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in 2011 , the centers for disease control and prevention ( cdc ) assisted state and local health departments in an investigation of a cluster of wnv disease transmitted through solid organ transplantation ( 6 ) . the adult male donor had a history of cerebral palsy , seizures , and blindness . he was cared for at home and had outdoor exposure in a county with known wnv activity . in late summer , he had acute onset of fever and lethargy ; 2 days after symptom onset , a urinary tract infection was diagnosed , and he received oral antimicrobial drugs . after consent was obtained , solid organs ( i.e. , kidneys , lungs , and liver ) and tissues ( i.e. , skin , fat , muscle , tendon , and bone ) were procured 9 days after his illness onset . the donor s organs were transplanted into 4 recipients ; none of the donor tissues were transplanted . after wnv infection was detected in 1 of the organ recipients 10 days after transplantation , the donor s stored clinical samples ( i.e. , serum and spleen / lymph node homogenate ) were retrospectively tested for wnv ; this testing occurred within 5 weeks after transplantation . the donor s serum sample was positive for wnv igm , igg , and neutralizing antibodies by serologic testing but negative for wnv rna by nucleic acid amplification testing . subsequently , all 4 organ donor recipients were tested and had positive results for wnv rna . five weeks after the donor s death , frozen spleen / lymph node homogenate from the donor that had been used for human leukocyte antigen testing was sent from the transplant center to cdc , and initial wnv pcr testing was performed as part of the transplant - transmission investigation ( 7 ) . eight weeks after the donor s death , skin samples that had been treated in cryopreservative solution containing an antibiotic and unprocessed fat , muscle , tendon , and bone samples , all of which had been stored frozen at 70c at a tissue bank , were transferred to cdc . at cdc , the tissues remained frozen at 20c to 70c in individual double - wrapping and plastic bags and were handled and tested separately to reduce the risk for cross - contamination . rna was extracted from each 35 mm section of tissue by using a phenol - chloroform extraction method as described ( 8) , with the following modifications . tissue was homogenized in buffer rlt ( qiagen , valencia , ca , usa ) and digested with proteinase k for 15 min at 55c ; an additional 24-h digestion at 40c was used for bone . rna samples were tested by using wnv - specific reverse transcription pcr ( rt - pcr ) targeting the nonstructural protein 1 ( ns1 ) , capsid , and premembrane genes ( 9 ) . , we injected homogenates from tissues positive by rt - pcr into vero e6 cells ; for cells with cytopathic effect , we confirmed the presence of wnv by rt - pcr , immunofluorescence , and electron microscopy . immunohistochemical ( ihc ) staining for wnv was performed on rna - positive tissues ( 10 ) . rt - pcr was performed 2526 weeks after the specimens were collected from the donor ; virus culture and ihc staining were performed 50 weeks after specimens were collected . wnv rna was detected in samples from the spleen / lymph node , skin , and fat associated with the tibia bone , as well as 1 of 2 muscle specimens , 1 of 4 tendon specimens , and 1 of 2 bone marrow specimens ( table ) . cytopathic effect was noted only in vero cells injected with the spleen / lymph node homogenate ; these cells were positive for wnv by rt - pcr , immunofluorescence , and electron microscopy . cytopathic effect was not observed in vero cells injected with skin , fat , muscle , tendon , or bone marrow . results of ihc staining of skin , fat , muscle , and bone marrow samples were negative for wnv antigens . * wnv , west nile virus ; rt - pcr , reverse transcription pcr ; ihc , immunohistochemical ; + , positive ; nt , not tested ; , negative . for spleen / lymph node homogenate , fat , tendon , muscle , bone marrow , and bone , a single sample was tested for wnv rna by rt - pcr . if positive , a second specimen was tested by rt - pcr , inoculated into vero e6 cells , and evaluated by ihc . for skin , after initial wnv rt - pcr was positive , 3 subsequent samples were tested for wnv rna by rt - pcr , inoculated into vero e6 cells , and evaluated by ihc . we identified wnv rna in spleen / lymph node homogenate , skin , fat , muscle , tendon , and bone marrow samples obtained postmortem from a donor associated with transmission of wnv through solid organ transplantation . however , infectious virus could not be cultured , and wnv antigens were not identified by ihc staining from any of the wnv rna - positive tissues . data on the detection of wnv in postmortem organs or tissues are limited . in a study published in 1954 , a total of 95 patients with terminal cancer were injected intramuscularly with wnv ( 11 ) . among 14 patients who died within 1 month after inoculation , virus was isolated postmortem from solid organs in 11 patients and , in 1 patient each , from skin , muscle , or connective tissue . in a more recent study of 6 patients with fatal mosquito - borne wnv encephalitis , wnv rna or antigens were variably detected in solid organ samples from all patients , and wnv antigens were identified in skin samples from 1 patient ( 12 ) . however , 4 ( 67% ) of these patients were severely immunocompromised transplant recipients ; of the 2 immunocompetent patients , 1 had wnv rna in brain , spleen , and kidney samples and 1 had wnv antigens only in brain samples . wnv has also been cultured from an antemortem skin biopsy sample from a patient with rare hemorrhagic manifestations of disease ( 9 ) . the tissues were stored frozen for almost 1 year before culture , which may have decreased the ability to isolate viable wnv , although virus was isolated from the spleen / lymph node homogenate . several tissues that are commonly transplanted with minimal processing ( e.g. , corneas , heart valves , and vascular grafts ) and that have been implicated in recent transmission of other viruses , such as hepatitis b and c ( 13,14 ) , were not procured or tested in our study . finally , although the specimens were stored , handled , and tested individually , false - positive results or cross - contamination can not be completely ruled out . although wnv rna was detected in unprocessed tissues obtained from the organ donor , the absence of viral antigen by ihc staining and failure to culture infectious virus from skin , muscle , and tendon suggests that the risk for wnv transmission may be lower for transplantation of these tissues than for transplantation of solid organs . further studies are needed to determine if infectious wnv can be recovered from and possibly transmitted by transplantation of postmortem tissues and , if so , to assess the period of risk and whether tissue processing would mitigate the risk ( 15 ) .

we identified west nile virus ( wnv ) rna in skin , fat , muscle , tendon , and bone marrow from a deceased donor associated with wnv transmission through solid organ transplantation . wnv could not be cultured from the rna - positive tissues . further studies are needed to determine if wnv can be transmitted from postmortem tissues .

a 60yearold male patient referred to the clinic presented with painful swelling of both great toes . he was diagnosed as having gout four years ago , and was suffering from waxing and waning symptoms in spite of treatment with allopurinol . , the lesions became markedly swollen , which were not subsided by conservative management and were complicated with ulcerated mass and whitish discharge ( fig . polarized microscope revealed a deposition of monosodium urate crystals with negative birefringence ( fig . we detected giant gouty tophi in both great toes and multiple tophi around medial and lateral malleoli by threedimensional dualenergy computed tomography ( 3d dect ) ( fig . surgical excision and curettage of tophi in the great toes were performed to remove a source of infection and to prevent functional impairment . he continued to be treated with lifestyle adjustment and intensified uratelowering agent of allopurinol 300 mg daily , and uric acid level was maintained below 6 mg / dl . transiently , prednisolone 10 mg and colchicine 1 t were given to the patient . during followup visits for 1 year followup 3d dect at eight months after treatment showed elimination of urate deposition in the great toes as well as in other lesions ( fig . giant gouty tophi in both great toes and multiple tophi around medial and lateral malleoli . diagnosis of gout is confirmed by polarized microscope revealing a deposition of monosodium urate crystals ( msu ) with negative birefringence . in real clinic , it is frequently not feasible to obtain msc crystal . needle puncture , risk of cellulitis , and bleeding tendency are barriers to access direct visualization of msu crystal in goutsuspected patients . furthermore , it is impossible to get samples at deepseated places such as atlantoaxial joint , achilles tendon , and so on . therefore , dect is now regarded as the new promising diagnostic tool in gout diagnosis . acute gouty attack is usually alleviated by intensive treatment such as nonsteroidal antiinflammatory drug and steroid . even in patients with chronic tophaceous gout , active treatment with pharmacologic and nonpharmacologic modalities

key clinical messagelarge gout tophi are difficult to treat and sometimes needs operation for its elimination . dualenergy computed tomography ( dect ) is now being used for detection of tophi in patients with gouty arthritis . after intensive treatment , we could observe vanishing tophi with dect .

primary squamous cell carcinomas ( scc ) of the breast are exceedingly uncommon lesions , since they occur in less than 0.074% of all primary invasive breast carcinomas . we should exclude an epidermal origin , especially from the nipple region and the possibility of metastatic infiltration of the breast by an scc from a different location and to classify the breast tumor as a primary scc . also , differential diagnosis must include other primary carcinomas in which squamous metaplasia are found . prognosis and treatment of this disease a 45-year - old woman was admitted with complaint of lump in the left breast for 3 months . physical examination revealed a hard , tender lump of size 8 7 cm in upper and outer quadrant in the left breast . chest radiograph , ultrasonography of the abdomen , computed tomography of the thorax , and gynecological examination were performed . on fine needle aspiration cytology carcinoma of the breast was diagnosed . according to all these findings , the patient underwent modified radical mastectomy with axillary lymph node clearance was performed [ figure 1 ] . gross operative picture of the left breast showing axillary lymph nodes on microscopic examination , tumoral structure composed of large hyperchromatic nuclei with abundant cytoplasm , along with multiple foci of keratin pearl in different sizes and marked increase in mitotic activity [ figures 2 and 3 ] was observed . there was no origin from the surface epithelium and no different tumoral components were seen . the patient was started with adjuvant 6 cycles of cap ( cyclophosphamide , adriamycin , and cisplatinum ) chemotherapy . the patient is alive and disease - free , 8 months follow - up after the diagnosis . malignant squamous cells in trabeculae arrangement forming keratin pearls in the center ( 100 , h and e , 200 ) histopathology showing squamous cells arranged in whorls with centrally keratin pearl formation ( 100 , h and e , 200 ) scc is a well - known malignancy of the skin and other organs surrounded with squamous cells such as the esophagus and the anus . primary scc is an extremely rare malignancy and is believed to originate from the epithelium of the mammary ducts but tumor may also arise from foci of squamous metaplasia within a pre - existing adenocarcinoma of the breast . there are few reported cases of primary scc with origin from the capsules surrounding the silicone breast prostheses . according to our search in the world literature , the incidence of the primary scc among all the breast carcinomas is approximately between of 0.1% to less than 0.04% . primary scc of the breast is defined when more than 90% of the malignant cells are of the squamous cell type without any relation with the skin and there is no primary location elsewhere in the body . classically metaplastic tumors are mainly divided into two types : firstly tumors with squamous metaplasia , and secondly tumors with heterologus components . morphologically these tumors are of five subtypes : ( a ) matrix - producing carcinoma , ( b ) spindle cell carcinoma , ( c ) carcinosarcoma , ( d ) squamous cell carcinoma of ductal origin , and ( e ) metaplastic carcinoma with osteoclastic giant cells . breast carcinoma arises from the mammary glandular epithelium , the phenotypic expression of squamous differentiation in breast cancer is considered a form of metaplastic carcinoma . scc can occur from 29 years to 90 years of age in adult women , with a median of 52 years of age . primary tumors tend to be relatively large ranging from 2 to 5 cm and enlarged over a period of 2 to 3 weeks or in some cases for as long as 18 months . about two - thirds of these tumors are cystic or have a cystic component with central necrosis . axillary lymph node metastasis occurs rarely which is usually associated with metaplastic scc arising in an invasive ductal carcinoma . but some thought that scc of the breast can be presented with aggressive course along with outcome comparable to poorly differentiated breast adenocarcinoma . patient should get cisplatinum - based chemotherapy regimen with diagnosis of scc , as documented by dejager et al . most of the scc are radiosensitive and primary scc of the breast of small in size could be treated with lumpectomy with axillary clearance followed by radiotherapy . treatment should be based on the pathological features of the tumor rather than the age of the patient , but very young women have excessive risk of local recurrence and dying , as compared to their middle - aged counterparts , even if diagnosed early and receiving an intense treatment . after correction for stage , tumor characteristics , and treatment , age is an independent risk factor for death in women less than 34 years of age , in breast carcinoma . menes et al . recommended a selective approach like sentinel node biopsy , because lymph node involvement plays a lesser prognostic and therapeutic role in this disease . the diagnosis of primary scc of the breast can only be made in the absence of an associated primary scc in a second site and in the absence of skin involvement . the prognosis of the pure scc of the breast and proper approach for the treatment is still in doubt . surgical and medical treatment of scc of the breast should be started to fit its distinct biologic characteristics . scc is reported to result in less lymphatic spread than adenocarcinomas . in 10 to 30% of cases , on other side , distant metastasis may be seen in about 30% of the patients . it is recommended to give patients similar adjuvant therapy but the radiosensitivity of sccs is uncertain . it may be prudent to initiate adjuvant radiation therapy earlier than usual for breast cancer because of the tendency for locoregional relapse . breast scc is an extremely aggressive disease associated with frequent locoregional and distant relapses and resultant deaths .

in females , the most common cancer is breast carcinoma in which squamous cell carcinoma ( scc ) is a rare type of malignancy . histologically , infiltrating ductal carcinoma is the most common type and lobular , mucinous , and medullary types have lower incidence . pure scc of the breast can originate from the skin , nipple , or epithelium of a deep - seated dermoid cyst or squamous metaplasia on chronic inflammation background . we are reporting a rare case of primary scc of the breast in a 45-year - old female . in follow - up of 8 months , patient is doing well . we discussed our approach for treatment with review of the literature . we have treated this patient successfully with surgical and adjuvant chemotherapy .

during october 12 , 2014march 28 , 2015 , samples collected from 1,058 persons in liberia with suspected ebov infection were submitted to the cdc nih elwa laboratory . the samples used for this research were collected for public health surveillance and not human subjects research , so institutional review board review and approval were not required . early during the study period ( october november ) , most of the patients from whom samples were collected received a diagnosis of ebov infection ( figure 1 , panel a ) ; toward the end , however , few cases of ebov infection were diagnosed in liberia . the number of patients who received a diagnosis of plasmodium spp . parasitemia remained stable over time ; thus , despite the lack of positive ebov test results in the final months of the study period , overall , 40%60% of patients each week received a diagnosis of ebov infection , plasmodium spp . parasitemia , or both ( figure 1 , panel a ) . of 1,058 samples tested , 259 ( 24.5% ) were positive for ebov alone , 243 ( 23% ) were positive for plasmodium spp . alone , and 47 ( 4.4% ) were positive for both ( figure 1 , panel b ) . of 311 plasmodium - positive samples that were further analyzed , 296 ( 95% ) were positive for p. falciparum ( figure 1 , panel c ) , confirming that p. falciparum was the main plasmodium species causing parasitemia in our cohort . rna in patient samples submitted to the centers for disease control and prevention national institutes of health diagnostic laboratory at the eternal love winning africa campus in monrovia , liberia , from october 12 , 2014 ( epidemiologic week 42 ) , through march 28 , 2015 ( week 13 ) . whole blood samples were inactivated , and rna was extracted by using the qiaamp viral rna mini kit ( qiagen , hilden , germany ) . rna by real - time quantitative reverse transcription pcr ( qrt - pcr ) ( 13 ) . a ) number of patients , as determined by qrt - pcr , positive for ebov , plasmodium spp . , both , or neither ( i.e. , no ebov and no plasmodium spp . ) , by epidemiologic week . b ) total number of patients receiving a laboratory diagnosis of ebola viremia , plasmodium spp . qrt - pcr positive samples that were retested with a qrt - pcr specific for p. falciparum ( 14 ) . a high ct value corresponds to a low - level parasitemia ; the lower the ct value , the higher the number of plasmodium parasites detected . all patients in the cohort were triaged as having suspected ebov infection , and thus all had clinical symptoms that might have been caused by ebov , plasmodium spp . , or a different pathogen . of note , significantly fewer plasmodium parasites were detected in patients with ebov infection than in patients who were not infected with ebov ( average plasmodium ct 24.7 vs. 20.37 ; p<0.01 by unpaired student t - test ) , likely because clinical symptoms in these patients were caused by the ebov infection rather than malaria . some of the patients in our cohort with plasmodium spp . parasitemia might have been asymptomatic carriers , especially those with a low - level parasitemia . parasitemia over time by month of sample submission , for samples submitted to the centers for disease control and prevention national institutes of health diagnostic laboratory at the eternal love winning africa campus in monrovia , liberia , from october 12 , 2014 , through march 28 , 2015 . cycle threshold ( ct ) values were detected by using real - time quantitative reverse transcription pcr . triangles represent parasite loads in parasitemic patients co - infected with ebola virus ; circles represent patients with plasmodium spp . similar to other malaria - endemic regions , a large proportion of the population is infected with plasmodium parasites without developing clinical disease . to compensate for this and the higher sensitivity of the pcr assay compared with light microscopy , we used a cutoff of ct < 30 rather than ct < 40 under the assumption that a 10-ct difference would compensate for the 1,000-fold higher sensitivity of pcr over microscopy . this principle could be carried further to assume that a ct < 25 would be in the range detectable by the rapid diagnostic test . of note one could argue that because all patients with febrile illness who were seen at many of the etus were given antimalarial treatment when they first sought medical care , providing laboratory testing for plasmodium spp . presumptive artemisinin - based combination treatment is recommended for all patients seen at etus , followed by prompt malaria diagnostic testing so that appropriate measures can be taken if oral treatment can not be sustained because of clinical symptoms ( 9,10 ) . moreover , mathematical models predict a large increase in malaria in the epidemic region because of lapses in malaria control ( 7 ) . parasitemia testing of all febrile patients seen at healthcare facilities could be used to determine whether this increase is indeed occurring so that countermeasures can be scaled up accordingly . differential diagnostic testing should be expanded to identify the cause of disease in the patients in our cohort whose samples tested negative for ebov and plasmodium spp . , as was attempted in 1 laboratory in sierra leone ( 15 ) . however , this kind of testing was difficult for several reasons . first , during the height of the evd epidemic in liberia , most laboratories were already working close to capacity while testing for ebov alone . testing for additional pathogens would have required the allocation of additional resources , including equipment and personnel . second , it might not be possible to perform diagnostics using a whole blood sample for all the pathogens of differential diagnostic importance that can cause signs and symptoms similar to those of evd ( e.g. , typhoid , bacterial sepsis , shigellosis , cholera , leptospirosis , dengue fever , rickettsioses , relapsing fever , meningitis , viral hepatitis , influenza , lassa fever ) . third , each of these pathogens likely is the cause of disease in only a small subset of febrile patients . because broad - spectrum antimicrobial drugs and antimalarial drugs are routinely administered to all patients seen at an etu , consideration for additional testing should focus on endemic pathogens that would not respond to these treatments . by using pcr - based detection for plasmodium spp . parasitemia , the need for additional handling of clinical specimens possibly infected with ebov was eliminated . thus , the addition of pcr - based diagnostic tests to detect plasmodium spp . does not pose an additional safety risk to laboratory staff . also , it is less time - consuming to add additional pcr reactions to a pcr run than to separately perform microscopy or an rdt on each sample , and these additions would add only 15 minutes to the overall time needed from sample submission to reporting of results . moreover , if a multiplex approach is used , the additions would not require extra time or reagents . parasitemia can be implemented easily and safely in laboratories performing ebov diagnostics to assist with case - patient management during evd outbreaks in malaria - endemic areas .

