's health .

recent studies suggest that acquisition of hiv-1 infection during pregnancy and breastfeeding is associated with a high risk of hiv mother - to - child transmission . this study evaluates risk factors associated with hiv acquisition during pregnancy in women delivering at a large metropolitan medical facility located in the south of brazil . from february to august 2009 , our group conducted a cross - sectional study assessing women 's risk for hiv acquisition by administering an oral survey to peripartum women . of 2465 participants , 42 % ( n = 1046 ) knew that partner had been tested for hiv . during pregnancy , 82 % ( n = 2022 ) of participants never used condoms ; yet 97 % ( n = 2399 ) practiced vaginal sex . multivariate logistic regression analysis showed that patients with more years of education , in a relationship for more than 1 year , and who knew their own hiv status were more likely to know their partners ' hiv status ( p < 0.05 ) . those who were in relationship for more than 1 year and were married / living together were more likely to be comfortable discussing hiv testing with partners ( p < 0.05 ) . in conclusion , women in brazil are at risk of hiv - infection during pregnancy as they remain sexually active , often do not know their sexual partner 's hiv status , and have minimal condom use .

home care is a rapidly expanding and evolving industry . as levit and her colleagues highlight , home health is the fastest growing component of medicare expenditures . medicare spending on the home health benefit has grown from $ 2.12 billion in 1988 to $ 10.5 billion in 1993 and is projected to exceed $ 22 billion by the end of this century . home health care expenditures represented 5.3 percent of total medicare spending in 1993 and have experienced annual growth rates exceeding 25 percent every year since home health coverage criteria were clarified in 1988 . in addition to a mandatory home health benefit , medicaid provides two optional sources of funding for home care services : the personal care optional benefit and the section 1915 ( c ) home and community - based care waiver program . medicaid home health expenditures have risen from $ 2 billion in 1988 to $ 4.5 billion 1993 , while home and community - based care waiver dollars have grown from $ 3.8 million in 1982 to close to $ 3 billion in 1993 . factors contributing to increased use of home care services include the aging of the population , the development of complex medical technologies that can be provided in the home , and a growing capacity among home care providers and other community - based agencies to respond to increasing demand . public policy changes , including the implementation of medicare hospital prospective payment in 1984 and the clarification of medicare home health coverage requirements in 1988 , have added to the demand for home care services . these trends are consistent with preferences among the elderly and persons with disabilities to receive services in home and community , rather than institutional settings . there is increasing attention within government and the private sector being focused on the access , quality , and cost of home care services . in particular , hcfa is interested in determining how medicare and medicaid can more actively and responsibly address the issues associated with rapid growth of home care services . research questions central to the policy debate include : who uses home health services ? what is the accessibility and quality of home health services provided under public programs ? how do we improve the efficiency , effectiveness , and accountability of skilled and unskilled care services provided in home settings ? how effective are home health services in new forms of service delivery , such as health maintenance organizations ( hmos ) and other forms of managed care ?

this overview discusses articles published in this issue of the health care financing review , entitled issues in reforming home health care . articles focus on basic policy issues in the financing and delivery of home care services , illustrate how research provides insights into these issues , and report on some recent research and demonstration initiatives that are designed to further our understanding of how to improve the effectiveness and efficiency of home care services under medicare and medicaid .

reports have described the increasing use of endoscopic ultrasound - guided hepaticogastrostomy ( eus - hg ) to treat malignant biliary obstruction in patients with endoscopic retrograde cholangiopancreatography ( ercp ) failure . however , a previous review article noted that despite its high success rate , eus - hg is associated with a relatively high rate of adverse events 1 , which is attributable to the lack of standardized protocols and specialized equipment . previously at our institution , eus - hg was performed on three patients using a biliary dilation catheter for hepaticogastric fistula dilation and a 7-cm , straight plastic stent or 8-cm fully covered metal stent . however , in two of the three patients , achieving fistula dilation was time - consuming and the stent migrated into the peritoneal cavity in two of the three patients . recently , we introduced a 6f cystotome ( cysto gastro set ; endo - flex , gmbh , voerde , germany ) for fistula dilation and an 8-mm , 12-cm covered stent with a 1-cm uncovered portion at the distal , intrahepatic end ( bare - end type , niti - s biliary s - type ; taewoong medical , seoul , korea ) ( fig . , we present our experience with four cases of eus - hg in which our institutional procedure ( 6f cystotome and 8-mm , 12-cm covered metal stent ) was used , and evaluate the safety of this procedure . bare - end type niti - s biliary s - type stent with a 1-cm uncovered portion at the distal end ( red arrow ) ; the remaining portion is fully covered .

background and study aims : an iincreasing number of reports describe endoscopic ultrasound - guided hepaticogastrostomy for malignant biliary obstruction in patients with endoscopic retrograde cholangiopancreatography failure . however , this procedure has not yet been standardized ; as a result , the rate of adverse events , including bile leakage and stent migration , is relatively high . here , we report our experience with four cases of endoscopic ultrasound - guided hepaticogastrostomy performed according to our institutional procedure .

consumer - directed healthcare ( cdhc ) is center stage in health policy debates . many politicians and corporate leaders hope that high deductible health insurance policies will cut costs by coaxing people to think twice before visiting the emergency department ( ed ) , drug store , or mri suite . the basic idea is that americans are too well insured ; if they spend their own money so the logic goes they will spend it more wisely . sometimes , after a morning in the clinic during cold season when we are inundated with snifflers seeking antibiotics , we see the attraction of such incentives . but then comes a patient with sniffles and pneumonia , or a diabetic heading toward a foot amputation for want of timely podiatric care and reluctance to endure constant needling , or a woman looking for any excuse to put off the discomfort and embarrassment of a mammogram or pelvic exam , or a middle - aged man who finds the prospect of colonoscopy disquieting . little of what we do to our patients is pleasant for them , and past studies indicate that patients facing steep out - of - pocket costs skip vital care , not just useless visits.1 medical care differs from most consumer goods . so far as we know , there is no biological need for a flat - panel television . true , clothing , food , and shelter are necessities , but neither bad genes nor bad luck compels you to buy the high - priced versions those purchases are generally driven by comfort , aesthetics , or social norms , not fear for life and limb . for patients , the luck of the draw usually dictates the care they must buy . men do not require pap smears , birth control pills , obstetrical care , or routine breast exams . americans of european descent rarely suffer sickle cell disease , or non - jews tay sachs . diabetes and cancer which reflect a mix of bad luck and bad choices do not just bring medical complications ; they bring financial ones as well . in addition , cdhc ups the ante , amplifying the financial consequences of both bad luck and unfortunate choices .

many politicians and business leaders are advocating high deductible health insurance plans linked with health savings accounts so - called consumer - directed healthcare . these policies penalize the sick , discourage needed care ( especially primary and preventive care ) , and direct tax subsidies towards the wealthiest americans . they offer little hope of slowing the growth of health care costs and add further bureaucratic costs and complexity to our health care financing system .

chronic recurrent multifocal osteomyelitis ( crmo ) , a disorder that primarily affects children and adolescents , is characterized by episodic osseous pain over several years . crmo is an idiopathic , aseptic , auto - inflammatory disease with no uniformly effective treatment . the long bones of the lower extremities are frequently affected , and skull involvement is rare . although in the majority of patients with crmo , symptoms resolve post - puberty , the bone pain that accompanies the active disease is severe . the critical factors leading to its diagnosis are patient demographics , clinical course , and lesion localization .

abstractan 11-year - old boy was diagnosed with chronic recurrent multifocal osteomyelitis ( crmo ) and presented with right sacro - femoral and occipital lesions . initially , a tumor was suspected . however , the bone biopsy showed osteomyelitis with a negative bacterial culture . bone scintigraphy revealed inflammatory changes on multiple bone lesions . the slight elevation in inflammatory markers such as c - reactive protein was of little clinical value . he was diagnosed with crmo by sacral biopsy , and the clinical course progressed , with the presence of a new occipital lesion observed after the 1-year follow - up . the administration of non - steroidal anti - inflammatory drugs successfully improved his clinical symptoms . the presence of a skull lesion in the occipital bone of a pediatric patient with crmo has not been previously reported .

exercise physiology and the salutatory effects on weight loss , fat reduction , and insulin sensitivity have been described in great detail . these beneficial effects are now considered to reflect , at least in part , the effect of exercise on the activation of amp - activated protein kinase ( ampk ) . in obese non - diabetics , exercise has been shown to reduce the risk of developing type 2 diabetes by up to 46 % . physical training , consisting of 20 min cycling or running , 20 min swimming at submaximal heart rate , followed by 20 min of warm up / cool down three times per week for 4 wk , resulted in a significant reduction in body weight and percentage body fat , and this was associated with improved whole - body glucose uptake , decreased fasting insulin concentrations , and increased circulating adiponectin and mrna expression in muscle . among patients with type 2 diabetes mellitus , increasing exercise led to a reduction in fasting plasma glucose . the 24-hour energy expenditure , whether measured in a respiratory chamber or by using doubly labelled water , increases linearly with increasing body weight . multivariate analysis shows that fat - free mass is the major determinant of energy expenditure , with minor influences of fat mass , age , and gender . nevertheless , the considerable interindividual variation is currently unexplained . there is at the present time little evidence for major adaptations of energy expenditure during overfeeding , and changes in body weight and body composition appear to be the major factors that , by increasing energy expenditure , allow energy balance to be restored . the body - weight gain may therefore be seen as an adaptative change to overfeeding [ 6 , 7 ] . total energy expenditure can be subdivided into three main components : basal metabolic rate ( bmr ) ; the thermic effect of food , or diet - induced thermogenesis ; energy expended in physical activity ( pha ) . the first two components can be measured opportunely with reasonable accuracy and have been fully studied in lean and obese subjects . there is actually no clear evidence that a low bmr is a factor in the development of obesity , even if the issue continues to be debated [ 8 , 9 ] . the thermic effect of food , and more specifically the thermic effect of carbohydrate , has been shown to decrease in obese subjects [ 10 , 11 ] . this decrease may , nevertheless , be secondary to obesity - related insulin resistance and is of too small magnitude to account for a major weight gain . nonexercise activity thermogenesis ( neat ) the energy expended for everything we do that is not sleeping , eating , or sports - like exercise and pha , that is crucial for weight control , may be important in the physiology of weight change . we review the current concepts about energy expenditure and evaluate the pha in the context of this knowledge and the available literature .

we review the current concepts about energy expenditure and evaluate the physical activity ( pha ) in the context of this knowledge and the available literature . regular pha is correlated with low body weight and low body fat mass . the negative fat balance is probably secondary to this negative energy balance . nonexercise activity thermogenesis ( neat ) and physical activity , that is crucial for weight control , may be important in the physiology of weight change . an intriguing doubt that remains unresolved is whether changes in nutrient intake or body composition secondarily affect the spontaneous physical activity .

in the united states nearly 40,000 deaths are attributed to metastatic breast cancer ( mbc ) annually . once breast cancer has metastasized it is usually fatal ; however , intensive research into the causes of breast cancer and the development of an array of effective targeted therapeutics has improved survival for these women . circulating tumor cell ( ctc ) analysis is a promising tool to address the need for better disease management , potentially improving both survival and quality of life for mbc patients .

circulating tumor cells ( ctcs ) were discovered nearly 150 years ago but have only recently been recognized as a feature of most solid tumors due to their extremely low concentration in the peripheral circulation . several technologies have been developed to isolate and analyze ctcs , which can now be routinely accessed for clinical information . the most mature of these ( the cellsearch system ) uses immunomagnetic selection of epithelial cell adhesion molecule to isolate ctcs for analysis . studies using this system have demonstrated that categorization of patients into high and low ctc groups using a validated decision point is prognostic in patients with metastatic breast , colorectal , or prostate cancer . initial attempts to use ctc counts to guide therapeutic decisions appeared to yield positive results and key concepts in clinical application of ctc information , including the ctc cutoff , predictive value in disease subtypes , and comparison to current evaluation methods , have been demonstrated . clinical studies of the impact of ctc counts in routine clinical practice are ongoing ; however , recent published evidence on the clinical use of ctcs in metastatic breast cancer continues to support these concepts , and experience in the community oncology setting also suggests that ctc enumeration can be useful for therapy management .

idiopathic granulomatous mastitis ( igm ) is an uncommon disease which usually arises in premenopausal women shortly after their last childbirth . its etiology is unclear , however , breast - feeding and the use of oral contraceptives could exert an influence in its pathogenesis . very often clinical and radiological findings mimic multifocal breast cancer and the diagnosis is made by histopathology . etiopathogenesis of igm often involves an inflammatory mechanism which could be resolved by the administration of corticosteroids or methotrexate , negating the requirement complete surgical excision . cases of igm are related to the chronic use of selective inhibitors of serotonin reuptake ( ssri ) during antidepressant therapy are underestimated and should be treated with non - surgical therapeutic approaches .

