Persius/hicric huggingface dataset:
Ross procedure
The Ross procedure (or pulmonary autograft) is a cardiac surgery operation where a diseased aortic valve is replaced with the person's own pulmonary valve.  A pulmonary homograft (valve taken from a cadaver) is then used to replace the patient's own pulmonary valve. Pulmonary autograft replacement of the aortic valve is the operation of choice in infants and children, but its use in adults remains controversial.

# History
The Ross procedure is named after Dr. Donald Ross - a pioneer in cardiac surgery in the UK - who proposed the procedure in 1962 and first performed it in 1967.

# Advantages / Disadvantages

## Advantages
- Freedom from thromboembolism without the need for anticoagulation.
- The valve grows as the patient grows (i.e. children).
- Favourable hemodynamics.
- No foreign material present in the valve.

## Disadvantages
- Single valve disease (aortic) treated with a two valve procedure (aortic and pulmonary).

# Pulmonary valve replacement
One of the main objections to the Ross procedure is the genesis of pulmonary valve disease in addition to aortic valve disease. Protagonists have argued that biological valves implanted in the pulmonary position would be slow to develop dysfunction, and any dysfunction would be well tolerated due to the lower pressures in the right side of the heart. Survival of homografts in the pulmonary position is good (20-year freedom from reoperation of 80%), and homograft dysfunction is infrequently implicated in the observed morbidity and mortality.
Homografts (aortic or pulmonary) should be the replacement of choice; no other valve performed as well in the pulmonary position.  Many homograft valves are sterilized with ethylene oxide or irradiation; methods recognized to have deleterious effects on valve performance. The results of the pulmonary autograft procedure are likely to be superior with the use of fresh homograft valves.  Today, cryopreservation is the method of choice for homograft preservation.
Rotor syndrome
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# Overview
Rotor syndrome is a rare, benign autosomal recessive disorder of unknown origin.

## Presentation
It has many things in common with Dubin-Johnson syndrome except that in Rotor Syndrome, the liver cells are not pigmented.  The main symptom is a non-itching jaundice. There is a rise in bilirubin in the patient's serum, mainly of the conjugated type.

# Historical Perspective

# Classification

# Pathophysiology

# Causes

# Differentiating Rotor syndrome from Other Diseases

# Epidemiology and Demographics

# Risk Factors

# Screening

# Natural History, Complications, and Prognosis

## Natural History

## Complications

## Prognosis

# Diagnosis

## Diagnostic Criteria

## History and Symptoms

## Physical Examination

## Laboratory Findings

## Imaging Findings

## Other Diagnostic Studies

# Treatment
The liver is otherwise normal, and there is no need to treat this condition. It can be differentiated from Dubin Johnson syndrome by measuring the difference in urinary poryphrins. In Rotor syndrome there is an associated marked increase in urinary excretion of coproporyhrin I and III with < 80% being the I isomer.

## Medical Therapy

## Surgery

## Prevention

# Eponym
Rotor syndrome is named after the Filipino internist, Arturo Belleza Rotor (1907-1988).
Rovsing's sign

# Overview
Rovsing's sign is a sign of appendicitis. If palpation of the lower left quadrant of a person's abdomen results in more pain in the right lower quadrant, the patient is said to have a positive Rovsing's sign and may have appendicitis.

# Historical Perspective
The sign is named for Niels Thorkild Rovsing, Danish surgeon, 1862-1927.

# Pathophysiology
This anomaly occurs because the pain nerves deep in the intestines do not localize well to an exact spot on the abdominal wall, unlike pain nerves in muscles.  Pain from a stomach ulcer or gallstone can be interpreted by the brain as pain from the stomach, liver, gall bladder, duodenum, or first part of the small intestine.  It will "refer" pain often to the mid upper abdomen.
Because the appendix is a piece of intestine, it follows a similar referral pattern. An appendix with some early inflammation may give a non-specific irritation somewhere near the umbilicus (belly button). Should the inflammation become severe, it may actually irritate the inner lining of the abdominal cavity called the peritoneum. This thin layer lies under or behind the abdominal wall muscles. The pain is "localized."  If pressure is applied to the muscles of the right lower abdomen (or iliac fossa) near a very irritated appendix, then the muscle fibers in that area will be stretched and will hurt.