malaria is a major public health concern in the countries affected by the ebola virus disease epidemic in west africa . we determined the feasibility of using molecular malaria diagnostics during an ebola virus disease outbreak and report the incidence of plasmodium spp . parasitemia in persons with suspected ebola virus infection .

celiac disease ( cd ) , an inflammatory disorder of the upper small intestines , is characterized by intestinal villous atrophy and crypt hyperplasia and is caused by an abnormal immune reaction to wheat gliadin . it may be associated with different symptoms and signs , depending on the degree of intestinal involvement . the damage to the intestine makes it difficult for the body to absorb nutrients , especially fat , calcium , iron , and folate . this often results in diarrhea , abdominal distension , generalized malnutrition and failure to thrive , or subclinical deficiencies along with isolated nutrient deficiencies such as anemia , aphthous ulcer , bone pain , etc . the prevalence of cd is high in saudi patients ( 4% ) when compared to the prevalence rates reported from the usa and europe ( i.e. , 3% ) and is comparable to the rates reported from other tropical countries . moreover , a high prevalence of serological markers of cd has been reported among patients with autoimmune thyroid disease . osteomalacia and iron deficiency anemia were common clinical presentations of adult cd in saudi arabia . hence , the presence of either one of these presentations in a female patient should raise the possibility of cd . trichotillomania has been classified as an obsessive - compulsive and related disorder ( dsm-5 ) that is characterized by recurrent body - focused repetitive behavior ( hair pulling ) and repeated attempts to decrease or stop the behavior . it may result in impairment in important areas of functioning , such as relationships , social functioning , etc . . in addition , it is 7 times more prevalent in children ( peak prevalence observed between 417 years of age ) than in adults . hair pulling in early childhood ( < 5 years of age ) can be regarded as a distinct clinical entity that tends to be self - limiting without the need for intervention . however , pathological hair pulling has been observed in 1.5% of adult males and 3.4% adult females . trichotillomania is typically confined to one or two sites , frequently affecting the scalp , but it can also involve the eyelashes , eyebrows , pubic hair , body hair , and facial hair [ 8 , 9 ] . the patients tend to be highly secretive about the condition and regard their behavior as shameful . many hair pullers exhibit additional stereotypic movements such as nail biting , knuckle cracking , touching or playing with pulled hair , and hair eating ( trichophagia ) . insufficient data exist on the association of cd with various neurological disorders , including certain common and soft neurological conditions such as headache , learning disorders , attention deficit hyperactivity disorder , and tic disorders , in children , adolescents , and young adults . to the best of our knowledge , there are only four articles that have reported on the association between cd and trichobezoars [ 11 , 12 , 13 , 14 ] . a 22-year - old saudi female university student presented with cd and complaints of an uncontrollable , irresistible , and repetitive urge to pull her scalp hair . this condition started 15 years ago with the pulling of hair on the legs and then shifted to scalp hair 2 years ago after a year of no hair pulling . the hair pulling had currently become distressing , problematic , and out of control. in addition , there was a significant deterioration in her academic performance and social adjustment . the patient engaged in hair pulling on a daily basis for 13 h irrespective of whether she was relaxed ( like watching tv ) or under stress ( like preparing for exams ) . however , when she was anxious during her exams or when assigned a project ( with minor changes in sleep and appetite ) , her hair pulling behavior increased . immediately before pulling her hair , she felt a mounting tension , which was relieved with the successful pulling out of a hair root . she carefully examined the hair root but did not ingest them . if the hair root remained intact and instead the hair shaft was broken , she repetitively pulled the hairs until successful . she felt guilty and embarrassed by her hair pulling behavior and wore a head scarf most of the time to cover the bald patches of 12 cm on her scalp . the hair , particularly on the top of her head , was very thin , brittle and uneven . two years ago , she was diagnosed with cd and had symptoms like digestive problems ( abdominal bloating , pain , and gas ) , skin eczema and psoriasis , iron deficiency anemia , and diarrhea . she then started a gluten free diet and noticed a decrease in the frequency of symptoms and hair pulling . the trichotillomania symptom severity scale showed that the patient had moderate symptoms ( 20 out 30 ) . the hamilton anxiety rating scale showed mild anxiety and the hamilton rating scale of depression showed no depression in the patient . trichotillomania is associated with significant social and functional impairment [ 5 , 6 ] . along with the cosmetic and psychosocial consequences , this disorder is also associated with certain medical complications , including infection , permanent loss of hair , repetitive stress injury , carpal tunnel syndrome , and gastrointestinal obstruction with bezoars as a result of trichophagia . the patients actively disguise their symptoms to avoid disclosure , and clinicians should be vigilant when patients present with inappropriate or unusual head coverings . in addition , the assessment of such disorders requires great clinical sensitivity as patients frequently regard their behavior as shameful . studies have reported a history of psychiatric disorders in a high proportion of adults who were newly diagnosed with cd . in our case this was further supported by the fact that her symptoms improved when she started a gluten - free diet . screening for comorbid anxiety disorders , obsessive - compulsive and related disorders , and depression in patients with cd by general practitioners and gastroenterologists is recommended .

trichotillomania is an underreported and underdiagnosed condition associated with significant impairments in social and functional relationships . the connection between celiac disease and trichotillomania is not yet established clearly . only a few cases of trichotillomania have been reported to date . here , we report the case of a 22-year - old saudi female , who presented with celiac disease and trichotillomania to the psychiatry clinic . this is the first report of its kind in saudi arabia . by reporting this case , i highlight the importance of psychiatric and comprehensive approaches in patients with celiac disease .

optimal treatment of cancers in children often requires combined - modality therapy , including : chemotherapy , surgery , and/or radiotherapy . chemotherapy is not always sufficient to achieve the cure of solid tumors in children ; either resection or radiation may be needed for local tumor control as well ( 1 ) . children with radiosensitive malignant tumors typically require radiation therapy for a number of sessions over a period of several weeks . although the procedure is painless , young children need to be sedated or anesthetised in order to provide a motionless state during the procedure . a short period of sedation , analgesia or general anaesthesia the patient and anaesthesia equipment are observed continuously by closed - circuit television , and monitors are mirrored to the remote observation site outside the treatment room . different anesthesia methods and anesthetics have been recommended to provide a safe and optimal situation of motionless with a short recovery period in children undergoing general anaesthesia or sedation for external beam irradiation ( 37 ) . this report describes the accidental detection of a missed complication by the anesthetist at the time of radiotherapy , from the previous chemotherapy , which was preliminarily and unduly attributed to anesthesia . a 2.5 year - old , 13-kg boy , asa ( american society of anesthesiologists ) class ii , with acute lymphoblastic leukaemia ( all ) , was scheduled for radiotherapy . anesthesia was planned by the anesthetist , and the physical examination was normal before radiotherapy . routine monitoring was established , and for peripheral pulse monitoring , the distal portion of the right upper limb of the child was rested out of the covers . after about 5 minutes , when the anesthetic effect of ketamine began , we noticed a lack of right radial pulse . anesthesia - related hemodynamic instability was expected , however no other manifestation of hypoxia or hypo - perfusion was detected . furthermore , carotid pulsation was normal , and examination of the left radial pulse and other peripheral pulses showed normal pulsation . the patient showed a scar and swelling on the right antecubital area . a more detailed history taken from the child s parents showed his history of chemotherapy during which extravasation of the chemotherapy drug had resulted in severe inflammation and edema at the site of injection . a colour doppler ultrasound of the antecubital area showed deep edema and chronic compression on the antecubital tissue and confirmed the diagnosis . permission was obtained from the patient s parents to use the patient s reports , however the patient s information was to remain confidential . the incidence range of extravasations of cytostatic drugs in cancer patients has been reported from 0.2 to 1.4% in a five - year study ( 8) . extravasations in cytostatic treatment may cause a wide range of symptoms , from patients discomfort to severe complications such as necrosis and amputation . ( 9 ) eccrine squamous syringometaplasia , while rare , has also occurred in patients who have received chemotherapy treatment ( 10 ) . yeung et al described a case of metastatic ovarian carcinoma with repeated thrombosis of the femoral arteries following intravenous carboplatin - based combination chemotherapy . persistent withdrawal occlusion ( pwo ) is frequently caused by fibrin sheath formation around venous access devices . small doses of thrombolytic drugs ( such as urokinase ) could manage pwo , but could also serious complicate chemotherapy drug extravasation ( 12 ) . keratolytic ointment was applied for old lesions , whereas in new lesions , multiple subcutaneous injections of hydrocortisone solution were used before the application of betamethasone ointment . application of conservative agents in radiotherapy - induced extravasation areas may avoid tissue necrosis and consequently , reconstructive surgery ( 13 ) . management of cytotoxic drug extravasation in humans is based on the experimental evidences and available case reports because of lack of randomized trials . for instance , topical dimethylsulfoxide ( dmso ) and cooling for extravasation of anthracyclines or mitomycin , local injection of hyaluronidase for extravasation of vinca alkaloids , and local injection of sodium thiosulfate ( sodium hyposulfite ) for extravasation of chlormethine ( mechlorethamine ; mustine ) should be empirically recommended . in the case of failed conservative treatment , history and physical examination before injection of anesthetic agents could be useful in preventing patient mismanagement . a weak pulse in a child can be a significant problem for the anesthesiologist and in this case , it was shown to be a critically misleading factor . increased emphasis is on clinical evaluation and pulse checking is necessary , especially in children with a history of chemotherapy . providing thorough pulse evaluation when we work on children and avoiding immediate aggressive intervention before being certain about the cause of weak pulse are additional issues of importance shown by this case report .

treatment of cancer in children often requires a combination of chemotherapy , surgery , and/or radiotherapy . radiotherapy and chemotherapy are not painful processes , but children undergoing these procedures must be made motionless through anesthesia or sedation . there are a few reports of complications during these procedures in relation to the procedures themselves or to the anesthesia given . this report describes an unexpected pulseless radial artery which was preliminarily and unduly attributed to anesthesia . a 2.5 year - old male pediatric patient with an acute lymphoblastic leukaemia was scheduled for radiotherapy . anesthesia with intramuscular ketamine was induced before starting radiotherapy . about 5 minutes after injection of ketamine we found the right radial pulse undetectable . there was no other manifestation of hypoxia or hypo - perfusion . carotid pulsation was normal . examination of the left radial pulse and other peripheral pulses showed normal pulsation . the procedure was continued uneventfully . the next follow - up after radiotherapy , showed a scar and swelling on the right antecubital area , caused by extravasation of chemotherapeutic agent in the prior period of chemotherapy . doppler ultrasonography of the antecubital vein confirmed the diagnosis . this case study therefore demonstrates that proper intravenous cannula establishment before chemotherapy is of great importance . furthermore , accurate history and physical examination before induction of anesthesia or sedation may be useful in preventing mismanagement in pediatric cancer procedures .

they are the most common adult type - fat cell tumor , often referred to as universal tumor or a ubiquitous tumor . lipomas have been identified in all age groups , but usually appear between 40 and 60 years of age . solitary lipomas are common in women and multiple tumors ( lipomatosis ) are common in men . while about 80% of lipomas are less than 5 cm in diameter , some can reach more than 20 cm and weigh several kilograms . we report a case of solitary lipoma in the retromandibular region in a young male patient . a 21-year - old male presented with a history of swelling , which was gradually increasing since 2 years , in the left preauricular region , inferior to the lobule of the ear , and associated with dull intermittent nonradiating type of pain with no aggravating and relieving factors . fullness was seen in the parotid and retromandibular regions on the ipsilateral side with raised ear lobe . margins of the swelling were diffused , extending up to 1 cm superior to the ear lobe , 3 cm inferior to the inferior border of the mandible , anteriorly up to the level of the body of the mandible and posteriorly to the mastoid region . skin over the swelling was pinchable , with no local rise in temperature , but mildly tender on palpation . his general physical examination and medical history did not show the presence of any co - morbid conditions . a computed tomography ( ct ) scan of the parotid region with intravenous contrast was performed , which showed a hypodense fat - attenuated lesion with linear strands measuring 52 mm 37 mm in the retromandibular region deep to the sternocleidomastoid muscle , inferior to the parotid gland extending to the submandibular region . medially the carotid vessels , supero - laterally the parotid gland and antero - superiorly the submandibular gland were displaced . based on the above findings , the lesion was provisionally diagnosed as lipoma in the retromandibular region [ figure 2 ] . computed tomography scan of the lesion a risdon 's incision extending up to the retromandibular region [ figure 3 ] was placed and a subplatysmal dissection was performed to approach the mass . the dissection was carried out to expose the sternocleidomastoid muscle , which was retracted laterally as the lesion was found beneath the muscle . the inferior aspect of the lesion was found to be in close proximity to the external carotid artery . hence , careful dissection was performed to separate it from the vessel to prevent any injury to the same [ figure 4 ] . because the lesion was well - encapsulated , blunt dissection was performed to free its margin and the mass was excised in toto . the excised mass [ figure 5 ] was soft , yellow , smooth , shiny and ovoid , measuring about 5 cm 4 cm , which was sent for histopathological examination . the biopsy report revealed lobular growth of large mature fat cells with clear cytoplasm and thin strands of connective tissue , scanty inflammatory cells and few blood vessels [ figure 6 ] . intra - operative , lesion exposed in the neck postoperatively , symmetry of the face could be appreciated [ figure 7 ] without any facial nerve palsy and other complications . he is on follow - up for the last 2 years with no evidence of recurrence till date . lipomas are hamartomatous proliferations of mature fat cells . these are most common in obese patients , usually in the fourth to sixth decades of life , but our patient was aged only 21 years old with an average built and weighing 60 kgs . solitary lesions are most common in females ( 80% ) , but here we came across a solitary lesion in a young male person . the cheek is the most favored site in the head and neck region , followed by the tongue , floor of the mouth , buccal sulcus , vestibule , lip , palate and gingival , but we found the lesion in the retromandibular region . the diagnosis of lipoma is often dependent on the history and clinical examination with the use of aids such as ultrasonography , ct , magnetic resonance imaging techniques and fine needle aspiration biopsy . lipomas histologically resemble mature adipose tissue , but the presence of a fibrous capsule helps to differentiate them from simple fat aggregations . nonexcisional techniques involve steroid injections , which result in fat atrophy , and liposuction , which destroys the adipose tissue but not the fibrous capsule and hence will not eliminate lipoma completely . steroid injections are used for patients who have small lipomas or do not desire excision . liposuction may be used for small or large lipomas ; however , removal of the entire tumor is difficult and hence surgical excision is the most preferred unless it is highly avoided due to some expected complications . complications after excision of a lipoma are hematoma formation , surgical infection , cellulitis , fasciitis , ecchymosis and injury to the nearby nerves with permanent paraesthesiae / anesthesia , injury to nearby vessels / vascular compromise , seroma , fat embolus and muscle injury irritation , but careful execution of surgery with sound knowledge of regional anatomy aid in the success of the excisional therapy with uneventful recovery of the patient .

lipomas are the most common subcutaneous soft - tissue tumors . these are benign tumors originating from the adipocytes . they may be located in any part of the body and can be confused clinically with other soft tissue masses . they infrequently occur in the head and neck region . we present a case of solitary lipoma arising in the neck region that was reported to our division of oral and maxillofacial surgery .

since the first report on the use of the combination of gonadotropin - releasing hormone agonists ( gnrha ) and gonadotropins for in vitro fertilization ( ivf ) in 1984 ( 1 ) , gnrha has widely been used in controlled ovarian stimulation cycles for assisted reproduction . one known complication of pituitary down - regulation using gnrha in ivf treatment cycles is the formation of functional ovarian cysts ( 2 ) . several case reports have indicated that a very small subgroup of patients may experience ovarian hyperstimulation following the administration of gnrha without gonadotropins ( 3 - 6 ) . however , since very few case reports have been published on this topic , it is unclear what course to follow in subsequent cycles after ovarian hyperstimulation using only gnrha in the first cycle . in the present report , a depot preparation ( 3.75 mg ) of tryptorelin without gonadotropins induced ovarian multifollicular enlargement with high estradiol level , and was followed by human chorionic gonadotropin ( hcg ) administration and oocyte retrieval . in a subsequent cycle of the same patient , a low dose of triptorelin ( 0.05 mg ) did not induce ovarian hyperstimulation , and resulted in clinical pregnancy . our patient was a 33-yr - old nulliparous korean woman undergoing oocyte donation for her sister on march 2010 . the patient reported irregular menstrual cycles , with only four to six periods each year . her body mass index was 21.5 kg / m , with a gynecoid fat distribution . she had mild acne on her face , but no hirsutism , virilization , or acanthosis nigricans . her exam results for the 53rd day of her cycle were as follows : negative u - hcg , follicle - stimulating hormone ( fsh ) 5.39 iu / l , luteinizing hormone ( lh ) 11.29 iu / l , estradiol 45 pg / ml , progesterone 0.66 ng / ml , and total testosterone 1.09 ng / ml . transvaginal ultrasound showed that the right ovary measured 3.9 3.5 2.8 cm ( 19 cm ) and the left ovary 3.0 2.8 2.5 ( 10 cm ) . we scheduled a gnrha long protocol for controlled ovarian stimulation . on the 54th day of the cycle , a depot preparation of triptorelin ( 3.75 mg decapeptyl cr ; ferring , malmo , sweden ) was administered subcutaneously . an ultrasound revealed multiple follicles ranging from 15 to 28 mm in diameter ( fig . her exam results were : estradiol 2,560 pg / ml , lh 9.83 iu / l , fsh 2.24 iu / l , and progesterone 4.18 ng / ml . since serum estradiol concentrations were considered appropriate for the number of follicles present , a decision was made to continue the oocyte donation cycle . ( fsh 5.96 iu / l , lh 10.78 iu / l , estradiol 41 pg / ml , progesterone 0.54 ng / ml ) , a short - acting preparation of triptorelin ( decapeptyl ; ferring ) was administered s.c . at a dose of 0.05 mg per day , which is half of the conventional dosage . seven and ten days after the initiation of gnrha , an ultrasound revealed no evidence of functional ovarian cyst . rockland , ma , usa ) was started , which she received daily for 7 days . the dosage was later increased to 225 iu for an additional 5 days . on day 13 , a total of 11 oocytes were retrieved , and three embryos were transferred to the recipient . a single gestational sac and fetal pulse one possible explanation is the initial flare - up caused by gnrha , which induced the release of gonadotropins from the pituitary thereby stimulating the growth of ovarian follicles . these follicles acquired fsh - independent growth dynamics , which finally led to mature follicles by relatively abundant lh . it is accepted that in the late stages of follicle development , granulosa cells become receptive to lh stimulation and lh becomes active ( 7 ) . in pcos , lh secretion is characterized by greater sensitivity to gnrh , as compared to women without pcos . these responses to gnrh are more prominent in lean - pcos ( 8) ; for this reason , we speculate that the serum lh concentration remained high for ten days following the initiation of gnrha due to an extremely high initial flare - up . alternatively , previous researchers have suggested a direct effect of gnrha at the ovarian level ( 3 , 5 , 9 ) . however , during treatment with gnrha , high concentration of gnrha circulate in the central and peripheral tissue . many studies have investigated the effects of gnrha on ovarian cell proliferation and steroidogenesis . in bussenot et al . ( 10 ) , 5 different gnrh agonists were compared based on their effect on estradiol secretion in human granulosa lutein cell cultures . the results showed that buserelin and leuprolein significantly enhanced estradiol secretion . however , triptorelin , which was used in our case , had no effect on estradiol secretion in their study . recently , azem et al . ( 11 ) reported a live birth following the administration of gnrha without gonadotropins . they scheduled a conventional flare - up regimen on day 1 of the cycle ( triptorelin 0.1 mg ) and daily injections of gonadotropins from day 3 and on . contrary to their expectation , they observed that continued gnrha injection without gonadotropins induced follicular development with high estradiol levels until oocyte retrieval . however , it is unclear what course to follow in subsequent cycles , after ovarian hyperstimulation using only gnrha in the first cycle , as very few case reports have been published on this topic . weissman et al . ( 3 ) reported two cases of ovarian hyperstimulation following the administration of gnrha without gonadotropins . they also reported that recurrent ovarian hyperstimulation occurred in subsequent cycles of the same patients . in the present report the main difference between their cases and ours is the dose of gnrha . while weissman et al . ( 3 ) used a depot preparation of triptorelin ( first cycle ) and short acting preparation 0.1 mg / day in ( subsequent cycle ) , we used triptorelin at 0.05 mg / day . however , we can not say that the dose of gnrha is only responsible for different results . some differences regarding patient 's characteristics and the timing of initiation of gnrha should be considered . in summary , a small subgroup of patients may develop ovarian hyperstimulation following the administration of gnrha without gonadotropins .