granulomatous mastitis is a rare benign inflammatory disease of the breast with multiple etiologies such as tuberculosis , sarcoidosis , foreign body reaction , and mycotic and parasitic infections . in contrast , idiopathic granulomatous mastitis ( igm ) is characterized by the presence of chronic granulomatous lobulitis in the absence of an obvious etiology . clinically and radiologically it may mimic breast carcinoma and so awareness of surgeons , pathologists , and radiologists is essential to avoid unnecessary mastectomies . cases of igm are reported during antidepressant therapy in patients also showing high levels of prolactinemia . in these cases , we believe that surgical excision must be avoided being replaced with a conservative management of the pathological condition based on a corticosteroid treatment .

scapular spine stress fractures are uncommon following cuff tear arthropathy , there are only six reported cases in the english literature . management of these fractures remains a challenge because of poor bone quality and persistent deforming force at the fracture site . management of these fractures can be conservative or surgical , with good functional outcome being associated with fracture union . conservative management can lead to asymptomatic nonunion , and there is a risk of recurrence of symptoms leading to a painful stiff shoulder . we present a case of bilateral scapular spine stress fractures that was treated operatively on one side and conservatively on the other with satisfactory functional outcome , besides we reviewed the literature to find the optimal treatment option .

we report a case of bilateral scapular spine stress fracture , treated conservatively on one side and operatively on the other side . besides , we performed a literature review to establish management options . a 61-year - old right - handed gentleman came to our clinic with acute on chronic deterioration of shoulder pain and loss of arm function . clinical assessment and investigations revealed long - standing bilateral rotator cuff tear and scapular spine stress fractures . the fracture on the right side united with conservative management for 2 months . however , his left side remained symptomatic with pain , abnormal mobility and no radiological evidence of union . the fracture progressed to union after fixation and bone grafting . at the final follow - up at 2 years , the patient was asymptomatic with regards to the fractures with oxford shoulder score ( oss ) -30 and disabilities of the arm , shoulder and hand ( dash ) -30.8 . fracture union either by conservative or operative treatment is associated with good functional outcome and is supported by our review .

preparation of hard tissues for the insertion of dental implants is usually performed by drilling at high - speed with irrigation . recently , a new concept of low - speed drilling ( 50 rpm ) without irrigation was suggested as an alternative to the conventional procedure123 . the low - speed drilling has several advantages over the high - speed drilling with irrigation . another advantage is the possibility to collect the bone cut by the drills without contamination by saliva , which can be used for an autograft6 . the low - speed drilling can also provide the operator with more precise information on the path of the drill so that corrections can be made if necessary . kim et al.1 measured the temperature change in pig rib bone during implant site preparation by drilling at 50 rpm without irrigation and reported that drilling at 50 rpm without irrigation did not produce overheating . in the study , the animal bone without a uniform cortical layer was used . in an attempt to provide more rigorous data , in this study we evaluated heat generation during the low - speed drilling procedure without irrigation .

objectivesin this study we evaluated heat generation during the low - speed drilling procedure without irrigation.materials and methodsten artificial bone blocks that were similar to human d1 bone were used in this study . the baseline temperature was 37.0. we drilled into 5 artificial bone blocks 60 times at the speed of 50 rpm without irrigation . as a control group , we drilled into an additional 5 artificial bone blocks 60 times at the speed of 1,500 rpm with irrigation . the temperature changes during diameter 2 mm drilling were measured using thermocouples.resultsthe mean maximum temperatures during drilling were 40.9 in the test group and 39.7 in the control group . even though a statistically significant difference existed between the two groups , the low - speed drilling did not produce overheating.conclusionthese findings suggest that low - speed drilling without irrigation may not lead to overheating during drilling .

periodontitis is a multifactorial chronic inflammatory disease characterized by destruction of tooth - supporting tissues . the progression of periodontal destruction involves complex interaction between periodontal bacteria and cells of immune system . the complex cytokine network that mediates the immune response includes proinflammatory cytokines , anti - inflammatory cytokines , and specific cytokine receptors . cytokines play an important role in the initiation , progression , and the host modulation of periodontal disease . statins , 3-hydroxy 3-methylglutaryl coenzyme a ( hmg - coa ) reductase inhibitors , prescribed to prevent cardiovascular and cerebrovascular diseases . the effectiveness of statin medication is based on their capacity to reduce serum cholesterol levels , primarily low - density lipoprotein ( ldl ) cholesterol . statins inhibit hmg - coa reductase and decrease the production of mevalonate , geranyl pyrophosphate , and farnesyl pyrophosphate , and subsequent products on the way to construction of the cholesterol molecule . thus , statins could inhibit inflammation , by inhibition of the cholesterol pathway and intracellularly interfering with ras superfamily protein function . interleukin ( il ) -1 is found in two active forms , il-1 and il-1 encoded by separate genes . both are potent proinflammatory molecules and are the main constituents of what was once called osteoclast - activating factor . the proinflammatory effects of il-1 include stimulation of endothelial cells to express selectins that facilitate recruitment of leukocytes and induction of prostaglandin e2 by macrophages and gingival fibroblasts . gingival crevicular fluid ( gcf ) provides a noninvasive means of studying the host response factor by change of constituents in the fluid . the inflammatory exudate from gingival microcirculation crosses inflamed periodontal tissue and en route collects molecules of potential interest from the local inflammatory reaction . therefore , the fluid offers a great potential source of factors like inflammatory mediators , tissue break down products , and host derived enzymes that may be associated with tissue destruction . increase in the levels of inflammatory mediators in gcf may be of diagnostic value in evaluating periodontal disease status . although gcf il-1 levels in periodontal disease have been studied extensively , ours could be the first study carried out to know the influence of statin medication on the inflammatory mediator especially il-1 . statins also have shown to have anti - inflammatory effect . the aim of our study was to know the effect of statin medication on the inflammatory mediator gcf il-1 levels in chronic periodontitis subjects .

objectives : statins are the group of lipid - lowering drugs commonly used to control cardiovascular and cerebrovascular diseases . statins have potential anti - inflammatory effect by blocking the intermediate metabolites of the mevalonate pathway . the objective of this study was to evaluate the anti - inflammatory effect of statin medication in chronic periodontitis patients.materials and methods : thirty patients of age group between 40 and 60 years were selected from the outpatient pool of department of periodontics , thaimoogambigai dental college and hospital , chennai . thirty patients selected were grouped into two groups , group - i consists of patients with generalized chronic periodontitis and on statin medication and group - ii consists of patients with generalized chronic periodontitis . clinical parameters were recorded and gingival crevicular fluid ( gcf ) samples were analyzed for interleukin ( il ) -1 using commercially available enzyme - linked immunosorbent assay.results : the mean gcf il-1 levels in generalized chronic periodontitis patients who are on statin medication ( group - i ) were lower than the generalized chronic periodontitis patients without statin medication ( group - ii ) .conclusion : reduction of gcf il-1 levels in statin users indicate that statins have anti - inflammatory effect on periodontal disease .

cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy ( cadasil ) is a systemic arteriopathy due to missense mutations of notch3 gene . earlyonset ischemic strokes and vascular dementia are the main clinical features . migraine , psychiatric disorders , and epileptic seizures are additional features 1 . asymptomatic cerebral microbleeds are also frequent , while spontaneous lobar hemorrhages are very rare 2 . vascular dementia generally follows recurrent strokes , while progressive subcortical dementia without strokes is rare 3 , 4 . cognitive decline generally starts with alterations in attention and executive functions and is the result of dysfunction within the subcortical / frontal network . in contrast , visuospatial abilities , recognition , and semantic memory generally remain spared until the late stages 5 . the pathological hallmarks of cadasil are the degeneration of vascular smooth muscle cells ( vsmcs ) and extracellular accumulation of granular osmiophilic materials ( goms ) 6 . notch3 gene mutations are stereotyped and alter the odd number of cysteines in one of the 34 egflike repeats ( coded by exons 224 ) of notch3 . earliest studies suggested that notch3 gene mutations were mainly clustered in some exons , but the increasing number of new mutations out of these exons strongly weakens this assumption , with relevant meanings about the molecular diagnosis . in fact , due to the high costs , the mutation screening covering the whole region coding for egf repeats is not generally performed in all cases 7 . we report a cadasil patient carrying a notch3 gene mutation involving exon 24 and presenting with recurrent transient global amnesia ( tga ) and atypical cognitive decline .

key clinical messagedespite transient global amnesia is considered unusual in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy ( cadasil ) and causal relation is still unclear , this report suggests to consider cadasil in those patients with recurrent transient global amnesia , especially when mri shows multifocal hyperintensities affecting the cerebral white matter or when it is followed by cognitive decline .

however , metastatic disease can arise in approximately 20 % 30 % of patients and accounts for over 28,000 deaths a year in the united states.1 androgen - deprivation therapy ( adt ) has been the standard treatment for advanced and metastatic prostate adenocarcinoma for decades and is achieved by medical castration ( luteinizing - hormone releasing hormone [ lhrh ] agonist or antagonist ) or surgical castration ( bilateral orchiectomy ) . although the disease is initially sensitive to adt , resistance is inevitably acquired , leading to castrate - resistant prostate cancer ( crpc ) which is incurable . however , there are several agents which can improve survival in such patients ( see table 1 ) . antiandrogens are oral compounds that compete with endogenous ligands for the androgen receptor ( ar ) , and when bound induce a conformational change that impedes transcription of key androgen - regulated genes . steroidal antiandrogens were first developed in the late 1960s , can be distinguished by their physiologic progestational effects , and include agents such as cyproter - one acetate , megestrol acetate and medroxyprogesterone . the nonsteroidal antiandrogens , including flutamide , nilutamide and bicalutamide , act only at the androgen receptors and are generally better tolerated by patients . the addition of bicalutamide to standard care , either as monotherapy or as adjuvant treatment , improved progression - free survival ( pfs ) in men with locally - advanced prostate cancer , but not in patients with clinically localized disease.2 in the setting of metastatic prostate cancer , survival in men treated with bicalutamide monotherapy was found to be inferior when compared to castration.3 the combination of medical or surgical castration with an antiandrogen , known as combined androgen blockade , may possibly improve five - year overall survival when compared to lhrh monotherapy ( hazard ratio [ hr ] = 0.87 ; 95 % confidence interval [ ci ] , 0.810.94 ) 4 , although the significance of this finding has been debated . intriguingly , an antiandrogen withdrawal effect can be observed in up to 25 % of patients after discontinuation of these agents following clinical or biochemical progression.5 in this situation , bicalutamide can undergo an antagonist - to - agonist switch , thereby paradoxically stimulating ar activity and promoting prostate tumor cell growth .

introductionenzalutamide is an oral androgen receptor ( ar ) signaling inhibitor that was specifically engineered to overcome castration - resistant prostate cancer ( crpc ) harboring ar amplification or overexpression . enzalutamide has demonstrated significant activity in men with metastatic crpc.aimsto update the evidence and provide an overview of the available data on enzalutamide.evidence reviewpeer reviewed articles published and listed in medline search were reviewed . in addition , relevant asco and esmo abstracts were searched . the activity of enzalutamide is mediated by potently antagonizing the full - length ar , impairing translocation of the ar from the cytoplasm into the nucleus , and inhibiting the transcriptional activity of the ar by modulating the interaction of the ar with androgen - response elements in gene promoter regions . enzalutamide has a favorable safety profile and the most common adverse events include fatigue , hot flashes and headache ; 1 % of patients experienced seizure.place in therapythe affirm phase iii study evaluated the clinical utility of treatment with enzalutamide in men with docetaxel - refractory metastatic crpc . enzalutamide improved overall survival compared to placebo , with a median overall survival of 18.4 months versus 13.6 months respectively.conclusionenzalutamide has demonstrated impressive efficacy in men with metastatic crpc , moving swiftly from a phase i / ii study to two pivotal phase iii trials testing this agent in both chemotherapy - pretreated as well as chemotherapy - nave crpc patients . ongoing studies are aiming to explore the utility of enzalutamide in earlier stages of the disease , and to investigate the optimal sequencing and combination of enzalutamide with other standard and novel therapies for prostate cancer .

more than 50 % of individuals with voice disorders have benign alterations of the vocal fold mucosa . polyps are one of the most frequent vocal cord lesions and are the most prevalent indication for laryngeal microsurgery . like nodules , polyps are caused by overuse and abuse of the voice1 , although they may also occur as a result of a single traumatic incident2 3 . trauma can affect the superficial vases of the lamina propria causing the liquids within to overflow , displacing the epithelial layer and inducing scarring due to the deposition of fibrin and vascular proliferation . depending on the type of vascularization , polyps are classified as angiomatous or hemorrhagic if accompanied by vascularity or as hyaline or gelatinous in the absence of vascularization . the clinical picture is characterized by dysphonia related to intense vocal use , and is generally well - defined and recognized by the patient . the dysphonia is constant , and may progressively worsen . the voice presents as hoarse and breathy ; sometimes it can be rough and , infrequently , diplophonic . a diagnosis is made by assessing the clinical history , and by perceptive analysis and observation of the phonatory system , which includes assessments of the phonatory posture adopted , articulation , and attitude . vocal polyps can have many presentations and characteristics , and the aim of our study was to identify the characteristics of the polyps found in our population . the objective of this study was to analyze and compare the features of polyps ( intrinsic characteristics , associated lesions , and treatment outcomes ) from patients undergoing laryngeal surgery at our hospital .