# Technique
A Rovsing's sign is elicited by pushing on the abdomen far away from the appendix in the left lower quadrant as in most people the appendix is in the right lower quadrant. While this maneuver stretches the entire peritoneal lining, it only causes pain in any location where the peritoneum is irritating the muscle. In the case of appendicitis, the pain is felt in the right lower quadrant despite pressure being placed elsewhere.
Most practitioners push on the left lower quadrant to see where the patient complains of pain. If pain is felt in the right lower quadrant, then there may be an inflamed organ or piece of tissue in the right lower quadrant.  The appendix is generally the prime suspect, although other pathology can also give a "positive" Rovsing's sign. If left lower quadrant pressure by the examiner leads only to left-sided pain or pain on both the left and right sides, then there may be some other pathologic etiology.  This may include causes relating to the bladder, uterus, descending (left) colon, fallopian tubes, ovaries, or other structures.

# Video

# Related Chapters
- Abdominal exam
- McBurney's sign
- Obturator sign
- Psoas sign
Roxana Moslehi

# Overview
Roxana Moslehi, Ph.D. is a genetic epidemiologist. Most of her research is dedicated to the study of cancer and cancer precursors.  Born in Iran and raised in Canada, she is currently an assistant professor in Epidemiology and Statistics at the State University of New York (SUNY), where she has developed a course entitled "genetic epidemiology. Through her research she has been contributing to the understanding of hereditary causes of diseases as well as the influence of gene-environment interactions on the risk of developing disease.

# Education
Roxana received her B.Sc. with honors, M.Sc. and Ph.D. degrees from the University of British Columbia (UBC) in Vancouver, Canada. Following her Ph.D., she completed a postdoctoral fellowship at the National Institutes of Health (NIH), Division of Cancer Epidemiology and Genetics (DCEG) under the supervision of Dr. Mitchell Gail. While being a postdoctoral fellow at NIH, she also received an adjunct assistant professor position at George Washington University (GWU), where she developed a course entitled "controversies in cancer epidemiology" with Dr. Paul Levine.

# Research
Working with Steven Narod and J.M. Friedman, she was first to estimate the penetrance of BRCA1 and BRCA2 mutations for breast, ovarian and other cancers in a study of Jewish women with ovarian cancer, now the most studied hereditary cancer predisposing genes in the human genome. She has also made significant contributions in the research on modifies of breast and ovarian cancer risk  as well as research on other cancers such as Non-Hodgkin Lymphoma  and on cancer precursors , , .

# Awards
Roxana Moslehi is a recipient of multiple awards and honors, including the Award for Excellence in Teaching (UBC), a Biovision Fellowship from Academie des Sciences (France) and two Awards for Research Excellence from the NIH.

# Trivia
In addition to her scientific career she has also done professional runway modeling for fashion shows.
Ruptured globe

# Overview
Rupture globe leads to ocular hypotony. Ocular hypotony may also be caused by ocular surgery and glaucoma therapy.

# Diagnosis

## CT
- "Flat tire" sign
"Umbrella" sign
- "Flat tire" sign
- "Umbrella" sign
- Flat tire Image courtesy of RadsWiki and copylefted
- Umbrella Image courtesy of RadsWiki and copylefted
- CT demonstrates a ruptured globe Image courtesy of RadsWiki and copylefted
- CT demonstrates a ruptured globe Image courtesy of RadsWiki and copylefted
- CT demonstrates a ruptured globe Image courtesy of RadsWiki and copylefted
Russell's sign
Russell's sign is a sign defined as scarring on the knuckles or back of the hand due to self-induced vomiting over long periods of time.  The condition generally arises from the afflicted making contact with the incisor teeth during the act of inducing the gag reflex at the back of the throat with their finger(s).
This type of scarring is considered one of the physical indicators of a mental illness, and Russell's sign is primarily found in patients with an eating disorder such as bulimia nervosa or anorexia nervosa.  However, it is not always a reliable indicator of an eating disorder.  Russell's sign may be dermatologically treated with urea.
Bulimics who are capable of "handsfree purging", or the induction of vomiting by willful opening of the lower throat flapper (esophageal sphincter) in a manner similar to when belching, while contracting the stomache muscles, rarely have Russell's sign. This is primarily true since handsfree bulimics do not need to thrust their hands down their throats in order to release consumed food, and thus, do not harm their hands during the act of purging.
Sagittal plane

# Overview
A sagittal plane of the human body is an imaginary plane that travels from the top to the bottom of the body, dividing it into left and right portions.