several case reports have indicated that a small subgroup of patients may develop ovarian hyperstimulation following the administration of gonadotropin - releasing hormone agonists ( gnrha ) without gonadotropins . however , since only few such cases have been published , it is unclear what course to follow in subsequent cycles after ovarian hyperstimulation in the first cycle using only gnrha . a 33-yr - old woman was referred to in vitro fertilization for oocyte donation . a depot preparation ( 3.75 mg ) of tryptorelin without gonadotropins induced ovarian multifollicular enlargement with high estradiol level , and was followed by human chorionic gonadotropin administration and oocyte retrieval . in a subsequent cycle of the same patient , a low dose of tryptorelin ( 0.05 mg ) did not induce ovarian hyperstimulation , and resulted in clinical pregnancy . this report shows potential management of ovarian hyperstimulation following the administration of gnrha without gonadotropins .

great vessel injury is a rare but fatal complication that can occur during lumbar disc surgery . great vessel injury can result in massive retroperitoneal hemorrhage or present as a delayed pseudoaneurysm or arteriovenous fistula ( avf)2,3,6,8,9,11 ) . despite a very low incidence ( 0.016 - 0.17% ) , the reported mortality rate ranges from 15% to 100% , and this complication may elicit serious medicolegal problems2,4,5,7,9,10,12 ) . in cases of great vessel injury , early detection and management is critical to ensure patient survival1,4,7 ) . major vascular surgery is often required to prevent fatality ; however , procedure - related morbidity and mortality must also be considered4,5,10 ) . we describe the case of a woman who sustained a common iliac artery and vein injury after l4 - 5 lumbar microdiscectomy . a 48-year - old woman referred to hospital for radiating pain in her lower back and right leg . magnetic resonance imaging of the lumbar spine showed a ruptured disc in l4 - 5 . patient vital signs were stable during the operation and immediate postoperative period , and the radiating pain disappeared with no evidence of neurological deficit . although no symptoms such as abdominal cramps were noted , the postoperative hemoglobin level decreased from 13.5 g / dl initially to 8.6mg / dl postoperatively . 1 ) . with the suspicion of postoperative hemorrhage , emergent abdominal ultrasonography and computed tomography ( ct ) were performed . imaging studies revealed a large retroperitoneal hematoma and a pseudoaneurysm near the right common iliac artery and right common iliac vein ( fig . vital signs were monitored , with blood pressure at 110/70 mmhg and heart rate at 70 beats / min . while vital signs were stable , an endovascular intervention was planned . aortography demonstrated a traumatic avf between the right common iliac artery and the right common iliac vein with a 1cm - sized pseudoaneurysm ( fig . seoul , korea ) and a 94 cm - sized balloon at the right common iliac artery ( fig . no retroperitoneal hemorrhage was identified on the 3-month follow - up ct scan ( fig . the patient was given a 1-year supply of clopidogrel , and was stable and asymptomatic 3 years after the surgery . major vessel injury is a rare but well - known complication in lumbar disc surgery . despite advances in modern microscopic surgical techniques and laser - assisted surgery , since many cases remain undetected or are not reported , the true incidence of major vessel injury may be higher than what is reported in the literature . the common iliac artery and common iliac vein are located anterior to the l4-l5 lumbar and l1 sacral vertebral bodies , which is where great vessel injury most frequently occurs1,4 ) . great vessel injury is the most frequent injury that occurs when operating on the l4 - 5 lumbar segments6,9 ) . the injury is caused by the perforation of the anterior spinal ligament while attempting complete removal of disc material using a rongeur . the common iliac vessels and the disc are usually separated by the anterior spinal ligament alone at the lower lumbar spinal level . disc degeneration may weaken this ligament and alter the relationship between the ligament and the adjacent vascular structures2,3 ) . the clinical course of vascular injuries can vary and can be categorized into acute , subacute , and chronic . acute blood loss may occur due to damage caused by a severe arterial laceration and lead to sudden hypovolemia10 - 12 ) . diagnosis of avfs or pseudoaneurysms can be delayed because of unusual clinical symptoms and a lack of specific warning signs . vessel injuries may be detected quickly , especially in cases of profuse arterial bleeding and hypotension with tachycardia . however , as in the present case , bleeding may be minimal or go undetected in half of the injuries6,7 ) . even when massive hemorrhage occurs , blood usually collects in the retroperitoneal space , and blood pooling in the disc space may not be recognized in the surgical field . moreover , the prone position in which the patients are operated may confer a degree of vascular compression during surgery , and as such , this may temporarily tamponade any vascular tears7,9 ) . surgeons should suspect vessel injury if hemorrhage or fat tissue is observed during a lumbar discectomy even when vital signs are stable . after a vessel injury , the duration of detection and the treatment approach are associated with the mortality rate1,2,5,7,12 ) . when the vessel injury is recognized intraoperatively and signs of life - threatening hypovolemic shock are observed , vigorous volume replacement and urgent repair of vascular laceration should be considered . in arterial injuries with critical bleeding , although the injury is not confirmed during surgery and the vital signs are stable , insignificant symptoms such as abdominal distension , pain , palpitation , unexplainable anemia , and blurring of the psoas muscle on radiographs are possible predictors of vessel laceration . abdominal ultrasonography and ct angiography are the preferred methods of diagnosis in confirming vessel injury and retroperitoneal hematoma11,12 ) . when diagnosed , conventional angiography and interventional procedure should be performed . in the past , vascular injury following a lumbar discectomy was treated by direct surgical repair of the damaged vessels9,10 ) . although the current outcomes are considered good , surgical repair of traumatic or postoperative vascular injury may result in considerable blood loss and complications4,10 ) . endovascular techniques are an alternative method of managing the vascular injury following lumbar disc surgery . endovascular techniques using a stent graft to occlude avf or leakage show satisfactory bleeding control with few complications1,4,7,10,11 ) . the advantages of these procedures are the absence of a lower abdominal incision , minimal blood loss , and reduced depth and length of anesthesia , which consequently allows for shorter hospitalization periods compared with conventional surgery . however , proper facilities and preparation of stent grafts and other materials are mandated for endovascular intervention7 ) . delayed onset of symptoms or signs may occur in patients who undergo lumbar disc surgery because of an avf or pseudoaneurysm2,8,11 ) . swelling of the legs , fatigue , shortness of breath , cardiac failure , classic machinery bruit in the abdomen , and delayed bleeding may lead to the diagnosis of avf6,8 ) . most isolated vascular injuries of the great retroperitoneal veins remain clinically silent because of a tamponade effect of a perivascular hematoma1 ) . therefore , the treatment of stable avfs or pseudoneurysms should not be delayed , and only arterial side sealing would be sufficient , as in the present case . vascular injury following lumbar disc surgery necessitates early recognition , diagnosis , and prompt surgical repair for prevention of fatal outcomes . an endovascular repair using a stent graft is a minimally invasive and efficient treatment modality with low morbidity .

great vessel injury is a rare but well - known complication of lumbar disc surgery , which may result in acute or fatal outcomes of delayed diagnosis . thus , early detection and proper management is vital . the authors report a case of retroperitoneal hemorrhage with arteriovenous fistula and pseudoaneurysm after lumbar microdiscectomy . the patient was successfully managed by endovascular intervention using a stent graft . endovascular repair is a minimally invasive and efficient treatment modality with considerably low morbidity and mortality .

thyroid associated orbitopathy ( tao ) , although commonly seen in graves thyrotoxicosis , has also been known to occur in patients with primary hypothyroidism . myasthenia gravis is an autoimmune disease involving the neuromuscular junction with an association with autoimmune thyroid disease . the clinical features of tao and ocular myasthenia gravis have significant overlap and in the rare instance of their coexistence , recognition of the second entity may be missed , unless looked for specifically . we report here the case of a woman who presented with tao with primary hypothyroidism with ocular myasthenia gravis to highlight the same . a 62-year - old lady sought an ophthalmology consultation for complaints of drooping of right eyelid since 10 days . the drooping of the right eyelid was sudden and was better at the start of the day and got worse as the day progressed . when she lifted the lid with her hands , she also noted double vision . on questioning , she had complaints of watering from both eyes and occasional redness with a gritty sensation since a year . she had no past history or family history of thyroid illness and had no complaints suggestive of thyrotoxicosis although she had constipation and malaise . she had no difficulty in getting up from the squatting position , or climbing stairs or combing her hair . she had no history of cough , hemoptysis or shortness of breath . on examination , she was a moderately built lady , conscious oriented and alert . general examination revealed a visible diffuse goiter , dry skin with delayed relaxation of ankle jerks . examination of the eyes revealed bilateral proptosis ( 26 mm in the left eye and 24 mm in the right eye ) . clinical activity score was 1/7 in both eyes ( right conjunctival congestion and left pain at rest ) . profile of patient showing bilateral proptosis ( left > right ) with the right eye ptosis a provisional diagnosis of tao , hypothyroidism and myasthenia gravis was made . thyroid function tests revealed primary hypothyroidism ( thyroid - stimulating hormone 38 miu / l , free t4 0.8 ng / dl , anti - thyroid peroxidase 189 iu / l ) . computed tomography of the orbit [ figure 2 ] showed bilateral proptosis ( left > right ) with no mass lesions in the orbit . figure 3 shows enlargement of extra ocular muscles both eyes , especially inferior recti and medial recti , findings characteristic of tao . computerized tomography orbits showing bilateral thickening of intraocular muscles , predominantly involving inferior and medial rectus followed by superior rectus and lateral rectus due to thyroid associated ophthalmopathy transverse section of computerized tomography orbits showing bilateral proptosis ( left > right ) a neurology consultation was obtained . a repetitive nerve stimulation test at the limbs was normal but the testing at the nasalis muscle was found to inconsistently positive she was started on levothyroxine 75 mcg / day and pyridostigmine 15 mg thrice daily and showed improvement in general well - being and ptosis . it is recognized that about 5% of patients with thyroid associated ophthalmopathy have hypothyroidism as against the expected picture of thyrotoxicosis . the presence of ptosis in a patient of tao should alert one to the coexistence of myasthenia gravis , a condition known to be associated to be associated with autoimmune thyroid disease although ptosis has been described as a rare feature of tao in anecdotal case reports . autoimmune thyroid disease occurs in about 3 - 8% of patients with myasthenia gravis and thyroid function tests are routinely recommended in all myasthenia patients . ocular myasthenia gravis is a subtype where the weakness remains restricted to the extra ocular muscles with no generalized weakness . patients with myasthenia gravis with autoimmune thyroid disease are more likely to have milder clinical features with preferential ocular involvement as compared with myasthenia patients with none - autoimmune thyroid disease or no thyroid disease . the management of thyroid condition ( hyperthyroidism or hypothyroidism ) significantly improves response of myasthenia to treatment . the presence of antiachr antibody is virtually diagnostic of myasthenia gravis , but a negative test does not exclude the disease . only about 50% of patients with disease restricted to ocular muscles have detectable antiachr antibodies in serum . our patient is on follow - up since a year and is doing well with no progression of myasthenia gravis . we report this case to highlight the association of tao , in this case with primary hypothyroidism with myasthenia ocular variant . the presence of ptosis in a patient with tao should alert the clinician to the presence of myasthenia gravis .

thyroid associated orbitopathy , although seen most commonly with thyrotoxicosis , is also known to occur in primary hypothyroidism . myasthenia gravis is an autoimmune condition with an established association with autoimmune thyroid disease . we report the case of a patient who presented with recent onset unilateral ptosis that was fatigable with a history of proptosis since a year . on examination , she had a goiter , bilateral proptosis , restriction of upward gaze and adduction both eyes and normal pupils . investigations revealed primary hypothyroidism with anti - thyroid peroxidase positive and anti - acetylcholine receptor antibody positive . computerized tomography orbit showed thickening of medial and inferior rectus characteristic of thyroid orbitopathy . a diagnosis of primary hypothyroidism with thyroid orbitopathy with ocular myasthenia gravis was made . patient is on levothyroxine and anticholinesterase medications and is on follow - up . we present this case to highlight that the presence of ptosis in a patient with thyroid orbitopathy should alert the clinician to the possible coexistence of myasthenia gravis .

juvenile hyaline fibromatosis ( jhf ) is a rare , autosomal - recessive hereditary disease with distinct clinical and histopathological features . a scan of the world literature revealed that less than 70 cases have been reported so far.[13 ] the clinical onset is usually noted from birth up to 5 years of age . it is characterized by papular and nodular skin lesions , gingival hyperplasia , joint contractures and bone involvement in variable degrees . we report a 5-year - old female born of first - degree consanguineous marriage who presented with multiple , recurrent , painless , variable - sized nodules over the scalp , back , ear lobules and lower lip [ figure 1 ] . the lesions were first noticed when the child was 6 months old and , since then , the nodules gradually increased in size . two of the nodules on the scalp were excised when the child was 2 years old . . multiple nodules over the back and lower lip on examination , the lesions consisted of multiple papules and nodules of varying sizes . fine needle aspiration cytology ( fnac ) smears from the nodules showed sparse spindle cells in a periodic acid schiff ( pas)-positive background , the features of which were suggestive of fibromatosis [ figure 2 ] . fnac smears showing few spindle cells in a pas + ve myxoid background the nodules over the back , scalp , ear lobule and lower lip were excised in multiple sittings and sent for histopathological examination . grossly , the nodules were of variable sizes and grayish - white , and the cut surface showed a gelatinous grey - white appearance [ figure 3 ] . variable - sized grey - white nodular masses with gelatinous cut surface microscopically , there were poorly circumscribed lesions in the dermis and subcutis composed of a sparse population of uniform spindle cells embedded in an abundant homogenous eosinophilic fibrillary matrix [ figure 4 ] . these findings were diagnostic of jhf . sparse population of uniform spindle cells ( hematoxylin and eosin stain , 100 ) matrix showing pas positivity ( 100 ) the patient was lost to follow - up for the past 7 years and now she has presented with many more new nodules over the forehead , chest and abdomen . the lesions on the cheek and ear lobule have increased in size [ figure 6 ] . grossly , the nodules were of variable sizes and grayish - white , and the cut surface showed a gelatinous grey - white appearance [ figure 3 ] . variable - sized grey - white nodular masses with gelatinous cut surface microscopically , there were poorly circumscribed lesions in the dermis and subcutis composed of a sparse population of uniform spindle cells embedded in an abundant homogenous eosinophilic fibrillary matrix [ figure 4 ] . these findings were diagnostic of jhf . sparse population of uniform spindle cells ( hematoxylin and eosin stain , 100 ) matrix showing pas positivity ( 100 ) the patient was lost to follow - up for the past 7 years and now she has presented with many more new nodules over the forehead , chest and abdomen . the lesions on the cheek and ear lobule have increased in size [ figure 6 ] . grossly , the nodules were of variable sizes and grayish - white , and the cut surface showed a gelatinous grey - white appearance [ figure 3 ] . variable - sized grey - white nodular masses with gelatinous cut surface microscopically , there were poorly circumscribed lesions in the dermis and subcutis composed of a sparse population of uniform spindle cells embedded in an abundant homogenous eosinophilic fibrillary matrix [ figure 4 ] . these findings were diagnostic of jhf . sparse population of uniform spindle cells ( hematoxylin and eosin stain , 100 ) matrix showing pas positivity ( 100 ) the patient was lost to follow - up for the past 7 years and now she has presented with many more new nodules over the forehead , chest and abdomen . the lesions on the cheek and ear lobule have increased in size [ figure 6 ] . jhf is a rare , crippling autosomal - recessive disorder , first described by mc murray in 1873 as molluscum fibrosum and renamed by kitano as jhf in 1972.[12 ] the etiology of jhf is unknown . it has been hypothesized that jhf is a connective tissue disorder characterized by aberrant synthesis of glycosaminoglycans by fibroblasts . glycosaminoglycans in the tumor tissue comprised dermatan sulfate , chondroitin sulfate and hyaluronan , with the dermatan sulfate predominating . it usually affects one or more siblings and , as in the present case , it initially presents in children between 2 and 5 years of age . the condition is characterized by multiple cutaneous papules , nodules or tumor masses , gingival hypertrophy , joint contractures and osteolytic defects . skin lesions may be the most outstanding symptoms of jhf , but joint contracture and gingival hypertrophy precede the skin manifestation . joint contractures cripple the patients and retard normal motor development if it occurs in infancy . the present case has only cutaneous lesions , but there is no gingival hypertrophy , joint or bone involvement till date . they are slow growing and painless and have a tendency to recur following excision , as was seen in the present case . reported a patient who underwent successful surgical removal of more than 100 tumors over a period of 19 years with good cosmetic results . quintal and jackson reported a patient who had numerous surgical excisions over a period of 34 years and found that the therapy was as mutilating as the disease . the tumors are poorly circumscribed and consist of cords of spindle - shaped cells embedded in a homogeneous eosinophilic matrix . they are often found in the dermis , subcutis and gingiva , although the bone and joints may also be involved . early lesions show increased cellularity and less - prominent stroma , whereas the large , older lesions are less cellular and contain more ground substance . the matrix stains positively with pas and alcian blue but does not stain with toluidine blue or congo red . the differential diagnosis of jhf includes neurofibromatosis , gingival fibromatosis , nodular amyloidosis , infantile systemic hyalinosis , congenital generalized fibromatosis , lipoid proteinosis and winchester syndrome . the disease has a relentlessly progressive course , with most patients surviving only up to the 4 decade.[12 ] as of now , there is no specific treatment for this disorder . genetic counseling is essential to explain to parents about a 25% chance of having a diseased baby in any pregnancy . with the gene for the disease

juvenile hyaline fibromatosis is a rare , autosomal - recessive disease characterized by papular and nodular skin lesions , gingival hyperplasia , joint contractures and bone involvement in variable degrees . it is a connective tissue disorder with aberrant synthesis of glycosaminoglycans by fibroblasts . we report a 5-year - old female born of first - degree consanguineous marriage who presented with multiple , recurrent , painless , variable - sized nodules . fine needle aspiration cytology smears and the subsequent histopathological examination from the nodules showed benign spindle cells in a periodic acid schiff - positive myxoid background . the disease has a relentlessly progressive course , with most patients surviving only up to the 4th decade . as of now , there is no specific treatment for this disorder . genetic counseling is essential to explain to parents about a 25% chance of having a diseased baby in any pregnancy . with the gene being mapped recently , techniques for antenatal diagnosis are likely to be established .