summary introduction : dysphonia is the main symptom of lesions that affect the vocal tract . many of those lesions may require surgical treatment . polyps are one of the most common forms of vocal cord lesions and the most prevalent indication for laryngeal microsurgery . there are different types of polyps , and their different characteristics can indicate different prognosis and treatments . aim : to conduct a comparative study of polypoid lesions ( angiomatous and gelatinous ) in patients undergoing laryngeal microsurgery via an electronic protocol . method : we prospectively evaluated 93 patients diagnosed with vocal fold polyps ; the polyps were classified as angiomatous or gelatinous . results : in total , 93 patients undergoing laryngeal microsurgery were diagnosed with vocal fold polyps . of these , 63 ( 64.74 % ) had angiomatous and 30 ( 32.26 % ) gelatinous polyps . most patients with angiomatous polyps were men ; their polyps were frequently of medium size , positioned in the middle third of the vocal fold , and accompanied by minimal structural alterations ( msa ) . in contrast , the majority of patients with gelatinous polyps were women ; their polyps were smaller , positioned in the middle and posterior third of the vocal fold , and were not accompanied by msa . both types of polyps were more frequently located on the right vocal fold . conclusion : angiomatous polyps were more frequently encountered than gelatinous polyps . in addition , correlations between polyp type and sex , polyp size , position , location , and the presence of msa were observed . different surgical techniques were used , but the postoperative results were similar and satisfactory after speech therapy .

amalgam is a restorative material especially suitable for classes i and ii restorations in teeth that encounter heavy chewing forces . the advantages of amalgam restorations include resistance to wear , tolerance to a wide range of clinical placement conditions , and excellent load - bearing properties [ 13 ] . however , amalgam restorations may also present degradation in the intraoral environment due to secondary caries , fracture , marginal breakdown , and wear [ 46 ] . the traditional solution for those failures has been the complete replacement of the restorations , which may also include minor imperfections in the restorations , and replacement of defective restorations represents a major concern in dental practice , reaching up to 60 % of operative dentistry interventions . consequently , the median survival time ( mst ) of amalgam varies from 2 to 11 years , but most studies place it at over 5 years [ 810 ] . complete replacement of restorations has the disadvantages of being time consuming , unnecessary removal of healthy tooth tissue , enlarging preparations and restoration sizes [ 11 , 12 ] , the risk of converting the restoration to an indirect restoration , and the possibility of major injuries in pulp tissues [ 1214 ] . during the last years , new strategies , such as repair and refinishing of localized defects , have shown improvement in the quality of the defective restorations and increased longevity of restorations with minimal intervention [ 1517 ] . repair rather than replacement of failing restorations is a part of minimally invasive dentistry , preservation of natural tooth structure , early detection of carious lesions , nonsurgical interventions , and a modified surgical approach that includes delayed restoration and smaller tooth preparations with modified cavity designs . the aim of this clinical trial was to assess the long - term performance of two minimally invasive clinical procedures , repair and refinishing , as treatments for localized defects of classes i and ii amalgam restorations .

replacement of dental restorations has been the traditional treatment for defective restorations . this five - year prospective clinical trial evaluated amalgam restorations with localized defects that were treated by means of repair or refurbishing . fifty - two patients ( 50 % female and 50 % male , mean age 28.3 18.1 years , range 1880 ) with 160 class i and class ii defective restorations were included . the study focused on the application of two minimally invasive treatments for localized restoration defects and compared these with no treatment and total replacement as negative and positive controls , respectively . restorations were assessed by two calibrated examiners according to modified u.s . public health service criteria , including marginal adaptation , anatomic form , secondary caries , and roughness . at five years , recall was examined in 45 patients with 108 restorations ( 67.5 % ) . the results suggest that repair treatment is as effective as total replacement of restorations with localized defects , reducing biological costs to the patient and providing new tools to the clinician . refinishing restoration is a useful treatment for localized anatomic form defects .

advances in chemotherapy and radiotherapy have altered the natural course of disease in patients with systemic cancer , who now live longer than ever before . on the downside , prolonged survival has led to increased incidence of distant spread of disease , leptomeningeal metastasis being one such dreaded complication . however , prompt diagnosis and treatment in these patients can not only provide symptomatic relief and improve the quality of life but can also increase survival . contrast - enhanced mr has not only increased the sensitivity and specificity to detect meningeal disease but can act as a guide to biopsy and assess response to therapy . advances in cytological techniques and tumour markers have further increased the sensitivity in detection of malignant cells in the cerebrospinal fluid .

abstractprimary malignant tumours arising from the meninges are distinctly uncommon , and when they occur , they are usually sarcomas . in contrast , metastatic meningeal involvement is increasingly seen as advances in cancer therapy have changed the natural history of malignant disease and prolonged the life span of cancer patients . the meninges can either be infiltrated by contiguous extension of primary tumours of the central nervous system , paranasal sinuses and skull base origin or can be diffusely infiltrated from haematogenous dissemination from distant primary malignancies . imaging in these patients provides crucial information in planning management . this article reviews the pertinent anatomy that underlies imaging findings , discusses the mechanism of meningeal metastasis and highlights different imaging patterns of meningeal carcinomatosis and the pitfalls .

g protein - coupled receptors ( gpcrs ) compose the largest family of membrane - bound receptors and many members still have unrevealed functions . efforts have been made to find ligands for gpcrs , and a broad range of ligands , including small organic compounds [ 1 , 2 ] , eicosanoids , peptides , and proteins , have been identified . members of the mas - related gpcr ( mrgpr ) family are known to be expressed mainly in the subpopulations of sensory neurons . this has resulted in their having another name sensory neuron specific receptors ( snsrs ) . mas - related g - protein coupled receptor member d ( mrgprd ) , formerly called mas - related gene d ( mrgd ) and also referred to as hgpcr45 or tgr7 , belongs to the mrgpr family and is known to be mainly expressed in the dorsal root ganglia ( drg ) [ 6 , 912 ] . when phylogenic trees of the hmrgpr family and the mouse mrgpr family are compared , variation of the members found in those phylogenic trees are not parallel . members of the human mrgpr family may cover other functions from the ones revealed by studies with the mouse mrgpr family . we hypothesized mrgprd could possess functions besides the ones in the drg and found a spheroid forming activity . at this time , for mrgprd , beta - alanine ( ala ) is the only known ligand that would be physiological . when we screened a physiologically active substance library and a known small compound library , we found two novel ligands for mrgprd , that is , beta - aminoisobutyric acid ( aiba ) and diethylstilbestrol ( des ) . as ala promoted spheroid growth of mrgprd stably expressing cells , it would be useful to obtain antagonists in order to analyze the tumorigenic character of mrgprd . we obtained mu-6840 as an antagonist of mrgprd by high - throughput - screening at a large small chemical library . since it specifically inhibits the growth of spheroids formed with cells stably expressing mrgprd , mu-6840 is a potential anticancer agent . in this paper , we will discuss the novel ligand , the antagonist , and the novel character of mrgprd .

mas - related g - protein coupled receptor member d ( mrgprd ) is a g protein - coupled receptor ( gpcr ) which belongs to the mas - related gpcrs expressed in the dorsal root ganglia ( drg ) . in this study , we investigated two novel ligands in addition to beta - alanine : ( 1 ) beta - aminoisobutyric acid , a physiologically active substance , with which possible relation to tumors has been seen together with beta - alanine ; ( 2 ) diethylstilbestrol , a synthetic estrogen hormone . in addition to the novel ligands , we found that transfection of mrgprd leads fibroblast cells to form spheroids , which would be related to oncogenicity . to understand the mrgprd novel character , oncogenicity , a large chemical library was screened in order to obtain mrgprd antagonists to utilize in exploring the character . the antagonist in turn inhibited the spheroid proliferation that is dependent on mrgprd signaling as well as mrgprd signals activated by beta - alanine . the antagonist , a small - molecule compound we found in this study , is a potential anticancer agent .

chronic infection with hepatitis b virus ( hbv ) results in an estimated 786 000 deaths annually worldwide 1 . infected individuals may remain asymptomatic for long periods but are at risk of progressive liver disease , and can transmit the virus to other susceptible individuals . the primary marker for screening and laboratory diagnosis of hbv infection is hepatitis b surface antigen ( hbsag ) , a component of the virus envelope that is also found in the blood in great excess as noninfectious subviral particles . immunoassays with high sensitivity and specificity for hbsag detection are used in developed countries and are subject to strict regulatory requirements and quality assurance . while hbsag testing has been at the forefront of blood screening and subsequent improvements to public health , the cost and the lack of access to commercial immunoassays can limit their usefulness in resource - limited settings and among marginalized high - risk populations including injection drug users , immigrants and the homeless . the time and expense involved in blood processing and patient call - back and counselling can be considerable , and many patients are lost to follow - up . high - quality point - of - care ( poc ) testing may overcome some of these hurdles and reduce costs . these tests have a range of diagnostic accuracy and generally do not have the same sensitivity and specificity as commercial screening immunoassays , potentially returning false - negative or false - positive results leading to subsequent inappropriate clinical management . with ten different hbv genotypes ( a j ) , genetic diversity presents a major challenge , and genotype - dependent reduced sensitivity has been shown with some assays 2 . in addition , hbv variants carrying amino acid substitutions in the a determinant of hbsag can escape detection 24 ; such amino acid substitutions can emerge under the selective pressure of antiviral therapy ( e.g . lamivudine ) or immune response ( e.g . postvaccination ) . the nanosign hbs poc strips using samples from patients infected with different hbv genotypes and defined specimens with substitutions in the a determinant . we also used the test to screen a panel of at - risk patients and compared the results with standard - of - care ( soc ) serologic testing .

early identification of chronic hepatitis b is important for optimal disease management and prevention of transmission . cost and lack of access to commercial hepatitis b surface antigen ( hbsag ) immunoassays can compromise the effectiveness of hbv screening in resource - limited settings and among marginalized populations . high - quality point - of - care ( poc ) testing may improve hbv diagnosis in these situations . currently available poc hbsag assays are often limited in sensitivity . we evaluated the nanosign hbs poc chromatographic immunoassay for its ability to detect hbsag of different genotypes and with substitutions in the a determinant . thirty - seven serum samples from patients with hbv infection , covering hbv genotypes a g , were assessed for hbsag titre with the roche elecsys hbsag ii quantification assay and with the poc assay . the poc assay reliably detected hbsag at a concentration of at least 50 iu / ml for all genotypes , and at lower concentrations for some genotypes . eight samples with substitutions in the hbv a determinant were reliably detected after a 1/100 dilution . the poc strips were used to screen serum samples from 297 individuals at risk for hbv in local clinical settings ( health fairs and outreach events ) in parallel with commercial laboratory hbsag testing ( quest diagnostics eia ) . poc testing was 73.7 % sensitive and 97.8 % specific for detection of hbsag . although the poc test demonstrated high sensitivity over a range of genotypes , false negatives were frequent in a clinical setting . nevertheless , the poc assay offers advantages for testing in both developed and resource - limited countries due to its low cost ( 0.50 $ ) and immediately available results .

large scale trials with insecticide treated bed nets ( itns ) have been shown to have a profound impact on reducing malaria transmission in experimental trials in sub - saharan africa and were recommended for large scale operations . however , this tool did not become practical before the first long lasting insecticide nets ( llins ) were marketed and recommended by world health organization . preliminary who recommendations of llin are based on short term studies on vector impact and wash resistance . however , in sub - saharan african settings , loss of insecticide is not primarily due to washing , but due to handling and evaporation . dabire indicated that , though llins showed good efficacy on mosquitoes under controlled conditions , their effectiveness in the field conditions with respect to actual duration of insecticide protection in the field did not last for five years as indicated on the bed nets . recent research has shown that wear and tear may be more important for bed net durability than wash removal of insecticide . this has led to the development of several hole indexes , and who recently modified the model it recommend . since holes can only be measured on nets still present , it is the most meaningful when attrition rate can be followed , which means that cohorts of nets must be followed . however , the effect of gradually declining insecticide in the net , increasing the number of holes , and net disappearing has not been combined with observations of malaria incidence in field studies , and the effect is thus uncertain . this study was set up to see how an llin with a preliminary who recommendation performs in the field as a vector control tool , combining field observations of mosquito density to net parameters as insecticide load , bioassay performance , and hole index , and to see how the expected decline in efficacy impact malaria incidens . netprotect bed nets were reportedly developed on the advantage of the first two long lasting bed nets using a fine mesh - like polyester net but having the strength and incorporation technology of a polyethylene nets . the bed net is made out of polyethylene mixture in which the insecticide ( deltamethrin ) is incorporated directly into the fabric at the rate of 1.8 g / kg or 60 mg / m .