# Variations
Examples include:
- The terms median plane or mid-sagittal plane are sometimes used to describe the sagittal plane running through the midline. This plane cuts the body into two halves of equal portions (assuming bilateral symmetry), passing through midline structures such as the navel and spine. It is one of the lines defining the right upper quadrant of the human abdomen.
- In general, planes that are parallel to the sagittal plane, but do not pass through the midline, are known as parasagittal.
The midclavicular line crosses through the clavicle.
Other sagittal lines/planes include the "lateral sternal" and "parasternal".
- The midclavicular line crosses through the clavicle.
- Other sagittal lines/planes include the "lateral sternal" and "parasternal".

# Terminology
The term is derived from the Latin word Sagitta, meaning "arrow". An image of an arrow piercing a body and passing from front (anterior) to back (posterior) on a parabolic trajectory]would be one way to demonstrate the derivation of the term.  Another explanation would be the notching of the sagittal suture posteriorly by the lamboidal suturesimilar to feathers on an arrow.
Sagittal axis: Sagittal axis is the axis perpendicular to the sagittal plane, i.e. the sagittal axis lies in the coronal plane. Abduction and adduction are terms for movements of limbs relative to the coronal plane.
Coronal (or frontal) axis: Coronal axis is the axis perpendicular to the coronal plane, i.e. the coronal axis lies in the sagittal plane. Extension and flexion is the movement of limb in sagittal plane.

# Anatomy
From a broader perspective, it is one of the planes of the body used to describe the location of body parts in relation to each other - for example, the extent of prognathism. The other reference planes used in anatomy are:
- The coronal (or frontal) plane divides the body into dorsal and ventral (back and front) portions.
- A transverse (or horizontal) plane divides the body into cranial and caudal (top and bottom) portions.
Salih myopathy

# Overview
Salih myopathy is an inherited muscle disease that affects the skeletal muscles, which are used for movement, and the heart (cardiac) muscle.

# Pathophysiology

## Genetics
Salih myopathy is caused by mutations in the TTN gene. This gene provides instructions for making a protein called titin, which plays an important role in skeletal and cardiac muscle function.
Within muscle cells, titin is an essential component of structures called sarcomeres. Sarcomeres are the basic units of muscle contraction; they are made of proteins that generate the mechanical force needed for muscles to contract. Titin has several functions within sarcomeres. One of this protein's most important jobs is to provide structure, flexibility, and stability to these cell structures. Titin also plays a role in chemical signaling and in assembling new sarcomeres.
The TTN gene mutations responsible for Salih myopathy lead to the production of an abnormally short version of titin. The defective protein disrupts the function of sarcomeres, which prevents skeletal and cardiac muscle from contracting normally. These muscle abnormalities underlie the features of Salih myopathy, including skeletal muscle weakness and dilated cardiomyopathy.
This condition is inherited in an autosomal recessive pattern, which means both copies of the gene in each cell have mutations. The parents of an individual with an autosomal recessive condition each carry one copy of the mutated gene, but they typically do not show signs and symptoms of the condition.

# Epidemiology and Demographics
Salih myopathy appears to be a rare disorder, although its prevalence is unknown. It has been reported in a small number of families of Moroccan and Sudanese descent.

# Diagnosis
This condition is characterized by skeletal muscle weakness that becomes apparent in early infancy. Affected individuals have delayed development of motor skills, such as sitting, standing, and walking. Beginning later in childhood, people with Salih myopathy may also develop joint deformities called contractures that restrict the movement of the neck and back. Scoliosis, which is an abnormal side-to-side curvature of the spine, also develops in late childhood.
A form of heart disease called dilated cardiomyopathy is another feature of Salih myopathy. Dilated cardiomyopathy enlarges and weakens the cardiac muscle, preventing the heart from pumping blood efficiently. Signs and symptoms of this condition can include an irregular heartbeat (arrhythmia), shortness of breath, extreme tiredness (fatigue), and swelling of the legs and feet. The heart abnormalities associated with Salih myopathy usually become apparent in childhood, after the skeletal muscle abnormalities. The heart disease worsens quickly, and it often causes heart failure and sudden death in adolescence or early adulthood.
Salvia sclarea
Salvia sclarea (clary or clary sage), is a biennial or short-lived perennial herb in the genus Salvia, native to Europe east to central Asia. It grows to 1 m tall, with opposite leaves 10-20 cm long and 6-12 cm broad, with a thick woolly texture. The flowers are in several clusters of 2-6 together on the stem, 2.5-3.5 cm long, white to pink or pale purple. Its strong and unusual odour is considered unpleasant by some, while others find it very attractive.