traumatic brain injury ( tbi ) is the most common cause of morbidity and mortality in children . many scoring systems have been established to predict the neurological outcomes in children with tbi . clinically , different scoring systems may show different characteristics and various effects in estimating children with tbi . however , the golden standard scoring system for predicting neurological outcome in children with tbi is still unclear . also , it is equivocal which clinical scoring system can be the most useful scale in the emergency department . this concern has led to renewed interest in clinical scoring systems to be better applied clinically and accurately predict neurological outcomes in children with tbi . tbi is the most common cause of morbidity and mortality in children over 1 year of age and young adults . clinically , many scoring systems may aid clinicians in evaluating the neurologic conditions and predicting the outcomes in patients with tbi . however , different scoring systems may show different characteristics for clinicians to evaluate these patients . on the basis of glasgow coma scale ( gcs ) , the severity of the tbi is graded as mild ( gcs 15 - 13 ) , moderate ( gcs 12 - 9 ) or severe ( gcs 8 - 3 ) . since the glasgow outcome scale ( gos ) published by jennett and bond in 1975 , it becomes the most widely used scoring system in evaluating neurological outcome for head injury patients . the current recommendations are to use the gos at 6 months to measure outcome after severe head injury . however , it is likely to underestimate morbidity in children and is not always readily applicable in this group . in 2001 , crouchman and colleagues developed a pediatric adaptation of the gos , the king 's outcome scale for childhood head injury ( koschi ) . they expand the five categories of gos to provide more sensitivity at the milder end of the disability range . in the koschi , the gos category of persistent vegetative state was replaced by vegetative . severe disability , moderate disability and good recovery were allocated two categories , in acknowledgement of the long - term importance of relatively minor sequelae in a developing child . in addition , they suggested that the koschi could be used to ( 1 ) document recovery and monitor the burden of disability in individual children ; ( 2 ) plan service and evaluate rehabilitation programs ; and ( 3 ) assess effects of service and research interventions . in a prospective cohort study , calvert et al . reported that koschi scored at hospital discharge correlates with severity of injury and some cognitive , health status and health - related quality of life ( hrql ) outcomes early after tbi . in addition , another neurological outcome score for children was developed by okada et al . in 2003 such as neurologic outcome scale for infants and children ( nosic ) . they recommended that the nosic was a practical , reliable , valid , nonproprietary instrument applicable to children with a broad range of ages and neurologic diagnoses . but the limitations of nosic were relatively low sensitivity to mild deficits , lacking much clinical experience and can not be administered by mail or telephone . it is really a big challenge for primary clinicians to early predict the outcome of individual patients with severe head injuries . however , predicting and establishing the prognosis after tbi is an important question for doctors , patients and their families , as well as for health organizations and insurers . previous studies had shown some important factors associated with poor outcome after pediatric tbi , including : low admission gcs score , poor pupil reflexes recovery , coagulopathy , brain computed tomography ( ct ) results : ( subarachnoid hemorrhage with brain swelling and edema , subdural , intracerebral hemorrhage , and basal ganglion lesions ) , hyperglycemia , hypoxia , impaired cerebral autoregulation and early hypotension.[58 ] in this issue entitled outcome analysis and outcome predictors of traumatic head injury in childhood - analysis of 454 observations in journal of emergencies , trauma , and shock , the authors did their effort to evaluate the factors correlated with poor outcome in children with tbi . based on the results of multivariate analysis , they found that factors associated with a bad outcome ( gos<4 : death , persistent vegetative state , severe disability ) were prism 24 ( p=0.03 ; or:5.75 ) ; gcs score 8 ( p=0.04 ; or:2.42 ) ; cerebral edema ( p=0.03 ; or : 2.23 ) ; lesion type vi on ct according to traumatic coma data bank classification ( p=0.002 ; or:55.95 ) ; hypoxemia ( p=0.02 ; or:2.97 ) and sodium level > 145 mmol / l ( p=0.04 ; or:4.41 ) . the authors concluded that the neurological outcome measure ( gos ) was a very blunt instrument , especially for survivors who were not vegetative or severely disability . in addition , gos was not only poor - sensitive to children with neurobehavioral impairments but also less sensitive to children with substantial impact on academic , social function and quality of life . as most of previous studies mentioned,[58 ] gos was commonly used to evaluate patients neurological conditions . although gos appears to be simple and easy - recorded , the variables of gos involve more physical evaluation than cognitive , emotional and behavior surveys . this issue may lead clinicians to underestimate the severity and prognosis in tbi . moreover , the above study also has provided some important predictive factors associated with poor neurologic outcome . the results might be helpful for clinicians in further evaluation and management of tbi patients . however , even in tbi patients with initially good outcome indicators ( good recovery and only mild - to - moderate disability ) , poor learning and poor social behavior functions may occur in 6 months after tbi events . during the recent 30 years , the survival rate and neurological outcome of tbi in children have improved a lot . however , the disabled survivors remain a significant financial burden on health , education and social - service budgets not only in developing countries but also in developed countries . in order to adequately evaluate neurological outcomes after tbi , some studies had used a variety of instruments from complex neuropsychological tests to simple clinical outcome scales . nevertheless , which is the gold standard neurological outcome scoring system in children with tbi remains equivocal . until now , there have been several particular challenges for clinicians in evaluating outcomes after childhood tbi . physical , behavioral , emotional and cognitive impairments make various contributions to the overall morbidity , depending on the age at injury , interval since injury and the severity of injury . in addition , measurements in children need to be considered to age - appropriate expectations , and since the process of development and growth continues after the injury , the shortfall between current functional status and age - dependent normality is dynamic . the dynamic correlation and interaction among the components of the morbidity developed after tbi may lead to dilemma in further management and evaluation . therefore , we think that to develop a practical , reliable and valid neurological outcome instrument in children is an important issue in forwarding research . furthermore , to achieve early accurate assessment , adequate rehabilitation and long - term follow - up is also the key point of improving neurological outcome in children with tbi .

traumatic brain injury is the most common cause of morbidity and mortality in children . however , it is still challengeable to early predict the outcome of individual patients with severe head injuries . glasgow outcome scale is the most widely used scoring system in evaluating neurological outcome for head injury patients . moreover , it is likely to underestimate morbidity and is not always readily applicable in children . it is an important issue to develop a practical , reliable and valid neurological outcome instrument in children in forwarding research .

peripheral giant cell granuloma ( pgcg ) is the most common oral giant cell lesion appearing as a soft tissue extra - osseous purplish - red nodule consisting of multinucleated giant cells in a background of mononuclear stromal cells and extravasated red blood cells . this lesion is probably not present as a true neoplasm , but rather may be reactive in nature . the initiating stimulus has been believed to be due to local irritation or trauma , but the cause is not certainly known . it has been termed a peripheral giant cell reparative granuloma , but whether it is in fact reparative has not been established and its osteoclastic activity nature appears doubtful . its membrane receptors for calcitonin demonstrated by immunohistochemistry and its osteoclastic activity when cultured in vitro are evidences that the lesions are osteoclasts,[15 ] whereas other authors have suggested that the lesion is formed by cells of the mononuclear phagocyte system . the pgcg bears a close microscopic resemblance to the central giant cell granuloma , and some pathologists believe that it may represent a soft tissue counterpart of the central bony lesion . a 22-year - old female patient reported to the department of oral and maxillofacial surgery with the complaint of swelling in the left upper jaw since 1 year . history revealed that the swelling started as a small one and progressively increased to the present size over a period of 1 year . there was no history of trauma , neurological deficit , fever , loss of appetite , loss of weight . on extraoral examination , a single , diffuse swelling was seen on the left side of the face in the region of anterior maxilla . the surface of the swelling was lobulated and present in relation to 11 21 22 . the swelling was firm in consistency and bluish in color , and the overlying mucus membrane was intact [ figure 1 ] . the fine needle aspiration cytology ( fnac ) features showed numerous giant cells in a hemorrhagic background . preoperative intraoral presentation of lesion surgery ( excisional biopsy ) was planned under local anesthesia ( la ) . lesion was separated from the adjacent tissue by blunt dissection and removed in one piece [ figure 2 ] . there was no evidence of recurrence till 5 months of follow - up [ figure 4 ] . immediate postoperative view postoperative view after 1 month histopathologic examination of biopsied specimen revealed it to be whitish in color , oval in shape , firm in consistency and measuring about 2 1 cm in dimension [ figure 5 ] . numerous giant cells of various shapes and sizes , containing 815 nuclei , were seen with proliferating and dilated endothelial lined blood capillaries with extravasated red blood cells ( rbcs ) . histopathologic examination of biopsied specimen revealed it to be whitish in color , oval in shape , firm in consistency and measuring about 2 1 cm in dimension [ figure 5 ] . numerous giant cells of various shapes and sizes , containing 815 nuclei , were seen with proliferating and dilated endothelial lined blood capillaries with extravasated red blood cells ( rbcs ) . the etiology and nature of pgcg ( giant cell epulides ) still remains undecided . in the past , several hypotheses had been proposed to explain the nature of multinucleated giant cells , including the explanation that they were osteoclasts left from physiological resorption of teeth or reaction to injury to periosteum . there is strong evidence that these cells are osteoclasts as they have been shown to possess receptors for calcitonin and were able to excavate bone in vitro . the pgcg occurs throughout life , with peaks in incidence during the mixed dentitional years and in the age group of 3040 years . the clinical appearance is similar to that of the more common pyogenic granuloma , although the pgcg often is more bluish - purple compared with the bright red color of a typical pyogenic granuloma . although the pgcg develops within soft tissue , cupping superficial resorption of the underlying alveolar bony crest is sometimes seen . at times , it may be difficult to determine whether the mass is a peripheral lesion or a central giant cell granuloma eroding through the cortical plate into the gingival soft tissues . the extra - osseous lesions of cherubism involving the gingiva appear very similar to giant cell epulides . however , the other distinctive clinical and radiographic features of cherubism will indicate the correct diagnosis . histologically , pgcg is composed of nodules of multinucleated giant cells in a background of plump ovoid and spindle - shaped mesenchymal cells and extravasated rbcs . the giant cells may contain only a few nuclei or up to several dozen of them . some of them are large , vesicular nuclei ; others demonstrate small , pyknotic nuclei . ultrastructural and immunological studies[26 ] have shown that the giant cells are derived from osteoclasts . there is also a growing body of opinion that giant cells may simply represent a reactionary component of the lesion and are derived via blood stream from bone marrow mononuclear cells and may be present only in response to an as yet unknown stimulus from the stroma . this concept is based on the results of some more recent studies using cell culture and transplantation , in which the giant cells have been found to be short lived and to disappear early in culture in contrast to the active proliferation of the stromal cells . a study by willing et al . revealed that the stromal cells secrete a variety of cytokines and differentiation factors , including monocyte chemoattractant protein-1 ( mcp1 ) , osteoclast differentiation factor ( odf ) , and macrophage - colony stimulating factor ( m - csf ) . these molecules are monocyte chemoattractants and are essential for osteoclast differentiation , suggesting that the stromal cell stimulates blood monocyte immigration into tumor tissue and enhances their fusion into osteoclast - like , multinucleated giant cells . furthermore , the recently identified membrane - bound protein family , a disintegrin and metalloprotease ( adam ) , is considered to play a role in the multinucleation of osteoclasts and macrophage - derived giant cells from mononuclear precursor cells . in the most recent study by bo liu et al . , in situ hybridization was carried out to detect the mrna expression of the newly identified receptor activator of nuclear factor ( nf)-kappab ligand ( rankl ) that is shown to be essential in the osteoclastogenesis , its receptor , receptor activator of nf - kappab ( rank ) , and its decoy receptor , osteoprotegerin ( opg ) . they concluded that rankl , opg and rank expressed in these lesions may play important roles in the formation of multinucleated giant cells .

peripheral giant cell granuloma or the so - called giant cell epulis is the most common oral giant cell lesion . it normally presents as a soft tissue purplish - red nodule consisting of multinucleated giant cells in a background of mononuclear stromal cells and extravasated red blood cells . this lesion probably does not represent a true neoplasm , but rather may be reactive in nature , believed to be stimulated by local irritation or trauma , but the cause is not certainly known . this article reports a case of peripheral giant cell granuloma arising at the maxillary anterior region in a 22-year - old female patient . the lesion was completely excised to the periosteum level and there is no residual or recurrent swelling or bony defect apparent in the area of biopsy after a follow - up period of 6 months .

the differential diagnosis includes medullary thyroid cancer , anaplastic thyroid cancer , and primary versus metastatic sarcoma . it is an aggressive malignancy with poor long - term prognosis [ 1 - 4 ] . we report a 56-year - old male with plt , who presented with enlargement of the neck , hoarseness and dysphagia . a 56-year - old male presented with 4 months history of a rapidly enlarging left anterior neck mass , hoarseness , and dysphagia . physical examination revealed a hard mass of about 3 cm in the left lobe of the thyroid gland . serum thyroid stimulating hormon , serum t3 ( triiodothyronine ) and t4 ( thyroxinne ) were within normal levels . ultrasound of the neck showed a 2.71 cm 2.59 cm solid nodule arising from the left thyroid lobe , with small contralateral nodules measuring 0.5 and 1.1 cm ( fig . fine - needle aspiration ( fna ) biopsy of the thyroid mass was then performed . fna biopsy reported malignant spindle - shaped cells . computed tomography of the chest and abdomen showed no distant metastases . initially , the left thyroid lobe was excised and sent to pathology for frozen section examination , which reported poorly - differentiated tumor suggesting a ' malignant spindle cell tumor ' . no complications occurred , and the patient was discharged on the first postoperative day . on gross examination , the tumor measured 3 cm 3 cm 2.5 cm . histologically , the tumor cells infiltrated the thyroid parenchyma , with no invasion to the thyroid capsule . the tumor cells showed a disordered fascicular growth pattern , round or spindle configuration with hyperchromatic , blunt - ended nuclei and abundant eosinophilic cytoplasm ( fig . the tumor was strongly positive for smooth muscle actin , positive for desmin , and negative for pancytokeratin ( fig . the patient was free of disease at three- and six - month 's follow - ups . about eight months after the operation , his family doctor informed us that he had developed sudden respiratory symptoms and died in the intensive care unit with numerous pulmonary metastases . although the the incidence of thyroid cancer rate is different in the korea population ( the age - standardized incidence rate of thyroid cancer in 2007 was 32.8 per 100,000 [ 9.9 per 100,000 men and 55.6 per 100,000 women ] ) , thyroid cancer represents less than 1% of all malignancies in the world . the 90% to 95% of thyroid cancer cases are categorized as well - differentiated tumors arising from the follicular cells . however , plt gland is extremely rare , and it is the most aggressive form of thyroid cancer . the unusual fna biopsy report of malignant spindle - shaped cells lead us to consider unusual tumors of the thyroid . computed tomography of the chest and abdomen did not add to the diagnosis , similar to several tumor markers within normal ranges . the frozen section examination also failed to define the exact pathology , although the definition of a poorly differentiated tumor with malignant spindle cells weighed in favor of our suspicion of plt . still , possibilities such as anaplastic thyroid cancer , and primary versus metastatic sarcoma existed . the final diagnosis could only be done by immunohistochemical staining . immunohistochemically , leiomyosarcomas are reactive for desmin or vimentin and actin . in our patient , the diagnosis of leiomyosarcoma was favored because smooth muscle markers and desmin were positive and immunostains for keratins were negative . leiomyosarcomas are malignant mesenchymal tumors with smooth muscle differentiation that can arise in the smooth muscle of any organ ; in the thyroid , this includes the muscular vessel walls located in the thyroid capsule . they tend to be larger than their benign counterparts with malignant histologic features characterized by pleomorphism , prominent mitotic activity , necrosis , hemorrhage , and invasive and/or extrathyroidal growth . thyroid leiomyosarcomas are generally fatal , although follow - up was limited in the published reports . leiomyosarcomas of the thyroid can also be metastatic in origin , with primary sites in soft tissue , stomach , and pelvis , all being excluded in our patient by preoperative imaging . the mainstay of treatment for plt is oncologic resection , as exemplified again in this case . the disease is invariably fatal , and survival rates are reported to be 5% to 10% at 1 year . in spite of the silent and optimistic short - term course , our patient also experienced a fulminating and fatal tumor attack sooner than a year .

a 56-year - old male with primary leiomyosarcoma of the thyroid is presented . the paucity of diagnostic maneuvers , including tumor markers , fine needle aspiration , and frozen section biopsy , are stressed , in addition to the fulminate course of the disease .