we studied the effect on malaria incidence , mosquito abundance , net efficacy , net use rate , chemical analysis , and holes of a long lasting insecticide treated bed net ( netprotect ) in western kenya , 20072010 . nets were hung in 150 households 6 months before they were hung in a second , 2 km away . indoor resting densities were monitored by pyrethrum spray catch and malaria cases by passive detection using clinical manifestations and rapid diagnostic test . the probability of finding an . arabiensis in the control area was 2.6 times higher than that in intervention area during the first 6 months . human blood feeding index of anopheles funestus declined 17 % . after bed nets were hung in the second area , malaria incidence declined 25 % down to the level in the first area . incidence remained at this low level for 2 years . 90 % of collected nets were efficacious after 3-year use . deltamethrin dosage declined from 1.9 to 0.5 g / kg over 3 years . attrition rate after 3 years was 21 % . who hole index changed from 333 to 114 to 381 over the three years . this index summarizes the numbers of holes in size categories and multiplies with the mean hole area per category . it is very sensitive to the impact of big holes in a few nets .

this lethal variant results from the inheritance of an autosomal recessive gene and causes abnormal development of cartilage and fibrous connective tissues . these features are broad , long - bone metaphyses ( dumbbell shaped ) and shortened ribs with pear - shaped vertebral bodies . we report a case of fibrochondrogenesis with severe pear - shaped platyspondyly ( flattened spine ) , suspected on antenatal ultrasound examination this case gives a comprehensive pictorial review of the antenatal ultrasound and postnatal radiographic findings , which are not available in current literature .

fibrochondrogenesis is a rare , neonatally lethal osteochondrodysplasia , with autosomal recessive inheritance . it differs from other lethal dwarfisms in that it leads to broad , long - bone metaphyses ( dumb - bell shaped ) and pear - shaped vertebral bodies . we report a case of fibrochondrogenesis with severe pear - shaped platyspondyly , suspected antenatally , and give a comprehensive pictorial review of the antenatal ultrasound and postnatal radiographic findings . only few cases of fibrochondrogenesis are diagnosed before the termination of pregnancy .

acute subdural hemorrhage requires emergent neurosurgery or close observation because of its high mortality rate . a number of cases who showed rapid resolution of acute subdural hemorrhage with neurological improvements have been reported2,6,7 ) . herein , we present a case who showed rapid resolution of acute subdural hemorrhage spontaneously within 2 days after severe head injury .

acute subdural hematoma is usually a neurological emergency that requires hematoma evacuation or close observation . however , spontaneous resolutions of an acute subdural hematoma without surgical interventions have been reported rarely . we report on a case who showed rapid resolution of an acute subdural hematoma with neurological improvement and review the relevant literatures .

in recent times in some occupations work in static sedentary postures for long hours in order to perform the tasks required of them . this can cause continuous muscle contraction in the neck and shoulders , which subsequently leads most people to adopt a forward head posture ( fhp ) in which their chins stick out1 . when fhp is maintained for prolonged periods the neck flexors and the erector spinae ( es ) muscles in the upper thoracic region are weakened due to their lengthening , and the scapula is elevated due to tension in the levator scapula , sternocleidomastoid ( scm ) , splenius muscles , and the suboccipitalis , which also causes tension in the upper trapezius ( ut ) 2 . therefore , because of an imbalance in the muscles , such as the shortening or lengthening , or straining or loosening of the muscles around the neck , a rounded shoulder posture is exhibited , in which the upper thoracic region is slightly bent while in a sitting posture3 , and chronic neck pain results due to mechanical stress1 . these changes in muscle activity result from changes in motor strategies to minimize the activities of muscles that are sensing pain and to compensate for these suppressed muscles4 . in addition , fhp is known to have a large influence on respiratory function by weakening the respiratory muscles5 , 6 . the scm , scalene muscles , ut , pectoralis major ( pm ) , and thoracolumbar es muscles are important accessory respiratory muscles involved in inspiration7 , 8 and prolonged fhp weakens these muscles , thereby decreasing their respiratory function7 . because of this , patients with fhp accompanied by chronic neck pain have been shown to have less respiratory muscle strength than normal individuals9 and their accessory respiratory muscles are shortened , which largely affects their respiratory function10 . in addition , a study reported that fhp changes the alignment of the thoracic spine and rib cage due to a slightly bent posture , thereby causing respiratory dysfunction5 . however , most previous studies on this topic were conducted on patients with neck pain or on patients with neck pain accompanied by fhp , whereas the number of studies that have identified the specific effects of just fhp on respiration is limited . therefore , this study measured the forced vital capacity ( fvc ) and the forced expiratory volume in 1 second ( fev1 ) in healthy normal adults and healthy adults with fhp to determine the effects of fhp on respiratory dysfunction . in addition , the present study attempted to determine the relationship between fhp and accessory respiratory muscle activity by measuring the activity of the scm , ut , pm , and thoracolumbar es muscles during deep breathing .

[ purpose ] this study investigated the effects of forward head posture on forced vital capacity and deep breathing . [ subjects ] twenty - six subjects , divided into the two groups ( normal and forward head posture groups ) , participated in this study . [ methods ] forced vital capacity and forced expiratory volume in 1 second were measured using respiratory function instrumentation that met the american thoracic society s recommendation for diagnostic spirometry . accessory respiratory muscle activity during deep breathing was measured by electromyography . a mann - whitney test was used to compare the measure variables between the normal and forward head posture group . [ results ] forced vital capacity and forced expiratory volume in 1 second were significantly lower in the forward head posture group than in the normal group . accessory respiratory muscle activity was also lower in the forward head posture group than in the normal group . in particular , the sternocleidomastoid and pectoralis major activity of the forward head posture group was significantly lower than that of normal group . activities of the other muscles were generally decreased with forward head posture , but were not significantly different between the two groups . [ conclusion ] these results indicate that forward head posture could reduce vital capacity , possibly because of weakness or disharmony of the accessory respiratory muscles .

older adults with a range of comorbidities are often prescribed multiple medications , some of which may impact on their function and cognition , and many have a potential for drug interactions.1 studies showing evidence of benefit from pharmacotherapy have mostly been conducted in younger patients , and it is unclear how this translates to frail older patients . these patients are often excluded from drug trials ; yet they are the largest consumers of medications.1 several studies have found current use of five or more drugs in well over a quarter of older community dwelling adults,24 with higher prevalence in frail older populations and in hospitalized patients.5,6 the assessment of frailty using various methods , including the frailty index , is being incorporated in recent studies of older adults and provides an insight into their accumulated deficits and reduced reserve.7,8 the increased number of comorbidities requiring medications makes these patients prone to polypharmacy , yet their frailty status , together with the pharmacokinetic and pharmacodynamic changes that occur with aging , places them at risk of adverse events . the risks of polypharmacy include non - adherence , adverse drug reactions , drug drug interactions , falls , fractures , poor nutrition , and mortality,914 as well as increased exposure to potentially inappropriate medications ( pims ) .5,15 however , few studies have reported on the association of polypharmacy with functional outcomes in older patients . the aims of the study were to explore the extent of polypharmacy in a cohort of older patients discharged from hospital to a home care program ; assess the relationship between polypharmacy and patient characteristics , functional outcomes , and frailty ; and describe the prevalence of the most common medications in this cohort , with particular emphasis on pims .

backgroundolder adults with a range of comorbidities are often prescribed multiple medications , which may impact on their function and cognition and increase the potential for drug interactions and adverse events.aimsthis study investigated the extent of polypharmacy and potentially inappropriate medications in patients receiving post - discharge transitional home care and explored the associations of polypharmacy with patient characteristics , functional outcomes , and frailty.methodsa prospective observational study was conducted of 351 patients discharged home from hospital with support from six transition care program ( tcp ) sites in two states of australia . a comprehensive geriatric assessment was conducted at tcp admission and discharge using the interrai home care assessment tool , with frailty measured using an index of 57 accumulated deficits . medications from hospital discharge summaries were coded using the world health organization anatomical therapeutic chemical classification system.resultspolypharmacy ( 59 drugs ) was observed in 46.7 % and hyperpolypharmacy ( 10 drugs ) in 39.2 % of patients . increasing numbers of medications were associated with greater number of comorbid conditions , a higher prevalence of diabetes mellitus , coronary heart disease , chronic obstructive pulmonary disease , dizziness , and dyspnea and increased frailty . at discharge from the program , the non - polypharmacy group ( < 5 drugs ) had improved outcomes in activities of daily living , instrumental activities of daily living and fewer falls , which was mediated because of lower levels of frailty . the commonest drugs were analgesics ( 56.8 % ) and antiulcer drugs ( 52.7 % ) . the commonest potentially inappropriate medications were tertiary tricyclic antidepressants.conclusionpolypharmacy is common in older patients discharged from hospital . it is associated with frailty , falls , and poor functional outcomes . efforts should be made to encourage regular medication reviews and rationalization of medications as part of discharge planning . whether careful deprescribing improves outcomes in frail patients should be the focus of randomized trials .

oxidative stress tends to occur during the neonatal period because the younger the gestational age , the lower the antioxidant capacity ( ac ) and a lower ac tends to result in an increase in free radicals ( fr ) and reactive oxygen species ( ros ) . cell damage due to oxidative stress during the neonatal period has been associated with disease . for example , oxidative stress has been reported in association with necrotizing enterocolitis ( nec ) if the site of the damage is in the digestive tract , with chronic lung disease ( cld ) if in the lungs , retinopathy of prematurity ( rop ) if in the eyes , and periventricular leukomalacia ( pvl ) and intraventricular hemorrhage ( ivh ) if in the brain [ 6 , 7 ] . the other is to strengthen ac , which protects the body from cell damage by scavenging fr and ros when they increase . one study of preventing factors that trigger the production of fr and ros reported that using 21 % oxygen instead of 100 % oxygen during resuscitation can keep oxidative stress low , since oxygen causes an increase in fr and ros . a number of studies of strengthening ac have investigated the oral administration of antioxidants ( vitamins a , e , and d ) , but the studies have not reached a consensus of opinion [ 912 ] . although based on short - term studies , it is known that breast milk has greater ac than formula milk [ 13 , 14 ] . for example , compared to formula feeding cohorts , breastfeeding cohorts have been reported to show a 1/10 decrease in risk for development of nec , better neurodevelopment , and a decrease in the development of rop . the present study was conducted to elucidate the significance of breastfeeding with a view toward preventing oxidative stress . thus far there have been no reports on long - term total antioxidant capacity ( tac ) in breast milk . a new method to measure tac was used to compare the ac in formula milk and breast milk and to clarify the relationship between ac in breast milk and the postnatal age in days when collected .

this study aimed to consider the significance of breast milk in preventing oxidative stress by comparing total antioxidant capacity ( tac ) in breast milk and formula milk for premature infants , demonstrating the relationship between tac in breast milk and postnatal age in days . we used the biological anti - oxidant potential test , a new method to measure tac in breast milk . breast milk for premature infants were stored at 20c and thawed within 48 h of collection . we measured tac in two types of formula milk in the same way . tac was clearly higher in breast milk than formula milk . although a negative correlation was observed between tac in breast milk and age when collected , tac was always higher than the average tac in formula milk . tac in breast milk is higher than tac in formula milk . we suggest the importance of breast milk for preventing oxidative stress and starting breastfeeding early .

presentations at international scientific conferences such as ics and iuga are the most important route for early dissemination and discussion of research findings . indeed for many studies that never reach full text publication , and in many regions where access to health care publications is limited , the conference abstract may be the only easily available record of the research . as if preparing a succinct and accurate summary of one s research is not challenging enough , there is also a certain art to writing an abstract that will appeal to conference scientific committees . over the last decade getting work accepted for oral presentation at either ics or iuga became increasingly difficult ( fig . the ics meeting in san francisco received 1,003 abstract submissions and was able to accept only 284 for oral presentation . the iuga meeting was usually more forgiving , with the 2009 como meeting receiving 477 submissions and accepting 200 oral presentations . 1total abstract submissions to the ics meeting 20002009 ( data courtesy of dan snowdon ) total abstract submissions to the ics meeting 20002009 ( data courtesy of dan snowdon )

introductionthis article aims to condense the lectures and discussions from workshops on good reporting at iuga como 2009 and ics san francisco 2009 , providing practical advice for the novice researcher summarising their data for the first time.conclusionsdrafting an abstract can be a time consuming process . formal guidance , such as consort and strobe , exists for the kinds of information that should be included regarding almost all designs of clinical trials . follow the abstract submission rules closely to avoid outright rejection . plan to highlight the novelty , scientific merit and clinical impact of the work . try not to overstate the importance of the findings . do not forget to publish the work in a peer reviewed journal .