# Uses
The distilled essential oil is occasionally found in specialty stores such as natural food stores and "scent shops". The odour is sometimes described as "sweaty", spicy or "hay-like". Clary seeds have a mucilaginous coat, and so old herbals recommended putting a seed into the eye of someone with a foreign object in it, to adhere to the object and make it easy to remove.
The leaves have been used as a vegetable in cookery. Clary was used as a flavouring in ales before the use of hops became common, and also in wine, notably muscatel. It is also used as a flavouring in some tobacco products. Clary can be used as a tea or in aromatherapy, and is supposed to have a calming effect.
It is also the primary ingredient in Norambrolide, a supplement which uses unfounded claims of fat catabolism properties of this plant extract.
Sam's GS Stash
Sam's GS Stash Cigars is a brand of hand-made premium cigar owned by Black Cat Cigar Company.

# History and Background
The brand was originally created by Jose "Pepin" Garcia for the company owner's personal use. Production was increased and the brand was released publicly in late 2006 or early 2007.  It is manufactured at the El Rey de los Habanos factory in the Little Havana section of Miami, Florida.

# Description
The cigars have an oily Nicaraguan corojo wrapper, with Nicaraguan tobacco also used for the filler and binder. It is a full-bodied cigar. The cigars come unbanded in bundles of 5 and 10 and a wheel of 50.

# Models/Vitolas
The brand consists of only one size, 6.5 x 52.

# Notes
-  Catalogue blurb.
Sambucus nigra
Sambucus nigra  is a species of elder native to most of Europe, northwest Africa and southwest Asia. It is most commonly called just Elder or Elderberry, but also Black Elder, European Elder, European Elderberry,  European Black Elderberry , Common Elder, or Elder Bush when distinction from other species of Sambucus is needed. It grows in a variety of conditions including both wet and dry soils, primarily in sunny locations.
It is a deciduous shrub growing to 4-6 m (rarely to 10 m) tall. The leaves are arranged in opposite pairs, 10-30 cm long, pinnate with five to seven (rarely nine) leaflets, the leaflets 5-12 cm long and 3-5 cm broad, with a serrated margin. The hermaphrodite flowers are borne in large corymbs 10-25 cm diameter in mid summer, the individual flowers white, 5-6 mm diameter, with five petals; they are pollinated by flies. The fruit is a dark purple to black berry 3-5 mm diameter, produced in drooping clusters in the late autumn; they are an important food for many fruit-eating birds, notably Blackcaps.
There are several other closely related species, native to Asia and North America, which are very similar, and treated as subspecies of S. nigra by some botanists (see the genus page for details).

# Uses
This plant is used as a medicinal plant and also used as a ornamental plant. It is cited as a poisonous plant to mammals as well as cited as a weed. 
- The flowerheads are commonly used in infusions, giving a very common refreshing drink in Northern Europe and Balkans. Commercially these are sold as elderflower cordial etc.
- The berries are edible after cooking, but all other parts of the plant are poisonous, containing toxic calcium oxalate crystals.
- The strong-smelling foliage was used in the past, tied to a horse's mane, to keep flies away while riding.
- Stembark, leaves, flowers, fruits, root extracts are used to treat bronchitis, cough, upper respiratory cold infections, fever.
- In Beerse, Belgium they make Jenever of the berries called Beers Vlierke.

# Notes
-  Sambucus nigra at Flora Europaea
-  Template:ITIS
-  Sambucus nigra at USDA PLANTS Database
-  Sambucus nigra at Germplasm Resources Information Network
Sandbox/branch