cd95 ( also known as fas ) belongs to the tnf ( tumour necrosis factor ) -receptor superfamily . fifteen years ago , it has been shown that when exposed to an agonistic anti - cd95 mab ( apo13 ) , the aggregated receptor recruits the adaptor protein fadd ( fas - associated protein with death domain ) , which then binds caspase-8/-10 and ultimately elicits the apoptotic signal and the death of the cell . this complex was designated the disc for death inducing signaling complex and since numerous factors have been found to modulate the implementation of this complex and thus , the transmission of death receptor - mediated apoptotic signal . the cognate cd95 ligand , cd95l ( also known as fasl or cd178 ) is a transmembrane cytokine belonging to the tnf family . cd95l exhibits a restricted expression pattern , being expressed primarily at the surface of activated t lymphocytes and nk cells , where it contributes to the elimination of infected and transformed cells . however , cd95l is also found under inflammatory conditions , at the surface of epithelial cells , macrophages or dendritic cells where its biological function remains elusive . this type ii transmembrane protein can be cleaved by metalloproteases such as mmp3 , mmp7 , mmp9 or adam-10 ( a disintegrin and metalloproteinase 10 ) and released as a soluble ligand into the connective tissue and the bloodstream . cleaved cd95l ( cl - cd95l ) was described initially as an inert ligand competing with its membrane - bound and pro - apoptotic counterpart ( m - cd95l ) for binding to cd95 . more recent studies confirmed that the homotrimeric cl - cd95l fails to trigger cell death but more importantly , they also bring to light that this soluble ligand possesses indeed a biological function by eliciting non - apoptotic signals leading to cell migration and/or proliferation . in this regard , we and others demonstrated that the metalloprotease - processed cd95l actively participates in aggravating inflammation and auto - immunity both in mouse model and humans affected by systemic lupus erythematosus ( sle ) . overall , these findings ascribe non - apoptotic rolesto cd95 through the implementation of different signals ( i.e. , jnk , pi3k and nf-b ) . the role(s ) of each cd95-mediated non - apoptotic signal remains however to be finely characterized in pathophysiological contexts . calcium ions ( ca ) participate in cell signaling as a second messenger that relies on magnitude ( cytosolic concentration ) , temporal parameters ( i.e. , duration and frequency ) and spatial localization to trigger a variety of cellular responses . following membrane receptor stimulation , ca responses mainly occur through a biphasic signal caused by activation of ip3 receptors and the release of ca from the endoplasmic reticulum ( er ) followed by a ca entry across the plasma membrane . this store - operated ca entry ( soce ) , mediated in t - lymphocytes by ca release - activated ca ( crac ) channels , plays a pivotal role in both the replenishment of the er store and in cell signaling . recently , stim1 was identified as the er - stored ca sensor that links er depletion to activation of the plasma membrane crac channel formed by orai1 subunits , allowing ca to selectively enter the cell . following contact of a t cell with an antigen - presenting dendritic cell , stim1 and orai1 colocalize with t cell receptors ( tcrs ) in the immunological synapse and tissues in which infected or transformed cells are disseminated require the recruitment of immune cells to specifically eliminate these threats . based on our findings , we surmise that the first line of activated t lymphocytes infiltrating the transformed or infected area expresses high amount of membrane - bound cd95l to trigger cell death in affected cells but also to provide a pool of ligand that will be processed by metalloproteases therefore engendering a cl - cd95l gradient . this gradient would in turn recruit a second wave of activated t cells , which ultimately amplifies if necessary the immune response and leads to the total eradication of the target cells . of note , we established that the amount of cl - cd95l is dramatically increased in sera of sle patients and contributes to the endothelial transmigration of activated t cells that accumulate in the damaged organs . we also observed that cl - cd95l evokes a transient and localized soce ( fig . 1 ) , which is instrumental in enhancing pi3k activation , actin remodeling and thus migration of activated t cells . seeking for their cellular targets , these migrating t cells may encounter cd95-expressing bystander cells in the inflamed tissue raising the question of how is prevented in these healthy cells an accidental and irreversible activation of the apoptotic signal that will lead to their deleterious elimination . our recent findings uncovered that engagement of cd95 by the membrane - bound form of cd95l ( experimentally replaced by a home - made igcd95l that mimics the membrane - bound multi - aggregated physiologic ligand ) evokes a sustained and localized ca entry ( fig . 1 ) , which freezes the initial steps of the cd95 apoptotic signal and doing so delays its delivery . although intensity and temporal parameters of the cd95-mediated ca signal diverge between cells exposed to cl - cd95l and m - cd95l , both ligands implement soce through the co - localization of crac channel orai1 with cd95 . in addition , we observed that whereas in presence of cl - cd95l , cells undergo the formation of a caspase and fadd - independent motility - inducing signaling complex ( misc ) , m - cd95l stimulates the transient and ca - dependent recruitment of pkc - beta2 within disc that participates in delaying the multiprotein complex formation and the transduction of the apoptotic signal . figure 1 . role of the orai1-driven ca entry in t lymphocytes challenged with the different forms of cd95l . when exposed to the two forms of cd95l , cleaved and membrane - bound , activated t lymphocytes , target cells ( infected or transformed cells ) or bystander cells undergo an orai1-driven ca entry that modulates differently the cd95-mediated signaling pathway . the ca traces obtained with cells exposed to cleaved - cd95l ( 1 ) or membrane - bound cd95l ( 2 ) are depicted . accordingly , these findings support the hypothesis that a non - specific t lymphocyte / bystander cell contact would transiently engage the cd95receptor and achieve a ca - dependent time - of - decision ( tod ) preventing the transmission of the cd95-mediated apoptotic signal in the target cell . in contrast , the selective recognition of the mhc / peptide by cytotoxic t lymphocytes may provide a sustained interaction that overrides the ca - driven tod allowing the selective elimination of infected or malignant cells . first , whether cl - cd95l induces cell motility of activated t cells in general or only on specific t - cell subpopulations involved in the etiology of the autoimmune disorders is still unknown . second , how two ligands only distinguishable by their divergent stoichiometries , are able to evoke such different intracellular ca patterns and biological outcomes using the same receptor is very puzzling , and finally , the molecular ordering leading to the activation of the ca signal remain to be identified .

our recent findings indicate that cells exposed to transmembrane ( m - cd95l ) or metalloprotease - cleaved cd95l ( cl - cd95l ) undergo a localized ca2+entry that not only inhibits the initial steps of the cd95-mediated apoptotic signal but also promotes cell motility . based on recent findings published on the non - apoptotic signals induced by cd95 , we discuss how m - cd95l and cl - cd95l diverging by their stoichiometry could both contribute to the immune response by first recruiting activated t lymphocytes in the inflamed area and later by eliminating infected and transformed cells .

nonconvulsive status epilepticus ( ncse ) is a condition that may result in serious morbidity and mortality.1 ncse has been easily overlooked , because of the absence of distinct behavior in contrast to convulsive status epilepticus . however , it is important to demonstrate the etiology of ncse and to correct that immediately . at this point , diffusion - weighted mri ( dwi ) may be helpful to identify an epileptogenic zone . a 70-year - old woman with altered mentality and unresponsiveness arrived at our emergency room . she had a medical history of alzheimer s disease , hypertension and chronic obstructive pulmonary disease , but no seizure or stroke . electrocardiogram revealed atrial fibrillation and the cardiac enzymes were normal . since eight hours before arrival , she had a cluster of generalized tonic clonic seizures at an interval of about ten minutes without full recovery of consciousness for just prior two hours . the convulsive seizure subsided with intravenous lorazepam injection . we took the dwi and the eeg to identify the cause of sustained abnormal mentality . the dwi revealed an ill - defined high signal intensity in the right thalamus and subtly in the right temporal area , in which the values of apparent diffusion coefficient ( adc ) were reduced ( fig . 1a ) . in the mr angiography , there was no significant steno - occlusive lesion . these dwi findings suggested a possibility of a clustered seizure - related change or an acute ischemic stroke . eeg recording showed a right temporal ictal onset zone with persisting ictal discharges with rhythmic alpha to theta activity ( fig . after the confirmation of ictal eeg , we applied intravenous phenytoin to control the ncse . oral topiramate and intravenous levetiracetam were added to suppress remnant ictal discharges . finally , ictal discharges disappeared ( fig . follow - up dwi at the 5th day clarified a brighter lesion localized to the pulvinar ( fig . transthoracic and transesophageal echocardiographies revealed a small echogenic nodular mass ( 7.5 3.5 mm sized ) attached to the posterior mitral valve leaflet and a severely dilated left atrium . other studies including csf examination and serologic markers for autoimmune and paraneoplastic diseases were normal . we suspected a ringt posterior cerebral artery ( pca ) infarction when we took her atrial fibrillation and the infarction territory into account . as cha2ds2-vasc score was 3 , it was reasonable to start anticoagulation irrespective of the feasible mechanism of the seizure.2 altered mentality with global aphasia persisted despite the adequate treatment . we report a case of ncse associated with a unilateral and diffuse thalamic hyperintensity in the dwi , which was localized to the pulvinar area in the follow - up dwi on day 5 . in this patient , the possible mechanism of ncse might be a transient ischemic attack or a stroke in the right pca territory because of the cardiac arrhythmia she had . ncse is defined as a change in behavior and/or mental processes from baseline associated with continuous epileptiform discharges in the eeg.3 it is unclear which brain structures are engaged in the development of ncse . one study suggested that thalamic dysfunction might participate in the pathogenesis of status epilepticus.4 in line with advanced neuroimaging techniques , higher resolution mr scan with dwi is helpful to identify etiologic factor in status epilepticus . transient focal hyperintensity on dwi with corresponding decrease of the adc is an increasingly - recognized phenomenon in the peri - ictal phase of epileptic seizures or acute stroke.5,6 it has been described in experimental models and human subjects with status epilepticus.5,7 the dwi changes in status epilepticus may be associated with enhanced energy metabolism , hyperperfusion and cell swelling as a consequence of increased ictal activity.8,9 in a large series of patients with poststroke seizures , 9% had status epilepticus . changes in cerebral blood flow , hypoxia , involvement of the cerebral cortex by hemorrhages or infarcts , and the development of epileptogenic changes in cortical neurons , their connections , or their environment have been proposed as potential mechanisms underlying seizures in patients with stroke.5 we experienced a case of ncse with a right thalamic dwi hyperintensity , the mechanism of which is presumed to be a transient ischemic attack or a stroke based on the risk factor , involved terrotory , and acceptable causal relationship . serial eeg and dwi measures are helpful to delineate the time course and to infer the underlying diagnosis .

we present a 70-year - old woman with nonconvulsive status epilepticus ( ncse ) with thalamic hyperintensity on diffusion - weighted mri ( dwi ) . she had no previous history of epilepsy . her altered mentality was not normalized though we successfully controlled the ictal activity by standard treatment . initial dwi showed diffuse hyperintensity in the right thalamus , which raised the possibility of seizure - related change . at the follow - up dwi , more localized high signal intensity lesion was present in the right pulvinar area . there was no apparent cause of her ncse despite our extensive work - ups . the authors suggest that transient ischemia is a possible causative pathomechanism in this case .

the potential to respond to environmental stimuli through dynamic rearrangements of synapto - dendritic networks , as well as by regulating the generation of new neuronal and glial cells , renders the brain highly mutable . these phenomena , collectively known as neuroplasticity , are critical to promote neuronal adaptations ; its failure is now increasingly considered to be a major component in many neuropsychiatric conditions . among these , depressive spectrum disorders are a paradigmatic example of the importance of neuroplastic alterations in the adult brain . recent studies provide a comprehensive picture of the effects of stress , a major trigger factor in depression , in the ( de)regulation of neuroplasticity ; the latter is , in turn , related to the emergence of physiological and behavioral alterations comprised in the symptomatic profile of depressive disorders . although these molecular and physiological mechanisms regulating neuroplastic processes are relevant for the onset of depressive symptoms , they have also been implicated in the action of antidepressants ( ads ) . so far , and although there is still much to be elucidated , it is becoming evident that the triad stress - neuroplasticity - depression constitutes fertile ground for new findings . although different forms of neuroplasticity are affected in depression , a debate endures concerning the exact neurobiological significance of postnatal hippocampal cell genesis , both for the development of depressive pathology and for the therapeutic action of ads . from the bulk of evidence gathered so far , it is increasingly appreciated that alterations in cell genesis are involved in the pathology and treatment of depression ; however , there are several conflicting reports regarding its relevance . first , there is a necessary ' difficulty to approach this question in humans suffering from depression ; postmortem studies in humans and animal models of depression have , nevertheless , provided important insights . second , it seems to exist a major prevalence of studies focusing on the functional implications of neurogenesis , in disregard of gliogenesis , a parallel cell - genesis process likely to be of relevance in this context . lastly , because these events are highly dynamic , the adoption of different experimental models and time frames when analyzing the participation of cell genesis in the pathology and treatment of depression is critical to have a complete perspective of the topic . on account of these experimental dissimilarities , an integrative , and careful , interpretation of data published in the last years suppression of hippocampal cell proliferation in naive animals through irradiation , pharmacological approaches or through the use of transgenic models of cytogenesis ablation has been shown to be associated with the development of deficits in different behavioral dimensions commonly affected in depression . strikingly , most of the studies in which analyses were performed shortly after cytogenesis ablation did not reveal significant deficits in most behavioral domains normally assessed in the characterization of animal models of depression ( figure 1 ) . however , recent reports in which abrogation of cytogenesis is maintained for long periods ( over 4 weeks ) or in which the behavioral analysis was conducted only 4 weeks after the cessation of cytogenesis suppression , reported multidimensional behavioral deficits that emerged only weeks after the antiproliferative insult . importantly , the specific late manifestation of depressive - like behavior and cognitive disabilities in animals in which cytogenesis had been suppressed illustrates how manipulating lengthy neuroplastic phenomena is associated with the non - immediate development of behavioral impairments , which are only fully manifested once newborn cells are expected to be incorporated in local neuroglial circuits . this view has been recently supported by the demonstration that the specific inhibition of 4-week old new hippocampal neurons causes deficits in memory retrieval in mice ; remarkably , inhibiting the activity of either younger or less - plastic older neurons does not produce effects in this cognitive domain . an exception must be made in respect to anxiety behavior , because disruption of hippocampal cytogenesis is associated to the immediate development of heightened anxiety , which is commonly comorbid in depressed patients . in fact , it has been demonstrated that immature newborn neurons display a major role in anxiety behavior control . in contrast with the slow reconfiguration of neuroglial networks promoted by the addition of new cells in the adult brain , are the rapid synaptic and dendritic morphological changes . these underlie the short - term impacts on distinct emotional and cognitive processes observed in the onset of depressive symptoms . indeed , defects on neuronal cytoarchitecture have been documented in postmortem analysis of brain tissue from depressive patients , which seem to be ameliorated by chronic ad treatment . these structural defects include cortico - limbic dendritic atrophy in depressed subjects , accompanied by abnormalities in glial cell structure . importantly , in animal models of depression , these changes are associated with hallmarks of depressive behavior , such as anhedonic behavior , behavioral despair and cognitive disabilities . besides this common participation of slow cytogenesis processes and rapid dendritic rearrangements in the pathology of depressive spectrum disorders , these two neuroplastic phenomena , with very different temporal dynamics , constitute the substrate by which ads ( partially ) exert their therapeutic actions . thus , the reestablishment of normal neuroglial networks seems to be achieved in a biphasic manner ( figure 1 ) : in a short - term context , ad actions rely on rapid modulatory effects upon genes involved in the restructuring of the synaptic network ; later on , the generation of new fully matured neuronal and glial cells will have an impact on the long - term remission from emotional and cognitive disabilities manifested during a depressive episode . in fact , despite triggering an immediate pro - proliferative response , this early effect corresponds only to the onset of a slow neuroadaptation whose neurobiological importance can only be fully appreciated later on , once new cells attain complete maturation and functionality , and are integrated in the local neurocircuitry . taken together , and because mammalian neurogenesis is described to take 46 weeks , the overall outcome of ad 's therapeutic action upon neuroplasticity may only be entirely manifested after this period . remarkably , this period correlates with the time latency that typically prescribed ads take to fully manifest their action in depressive patients . although the neuroplastic alterations occurring during the onset , treatment and remission from depression are being increasingly characterized , comprehension of the processes ( namely genetic and epigenetic programs ) that orchestrate these alterations is still limited . future research focusing on these processes should also be extended to the still underexplored glioplastic component of this disorder . furthermore , local neuroplastic adaptations are likely to occur in articulation with systemic neuroendocrine and immunological alterations , which are still to be integrated in the complex puzzle of mechanisms implicated in depression .

brain neuroplasticity is increasingly considered to be an important component of both the pathology and treatment of depressive spectrum disorders . recent studies shed light on the relevance of hippocampal cell genesis and cortico - limbic dendritic plasticity for the development and remission from depressive - like behavior . however , the neurobiological significance of neuroplastic phenomena in this context is still controversial . here we summarize recent developments in this topic and propose an integrative interpretation of data gathered so far .

qt was received as gifted by torrent pharmaceuticals pvt . ltd . , polyox n 10 , polyox n 80 , polyox n 750 and polyox n 205 were gifted by dow chemicals pvt preliminary trials were carried out for selection of appropriate grades of polyox from different grades mentioned above . concentration of polymer and plasticizers were optimized by central composite design . in this design 2 factors the amount of polyox n750 ( x1 ) and peg 400 ( x2 ) were selected as independent variables . the tensile strength , folding endurance , % drug released at 10 min ( y10 ) and disintegration time were selected as dependent variables . preliminary trials were carried out for selection of appropriate grades of polyox from different grades mentioned above . concentration of polymer and plasticizers were optimized by central composite design . in this design 2 factors the amount of polyox n750 ( x1 ) and peg 400 ( x2 ) were selected as independent variables . the tensile strength , folding endurance , % drug released at 10 min ( y10 ) and disintegration time were selected as dependent variables . different grades of polyox were used for film formation like n10 , n80 , n750 and n205 . initially , preliminary trials were carried out to select ideal grade of polymer used for film formation and then used for optimization of other parameters of film . different mentioned grades were tried between 1 - 4% concentrations . from the result , it was observed that by increasing the concentration of polymer up to 2% , thickness and strength of film was improved . but by increasing concentration more than 2% , folding endurance of film was improved but increase in disintegration time more than limit . thus , 2% concentration of polymer was used for further optimization of plasticiser and sweeteners . plasticizer tried were glycerin , peg 400 , and propylene glycol in 15% concentration each . glycerin and propylene glycol showed more sticky film which was unable to detach from surface . polyox n750 was selected for further optimization of film property due to its excellent film forming nature with optimum viscosity for rapid dissolving film . comparison of % elongation of design batches comparison of film thickness of design batches optimization of concentration of polyox n750 and % of peg as plasticisers was optimized systematically using with central composite design ( ccd ) . it was observed that disintegration time of all the batches ranges between 6 - 30 sec , tensile strength between 0.106 0.760 kg / cm , folding endurance between 10 - 89 and drug release profile with in 10 min 80%-99% . all the batches showed more than 80% drug release profile in initial 10 min . from all evaluation parameter , r10 batch with 2% polyox 750 and 15% of peg 400 was considered as promising batch with all satisfactory parameters . for validation of optimum formulation , check point r14 was prepared and evaluated for all the response . observed value was found close to the predicted value , which indicated good correlation of results . optimized film was analyzed by dsc spectra and compared with dsc spectra of pure drug . spectra showed presence of drug peak at same energy of enthalpy as that of pure qt . formulation was stored at 65% relative humidity and 37c temperature in the humidity oven . after 3 months film some predictable changes were observed in film property like decrease in disintegration time and more softness of film due to higher amount of moisture . film texture was evaluated after 3 months of storage which indicates increase in stickiness of film at higher relative humidity . the results of central composite design revealed that the entire factor significantly influences the dependent variable . thus , it can be concluded that by adopting a systematic formulation approaches , an optimum point can be reached in the shortest time with minimum effort . thus , developed film can be useful for curing the emergency condition like schizophrenia which gives rapid relief within short time . stability study data shows need of proper storage condition for film to protect from effect of moisture .

quick dissolving film prepared by various grades of polyox like polyox n10 , n80 , n750 and n205 . polyox having excellent film forming capacity with rapid hydration power which leads to rapid disintegration of film upon contact with saliva . film is optimized for concentration of polymer and plasticizer using ccd design . the tensile strength , folding endurance , % drug released at 10 min ( y10 ) and disintegration time were selected as dependent variables . the data revealed that 2% of polyox n 750 and 15% of peg 400 showed excellent film forming property with rapid drug release profile .

although vulvar varices complicate approximately 15% of all pregnancies and rarely cause bleeding during pregnancy and delivery , a cervical varix , which is rare , can cause massive obstetric hemorrhage . a 40-year - old japanese woman ( gravida 2 , para 1 ) presented at our hospital at 18 weeks gestation for prenatal care . at 22 weeks gestation , transvaginal ultrasonography revealed a low lying placenta ; the placenta was located on the lower side of the posterior uterine wall , with its lower edge near the internal cervical os . an ultrasound performed at 34 weeks revealed that the cervical tissue had been replaced with a dilated venous plexus with abundant blood flow ( fig . a vaginal delivery was extremely likely to cause catastrophic bleeding ; therefore , we performed a planned cesarean section at 37 weeks , yielding a healthy female infant ( 3,345 g ; apgar score 8/10 ( 1/5 min ) ) . after placental separation , inspection of the cervical lumen and the lower segment lumen revealed dilated blood vessels protruding into the lumen . some vessels ruptured with resultant active bleeding , which required several hemostatic z - sutures ( fig . the estimated blood loss was 3,610 ml ; 4 units of packed red blood cells were transfused . we describe a pregnant woman with cervical varices in whom a cesarean section was performed . even with the cesarean section , active bleeding ensued , which required a blood transfusion and hemostatic sutures . although the etiology of cervical varices during pregnancy is unclear , a lower placental location , a placenta previa , and a low - lying placenta are considered to be culprits . a lower placental location increases the blood flow to the cervix , leading to the development of cervical venous dilatation , and eventually cervical varices . hormonal dynamic changes , increased abdominal pressure , and the enlarged uterus that is a result of pregnancy will compress the inferior vena cava and pelvic veins , thus also accelerating varix formation . although this is rare occurrence , maternal exposure to diethylstilbestrol ( des ) in utero causes vascular malformations of pelvic organs in their daughters , which has also been considered to be causative for this disorder.1,2 while vulvar varices during pregnancy are frequently observed and they rarely cause clinically significant bleeding,9 cervical varices can cause massive obstetric hemorrhage . a pubmed search yielded only 10 case reports describing cervical varices.18 in seven of 11 cases ( including our case ) , prenatal bleeding occurred and required termination of pregnancy ; in five cases abnormal placental location was recognized ( table 1 ) . interestingly , two of 10 previously reported cases were from japan,5,7 and the present case was also a japanese woman . in our case , grey - scale with color doppler ultrasound detected this abnormality . in the last decade , transvaginal color doppler ultrasound has been employed in japan and it is becoming a general - purpose imaging modality in obstetrics . this may be the reason why three out of 11 cases have been reported from japan . in addition , without the employment of color doppler , the disorder may remain unrecognized and the cervical variceal rupture could be an undiagnosed factor in cases of massive perinatal hemorrhage . thus , the incidence of cervical varicosities might be higher than the expected level calculated from earlier case reports . due to des exposure , the placement of a cervical cerclage was performed in two cases.1,2 although bleeding did not occur during these pregnancies , hemorrhagic risk from a cerclage suture does exist . the cervical varices in the present case ruptured with significant hemorrhage , despite the cesarean delivery . we extended the uterine incision to the cervix and repaired the varices under direct vision . as a consequence , we assume that the cervical varix can be identified by a trans - vaginal ultrasound , with the awareness of its possible coexistence with abnormal placentation ; thus , a management strategy can be developed to prevent postpartum hemorrhage .