developmental dental disorders may be due to abnormalities in the differentiation of the dental lamina and the tooth germs ( anomalies in number , size and shape ) or to abnormalities in the formation of the dental hard tissues ( anomalies in structure ) . in some , both stages of differentiation are abnormal . developmental dental disorders are not only congenital but they may also be inherited , acquired or idiopathic . the terms double tooth , double formations , joined teeth , or fused teeth are often used to describe gemination and fusion , both of which are primary developmental abnormalities of the teeth.17 in the primary dentition , the frequency of gemination or fusion is about 2.5 % . a survey of the literature has revealed prevalence estimates for bilateral double teeth ranging from 0.01 to 0.04 % in the primary , and 0.05 % in the permanent dentition.1,7 gemination is defined as an attempt to make two teeth from one enamel organ . this results in a structure with two completely or incompletely separated crowns with a single root and root canal . occasionally we see complete cleavage or twinning ( two teeth from one enamel organ ) . the etiology is unknown , but trauma has been suggested as a possible cause , though a familial tendency has been suggested.8 gemination is observed in the deciduous as well as in the permanent dentition.3,4,7 in the anterior region , this anomaly can cause unpleasant esthetic appearance due to irregular morphology . if a deep groove is present , these teeth may be susceptible to caries and periodontal disease and may require endodontic intervention in some cases which may be complicated.1,2 gemination usually present asymptomatically . in fact , the co - operation of practitioners with expertise in multiple areas of dentistry is important to create or achieve functional and esthetic success in these cases . several treatment methods have been described in the literature with respect to the different types and morphological variations of fused teeth , including endodontic , restorative , surgical , periodontal and/or orthodontic treatment.1,2,4,911 in clinical situations , cases of fusion have the appearance of a congenitally missing tooth , while in gemination the number of teeth in the dentition is normal , provided the double tooth is counted as one unit.1,4 this paper reports aesthetic rehabilitation of a rare case ; bilateral gemination of permanent maxillary central incisors utilizing heat - pressed lithium disilicate all ceramic crowns .

geminated teeth are the consequences of developmental anomalies leading to the eruption of joined elements . according to current definitions , gemination occurs when one tooth bud tries to divide , while fusion occurs if two buds unite . clinical experience shows , however that diagnosis can be complicated due to superimposed anomalies . this report describes a unique case of bilateral gemination of permanent maxillary central incisors . the esthetic rehabilitation of the geminated incisors accomplished utilizing all ceramic crowns . it is important that in these types of cases , reaching to the available esthetics and avoiding the complication of caries and periodontal problems with prosthetic application is satisfactory .

tennis elbow ( te ) is not an inflammation of the outside portion of the elbow but rather is the degeneration of the extensor tendon of the humeral lateral epicondyle ( le ) due to microscopic injuries . common symptoms include pain , tenderness over the le , pain upon gripping , and dorsiflexion against resistance of the wrist , middle finger , or both1,2,3,4,5 . conservative treatments such as nonsteroidal anti - inflammatory drugs , local steroid injections , strengthening exercises , stretching , taping , ultrasound ( us ) , iontophoresis , laser , acupuncture , and massage are usually used6,7,8,9,10,11 . meanwhile , surgical intervention is required for cases of te when conservative management is deemed ineffective12 . one non - invasive treatment for te - associated pain is extracorporeal shock wave therapy ( eswt ) . although the underlying mechanism of eswt is not completely clear , it likely involves hyperstimulation analgesia ; it alleviates pain as a result of moderate - to - intense sensory input that is usually applied at the site of greatest discomfort . . however , there is a lack of comparative studies of the analgesic effects of various electrotherapy methods on chronic te . therefore , the present study compared the analgesic effects of eswt and us therapy in patients with chronic te .

[ purpose ] this study compared the analgesic effects of extracorporeal shock wave therapy with those of ultrasound therapy in patients with chronic tennis elbow . [ subjects ] fifty patients with tennis elbow were randomized to receive extracorporeal shock wave therapy or ultrasound therapy . [ methods ] the extracorporeal shock wave therapy group received 5 treatments once per week . meanwhile , the ultrasound group received 10 treatments 3 times per week . pain was assessed using the visual analogue scale during grip strength evaluation , palpation of the lateral epicondyle , thomsen test , and chair test . resting pain was also recorded . the scores were recorded and compared within and between groups pre - treatment , immediately post - treatment , and 3 months post - treatment . [ results ] intra- and intergroup comparisons immediately and 3 months post - treatment showed extracorporeal shock wave therapy decreased pain to a significantly greater extent than ultrasound therapy . [ conclusion ] extracorporeal shock wave therapy can significantly reduce pain in patients with chronic tennis elbow .

chest pain accounts for approximately 56 million emergency department ( ed ) visits and 1 in every 50 outpatient visits in the united states , ultimately costing more than $ 6 billion dollars in annual healthcare costs . while a majority of presentations for chest pain are ultimately deemed non - cardiac in origin , in light of the substantial morbidity and mortality due to coronary heart disease , most patients undergo non - invasive testing for coronary artery disease ( cad ) to better define individual cardiovascular risk . in an era of increasing focus on healthcare resource utilization , considerable interest is aimed at reducing the cost and time to provide appropriate care , ultimately identifying the right test , for the right patient , in the right clinical presentation ( assuming a test is needed or indicated at all ) . beyond its role as a well - established screening test for subclinical coronary atherosclerosis in asymptomatic patients , coronary artery calcium ( cac ) testing has garnered increasing attention as an inexpensive , rapid , reproducible and safe alternative to exclude cad in symptomatic patients at low- intermediate pre - test risk for obstructive coronary atherosclerosis . current national institute for health and clinical excellence ( nice ) guidelines recommend testing for cac as the first - line examination in lower risk patients with stable chest pain symptoms [ 2 ] . however , several potential limitations of this approach have curbed the widespread use of cac testing in symptomatic patients and led to discordant recommendations from other professional societies . these include concerns for the presence of obstructive disease in the absence of cac , particularly in patients at higher pre - test risk , the high background prevalence of cac in the general population , and a low - specificity of cac for obstructive disease , necessitating additional testing in a significant percentage of patients with evident cac . the concern for diagnostic inefficiency due to test layering in symptomatic patients with positive cac , as well as the ability to perform coronary computed tomographic angiography ( cta ) , with proven accuracy and prognostic value at radiation doses comparable to cac testing in many patients , are prominent limitations to cac testing in symptomatic patients in our practice . herein , we review the evidence supporting cac testing in symptomatic patients as well as the challenges to its widespread application .

the detection and quantification of coronary artery calcification ( cac ) significantly improves cardiovascular risk prediction in asymptomatic patients . many have advocated for expanded cac testing in symptomatic patients based on data demonstrating that the absence of quantifiable cac in patients with possible angina makes obstructive coronary artery disease ( cad ) and subsequent adverse events highly unlikely . however , the widespread use of cac testing in symptomatic patients may be limited by the high background prevalence of cac and its low specificity for obstructive cad , necessitating additional testing ( test layering ) in a large percentage of eligible patients . further , adequately powered prospective studies validating the comparative effectiveness of a cac first approach with regards to cost , safety , accuracy and clinical outcomes are lacking . due to marked reductions in patient radiation exposure and higher comparative accuracy and prognostic value make coronary computed tomographic angiography the preferred ct - based test for appropriately selected symptomatic patients .

currently , the combined prevalence of overweight ( bmi , body mass index 25 kg / m ) and obesity ( bmi 30 kg / m ) , defined by the world health organization ( who ) [ 1 , 2 ] , has ranged from approximately 50 to 65 percent in large samples of persons with ms [ 35 ] . these estimates may not differ considerably from those of nondiseased adult populations , but weight status may have important consequences for mobility and the accumulation of disability in persons with ms . mobility , assessed by a variety of measures , is compromised in nondiseased persons who carry excess body weight . compared to normal weight persons , those who were obese walked at slower speeds and covered less distance during a 6-minute walk ( 6mw ) test . a higher oxygen cost of walking ( cw ) has been established in nondiseased obese adults compared to adults of normal weight . altered gait kinematics including slower walking speed , shorter stride length , and more time spent in stance phase and double support during walking have further been observed in obese compared to normal - weight adults . such results in nondiseased populations would support the idea that weight status might similarly be a source of mobility dysfunction seen in persons with ms [ 1013 ] . our group has recently investigated the prospective relationship between self - reported bmi and disability , assessed by the patient determined disease status ( pdds ) scale , over a 24-month period in a large sample of persons with ms . interestingly , we observed a progression in disability status over time , but this change was not accompanied by , nor predicted by , a change in self - reported bmi . a comprehensive assessment of mobility may capture different information than that captured by the pdds alone , and may be affected by weight status in persons with ms , as seen in nondiseased obese populations . measures that assess mobility in persons with neurological disorders have been described by pearson et al . . these include timed walking tests , endurance tests , quantitative movement analysis , energy consumption , self - report questionnaires , and activity monitoring . we examined the effect of weight status on a comprehensive set of mobility outcomes , including ambulatory performance , cw , spatiotemporal parameters of gait , self - reported walking impairment , and free - living activity in persons with ms . based on previous research in healthy controls and mobility impairments in persons with ms , we expected that weight status would negatively impact outcomes of mobility , resulting in greater mobility impairment in persons with a higher bmi . such an examination is important given the prevalence of overweight and obesity in persons with ms and the possible impact this comorbidity may have on health and disease status . if weight status is important to mobility in persons with ms , targeted weight loss interventions may represent alterative and potential adjunct strategies for managing the consequences of this disease .

the accumulation of excess body weight may have important health and disease consequences for persons with multiple sclerosis ( ms ) . this study examined the effect of weight status on mobility using a comprehensive set of mobility outcomes including ambulatory performance ( timed 25-foot walk , t25fw ; 6-minute walk , 6mw ; oxygen cost of walking , cw ; spatiotemporal parameters of gait ; self - reported walking impairment , multiple sclerosis walking scale-12 ( msws-12 ) ; and free - living activity , accelerometry ) in 168 ambulatory persons with ms . mean ( sd ) bmi was 27.7 ( 5.1 ) kg / m2 . of the 168 participants , 31.0 % were classified as normal weight ( bmi = 18.524.9 kg / m2 ) , 36.3 % were classified as overweight ( bmi = 25.029.9 kg / m2 ) , and 32.7 % were classified as obese , classes i and ii ( bmi = 3039.9 kg / m2 ) . there were no significant differences among bmi groups on t25fw and 6mw , cw , spatiotemporal gait parameters , msws-12 , or daily step and movement counts . the prevalence of overweight and obesity in this sample was almost 70 % , but there was not a consistent nor significant impact of bmi on outcomes of mobility . the lack of an effect of weight status on mobility emphasizes the need to focus on and identify other factors which may be important targets of ambulatory performance in persons with ms .

nonalcoholic fatty liver disease ( nafld ) is a clinicopathological condition characterised by lipid deposition in the liver and is a common cause of liver dysfunction . the prevalence of nafld in asian population ranges from 9 % to 45 % and is estimated to be about 30 % in western population . apart from an increased risk of liver - related morbidity and mortality , patients of nafld also have higher cardiovascular risk [ 3 , 4 ] especially when present along with type 2 diabetes ( t2 dm ) [ 4 , 5 ] . a balanced autonomic output to liver is important for maintenance of circadian rhythms of liver metabolic enzymes and glucose level . the autonomic symptom burden assessed by orthostatic grading scale was higher in nondiabetic nafld and the sudomotor dysfunction was also higher in the nafld after accounting for all confounders . a recent systematic review of 27 studies showed an association of nafld with subclinical atherosclerosis independent of traditional risk factors and metabolic syndrome . similar independent association of nafld with subclinical atherosclerosis has been observed in asian indians also . in other clinical settings , it has been shown that arterial stiffness is inversely related to heart rate variability [ 12 , 13 ] . however , there are only a few studies in which heart rate variability has been evaluated in nafld [ 9 , 14 , 15 ] . a higher lf : hf ratio ( low frequency : high frequency ) of hrv was reported in patients ( n = 18 ) with nafld along with a lower baroreflex sensitivity . the independent contribution of diabetes and grade of nafld in development of autonomic dysfunction is not known . the present study was designed to evaluate cardiovascular autonomic status in the patients of nafld with or without diabetes as compared to control population of individuals without either diabetes or nafld . in the present study we evaluated the association of indices of hrv with anthropometric variables , lipid profile , and diabetic status in patients with and without nafld .