# Approach to a female of child-bearing age

# Do's
- Consider abdominal aortic aneurysm, mesenteric ischemia and malignancy in patients above 50 years as it is much less likely for younger patients.
- Perform pelvic and testicular examination in patients with low abdominal pain.
- Re-examine patients at high risk who were initially diagnosed with pain of unclear etiology.
- Taking careful history, characterizing the pain precisely and thorough physical examination is crucial for creating narrow differential diagnosis.
- Correlate the CD4 count in HIV positive patients with the most commonly occurring pathology.
- Order a pregnancy test before proceeding with a CT scan in females in the child bearing age.
- Order an ultrasound or magnetic resonance among pregnant females to avoid exposure to radiation. In case the previous tests were inconclusive and appendicitis is suspected, the next step in the management includes proceeding with either laparoscopy or limited CT scan.
- Suspect abdominal aortic aneurysm in old patients presenting with abdominal pain with history of tobacco use. 
- Suspect acute mesenteric ischemia and acute pancreatitis in patients presenting with poorly localized pain out of proportion to physical findings. 
- Recommend initial imaging studies based on the location of abdominal pain:
- Ultrasonography is recommended when a patient presents with right upper quadrant pain. 
- Computed tomography (CT) with intravenous contrast media is recommended for evaluating adults with acute right lower quadrant pain. 
- CT with oral and intravenous contrast media is recommended for patients with left lower quadrant pain. 
- Order ECG for old patients with upper abdominal pain with high cardiac risk factors.
- Administer narcotic analgesia for patients who present to the ED with moderate or severe abdominal pain. 

# Don'ts
- Fail to evaluate elder patients in the presence of overt clinical signs.
- Over rely on laboratory tests, they are only used as adjuncts.
- Do not delay the initial intervention.
- Do not order blood cultures routinely in all patients
- Dont delay resuscitation or surgical consultation for ill patient while waiting for imaging.
- Dont restrict the differential diagnosis of abdominal pain based on the location; for example, right-sided structures may refer pain to the left abdomen.
Sandbox:Aakash
Aakash Hans, MD

# Sandbox

## Hyperthyroidism

### Pathogenesis
- Grave's disease
TSI or TSH receptor antibodies are directed against TSH receptors on follicular cells, which stimulate thyroid hormone production.
Immunologically activated fibroblasts in the skin and eye cause the dermopathy and ophthalomopathy.
Genetic factors play a minor role, with HLA-DR3 being the only documented risk factor.
Viral or bacterial infections can also trigger hyperthyroidism as the antibodies against the cell membrane of E coli and Y enterocolitica cross react with TSH receptors.
- TSI or TSH receptor antibodies are directed against TSH receptors on follicular cells, which stimulate thyroid hormone production.
- Immunologically activated fibroblasts in the skin and eye cause the dermopathy and ophthalomopathy.
- Genetic factors play a minor role, with HLA-DR3 being the only documented risk factor.
- Viral or bacterial infections can also trigger hyperthyroidism as the antibodies against the cell membrane of E coli and Y enterocolitica cross react with TSH receptors.
- Drug induced
Iodine can cause hyperthyroidism due to excess oral intake or due to exposure to radiographic contrast material containing iodine.
Generally occurs in people with underlying autonomously functioning thyroid gland, but can also occur in patients with endemic goiter who are treated with iodine. This is known as Jod-Basedow phenomenon.
Anti-arrhythymic drug amiodarone contains more iodine than the recommended daily allowance, and therefore can precipitate hyperthyroidism.
- Iodine can cause hyperthyroidism due to excess oral intake or due to exposure to radiographic contrast material containing iodine.
- Generally occurs in people with underlying autonomously functioning thyroid gland, but can also occur in patients with endemic goiter who are treated with iodine. This is known as Jod-Basedow phenomenon.
- Anti-arrhythymic drug amiodarone contains more iodine than the recommended daily allowance, and therefore can precipitate hyperthyroidism.

### Clinical Features
- Thyroid : enlargement can be nodular or diffuse
- Gastrointestinal : weight loss, vomiting, diarrhea and increase appetite.
- Cardio-respiratory : palpitations, angina, sinus tachycardia and wide pulse pressure.
- Neuro-muscular : nervousness, tremors, psychosis and hyper-reflexia.
- Dermatological : increased sweating, palmar erythema, pigmentation and alopecia.

### Investigations
- TSH
Is decreased or not present in majority of cases.
This is the primary test performed, as if it tests normal, it virtually rules out hyperthyroidism.
- Is decreased or not present in majority of cases.
- This is the primary test performed, as if it tests normal, it virtually rules out hyperthyroidism.
- Serum T3 and T4
Is increased in almost all cases.
- Is increased in almost all cases.
- I-131 Uptake
Not required in most patients.
Uptake is usually increased.
- Not required in most patients.
- Uptake is usually increased.
- Antibodies
Thyroid peroxidase antibody levels are raised.
- Thyroid peroxidase antibody levels are raised.