we present a case of cervical varix and low - lying placenta . a cesarean section was performed because of the risk of bleeding with vaginal delivery ; hemostasis was achieved using z sutures at the bleeding points . after delivery , the cervical varix decreased dramatically in size . it is important to recognize the clinical features and available treatments for cervical varix .

arthroscopic fixation of tibial spine fracture without damage to the growth plate is very important in patients with open physis . the present article describes a simple and effective technique being used for the first time to treat this condition . a 16-year - old boy sustained avulsion fractures of tibial spine while playing . he was treated arthroscopically with excellent result . arthroscopic fixation of tibial spine fracture in patients with open physis with two cannulated screws perpendicular to each other is a very simple technique which provides strong construct , and allows early mobilization without risk of damage to the growth plate . avulsion fractures of tibial spine leading to discontinuity of anterior cruciate ligament fibers are uncommon but well described in literature in both pediatric and adult population . these injuries are commonly seen in children aged between 8 - 14 years and are usually sports related injuries . in adults , these injuries are commonly related to high energy trauma usually road traffic accidents [ 1 , 2 ] and have high incidence of associated injuries . the cause of increased incidence amongst children is hypothesized as being secondary to relative weakness of incompletely ossified tibial eminence compared to native acl fibres . meyers and mckeever classified these injuries in 1959 as non - displaced ( type i ) , partially displaced or hinged ( type ii ) and completely displaced ( type iii ) fractures . this classification was modified by zaricznyj to include comminuted avulsion fractures ( type iv ) . the patient had severe pain and swelling and was unable to bear weight in the affected knee . x - rays revealed displaced tibial spine fracture [ fig . 1 , 2 ] , and the young boy was treated with cast . however , the patient was uncomfortable with the cast and came to our institute . it was displaced fracture . note the heterogenous palpable mass about 35 28 30 mm in posterolateral aspect of the left lateral malleolus . notice the incision scar of foot shortening operation , the patient underwent at adolescent age . both the portals should be standard or slightly low as higher portal may put the scope above the fractured fragment and one may not be able to see the fracture clearly . it also involved significant portion of medial tibial platue [ fig . 4 , 5 ] . fracture was reduced with help of acl zig and under c- arm guidance provisionally fixed with guide wire from superolateral portal taking care not to cross physis , as it was a large fragment it was not sitting completely from medial side so another wire was used from superomedial portal to fix medial side of fragment perpendicular to lateral wire , again without crossing the physis . two 3.5 mm partially threaded cannulated screws ( zimmer ) were directly used 45 mm from lateral side and 35 mm from medial side [ fig . stability of the fragment was assessed with a probe and was found to be stable [ fig . 6 ] . post - op x - rays showed proper postion of both the screws [ fig . 8 , knee range of motion was allowed from 0 - 90 for 2 weeks than 0 - 120 for next 2 weeks . after one month , he was allowed to walk without knee brace . at 6 months , patients was allowed to run . mri clearly shows the heterogeneous large soft tissue mass lesion on the posterior aspect of left ankle . appearance of the ankle after local recurrence , which lead to dehiscence of surgical area . arthroscopic fixation of displaced tibial spine fracture is a standard procedure [ 8 , 9 ] . commonly , tibial spine is fixed either with cannulated screws or strong non absorbable sutures . in patients with open physis , injury to physis is a serious concern as it may lead to various growth disturbances [ 10 , 11 ] . in patients with open physis , suture fixation is considered safer than cannulated screw fixation but even suture fixation requires drilling through the physis which may cause damage to the physis , incidence of growth disturbances have been reported even with transphyseal suture technique which lead to development of transepiphyseal suture technique . both transphyseal and transepiphyseal suture techniques are quite complex and require more time as compared to screw fixation technique . biomechanical studies on strength of various fixation techniques have produced mixed results [ 5 , 6 , 7 ] . in porcine model , egger & colleagues demonstrated that fiber wire ( arthrex ) suture were superior to ethibond suture ( ethicon ) and 1 or 2 ante grade cannulated screws in single and cyclical loading protocol . in bovine model , mahar and colleagues found no difference between ethibond suture , bioabsorbable nails , single bioabsorbable screw or single metal screw in an ultimate failure test . in cyclical loading test , tsucada and coworkers found a statistically significant difference in displacement favoring cannulated screw over ethibond suture . in cases of comminuted fractures suture technique is preferred as screws are unlikely to provide adequate fixation [ 5 , 6 , 7 ] . in this case as this was large fragment , we used two cannulated screws ( zimmer ) perpendicular to each other holding only in epiphysis for fixation . thus avoiding any risk of physeal damage . these self tapping screws are directly used after provisional fixation with guidewire as no drilling is required . we started full weight bearing mobilization in post knee brace from second post op day . for first two weeks knee rom from 0 - 90 was allowed which was increased to 120 for next two weeks . thus , arthroscopic fixation with two cannulated screws perpendicular to each other is a very simple technique providing a strong construct and thus allows early mobilization . arthroscopic fixation of tibial spine fracture in patients with open physis with two cannulated screws perpendicular to each other is a very simple technique that provides a strong construct and allows early mobilization without any risk of damage to growth plate . arthroscopic fixation of tibial spine fracture in patients with open physis with two cannulated screws perpendicular to each other is very strong construct , allowing early mobilization without risk of damage to growth plate .

introduction : arthroscopic fixation of tibial spine fracture without damage to the growth plate is very important in patients with open physis . the present article describes a simple and effective technique being used for the first time to treat this condition.case report : a 16-year - old boy sustained avulsion fractures of tibial spine while playing . he was treated arthroscopically with excellent result.conclusion:arthroscopic fixation of tibial spine fracture in patients with open physis with two cannulated screws perpendicular to each other is a very simple technique which provides strong construct , and allows early mobilization without risk of damage to the growth plate .

schizophrenia , the most common psychotic disorder accounting for approximately 20% of all mental illnesses , is characterised by thought disorders , delusions and hallucinations . drugs used for the treatment of schizophrenia include neuroleptic drugs , which are dopamine receptor blockers . neuroleptic malignant syndrome ( nms ) is a relatively rare but potentially fatal complication of neuroleptic drugs . nms is caused by dopamine depletion or dopamine receptor blockade , which results in abnormal central thermoregulation and muscle rigidity . we describe the anaesthetic management of a case of catatonic schizophrenia with past history of nms who presented in emergency with active bleeding per rectum and haemoglobin of 3 gm% . a 44-year - old male with history of bleeding per rectum since the previous night was admitted to the surgical ward with stable vital parameters . he was diagnosed with catatonic schizophrenic 6 years ago and had a history of nms following start of treatment with antipsychotic drugs , which had been managed symptomatically then . presently , he was taking tablet ziprasidone 20 mg tds ( atypical antipsychotic and a serotonin dopamine blocker ) . he was agitated , uncooperative and violent when approached by any personnel , making all examination impossible . on restraining , it was possible to draw a venous blood sample for haemoglobin estimation and blood grouping , cross - matching . the psychiatrist was unable to increase the dose of antipsychotic medications or add any newer medication due to past history of nms . however , due to critically low haemoglobin , he had to be taken up for surgery on an emergency basis to determine the aetiology of the active bleeding per rectum and further management . after confirming nil by mouth status , informed written asa grade iiie consent was taken from his relatives , with cross - matched blood ready . despite his agitation , the patient was coaxed into the operation theatre and made to lie on the operating table . he was unwilling for any procedure , including the attachment of monitors , and insisted on lying prone . anaesthesia was induced in that position , with a mixture of oxygen nitrous oxide sevoflurane , with a hand on pulse . following induction , he was made supine and monitors were attached for pulse rate , blood pressure , electrocardiogram , oxygen saturation and end tidal carbon dioxide ( etco2 ) . pentazocine 30 mg , midazolam 2.5 mg and ondansetron 8 mg were given intravenously ( iv ) . nitrous oxide - sevoflurane mixture , spontaneous with intermittent assisted ventilation , using magill 's circuit . on per rectal examination oxygen was supplied with hudson 's mask , when he woke up to an agitated state and pulled out one iv line and had to be sedated with intravenous diazepam in titrated doses till a total of 10 mg diazepam , to gradually calm him down . administering anaesthesia to schizophrenics poses a great challenge because of impaired biological response to stress and increased risk for medical illnesses involving the cardiovascular and respiratory system , and diabetes mellitus . preoperatively , anaesthetists may be confronted with difficulties in patient communication similar to that experienced by us . concomitant medical conditions associated with chronic schizophrenics and interaction between antipsychotics and anaesthetics have to be kept in mind , as drugs used for the treatment of schizophrenia include neuroleptics like dopamine receptor blockers . an unusual , lethal side - effect of these antipsychotics is nms , characterised by an acute increase in body temperature , muscle rigidity and autonomic nervous system instability . nms is supposedly caused by dopamine depletion or dopamine receptor blockade in the hypothalamus , nigrostriatal and spinal pathways . the dopamine depletion theory is supported by a case reported by henderson and wooten 30 years ago about a patient who had never been on neuroleptics , who developed nms when l - dopa / carbidopa were withdrawn abruptly . this has also been proven by the fact that dopamine agonists like bromocriptine and amantidine have shown efficacy in nms treatment . nms was first described by delay and colleagues in 1960 after the introduction of neuroleptics into medical practice . these two entities have a common pathophysiology , and the possibility of patients with a history of nms developing mh should be considered , especially when administering general anaesthesia . we employed the technique of inhalational induction to overcome the patient 's lack of cooperation . studies have shown that isoflurane or sevoflurane is not associated with hypotension , arrhythmias or seizures , and is safe . patients on antipsychotics often have increased heart rate and risk of hypotension due to increasing age and individual sensitivity to anaesthetics . keeping this in mind , we adjusted the anaesthetic dose judiciously according to his response . adverse responses during anaesthesia to be borne in mind include arrhythmias , hypotension , hyperpyrexia , prolonged narcosis , coma , postoperative paralytic ileus and postoperative confusion . these patients have higher pain thresholds due to hypofunctioning n - methyl d - aspartate ( nmda ) receptors , with abnormal immune system , pituitary - adrenal - autonomic dysfunction and risk of water intoxication . postoperatively , pain is an important risk factor for postoperative confusion ; hence , controlling inflammatory cytokines , norepinephrine and cortisol levels during and after anaesthesia is important . chute et al . speculated that the etiology of this sudden death may be due to an agitated mental state resulting in imbalances between sympathetic and parasympathetic discharge . hence , it is imperative to avoid postoperative confusion and agitation with judicious use of benzodiazepines . chronic schizophrenics are at increased risk for developing various perioperative complications ; hence , prevention becomes important for the clinician . neuroleptics are effective medications with widespread use in medicine and psychiatry , but with associations with nms in about 0.2% of the patients . we have presented the successful anaesthetic management of a chronic schizophrenic with history of nms in emergency .

administering anaesthesia to a patient with chronic schizophrenia is a challenge due to the increased risk of various perioperative complications . neuroleptic agents are highly effective drugs used for the treatment of psychiatric disorders , but are rarely associated with neuroleptic malignant syndrome ( nms ) . here , we describe the successful anaesthetic management of a patient of chronic schizophrenia with past history of nms who presented in emergency with active bleeding per rectum and haemoglobin of 3 gm% .

injuries range from mild respiratory complaints , phytodermatitis , irritant contact dermatitis , and allergic contact dermatitis to toxin - induced injuries and mechanical damage . tulipalin a induced phytotoxicity , also tulip fingers and alstroemeria dermatitis , is a common occupational allergy in floral workers exposed to tulip and alstroemeria cultivars . tulipalin a ( a - methylene - g - butyrolactone ) and its parent compound tuliposide a ( a - methylene - g - hydroxybutyric acid ) are concentrated in the outer layers of the plant bulbs and the pistils . in the plant , they are protective antibiotics exerting a fungicidal effect in flower bulbs . they were assigned to category b : solid - based indication for contact allergenic effects , because there is evidence of contact allergenic effects in animals and humans as well as induction of cross reactions in humans . they can also be considered skin sensitizers because under the globally harmonized system for classification and labeling of chemicals ( ghs ) , a human skin sensitizer is a substance that will induce an allergic response following skin contact . tulip fingers and alstroemeria dermatitis , the latter in particular due to the popularity of the inexpensive alstroemeria in lower cost floral arrangements , should be considered as a differential diagnosis in cases of unresolved dermatitis in floral workers . in this article we highlight the importance of comprehensive patient histories in a case of tulipalin a induced phytotoxicity misdiagnosed as a tinea manuum infection in an individual with suspected occupational fungal exposure and a review of the relevant scientific literature necessary to evaluate risk factors for the disease . an immunocompetent 30-year - old female , was referred for a medical examination to assess persistent unresolved tinea manuum , possibly related to occupational fungal exposure . the patient complained of little bumps on the dorsal surface of her right index finger around the distal interphalangeal joint . the bumps erupted across the dorsal surface of her right hand between digits # 1 and # 2 , progressed up to her wrists , popped , dried , and flaked off the residual skin . all physical examination outcomes were normal with the exception of lichenification and peeling of multiple fingers , including the palmar and dorsal surface , ulcers on several fingertips of each hand , pain , and discoloration of hands . apart from the ongoing issue with her hands , the patient 's medical history was unremarkable . the patient was initially diagnosed with tinea manis and prescribed a lengthy course of prescription antifungal treatment in 2010 after a nail culture indicated yeast , later identified as cryptococcus . tinea manis is unlikely , given the absence of the characteristic ring - like pattern . the presence of a cryptococcus species was likely a skin contaminant as it is unlikely that she would have an infection since the vast majority of cryptococcal infections occur in immunocompromised individuals . the lesions seem to worsen over time , and then get better . over time , the skin on her finger pads has thinned greatly . she has resorted to wearing a band - aid over her right index finger tip because it is continuously tender and depigmented . at night , the dorsal surfaces of her fingers seem to itch a great deal with no relief . the patient was instructed not to wear gloves at work because the gloves reportedly trap the patient mentioned that she works a great deal with the ornamental plant and flower alstroemeria , which has a moderate literature database detailing cases of persistent allergic contact dermatitis in florists . as previously noted , the causative allergen is known as tulipalin a ( -methylene--butyrolactone ) . the glycoside and its parent compound are named for the tulip bulbs from which they were originally derived . there is also a moderate literature database describing tulip fingers , an allergic contact dermatitis found in tulip workers primarily in the netherlands . interestingly , areas of depigmentation often follow the characteristic lesions that are similar to the initial bumps that this patient reported at the first visit . the patient was instructed to wear nitrile gloves at work , as her condition is not a fungal problem . she should not wear vinyl gloves , as the causative allergen crosses every type of common gloves except nitrile . she was referred to a dermatologist who may elect to take a skin biopsy and/or perform patch testing . diagnosis of tulipalin a induced phytotoxicity requires patch testing with the routine true test , as well as a number of plant extracts including : sesquiterpene lactone mix 0.1% , parthenolide 0.1% , 2,6-ditert - butyl - p - cresol 2% , and at least one preparation of tulipalin a. first described as tulip fingers in the european tulip industry , tulipalin a induced phytotoxicity results in severe dermatitis . similar phytotoxicity , termed alstroemeria dermatitis , has been described in florists who use alstroemeria . it is a common occupational complaint in floral workers who handle alstoemeria and tulip cultivars . the toxin is most concentrated in the flower bulbs and stems , although smaller amounts may be found in other parts of the plant . manifestations of phototoxicity include pruritus and edema in the fingers and along the palmar surface of the hand . paronychia is commonly seen along with nail splitting and ulceration of the nail bed in more severe cases . typically , a sensitized individual will develop acute symptoms 12 - 24 h after any subsequent exposures . patch testing is used to demonstrate contact with the allergenic tulipaside a. given the occupational history of this patient , a diagnosis of tulipalin a phytotoxicity is far more appropriate than tinea manis or cryptococcus . follow - up with a dermatologist for skin biopsy and/or patch testing with true test is recommended .

tulipalin a induced phytotoxicity is a persistent allergic contact dermatitides documented in floral workers exposed to alstroemeria and its cultivars.[1 ] the causative allergen is tulipalin a , a toxic glycoside named for the tulip bulbs from which it was first isolated.[2 ] the condition is characterized by fissured acropulpitis , often accompanied by hyperpigmentation , onychorrhexis , and paronychia . more of the volar surface may be affected in sensitized florists . dermatitis and paronychia are extremely common conditions and diagnostic errors may occur . a thorough patient history , in conjunction with confirmatory patch testing with a bulb sliver and tuliposide a exposure , can prevent misdiagnosis . we report a case of tulipalin a induced phytotoxicity misdiagnosed as an unresolved tinea manuum infection in a patient evaluated for occupational exposure .