aim . the present study was designed to evaluate the heart rate variability ( hrv ) in nonalcoholic fatty liver disease ( nafld ) and to assess the effect of grade of nafld and diabetic status on hrv . methods . this cross - sectional study included 75 subjects ( 25 nafld without diabetes , 25 nafld with diabetes , and 25 controls ) . measurements included anthropometry , body composition analysis , estimation of plasma glucose , serum lipids , hscrp , and serum insulin . hrv analysis was performed in both time and frequency domains . results . the time and frequency domain indices of overall variability ( sdnn , total power ) were significantly lower in nafld with diabetes as compared to the controls . however , the lf : hf ratio did not differ among the three groups . the variables related to obesity , lipid profile , and glucose metabolism were also higher in nafld with diabetes and those with grade ii nafld without diabetes , as compared to controls . multivariate stepwise regression analysis showed a negative correlation between hrv and total cholesterol and fat percentage . conclusion . the grade of nafld as well as diabetic status contributes to the decrease in the cardiovascular autonomic function , with diabetic status rather than grade of nafld playing a critical role . serum lipids and adiposity may also contribute to cardiac autonomic dysfunction .

gastric cancer is the second leading cause of death due to malignancy worldwide and occurs most frequently in the age group of 5070 years [ 13 ] . however , over the past half century several studies have reported on the clinical and pathological features of gastric carcinoma in young adults in the range of 2 % 8 % in different series . the incidence of gastric cancer is the highest in japan , china , south america and eastern europe and the lowest in the united states . gastric cancer is the third most common cancer in kashmir only superseded by esophageal and lung cancer . napoleon , his father , his grand father , and several of his siblings died of cancer stomach . inherited or familial gastric cancer and hereditary diffuse gastric cancer ( hdgc ) are common in patients younger than 40 years of age . patients with hereditary nonpolyposis colorectal cancer ( lynch syndrome ii ) are at increased risk of stomach cancer . first degree relatives of patients with gastric cancer have a two- to threefold increased risk of developing this disease . diets rich in salted , smoked , or poorly preserved foods are associated with increased risk of cancer stomach , whereas diets rich in fruits and vegetables are associated with decreased risk . foods rich in nitrates , nitrites , and secondary amines can combine with n - nitro compounds which induce gastric tumors in animals . alcoholics have also an increased risk of developing this disease . a near universal finding in young patients has been the high frequency of advanced lesions and undifferentiated tumors at presentation in comparison with older patients ; this has often been attributed to the delay in diagnosis . however , sometimes we do come across the patients with stomach cancer in their third or fourth decade of life . this motivate us to undertake this study of stomach cancer in young patients to see their demographic and clinicopathological profile and their association with p53 gene .

aim . the aim of this study was to see the clinical , pathological , and demographic profile of young patients with stomach carcinoma besides association with p53 . patients and methods . prospective study of young patients with stomach carcinoma from january 2005 to december 2009 . a total of 50 patients with age less than 40 years were studied . results . male female ratio was 1 : 1.08 in young patients and 2.5 : 1 in older patients . a positive family history of stomach cancer in the first degree relatives was present in 10 % of young patients . resection was possible only in 50 % young patients . 26 % young patients underwent only palliative gastrojejunostomy . the most common operation was lower partial gastrectomy in 68 % . amongst the intraoperative findings peritoneal metastasis was seen in 17.4 % in young patients . 50 % young patients presented in stage iv as per ajcc classification ( p value .004 ; sig . ) . none of the patients presented as stage 1 disease in young group . conclusion . early detection of stomach carcinoma is very important in all patients but in young patients it is of paramount importance .

acute respiratory tract infections ( artis ) are a leading cause of morbidity and mortality in children worldwide [ 1 , 2 ] . many viruses are associated with respiratory syndromes in all age groups [ 3 , 4 ] . however , inadequate diagnostic methods and unknown viral pathogens limit current understanding of arti etiology . one known viral pathogen , human metapneumovirus ( hmpv ) , is a globally distributed pathogen associated with respiratory infection in children [ 515 ] . after the pathogen respiratory syncytial virus ( rsv ) , hmpv is the leading cause of respiratory infection in children in influenza off - seasons . one study suggested that , in china , almost all children are exposed to hmpv by 6 years of age . in chongqing , china , these studies suggest that hmpv has significant epidemiological and pathological impacts as a significant respiratory pathogen in children . previous hmpv studies focused on its epidemiological characteristics and compared its viral genetics to those of rsv . however , whether the hmpv viral load is correlated with the severity of respiratory infection remains unknown . compared to conventional methods , such as virus culture and indirect immunofluorescence , real - time reverse transcriptase polymerase chain reaction ( real - time pcr ) is more sensitive and efficient at quantifying viral load [ 1820 ] . with real - time rt - pcr , we evaluated the changes in hmpv viral load every - other - day from 18 hospitalized children with lower respiratory tract infections to elucidate the association of hmpv viral load in airway with the disease course and severity .

objectivehuman metapneumovirus ( hmpv ) is a respiratory pathogen responsible for disease and subsequent hospitalizations in young children around the world . the disease pathology , including how viral load correlates with respiratory disease severity , remains unclear . this study investigated the correlation between viral load and clinical characteristics of hmpv infections.methodsnasopharyngeal aspirate ( npa ) samples collected from 18 infants hospitalized for lower respiratory tract infections ( lrtis ) in winter were tested for hmpv by reverse transcriptase polymerase chain reaction ( rt - pcr ) and real - time rt - pcr . their npa samples were collected every - other - day to monitor changes in hmpv viral load during hospitalization . also all these 18 patients were monitored to characterize clinically their illness.findingshmpv load was not correlated with infection severity ( p=0.5 , 0.9 , 0.5 ) . in contrast , the log10 of hmpv viral load was significantly different between those lasted for 611 days and those for less than 5 days ( p=0.01 ) , also the significant difference was shown between those of 611 days duration and those of more than 11 days ( p=0.006 ) , but there was no significant difference between those lasted for less than 5 days and those for more than 11 days ( p=0.4 ) . additionally , high hmpv viral shedding occured between 6 and 11days.conclusionhmpv load was significantly correlated with the course of illness . the association between hmpv viral load and the course of disease suggested that hmpv is an important pathogen in lower respiratory tract infection in children . but hmpv did not always lead to more severe respiratory illness .

the presence of pancreatic tissue outside its normal localization and without anatomic and vascular continuity with the normal pancreas is termed heterotopic pancreas ( hp ) ; pancreatic rests , ectopic , aberrant , or accessory pancreas are the other terms to describe the entity . hp may occur throughout the gastrointestinal tract , but has a propensity to affect the stomach , duodenum , jejunum , meckel 's diverticulum , and ileum . less frequently , it is observed in the liver , gallbladder , bile duct system , and papilla of vater . hp is known to be associated with various associated anomalies like malrotation , small intestinal atresias , biliary atresias , congenital diaphragmatic hernias , meckel 's diverticuli , annular pancreas and esophageal atresias . there have been isolated case reports of the presence of hp within the choledochal cyst ( cc ) .

a 9-year - old boy presented with duodenal pancreatic rest causing obstruction and required surgical intervention . he had been treated at the age of 4 months for a choledochal cyst . both choledochal cyst and heterotopic pancreas are entities that are commonly encountered in children , but the incidental presence of both the entities in the same child , albeit presenting metachronously , is extremely rare .

. the prediction of domains from sequence information can improve tertiary structure prediction ( 1 ) , enhance protein function annotation ( 2 ) , aid structure determination ( 3 ) and guide protein engineering ( 4 ) and mutagenesis ( 5 ) . a number of different methods have been developed to identify domains starting from primary sequences . these methods can be roughly classified into four categories : template - based methods ( 610 ) , ab initio ( template - free ) methods ( 1122 ) , the hybrid approach combining template - based and ab initio methods ( 23 ) , and meta - domain prediction methods ( 24 ) . here we describe an accurate , hybrid domain prediction server ( domac ) that integrates homology modeling , domain parsing and ab initio methods together . the preliminary implementation of the server [ under the name : foldpro ( 25 ) ] participated in the domain evaluation in the seventh edition of critical assessment of techniques for protein structure prediction ( casp7 ) ( 26,27 ) .

protein domain prediction is important for protein structure prediction , structure determination , function annotation , mutagenesis analysis and protein engineering . here we describe an accurate protein domain prediction server ( domac ) combining both template - based and ab initio methods . the preliminary version of the server was ranked among the top domain prediction servers in the seventh edition of critical assessment of techniques for protein structure prediction ( casp7 ) , 2006 . domac server and datasets are available at : http : //www.bioinfotool.org/domac.html

diaphragmatic rupture is a very rare injury , which occurs in less than 2 % of all blunt injuries to the abdominal area . injury to the diaphragm is most commonly caused by a sudden change in intra - abdominal pressure , most commonly by a blunt blow to the abdominal area . another cause of diaphragmatic rupture is sudden decelaration , when abdominal organs continue movement due to inertia , and tear through the diaphragm . diaphragmatic rupture often manifests itself later than other injuries , after an organ progressively herniates into the pleural cavity . we present a patient with a delayed diagnose of right sided diaphragmatic rupture with a complicated post - operation state .

right - sided traumatic diaphragmatic rupture in childhood is a very rare injury . diaphragmatic rupture often manifests itself later , after an organ progressively herniates into the pleural cavity . when the patient is tubed , the ventilation pressure does not allow herniation of an organ , which occurs when the patient is ex - tubed . we present a patient with a delayed diagnose of right sided diaphragmatic rupture with a complicated post - operation state .

irritable bowel syndrome ( ibs ) is traditionally diagnosed using the rome diagnostic criteria , a symptom - based criteria standard , currently revised as the rome iv criteria.1 the rome iii criteria for ibs had a modest diagnostic ability with a sensitivity of 75 % in primary care,2 and a sensitivity of 69 % and specificity of 80 % in secondary care.3 however , validation of the rome criteria is lacking and most of the validations of these criteria compare the criteria to normal subjects and not organic gastrointestinal ( gi ) illness . in addition , diagnosis based on the rome criteria starts with excluding other organic gi diseases with inevitably expensive investigations . for example , more than 70 % of patients with inflammatory bowel disease ( ibd ) would meet the rome criteria for ibs.4 the indefinite clinical definition of ibs also makes it difficult to determine healthy controls.5 in clinical practice , as well as in research , it is hard to determine normal subjects relative to patients with ibs since the rome criteria does not provide a strict definition of normal or healthy . a biomarker is defined as a characteristic that is objectively measured and evaluated as an indicator of normal biological processes , pathogenic processes , or pharmacologic responses to a therapeutic intervention.6 up - to - date biomarkers for ibs have been developed with several purposes : ( 1 ) to improve the diagnosis,79 ( 2 ) to differentiate from other organic diseases,9,10 and ( 3 ) to discriminate between ibs subtypes.8 though the markers should be associated with a possible pathophysiologic mechanism of ibs , some biomarkers for other diseases such as ibd are used for differentiating ibs from non - ibs.7,9,10 various materials for developing biomarkers have been introduced , including serologic markers,79 fecal markers,10 cellular / molecular markers , breath tests , scintigraphic markers , and colonic mucosal immune markers . the most significant issues when developing biomarkers for ibs are the small population sample size and limiting comparisons between ibs patients and healthy subjects or subjects with other diseases . in this article , we discuss the biomarkers for ibs , including those for specific ibs subtypes , from various materials .

traditionally , irritable bowel syndrome ( ibs ) has not been regarded as an organic disease , and the pathophysiology of ibs is heterogeneous . currently , the diagnosis of ibs is based upon the rome diagnostic criteria . the performance of these criteria is only modest in predicting ibs , and moreover their validation is lacking . additionally , as functional symptoms are common in the general population , healthy controls or volunteers are difficult to define and there is currently no definition of normal in the rome criteria . due to the weaknesses of the current diagnostic criteria , patients and doctors expect new gold standard diagnostic tools . various etiologic mechanisms result in potential biomarkers . the focus of this research has been to find non - invasive biomarkers from serum , breath gas , and fecal materials . though biomarkers should be based on biological and pathogenic processes , most biomarkers for ibs have been developed to identify organic diseases and therefore eliminate ibs . to date , these types of biomarkers for ibs have been disappointing . the purposes of developing biomarkers include improvement of diagnosis , differentiation from other organic diseases , and discrimination of ibs subtypes . a true mechanistic biomarker would make it possible to rule in ibs , rather than to rule out other organic diseases . new serologic biomarkers for diarrhea - predominant ibs have been introduced based on the pathophysiologic findings from a rat model and validation in a large - scale clinical trial . further investigations of abnormal organic findings from each subtype of ibs would enable the development of new , simple subtype - specific biomarkers .

kawasaki disease , also known as mucocutaneous lymph node syndrome , is an acute self - limiting vasculitis of childhood.1 kawasaki disease surpassed rheumatic fever as the most common cause of acquired heart disease . if left untreated , 15 % 20 % of patients may develop coronary artery lesions and coronary artery dilatation.2 the majority of the literature focuses on the cardiac implications of kawasaki disease , but little is known about its pulmonary complications or associations . here we report a rare , if not unique , case of kawasaki disease associated with group a streptococcus ( gas ) pleural effusion and a review of the english language literature .

backgroundkawasaki disease is an acute self - limiting vasculitis that affects children . the most dreaded complication of kawasaki disease reported in the literature over the years is coronary artery disease , which is considered as the main cause of acquired heart disease . however , pulmonary associations with kawasaki disease have been overlooked . we present a rare , if not unique , case of kawasaki disease associated with group a streptococcus pleural effusion in the english language literature . a search of the pubmed database was carried out , using a combination of the terms kawasaki disease , pneumonia , and group a streptococcus . the majority of studies conducted in children with kawasaki disease have concentrated on the coronary artery implications . kawasaki disease is considered a self - limiting illness , but can have detrimental consequences if not diagnosed early . when there is a prolonged inflammatory reaction , with no infectious agent identified or remittent fever unresponsive to antibiotics , kawasaki disease should be taken into consideration . elevated v2 + t cells compared with healthy controls suggest possible involvement of a superantigen in the etiology of kawasaki disease , so it is wise that the health care provider concentrates not only on the cardiac consequences , but also on pulmonary associations .

the local inflammatory response and the anatomical features of the herniated disc and spinal canal determine the resultant clinical syndrome which may include low back pain , and sciatica with or without neurological deficit . it has been estimated that about 80 % of the western population would suffer some back pain in their lifetime . ten million people per year are affected in the united states alone , costing roughly around $ 20 billion , in addition to loss of manpower due the absence from work . [ 24 ] mainstay of treatment for patients with radicular pain due to lumbar disc herniation involves open lumbar discectomy , and has provided excellent outcome in over six decades . [ 58 ] surgery ( discectomy ) , aims to alleviate pain ahead of the natural history . almost all patients report significant pain relief in the early post - operative period . given the current trend of minimal access surgery which transcends all aspects of surgical practice , nucleoplasty has been described recently as a minimal - access procedure with good outcome . it utilizes coblation technology that dissolves the soft tissue of nucleus pulposus , and therefore causes disc decompression and symptom improvement .

background : nucleoplasty ( percutaneous lumbar disc decompression ) is a minimally invasive procedure that utilizes radiofrequency energy as a treatment for symptomatic lumbar disc herniation , against open microdiscectomy , which would be the mainstay treatment modality . the literature reports a favorable outcome in up to 77 % of patients at 6 months.aim : to evaluate the effectiveness of nucleoplasty in the management of discogenic radicular pain.materials and methods : the medical notes of 33 patients , admitted for nucleoplasty between june 2006 and september 2007 , were reviewed retrospectively . all had radicular pain , and contained herniated disc as seen on magnetic resonance imaging ( mri ) of lumbosacral spine . patients were followed up at 1 and 3 months post - procedure . the outcome measures employed in this study were satisfaction with symptoms and self - reported improvement.results : thirty-three cases were examined ( 18 males and 15 females ) . twenty - seven procedures were performed with no complications and six were abandoned due to anatomical reasons . there were 18 and 15 cases of disc herniation at l5/s1 and l4/5 levels , respectively . four weeks following the procedure , 13 patients reported improvement in symptoms , and 14 remained symptomatically the same and subsequently had open microdiscectomy.conclusion : nucleoplasty has been shown to be a safe and minimal - access procedure . less than half of our selected cohort of patients reported symptomatic improvement at 1-month follow - up . we no longer offer this procedure to our patients . possible reasons are discussed .

although psa was once described as a variant of rheumatoid arthritis ( ra ) , it has been included in the group of spondyloarthropathies . psa was first defined by moll and wright in 1973 in patients who were seronegative for rheumatoid factor ( rf ) with positive history of psoriasis , current skin or nail psoriasis , and inflammatory joints of axial disease . the exact estimation of psa prevalence among psoriasis patients is difficult because several epidemiologic studies on psa have not used validated criteria . psa incidence has increased from 5 % to 40 % among patients with psoriasis [ 25 ] . because psa might be as common as psoriasis approximately 40 % to 60 % of psa patients develop erosive arthropathy , and 17 % have five or more deformed joints . a delay in diagnosis and treatment dermatologists who lack expertise in psa might miss an opportunity for early treatment that could prevent functional joint disability . unfortunately , many dermatologists are indifferent to psoriatic arthritis with any degree of severity and instead search for signs of hidden arthritis or skin disorders .

psoriatic arthritis is a chronic inflammatory arthropathy associated with skin psoriasis . it is considered a unique arthropathy with distinct clinical and radiologic features . up to 40 % of patients with psoriasis may develop psoriatic arthritis . psoriasis usually precedes psoriatic arthritis , so dermatologists are in a critical position for screening patients of psoriatic arthritis early in the disease course . psoriatic arthritis may be challenging to diagnose , especially for dermatologists , because it has an insidious disease course , non - specific symptoms , and no specific biomarkers . psoriatic arthritis is a polygenic autoimmune disorder of unknown etiology , but immunologic roles have recently been validated . in recent years , treatment modalities have rapidly advanced in the fields of psoriasis and psoriatic arthritis . biologic agents , including tnf- inhibitors and anti - il12/23 agents , have shown dramatic improvement .

chronic obstructive pulmonary disease ( copd ) is a disabling disease , of which the prevalence increases with age and causes significant morbidity and mortality.1 it is the ninth leading cause of years of life lost according to world health organization global health observatory data ( http : //www.who.int/gho/en/ ) . in the previous version of the global initiative for chronic obstructive lung disease ( gold ) guidelines , classification of copd was based only on the forced expiratory volume in 1 second ( fev1 ) . in 2011 , the gold guidelines emphasized the use of a combined copd assessment based on exacerbation risk and patient symptoms , and a new classification of gold groups was suggested ( http : //www.goldcopd.com/ ) . in recent studies , the capacity of this new copd classification for predicting the clinical course of copd has varied.24 as the numbers of copd patients increase with longer life expectancy , more surgeons encounter surgical patients with underlying copd . it is known that copd is an independent risk factor for increased postoperative morbidity , mortality , and length of hospital stay.5 it has been reported previously that such morbidities not only include postoperative pulmonary complications , but also wound dehiscence , sepsis , and cardiac and renal complications . therefore , accurate assessment of the status of copd patients is important for guiding appropriate perioperative management . to the best of our knowledge , the relationship between the copd gold group and postoperative complications has not yet been studied . the aim of this study was to evaluate whether the copd gold group classification is associated with the rate and type of postoperative complications .

purposechronic obstructive pulmonary disease ( copd ) is associated with increased postoperative complications . recently , the global initiative for chronic obstructive lung disease ( gold ) classified copd patients into four groups based on spirometry results and the severity of symptoms . the objective of this study was to evaluate the impact of gold groups on postoperative complications.patients and methodswe reviewed the medical records of copd patients who underwent preoperative spirometry between april and august 2013 at a tertiary hospital in korea . we divided the patients into gold groups according to the results of spirometry and self - administered questionnaires that assessed the symptom severity and exacerbation history . gold groups , demographic characteristics , and operative conditions were analyzed.resultsamong a total of 405 copd patients , 70 ( 17.3 % ) patients experienced various postoperative complications , including infection , wound , or pulmonary complications . thoracic surgery , upper abdominal surgery , general anesthesia , large estimated blood loss during surgery , and longer anesthesia time were significant risk factors for postoperative complications . patients in high - risk group ( gold groups c or d ) had an increased risk of postoperative complications compared to those in low - risk group ( gold groups a or b ) .conclusioncopd patients in gold groups representing a high exacerbation risk have an increased risk of postoperative complications compared to those with low risk .

the burgeoning atrial fibrillation ( af ) epidemic which currently affects over five million americans is expected to reach a prevalence of nearly 16 million in the united states by 2050 . another established public health problem with far reaching health consequences is obesity , which has been identified as an independent risk factor for af . together , these two global diseases significantly impact cardiovascular outcomes , and pose an immense economic burden . as a result , a significant amount of research has been conducted to elucidate the association between obesity and af . three prior studies inform the design of the legacy study [ long - term effect of goal - directed weight management in an atrial fibrillation cohort : a long - term follow - up study ] to a large extent . in the women 's health study , with a follow - up duration of nearly 13 years additionally , the authors also found that dynamic changes in body - mass index were associated with short - term increased risk of af . to further investigate the causal relationship between obesity and af , authors at the centre for heart rhythm disorders ( chrd ) at the university of adelaide in australia conducted a randomized controlled study where patients were randomized to weight management vs. general lifestyle advice and found that patients in the weight management group had significantly greater weight loss ( wl ) and lower af symptom burden using the atrial fibrillation severity scale ( afss ) instrument after follow - up of approximately 15 months . the chrd investigators further studied the impact of risk factor management , including wl , in a cohort of obese af patients undergoing catheter ablation . the arrest - af study [ aggressive risk factor reduction study for atrial fibrillation ] concluded that patients receiving risk factor management ( n = 61 ) fared much better than patients in the control group ( n = 88 ) in terms of wl , blood pressure control , glycemic control , lipid profile as well af symptom burden ( using the afss instrument ) . in the legacy study , authors from the chrd sought to further characterize the benefit of aggressive weight management in af patients . specifically , they studied the impact of long - term wl and wf on rhythm control in obese patients with af .

as the global burden of atrial fibrillation ( af ) and its attendant economic impact on the healthcare system surges , there is increasing interest in the secondary prevention of af with various therapies . of the several identified risk factors for af , obesity is an important contributor that may be managed with intensive lifestyle modification . prior studies have demonstrated the short - term and long - term benefits of weight loss in reduction of af symptoms . in the legacy study [ long - term effect of goal - directed weight management in an atrial fibrillation cohort : a long - term follow - up study ] , the investigators evaluated the long - term effects of a weight management program on af symptoms . of the 355 patients included in this cohort , outcomes such as af symptom burden , arrhythmia - free survival , inflammatory markers and structural cardiac changes all appear to have improved in the intense weight loss group as compared to the 2 other groups . further , the benefits of weight loss appear to be lost when > 5 % weight fluctuation ( wf ) occurred over the 5-year follow - up period . in this review , we discuss the design of the weight management clinic and its impact on the management of af in the legacy study . given that weight management appears to be an effective intervention that will not have the marketing and financial push that pharmaceutical and device based therapies enjoy , it behooves administrators of af clinics to develop innovative funding strategies to incorporate weight management programs in order to improve patient - centered outcomes .

epidemiological data have demonstrated that low levels of highdensity lipoprotein cholesterol ( hdlc ) are a strong and independent predictor of cardiovascular disease . however , the clinical interaction between hdlc and lowdensity lipoprotein cholesterol ( ldlc ) level , especially the predictive value of hdlc in patients treated with statins or with low ldlc levels , is not well characterized . because hdlc may be a potential therapeutic target for considerable residual risk in patients who reached a very low ldlc level , it is important to evaluate the association between hdlc and cardiovascular risk among patients with low ldlc levels . percutaneous coronary intervention ( pci ) is frequently accompanied by cardiac marker elevation after the procedure ( also known as periprocedural myocardial injury ) , especially with the use of highsensitivity troponin . a large body of data demonstrated that postprocedural troponin elevation was associated with a worse clinical outcome . the study by sattler showed that high hdlc was associated with reduced risk for periprocedural myocardial infarction , which is defined as elevation of postprocedural cardiac troponin above 3 times upper limit of normal ( uln ) . no data exist about the association of hdlc with periprocedural myocardial infarction or injury following elective pci across a range of ldlc levels . therefore , the objective of this study was to assess the association of hdlc with periprocedural myocardial injury following elective pci across a range of ldlc levels , especially in patients with ldlc < 70 mg / dl in a large cohort of chinese population from a single center .

backgroundrecent data showed inconsistent association of highdensity lipoprotein cholesterol ( hdlc ) with cardiovascular risk in patients with different levels of lowdensity lipoprotein cholesterol ( ldlc ) or intensive statin therapy . this study sought to determine the relationship of hdlc with periprocedural myocardial injury following elective percutaneous coronary intervention ( pci ) across a range of ldlc levels , especially in patients with ldlc < 70 mg / dl.methods and resultswe enrolled 2529 consecutive patients with normal preprocedural cardiac troponin i ( ctni ) who underwent elective pci . the association between preprocedural hdlc and periprocedural myocardial injury was evaluated across ldlc levels , especially in patients with ldlc < 70 mg / dl . the hdlc level was not predictive of periprocedural myocardial injury across the entire study cohort . however , among patients with ldlc < 70 mg / dl , a 1 mg / dl increase in hdlc was associated with a 3 % reduced risk for postprocedural ctni above 1upper limit of normal ( uln ) ( odds ratio : 0.97 ; 95 % ci : 0.95 to 0.99 ; p=0.004 ) , a 3 % reduced risk for postprocedural ctni above 3uln odds ratio : 0.97 ; 95 % ci : 0.95 to 0.99 ; p=0.022 ) , and a 3 % reduced risk for postprocedural ctni above 5uln ( odds ratio : 0.97 ; 95 % ci : 0.95 to 0.99 ; p=0.017 ) . the relation between plasma hdlc level and risk of postprocedural ctni elevation above 1uln , 3uln , and 5uln was modified by ldlc level ( all p for interaction < 0.05 ) .conclusionshigher hdlc levels were associated with reduced risk of periprocedural myocardial injury only in patients with ldlc < 70 mg / dl .