a chondromyxoid fibroma ( cmf ) is an uncommon benign cartilaginous tumor of bone that makes up less than 1% of all bone tumors and furthermore , is the least common of the cartilage tumors ( 1 ) . this tumor classically occurs in the metaphyseal region of the long bones around the knees , but it also occurs in other long bones , short bones of the hands and feet , pelvis , ribs , scapula , and spinal column ( 2 - 5 ) . this metaphyseal tumor in the tubular bones may extend into the adjacent epiphysis or into the diaphysis or both . a primary diaphyseal or epiphyseal origin for this tumor is rare ( 2 - 7 ) . we present here a case of a cmf that occurred in the epiphysis of the proximal tibia with an open growth plate . a 15-year - old boy presented with generally increasing pain in his left knee during over the previous month ; he had no history of trauma . upon physical examination , the roentgenograms showed a 2.11.42.4-cm - sized , well defined , eccentric , osteolytic lesion with surrounding sclerosis in the proximal tibial epiphysis ( fig . the lesion slightly abutted the growth plate , which was still unfused . upon magnetic resonance ( mr ) imaging , the lesion showed low signal intensity on the t1-weighted image , high signal intensity with a hypointense peripheral rim , and suspicious matrix calcifications on the proton - density and fat - suppressed t2-weighted images . after intravenous administration of gadolinium diethylenetriamine pentaacetic acid ( gd - dtpa ) , the lesion enhanced heterogeneously with non - enhancing , hypointense foci ( fig . the histologic examination of the excised tissue showed macrolobules with hypercellularity at the periphery of the lobules , and low cellular myxoid stroma at the center of the lobules ( fig . 1g - i ) . chicken wire or granular calcifications were present , as well as woven bone formation . on the follow - up after three years a cmf is a relatively rare , benign cartilaginous bone tumor that was first described in 1948 by jaffe and lichtenstein ( 8) . it is most common in the second and third decades of life , with a reported age range from 4 to 87 years . the symptoms include slowly progressive pain , tenderness , swelling , and restriction of motion are observed ( 3 , 5 ) . although cmf is typically located in a metaphyseal location , it may also extend to the epiphysis or diaphysis . a primary epiphyseal location is very rare ; we were only able to identify four cmf cases occurred in the epiphysis of a long bone in the english language medical literature ( 4 - 7 ) . based on the roentgenograms , three of four cases were eccentric , osteolytic lesions with a sclerotic rim , whereas one of the tumors was expansile ( 4 , 6 , 7 ) . the mr imaging appearance of a cmf has been described in a few reports ( 9 - 11 ) . on t2-weighted spin echo images , it has been described as having multilobular patterns and high signal intensity , and these features are similar to the characteristics found in hyaline cartilage bone tumors ( 9 - 11 ) . however , for cmfs , the high signal intensity on the t2-weighted images is probably pathologically related to the abundant myxoid stroma maintained by thin fibrous tissue in a multilobular pattern ; this tumor may show hyaline cartilage differentiation ( 4 , 5 , 9 - 11 ) . the mr imaging appearance of cmf can be very heterogeneous ; and , its polymorphologic appearance depends on the different degrees of cellularity and the presence of varying amounts of myxoid and fibrous tissue ( 10 ) . when cmf involves the epiphysis in adolescents , the lesion may be confused with chondroblastoma or enchondroma ( 6 ) . chondroblastoma usually originates in the epiphysis or apophysis of a long tubular bone and as a result , may traverse the growth plate and involve the metaphysis . the lesion is seen with low signal intensity on the t1-weighted spin echo images and variable ( and often low ) signal intensity on the t2-weighted images ( 12 ) . calcification in cmfs has been reported to occur in 2% and 16% cases seen on roentgenograms , but much less than those of chondroblastoma ( 30 - 50% ) ( 2 - 4 , 12 ) . enchondroma generally appear as lucent , well demarcated round or oval lesions with typical cartilaginous matrix mineralization , and occasionally , expansile with thinned cortical margins . in addition , the lesion shows characteristic high signal intensity foci of the hyaline cartilage on t2-weighted mr images . in very rare cases , the tumor occurs in an epiphysis where the lesion tends to involve almost the entire epiphysis in contrast to cmf ( 2 , 6 , 11 ) . giant cell tumor ( gct ) is an epiphyseal lesion without calcification in a mature skeleton , and is seldom encountered in a patient younger than age 20 years or prior to epiphyseal closure ( 2 ) . the tumor tends to invade and destroy the adjacent cortex to a greater degree as compared to a cmf . as a benign lesion , a cmf is treated by curettage or excision . with curettage , a 13% to 25% recurrence rate has been reported . the recurrence rate has been reduced with the use of allograft bone or polymethylmethacrylate ( 3 , 7 ) . in the present case , there was no evidence of recurrence at three years post - operatively . histologically , a cmf consists of lobulated areas of myxomatous tissue separated by fibrocellular bands with little tendency for chondroid formation . many histological variations of this pattern occur , such that the lesion may be confused with other tumors or it may mimic a malignancy such as chondrosarcoma , fibromyxosarcoma or osteosarcoma ( 4 , 5 ) . suspected calcification within the tumor was also observed on the mr images as well as microscopically . the additional computed tomography ( ct ) was not performed to confirm the calcification . in our case , radiographic findings were consistent with the known imaging findings of epiphyseal cmfs and the mr imaging appearance was useful to distinguish the cmf from bone tumors of non - cartilage origin . however , an epiphyseal cmf is unusual and other bone tumors originating in the cartilage should be considered in the differential diagnoses . in summary , we report a case of a cmf that occurred in the epiphysis of the proximal tibia . to our knowledge , this is the first report of mr imaging of an epiphyseal cmf in the english literature .

chondromyxoid fibroma is an uncommon benign cartilaginous tumor of the bone . it occurs most frequently in the metaphysis of long tubular bones , and an epiphyseal location is exceedingly rare . we present here an unusual case of a chondromyxoid fibroma that occurred in the epiphysis of the proximal tibia with an open growth plate . mr imaging findings of this tumor , which has , to the best of our knowledge , never been described in an epiphyseal location , makes the present case unique .

rectal foreign bodies can present a difficult management dilemma , because the types encountered vary widely and they can cause not only local trauma to surrounding tissues but also obstruction or perforation that requires surgical treatment . for effective removal , it is important to precisely determine the size , shape , and material of the foreign body by patient interview and imaging diagnosis , and then to evaluate the possibility of rectal perforation and peritonitis [ 1 , 2 ] . in cases without perforation , transanal removal of a rectal foreign body is generally attempted as a first - line procedure in the emergency unit , with a reported success rate of approximately 75% . however , when the size is too large to grasp , transanal removal is difficult . we here report a patient with a large rectal foreign body that was successfully removed with manual compression from the abdominal wall , with assistance provided by endoscopic and x - ray fluoroscopic observation . a 50-year - old male came to the emergency room of our hospital and stated that a hand - made silicon rod had accidentally passed into his rectum 12 h prior to presentation . his vital signs were stable , and a physical examination showed that his abdomen was soft and without tenderness . there was a palpable elastic , hard mass in the lower abdomen and no signs of peritonitis . a digital rectal examination by palpation located the end of the foreign body in the deep rectum . an attempt to manually remove it in a transanal manner failed due to its shape , large size , and deep position . laboratory data were essentially normal , with the exception of slightly elevated c - reactive protein ( 1.76 mg / dl ) . plain abdominal x - ray imaging showed a foreign body in the pelvic area and absence of free air ( fig 1a ) , while computed tomography ( ct ) revealed an 18 4 cm foreign body with a cylindrical shape in the rectum ( fig 1b d ) . we decided to attempt removal in a transanal manner under endoscopic and x - ray fluoroscopic observation . following intravenous administration of 15 mg of pentazocine , a scope ( pcf - q260azi ; olympus , japan ) was inserted transanally with the patient in a left lateral decubitus position to directly visualize the foreign body . the lateral pelvic view obtained by x - ray fluoroscopy showed the foreign body in the rectosigmoid position . we attempted removal with endoscopic instruments , including a snare , biopsy forceps , grasping forceps , and net , though that failed because of the round shape and large diameter . when manually compressed from the abdominal wall under endoscopic and x - ray fluoroscopic observation , we noticed that the axis of the foreign body changed ( fig 2 ) . thus , we were able to guide it using manual abdominal compression with endoscopic and x - ray fluoroscopic assistance . once the object moved to the lower rectum , it could be removed transanally by manual extraction . after removal , we found that the foreign body was constructed of a silicon material and made by the patient himself , with a size of 18 4 cm ( fig 3 ) . sigmoidoscopy following extraction showed mild erosion in the rectal mucosa with no findings of bleeding or perforation . although not as common as upper gastrointestinal foreign bodies , the incidence has been suggested to be increasing , especially in urban areas [ 3 , 4 ] . in a review of 196 cases of rectal foreign bodies in 193 patients , it was reported that the mean age at presentation was 44.1 years ( range 1979 ) with a significantly higher proportion of males ( ratio approx . . numerous types of objects have been described in the literature , with the most common being household objects ( 42.2% ) , such as a bottle or glasses , while others include sex toys , personal care , sports equipment , and food . the majority of rectal foreign bodies reported in adults have been purposefully inserted for self - gratification . as they are likely to be smooth , round , cylindrical , or egg shaped for easy insertion , it is difficult to grasp and remove them in a transanal manner using standard endoscopic devices . because of the wide variety of objects and variation in trauma to local tissues of the rectum and distal colon , a systematic approach to the diagnosis and management of rectal foreign bodies is needed [ 1 , 2 ] . a physical examination and radiological imaging , such as plain x - ray and ct , are important to evaluate the general condition of the patient and to determine a treatment plan . in particular , ct can provide a great deal of information , such as the properties ( shape , size ) and precise location of the object , as well as the presence of perforation or obstruction . if a clinical or radiological examination shows signs of peritonitis or perforation , surgical procedures such as a laparotomy should immediately be considered . in cases without severe complications , transanal removal however , no specific criteria or guidelines have been established regarding an effective strategy for transanal removal of a rectal foreign body . the factors that determine whether a rectal foreign body can be removed transanally are the shape , size , and location of the object [ 2 , 3 ] . to date , various methods for transanal removal of foreign bodies most objects can be safely removed during an endoscopy procedure with the assistance of endoscopic devices such as a snare or forceps , while kocher clamps , suction devices , and various grasping forceps , though designed for other purposes , have been effective [ 9 , 10 ] . however , when foreign bodies are too large to be removed by those , other methods , including surgery , are required . in the present case , the object was located in the rectosigmoid area and considered to be removable , though its axial orientation made removal difficult . we attempted that by using various endoscopic instruments , but failed because the object had smooth sides and a large size . finally , we were able to use abdominal manual compression to guide the proximal end of the object under x - ray fluoroscopic observation and the distal side under endoscopic observation , and successfully removed it transanally without complications . in addition , gentle air insufflation performed during an endoscopy procedure can make it easier to move the object to the anal side by raising intraluminal pressure on the oral side of the foreign body , which may facilitate transanal removal . air insufflation is also useful to distend the collapsed distal bowel lumen and allow clear visualization of the foreign body . therefore , endoscopic assistance should be considered as a first step during management for rectal foreign bodies in cases without perforation . in conclusion , we report the successful transanal removal of a large - sized rectal foreign body . in cases without perforation , a minimally invasive endoscopic technique via a transanal approach should be considered as a first - line procedure . for transanal removal of the present , large - sized object , we found that endoscopic and x - ray fluoroscopic assistance were helpful to guide the direction and angle of abdominal compression .

we occasionally encounter patients with various types of rectal foreign bodies . when too large to grasp , transanal removal can be difficult . here , we report a case of successful manual transanal removal of an 18 4 4 cm silicon rod without complications . a 50-year - old male came to the emergency department of our hospital 12 h after transanal insertion of a whole silicon rod . an abdominal examination showed no evidence of peritonitis , while x - ray and computed tomography findings revealed a large foreign body in the rectum , without any sign of perforation . initially , we attempted removal using an endoscopy procedure with conventional endoscopic instruments , including a snare and grasp forceps , though we failed because of the large size . next , we manually compressed the foreign body from the abdominal wall under endoscopic and x - ray fluoroscopic observation , and successfully removed it in a transanal manner without complications . endoscopic and x - ray fluoroscopic assistance were helpful to guide the direction and angle of abdominal compression in this case .

epidural anesthesia ( ea ) is one of the most common and safest techniques of inducing regional anesthesia for the lower abdominal surgery and postoperative pain relief . the level of failure is either at the doctor 's end , due to faulty technique or inability in identification of anatomical landmarks , or may be due to some other factors such as obese patient , narrowing of intervertebral spaces , diseases of spine or ankylosis of spine leading to formation of bony column also called bamboo spine . we are reporting such a case in which unanticipated and repeated failures occurred in achieving the epidural block , as each time bony resistance was encountered during the administration of epidural injection . a 45-year - old female , weighing 60 kg , reported to the gynecological outpatient department with the chief complaint of something coming out of the vagina for the past 3 months . the patient did not elicit any history of fall or trauma . on clinical and systemic examination , she was diagnosed as a case of 2 degree uterine prolapse with cystocele and was scheduled for elective vaginal hysterectomy . during the pre - anesthetic check - up , the patient did not give any past history of systemic medical disease , drug allergy , hospitalization , any previous surgery , and as such , her entire medical record was not of much clinical significance . on clinical examination , a regular pulse rate of 76/min and airway examination revealed an adequate mouth opening with mallampatti class of i , normal thyromental distance and normal neck movements . the clinical and biochemical profile revealed hemoglobin level of 12.4 g / dl , normal electrocardiograph and chest x - ray , as well as normal values of all the routine investigations . consent was taken from the patient , after explaining to her about the regional anesthesia procedure during the check - up . as a part of premedication , she was prescribed ranitidine 150 mg and alprazolam 0.25 mg tablets , at night and in the morning of the surgery , 2 hours prior to the procedure . in the operation theater , a good peripheral venous access was secured and preloading was carried out with 500 ml of lactated ringer solution . monitoring devices were attached for the heart rate , electrocardiogram , non - invasive blood pressure and pulse oximetry . taking all aseptic precautions , local infiltration of lumbar spine at l45 intervertebral space was achieved with 1 ml of 2% lignocaine hydrochloride solution . lumbar puncture with an 18 g touhy epidural needle at l45 space was performed in the sitting position . unfortunately , bony resistance was encountered in the next three attempts , both in the midline and paramedian site . similar failures were encountered at l34 and l23 intervertebral space , both in the midline as well as the paramedian site , at a depth of 44.5 cm from the skin surface . the procedure was performed by a consultant anesthesiologist after the first failed attempt by a senior resident . fortunately , a successful subarachnoid block was established in the third attempt at l34 intervertebral space with a 23 g spinal needle inserted through paramedian entry point . a total of 3.5 ml of heavy bupivacaine hydrochloride was injected into subarachnoid space which was admixed with 45 mg of clonidine hydrochloride . surgical procedure started only when the effect of drug was established up to t-10 dermatome . the entire surgical procedure was uneventful with stable parameters and the procedure lasted for about 2 hours . postoperatively , x - ray of lumbar and cervical spine was done which revealed fusion of the lumbar spine , and surprisingly , cervical spine was absolutely normal . on thorough investigations , she was diagnosed as a rare case of isolated lumbar spine fusion by the orthopedician without any other articular or extra - articular manifestations to be labeled as ankylosing spondylitis ( as ) . the diagnosis of ankylosis of spine is made clinically according to the set criteria , but still a few patients may not have the relevant clinical features for the precise diagnosis of as . one can encounter unanticipated failure during the administration of regional anesthetic techniques in such patients who develop isolated ankylosis without the extra - articular involvement . all the necessary investigations which were essential for the scheduled surgery had been carried out preoperatively but not even a single laboratory or diagnostic test indicated toward the presence of fusion of the lumbar spine . the postoperative x - ray of spine showed isolated fusion of lumbar spine without the involvement of cervical or thoracic spine [ figure 1 ] . a typical case of as involves various articular junctions including atlanto - occipital , cervical spine , temporo - mandibular and crico - arytenoid joints , which confronts the anesthesiologist to an extremely difficult challenge for airway management . the literature is abundant with such reports where the involvement of cervical spine in ankylosis leads to higher rate of on - table mortality and morbidity . the radiological appearance in case of as typically reveals a bamboo spine which was difficult to ascertain in our patient as the x - ray showed only fusion of lumbar spine and not typically the features of as , which is mainly due to the bony fusion caused by syndesmophytes . image showing antero - posterior view of fused lumbar spine the disease may involve posterior longitudinal ligament as well as inter - spinous ligament , leading to the formation of a complete rigid column , thereby making it difficult to administer regional anesthesia in the midline . though there seems to exist a strong association of as with hla - b27 in approximately 8085% of the patients , our patient did not show this correlation . even the criteria designed for the identification of as sometimes do not help in exact formulation of precise diagnosis as it proved to be true in this case also . in such unanticipated difficult cases where one continuously encounters bony resistance , the presence of as should be considered . although the regional anesthesia technique may be difficult in such cases , the calcification and ossification of ligament flavum is extremely rare . such , before resorting to general anesthesia ( ga ) due to failed regional technique , airway evaluation and planning management should be carried out by a senior anesthesiologist before proceeding further as ga is associated with more challenging situations with regards to airway management due to possibility of fusion of cervical spines .

epidural anesthesia is one of the easier and safer techniques for lower abdominal surgery . it has a very high success rate in the experienced hands , and failure rates are minimal when it is administered by the experienced anesthesiologists . as it is a blind technique , failures can be encountered even by a senior anesthesiologist in many situations and one must analyze retrospectively the various causes responsible for such failures . we report a case of 45-year - old female , weighing 60 kg , who was scheduled for elective vaginal hysterectomy under regional anesthesia . initial four to five attempts were unsuccessful in establishing the epidural block as the epidural injection encountered bony resistance each time , but subarachnoid block could be achieved with a 23 g spinal needle in the paramedian site of entry in the third attempt . postoperatively , lumbar and cervical spine x - rays were done which revealed an isolated lumbar spine bony fusion . she was diagnosed as a rare case of isolated lumbar spine fusion without any involvement of cervical spine , other articular joints or any systemic manifestations of diseases like ankylosing spondylitis .

the organism in this study is bacillus okhensis strain kh10 - 101 t ( here after b. okhensis ) , a gram - positive , strictly aerobic , rod like bacterium . the b. okhensis was first isolated from a salt pan in india , near port of okha by nowlan et al . , 2006 . b. okhensis is tolerant to both high salt and high ph , can grow from neutral to high ph ( ph 711 ) and from low to high salt ( 0.512% nacl ) concentrations . the genomic dna was extracted from an active log phase culture ( grown in cmb medium , ph 10 and 5% nacl ) as per sambrook et al . the genome of kh10 - 101 t was sequenced using roche 454 gs ( flx titanium ) pyrosequencing platform . functional annotation was carried out using rast tool , identification of trna genes by trnascan - se and rrna genes by rnamerr . genome sequencing resulted in a total of 3,18,628 high quality reads with approximately 28 coverage of the entire genome . n50 contig size is 115,121 bp and the largest contig size is 349,697 bp . total 98 high quality contigs , with size greater than 500 bp were assembled . final assembled draft genome size is 4,865,284 bp ( 4.86 mb ) with 38.2% gc content . the genome size of b. okhensis is relatively larger than its closest and sequenced relatives , bacillus halodurans ( 4.2 mb ) and b. pseudofirmus ( 3.85 mb ) showing its evolutionary significance . annotation with rast has shown a total of 4952 coding sequences , ( 45% annotated and 55% hypothetical ) ( fig . 1 ) . 165 rna coding genes and 8 rrna ( 6 numbers of 5s rrna , one 23s rrna and one 16s rrna ) genes were present ( table 1 ) . of the total protein coding genes , genes involved in carbohydrate metabolism , amino acid metabolism , cofactors , vitamins , prosthetic groups , protein metabolism , nucleic acid metabolism , respiration were dominant ( fig . however , none of these stress responsive genes coded for acid stress responsive proteins . further , despite the fact that b. okhensis is aerobic , genes involved in fermentation and acid production were identified . in addition , 145 genes code for the proteins that are involved in transport across the membrane , such as abc transporters and cation transport proteins . interestingly , it was observed that though spore formation does not occur in high salt and high ph conditions in b. okhensis , its genome has 131 genes encoding proteins related to spore formation and dormancy . the b. okhensis strain kh10 - 101 t whole genome shot gun ( wgs ) project has been deposited at ddbj / embl / genbank under the project accession jrju00000000 . the project ( 01 ) has the accession number jrju01000000 and consists of sequences jrju01000001:jrju01000098 . comparative genome analysis and genome wide transcriptomic analysis of this halo - alakli tolerant strain will be helpful in better understanding of the mechanisms involved in salt and high ph tolerance . the authors declare that there is no conflict of interest on any work published in this paper .