although medical progress including new imaging modalities and technical support has been widely gained , controversy still continues in management of ureteroceles regarding classification , diagnosis , and treatment . the incidence of ureterocele is variable with the highest rate of 1 in 500 and it is generally found in females with duplex system association ( 95 % ) [ 1 , 2 ] . though there is a female dominance , the nature of the anomaly is more complex in boys . beginning from the prenatal stage , this anomaly causes different clinical presentations , such as antenatal hydronephrosis , vesicoureteral reflux ( vur ) , urinary tract infection ( uti ) , bladder outlet obstruction , prolapsed urethral mass , etc . an ureterocele related with the upper pole of the kidney is generally named as ectopic or pediatric type . dysplastic upper pole renal units in association with duplex system ureteroceles can also cause some management problems . hydronephrosis and ureteral dilatation are also evidences for the impairment of nephro - urinary system . a sonogram and voiding cystourethrography are essential initial procedures for a child suspected of having ureteral anomaly [ 1 , 3 4 ] . today , endoscopic incision is an initial procedure for management . even though it is the simplest and least invasive form of treatment particularly for single system ureteroceles , some urologists prefer ureterocele excision and ureteral reimplantation because of the risk of inducing reflux . reconstructive surgery is still a preferred method particularly for the duplex system ureteroceles and in the presence of vesicoureteral reflux . upper pole nephrectomy and ureterectomy is one of the treatment options for ureteroceles particularly in the absence of reflux ; some excised specimens show only obstructive or inflammatory changes [ 2 , 5 ] . we planned to evaluate our patients with ureterocele diagnosis particularly by giving emphasis to these points of interest to discuss different management options .

objectivethe aim of the study was to evaluate clinical characteristics of ureteroceles particularly for diagnostic and treatment challenges.methodsdata about patients treated for ureterocele in the two hospital clinics during 1996- 2009 are retrospectively evaluated.findingsthere were 12 girls and 7 boys . symptomatic urinary tract infection was found in twelve cases . ureterocele was associated with duplex systems in eleven cases . vesicoureteral reflux was detected in 4 patients . bladder diverticulum complicated with ureterocele in 1 patient . ultrasonography diagnosed ureterocele in 12 patients . renal scarring was detected in 6 patients at the side of ureterocele . fifteen patients showed varying degrees of hydro - ureteronephrosis . surgical therapy included upper pole nephrectomy in 3 cases . bladder level reconstruction was performed in 11 cases . five patients were treated only by endoscopic incision . in the follow up period 4 patients showed long term urinary tract infections whereas 3 of them were treated endoscopically . postoperative reflux was still present in two patients who were treated by endoscopic incision.conclusionureterocele diagnosis and treatment show challenges . urinary tract infection is important marker for urinary system evaluation . preoperative management generally depends on a combination of diagnostic methods . endoscopic incision needs serious follow up for postoperative problems .

bipolar disorder ( bd ) associated seasonal pattern ( mania during spring and summer together with depression during fall and winter ) referred to as seasonal affective disorder ( sad ) is associated with disrupted circadian rhythms . aryl hydrocarbon receptor nuclear translocator - like ( arntl ) protein is a transcription factor and a core component of mammalian circadian rhythms regulatory network . convergent functional genomics approach , integrating the genetics with functional genomics in human as well as animal models identified the arntl gene as the top candidate associated with bd . several polymorphisms in arntl gene are reported to be associated with bd and sad in different ethnic groups . as the family members in the study were experiencing sad , this study was undertaken to delineate the role of arntl gene in sad . we attempted to decipher the five single nucleotide polymorphisms ( snps ) ( rs2279287 , rs1982350 , rs7126303 , rs969485 , and rs2290035 ) in arntl gene [ figure 1 ] and correlated it to differential seasonal behavior . however , the interaction between photoperiodic mechanisms ( light - dark cycle ) and the circadian system in the onset of sad is obscure . distribution of the five single nucleotide polymorphisms in aryl hydrocarbon receptor nuclear translocator - like gene

background and aim : polymorphisms in aryl hydrocarbon receptor nuclear translocator - like ( arntl ) gene , the key component of circadian clock manifests circadian rhythm abnormalities . as seasonal affective disorder ( sad ) is associated with disrupted circadian rhythms , the main objective of this study was to screen an indian family with sad for arntl gene polymorphisms.materials and methods : in this study , 30 members of close - knit family with sad , 30 age- and sex - matched controls of the same caste with no prior history of psychiatric illness and 30 age- and sex - matched controls belonging to 17 different castes with no prior history of psychiatric illness were genotyped for five different single nucleotide polymorphisms ( snps ) in arntl gene by taqman allele - specific genotyping assay.statistical analysis : statistical significance was assessed by more powerful quasi - likelihood score test-xm.results : most of the family members carried the risk alleles and we observed a highly significant snp rs2279287 ( a / g ) in arntl gene with an allelic frequency of 0.75.conclusions : polymorphisms in arntl gene disrupt circadian rhythms causing sad and genetic predisposition becomes more deleterious in the presence of adverse environment .

the residual or resistant clubfoot represents one of the most difficult treatment challenges for the pediatric orthopaedist . often residual deformity is not obvious at the time of initial correction . with continued growth of the child , the persistent or undercorrected deformity becomes more apparent ( refer to case seen in fig . d ) . the resistant clubfoot must be carefully assessed , taking each deformity into account to plan appropriate treatment . dorsal rotatory subluxation of the navicular leading to residual cavovarus foot deformity is a common finding in a resistant postoperative clubfoot . previous series have reported incidences varying from 7.1 % ( 12 of 168 feet ) , to 34.9 % ( 22 of 63 feet ) , to 54.2 % ( 13 of 24 feet ) of previously operated feet [ 2 , 4 , 6 ] . barnett described the presentation of this deformity as a bimalleolar axis of less than 80 , internal foot progression angle , curved lateral border of the foot , shallow sinus tarsi , equinus , and rotation of the medial column of the forefoot . this residual cavovarus can lead to several clinical problems including painful forefoot deformity , difficulty with shoe wear due to painful dorsal prominence , abnormal gait , and poor cosmesis . as a result , dorsal rotatory subluxation of the navicular is associated with a high rate of revision surgery . surgical correction of symptomatic dorsal rotatory subluxation of the navicular is challenging . both our own experience and that reported by others has shown repeat conventional soft tissue release results in persistence of the subluxation . this retrospective review was performed for the following purposes : ( 1 ) to describe the outcomes of talonavicular arthrodesis with respect to symptomatic relief of dorsal rotatory subluxation of the navicular , ( 2 ) to assess correction of radiographic deformity , and ( 3 ) to identify associated complications .

dorsal rotatory subluxation of the navicular , a common sequela of resistant surgically treated clubfeet , presents a challenging treatment problem . this subluxation typically progresses after posteromedial release . patients develop a cavovarus foot deformity and complain of pain , gait problems , and difficulty with shoe wear . previous attempts at soft tissue release and reduction have been largely unsuccessful . we reviewed 13 patients with dorsal rotatory subluxation of the navicular treated with talonavicular arthrodesis . the minimum followup after surgery was 6 months ( average , 36 months ; range , 6 to 93 months ) . at last followup 12 of 13 patients were symptom - free . the mean preoperative subluxation of 42 % was reduced to a mean of 6 % at last followup . we noted improvement in the talo - first metatarsal angle from an average of 18 preoperatively to 8 postoperatively . one patient treated by another surgeon with attempted talonavicular arthrodesis developed a nonunion ; we observed no other complications . we believe talonavicular arthrodesis a reasonable option to correct the deformity and symptoms associated with dorsal rotatory subluxation of the navicular in a single surgical setting with a low complication rate.level of evidence : level iv , therapeutic study . see guidelines for authors for a complete description of levels of evidence .

an important goal of visual system studies in animals is to understand vision in humans . in past decades , emphasis has been placed on studying carnivores and nonhuman primates based on the belief that advanced species resemble humans in both behavior and brain organization more closely than less advanced species , such as rodents , whose visual system has been widely assumed to be much simpler by comparison . however , numerous studies in rats and mice have convincingly shown that the occipital cortex surrounding primary visual cortex ( v1 , striate cortex ) is significantly more elaborate than previously thought , consisting of about a dozen of interconnected , topographically organized extrastriate visual areas [ 115 ] . this knowledge , together with the availability of genetic and molecular tools , especially in mice , has triggered a surge of studies using rodents as models for advancing our understanding of cortical visual processing in mammals . indeed , recent advances include evidence that visual areas in rats [ 12 , 16 ] and mice [ 15 , 1722 ] are functionally specialized and organized into processing streams that resemble the temporal and parietal parallel processing streams of primates and that progressive functional transformations along these pathways conform to general hierarchical principles . while these and other studies have also pointed out differences between rodents , carnivores , and primates [ 16 , 22 , 23 ] , they nevertheless highlight the usefulness of rodents as models in mammalian visual research . however , the small size of the brains in rats and especially mice presents some challenges , such as greater difficulty in locating and recording from small cortical areas . experiments benefiting from , or requiring larger brains , such as studies using stimulating / recording microelectrode arrays to explore the potential for chronic recordings in visual cortex , or for restoring vision [ 25 , 26 ] , have often used rabbits , a lagomorph whose brain is lissencephalic as in rats and mice but about 6 and 30 times larger than the brain of rats and mice , respectively . rabbits have also been used in a variety of other investigations involving the visual cortex , including cross - modal and mri and fmri studies , but at present limited information about the organization of visual cortex beyond v1 is available in this species [ 2935 ] . studies of the distribution of extrastriate fields labeled following single anatomical tracer injections into rabbit v1 reported that the arrangement of extrastriate areas connected with v1 closely resembles the arrangement of visual areas in rats and mice [ 36 , 37 ] and suggested that the rodent visual cortical plan may be more general , encompassing species within the lagomorphs and perhaps other orders [ 11 , 36 ] . whereas these previous anatomical studies identified extrastriate areas connected with v1 , they were unable to reveal their internal topography due to the use of only single v1 tracer injections . to address this issue , in a group of albino rabbits we injected multiple distinguishable tracers into different regions of v1 in the same animal and analyzed the topography of resulting extrastriate labeled fields with reference to the patterns of callosal connections and myeloarchitecture revealed in tangential sections of the flattened cortex , an approach that has been fruitful for delineating the location and topography of extrastriate visual areas in several species [ 6 , 7 , 38 ] . we also revealed the patterns of callosal connections in a group of dutch belted rabbits to investigate possible differences in the overall organization of this interhemispheric pathway between albino and pigmented strains of rabbits .

previous studies in rabbits identified an array of extrastriate cortical areas anatomically connected with v1 but did not describe their internal topography . to address this issue , we injected multiple anatomical tracers into different regions in v1 of the same animal and analyzed the topography of resulting extrastriate labeled fields with reference to the patterns of callosal connections and myeloarchitecture revealed in tangential sections of the flattened cortex . our results extend previous studies and provide further evidence that rabbit extrastriate areas resemble the visual areas in rats and mice not only in their general location with respect to v1 but also in their internal topography . moreover , extrastriate areas in the rabbit maintain a constant relationship with myeloarchitectonic borders and features of the callosal pattern . these findings highlight the rabbit as an alternative model to rats and mice for advancing our understanding of cortical visual processing in mammals , especially for projects benefiting from a larger brain .

the surgical extraction of an impacted mandibular third molar is one of the most common procedures performed by oral and maxillofacial surgeons . most mandibular third molars are impacted in the mandibular ramus area near the second molar , and the level of difficulty of extraction is classified according to the degree of impaction , position in the mandibular ramus , and angulation of the long axis of teeth . usually , a third molar impacted far away from its original site is affected by a cyst or a tumor . only a few cases of ectopic mandibular third molar in the region of pterygomandibular space without association of cystic lesion -- such as odontogenic keratocyst and dentigerous cyst -- have been reported1,2 . we report a case of mandibular third molar located in the pterygomandibular space that seems to have been displaced by neither cyst nor tumor .

impacted mandibular third molars are located between the second mandibular molar and mandibular ramus . however , ectopic mandibular third molars with heterotopic positions are reported in the subcondylar or pterygomandibular space . the usual cause of malposition is a cyst or tumor , and malposition without a pathology is rare . this case report described an impacted mandibular third molar in the pterygomandibular space without any associated pathology .