we report the 4.86-mb draft genome sequence of bacillus okhensis strain kh10 - 101 t , a halo - alkali tolerant rod shaped bacterium isolated from a salt pan near port of okha , india . this bacterium is a potential model to study the molecular response of bacteria to salt as well as alkaline stress , as it thrives under both high salt and high ph conditions . the draft genome consist of 4,865,284 bp with 38.2% g + c , 4952 predicted cds , 157 trnas and 8 rrnas . sequence was deposited at ddbj / embl / genbank under the project accession jrju00000000 .

in a recent issue of the british journal of anaesthesia , moloney and griffiths reviewed basic issues surrounding the ongoing debate on ventilator induced / associated lung injury ( vili ) and the implications for patient care . the potential importance of vili / biotrauma is not only that it can aggravate ongoing lung injury but also that it may have important systemic consequences , and may explain why most patients with acute respiratory distress syndrome ( ards ) who go on to die , succumb to multiple organ failure ( mof ) . vili / biotrauma offers a clinically relevant window of therapeutic opportunity in the management of ards / acute lung injury ( ali ) . often the process of systemic inflammatory response syndrome has been initiated hours if not days before admission to the intensive care unit . in contrast , we know exactly when vili / biotrauma begins with intubation and initiation of mechanical ventilation . a full understanding of the mechanisms that mediate lung injury may permit potential strategies directed at reducing the incidence of vili - induced mof to be instituted early in the course of illness . this is no small issue for a syndrome with an incidence of 64.2 cases per 105 person - years and with a 4050% mortality rate . results from the ardsnet trial have underscored the potential importance of biotrauma in the management of ards : the results from that large multicenter trial showed a relative risk reduction of 22% in patients ventilated with the lower tidal volume . this improvement in mortality in patients ventilated with low tidal volumes was not due to a decrease in barotrauma between groups . it is postulated that injurious strategies of mechanical ventilation can cause pulmonary inflammation with release of various cytokines / mediators biotrauma . the initial insult ( pneumonia , acid aspiration , or contusion are a few examples ) ' primes ' the lung . a ' second hit ' , or subsequent insult , such as mechanical ventilation , leads to an overwhelming pulmonary inflammatory response . loss of pulmonary compartmentalization allows for important mediators to escape the confines of the lung and gain access to the systemic circulation . recent experiments have shown that this is associated with apoptosis of cells in distal organs ( kidney , villi of colon ) and end - organ dysfunction ( kidney ) , which potentially underlies the development of mof . in a randomized controlled trial conducted in 44 patients , ranieri and coworkers demonstrated that a lung protective strategy attenuated the levels of proinflammatory cytokines in plasma and bronchoalveolar lavage fluid , and was associated with a lower incidence of mof . however , the measurement of proinflammatory cytokines does not address the issue of maintenance of alveolar epithelial barrier integrity . in a recent study conducted by eisner and coworkers , circulating levels of surfactant protein ( sp)-a and sp - d were evaluated in plasma samples from participants in the ardsnet randomized trial . baseline plasma sp - a levels were not found to be related to clinical outcome . in contrast , higher baseline plasma sp - d levels were associated with a greater risk for death ( odds ratio 1.21 per 100 ng / ml increment ; 95% confidence interval 1.08 to 1.35 ) as well as higher overall morbidity . in addition , use of a lower tidal volume strategy significantly attenuated the rise in plasma sp - d levels ( p = 0.0006 ) . because injury to the alveolar epithelial barrier is a hallmark of ali , levels of circulating sps may not only represent a potential biomarker for ali / ards but they may also , in the future , be used to gauge the effects of treatment . ample evidence supports the use of a relatively low tidal volume , but what about the use of a open lung strategy ( e.g. recruitment maneuvers , positive end - expiratory pressure [ peep ] , proning ) ? the alveoli study ( prospective , randomized , multi - center trial of higher end - expiratory lung volume / lower fio2 versus lower end - expiratory lung volume / higher fio2 ventilation in acute lung injury and acute respiratory distress syndrome ) , performed by the ardsnet investigators to study the use of higher peep levels , was discontinued prematurely because of lack of efficacy . accumulating evidence from both animals and human experiments suggest that not all patients are recruitable ; moreover , if improved oxygenation does not seem to affect outcome , then should recruitment be pursued for the sole purpose of decreasing atelectrauma ? data have been reported that suggest that recruitment maneuvers may be deleterious if sufficient peep is not used to maintain recruitment . repeated de - recruitments accentuate lung injury during mechanical ventilation , and it has also been suggested that allowing the lung to remain in a state of de - recruitment may mitigate biotrauma . one of the mechanisms for upregulation of cytokines during mechanical ventilation of acutely injured lungs is alteration in alveolar mechanics ( i.e. the dynamic change in alveolar size and shape during ventilation ) alveolar instability and recruitment / de - recruitment . using direct visualization of subpleural alveoli , schiller and coworkers demonstrated that normal alveoli are extremely stable with minimal movement during mechanical ventilation . in contrast , surfactant deactivation ( also a classic finding in ards ) causes a continuum of altered alveolar mechanics seen as repetitive collapse of alveoli at end - expiration and re - inflation at end - inspiration . in a recent follow - up study , steinberg and coworkers demonstrated that alveolar instability can mechanically injure the lung independent of inflammatory damage . moreover , the application of peep in this animal model was sufficient to stabilize the alveoli . that group also noted that alveolar instability was associated with modest increases in interleukin-6 levels after 4 hours of mechanical ventilation , even in the absence of neutrophil infiltration , and that this increase could be attenuated by the application of peep . these data suggest that mechanical injury alone is sufficient to cause a rise in tissue and bronchoalveolar lavage levels of proinflammatory cytokines , and that stabilization of alveoli is a key issue in reducing atelectrauma . this probably occurs via a direct attenuation of the mechanical injury to the capillary alveolar membrane , thereby limiting the effects of mechanotransduction ( the response of cells to mechanical force ) on cellular molecular physiology . preliminary evidence suggests that use of strategies that stabilize alveoli are lung protective , but definitive clinical outcome data are not yet available . further research is required to determine whether alveolar stabilization is achievable , measurable , and desirable . again , the answer is probably ' yes ' , both as a consequence of mechanical injury and as the mechanism underlying the development of mof in this patient population . however , as pointed out by moloney and griffiths , a definitive answer to this latter question requires a study that monitors outcomes after specifically targeting certain mediator(s ) . ali = acute lung injury ; ards = acute respiratory distress syndrome ; mof = multiple organ failure ; peep = positive end - expiratory pressure ; sp = surfactant protein ; vili = ventilator - induced / associated lung injury . 1

in a recent issue of the british journal of anaesthesia , moloney and griffiths reviewed clinically pertinent issues surrounding the management of the acute respiratory distress syndrome ( ards ) patient , particularly as it pertains to the treatment of ventilator induced / associated lung injury ( vili ) . in addition to highlighting the important observations that have contributed to further our understanding of the relationship between the mechanical ventilator and inflammatory lung injury , the authors also offer a concise reappraisal of the clinical strategies used to minimize vili in ards . special emphasis is placed on the theory of biotrauma , which attempts to explain how multi - organ failure may develop in patients who ultimately succumb to this syndrome .

mechanism - based pk / pd models typically describe first - order physiological processes that require systems of ordinary differential equations . repeatedly solving these complex systems of ordinary differential equations during the iterative estimation of random and fixed effects can be very computationally intensive . another challenge is that mechanism - based models have many parameters to be estimated , permitting more degrees of freedom for which to describe the data . the limited size and breadth of typical experimental data sets do not permit estimation of all of the physiological parameters of complex mechanistic models ; often because many of the pd markers needed to describe the system are lacking and/or the number of samples collected over time too few . statistics suggests that a model should not have more degrees of freedom than are supported by the current analysis data set . however , physiological parameters are useful for extrapolation and may be informed by prior knowledge if the current analysis data set does not support their estimation . markov chain monte carlo ( mcmc ) bayesian estimation approaches allow this to be done in a more statistically rigorous manner . traditional nlme estimation approaches , such as weighted least squares and maximum likelihood , have limited options for incorporation of prior information ; parameters can be fixed to a specific value , or they can be estimated based on the analysis data set . mcmc bayesian approaches allow the incorporation of a probability distribution to the prior knowledge , with means and variance for the model 's prior parameters . the variance of the prior means for the model parameters determines how much weight should be given to the prior relative to current analysis data set ( figure 1 ) . the resulting posterior model is thus based on the combination of prior knowledge and the current experimental data . with bayesian estimation approaches , there is no need to either completely ignore prior knowledge ( an unrealistic prospect for mechanism - based models ) or assume it is correct with absolute certainty . the theory of bayesian statistics goes back to the 18th century , when thomas bayes introduced the theorem for how one may update the probability estimate for a hypothesis as additional evidence is acquired . his theory provided the mathematical equation for indicating that future outcome has a probability that is based on current data and prior knowledge : where the probability of a hypothesis h conditional on a given body of data e is the ratio of the unconditional probability of the conjunction of the hypothesis with the data to the unconditional probability of the data alone ( p(e ) ) . in bayesian model optimization , p(e|h ) is the marginal posterior density for model , given the priors and the analysis data set . bayesian theory fits quite well with the need for mechanistic pk / pd models to incorporate prior knowledge to adequately inform the parameters of the system of ordinary differential equations . this theory has been difficult to implement for statistical modeling until the advent of more powerful computing resources and mcmc sampling approaches . for nearly all statistical models , there is no closed form solution for the bayesian posterior density estimator needed for model optimization ; therefore , computational methods with numerical integration are a necessity . the mcmc sampling technique provides an effective approach for sampling from a distribution of parameters to solve this problem using iterative numerical integration . the mcmc approach samples a distribution of parameters at each iteration that is dependent on the conditional distribution , which is in turn dependent on the values sampled from the previous iterations . the posterior distribution is arrived at through this stochastic , iterative process that is informed by a combination of the current model , the model priors , and the analysis data set . the optimal set of fixed and random effects of the model is derived once the iterative mcmc process has reached a state of equilibrium , often called the the parameters vary stochastically about their means with a defined variance that is based on the optimal relationship between the model / priors and the analysis data . during the initial series of mcmc iterations , efficiently obtaining the stationary can be challenging . there are different approaches to arrive at the stationary distribution , but the most common is to use a burn - in period of mcmc iterations during which a large number of iterations are discarded . following a sufficiently long burn - in period , the posterior parameters will converge to the stationary distribution . this is analogous to convergence to the maximum likelihood using more traditional estimation algorithms , with the exception that there is not convergence to a single maximum likelihood , but rather a probability distribution from which various useful statistics can be derived ( e.g. , mean , median , and sd ) . determining the appropriate number of burn - in iterations to achieve convergence to the stationary distribution is the greatest challenge for model optimization using mcmc bayesian estimation algorithms , particularly with complex pk / pd models . two problems that cause difficulty for convergence to the stationary distribution are as follows : correlation of the parameters with their initial estimates and autocorrelation , which is a systematic sequential within chain correlation . diagnostic tests have been developed to determine whether convergence to the stationary distribution has occurred and include single chain vs. multiple mcmc approaches . many of these convergence diagnostics are available in the bayesian output analysis package available for r or s - plus ( table 1 ) . the geweke and gelman and rubin diagnostics can be plotted as a function of iteration to determine the progress of convergence as a function of the number of iterations . to determine whether the posterior parameters are uncorrelated with their initial estimates , it is typical to perform at least three mcmc with parameters that have different starting values . if the three chains converge to similar posterior distributions as determined by a multiple chain convergence diagnostic ( e.g. , gelman and rubin ) , then it is assumed that they are no longer correlated with their initial estimates . autocorrelation is typically a more difficult problem for bayesian nlme pk / pd modeling because it is often caused by correlation between parameters in the model ( often related to the structure of the model ) and may require tens of thousands of mcmc iterations before the autocorrelation is corrected . the degree of autocorrelation is typically assessed using a lag - autocorrelation plot , which determines the degree of autocorrelation within chains based on the distance ( i.e. , number of iterations or lag ) between the sampled parameters . nonmem and bugs ( winbugs or openbugs ) are two common platforms for implementation of mcmc bayesian estimation for pk / pd modeling . however , neither platform incorporates these convergence diagnostics ; thus , assessment of convergence must be conducted using an external tool . few published examples exist of the application of mcmc bayesian estimation to complex , mechanism - based pk / pd models . the approach has been more commonly adopted in the field of toxicology for physiologically based pk modeling of xenobiotic compounds in humans and animals . this is , in part , due to the fact that environmental toxicologists often need to estimate the risk posed by different xenobiotic agents , which fits in well with the ability of bayesian approaches to provide a posterior probability distribution for the model . in addition , there has been widespread adoption in toxicology of ordinary differential equation modeling software tools such as acslx , which have incorporated mcmc bayesian algorithms . the use of mcmc bayesian nlme approaches for application to clinical pk / pd problems is much less common . in 2007 , jonsson et al published a reanalysis of a mechanism - based pk / pd model of neutropenia , which was the first example of the fully transparent application of mcmc bayesian methods to a complex , hierarchical mechanistic pk / pd problem . they highlighted the difficulties with determining convergence and the time - consuming model optimization process using mcmc bayesian estimation . jonsson and co - authors conclude that the mcmc bayesian approach enables efficient use of all available information from data , scientific evidence , and more reliable predictions based on that information . in the current issue of pharmacometrics & systems pharmacology , leil et al report the application of an mcmc bayesian approach to a mechanism - based pk / pd model for prediction of cyp3a4-mediated drug interactions . these examples demonstrate that the bayesian approach to pk / pd modeling will require a shift in the approach to pk / pd modeling , with more effort being invested in identifying a biologically plausible model and in finding informative priors than in achieving parsimony . the mcmc bayesian approach currently represents the most robust and statistically rigorous manner in which to make use of prior knowledge to develop nlme pk / pd models that can be used to improve decision making in biomedical research and development .

mechanism - based pharmacokinetic / pharmacodynamic models have a fundamental basis in biology and pharmacology and , thus , are useful for hypothesis generation and extrapolation beyond the conditions of the original analysis data . the complexity of these models necessitates the incorporation of prior knowledge to inform many of the model parameters . markov chain monte carlo bayesian estimation offers a robust and statistically rigorous approach for incorporation of prior information into mechanism - based models . this article provides a perspective on the utility of this approach .

iatrogenic injury of the lumbar arteries after spinal surgery is a rare complication5 - 9 ) . it may result in the formation of a pseudoaneurysm and consequent acute or delayed retroperitoneal hemorrhage . because pseudoaneurysm develops gradually from a focal arterial wall disruption however , this condition may lead to a sudden and massive retroperitoneal hemorrhage and hypovolemic shock . we recently treated a patient who showed a large retroperitoneal hematoma caused by pseudoaneurysm that arose nine days after posterolateral fusion ( plf ) . a 55-year - old female patient with lower back pain and neurogenic intermittent claudication , who previously underwent l4-l5 plf due to spinal stenosis , was presented to our hospital . she experienced small thalamic infarction 5 years ago , and since then , she started antiplatelet and antihypertensive medications . there was minimal bleeding during the surgery , and post - operative complaints only include mild back pain . however , on the 9th post - operative day , the patient complained of a sudden onset of severe abdominal pain and distension . moreover , the patient was hemodynamically unstable ( 8.5 g / dl hemoglobin concentration ; 90/60 mm hg blood pressure ; and 120/minute pulse rate ) . a late abdominal complication was suspected , and an emergency computed tomography ( ct ) scan of the abdomen with contrast enhancement was performed . the patient was resuscitated with blood transfusion , intravenous fluids for hypovolemic shock and an interventional radiologist was urgently consulted . lumbar spinal angiography showed the delayed hematoma due to rupture of the 2nd lumbar artery pseudoaneurysm ( fig . after we confirmed the successful embolization through the final angiogram , the patient was sent to the ward . since then , the patient 's postoperative progress proceeded normally with recovery of the hemodynamic parameters . two weeks after the embolization , follow - up abdominal ct showed the decreased retroperitoneal hematoma ( fig . a few authors reported iatrogenic lumbar artery pseudoaneurysm as a consequence of spinal surgery4 - 8 ) . moreover , there were some reports about lumbar artery pseudoaneurysm after trauma1 - 3,11 ) . however , there were few reports about lumbar artery pseudoaneurysm after plf . in 1953 , watkins12 ) first introduced posterolateral intertransverse fusion and the indications for the use of this technique have been broadened to include degenerative disc disease and low back pain . nowadays , this technique is supplemented by the provision of a transpedicular fixation device and is widely used in lumbosacral spinal surgery . preparation of the bone fusion bed , which is the most important step in plf , was done through decortications of the transverse process by drilling . in the present case , the fracture of the right l3 transverse process was connected , thus the injury of the lumbar artery may have occurred close to the transverse process during drilling . we believe that this iatrogenic arterial wall injury was responsible for the formation of the lumbar artery pseudoaneurysm with the consequent delayed retroperitoneal hemorrhage . the lumbar arteries of l1 to l4 are small paired vessels that originate from the dorsal aspect of the abdominal aorta at the level of the transverse processes . the lower lumbar arteries can occasionally originate from a common trunk near the midline of the posterior aorta ( fig . these vessels run laterally along the bodies of the lumbar vertebrae and divide into anterior and posterior branches at the medial border of the psoas muscle and anterior of the transverse process1 ) . in the present case , we thought that the lumbar artery was injured at the anterior of the transverse process ( fig . lee et al.4 ) reported the case of a lumbar artery injury combined with a transverse process fracture after a fall . thus if the patient showed retroperitoneal hemorrhage along with a transverse process fracture , the clinician should consider the possibility of a lumbar artery injury . in case of retroperitoneal hemorrhage due to lumbar artery injury , endovascular embolization is effective in controlling hemorrhage as it avoids the risks associated with another anesthesia , surgical incision , and the locating and controlling the bleeding1,7,9,10 ) . in our case , a transcatheter embolization has successfully stopped retroperitoneal hemorrhage due to rupture of lumbar artery pseudoaneurysm . although plf is a safe and widespread surgical technique , major complications are possible if proper attention is not given to the preparation of fusion bed such as drilling or decortication of a transverse process .

a 55-year - old female patient presented with lower back pain and neurogenic intermittent claudication and underwent l3-l4 posterolateral fusion . to prepare the bone fusion bed , the transverse process of l3 and l4 was decorticated with a drill . on the 9th post - operative day , the patient complained of a sudden onset of severe abdominal pain and distension . abdominal computed tomography revealed retroperitoneal hematoma in the right psoas muscle and iatrogenic right l3 transverse process fracture . lumbar spinal angiography showed the delayed hematoma due to rupture of the 2nd lumbar artery pseudoaneurysm and coil embolization was done at the ruptured lumbar artery pseudoaneusyrm . since then , the patient 's postoperative progress proceeded normally with recovery of the hemodynamic parameters .

the increasing incidence of complex percutaneous coronary intervention ( pci ) is accompanied by risks of device fracture or dislodgement . guide wire fractures during pci are very rare , but in such cases , life - threatening complications such as embolization , thrombus formation and perforation may occur . although , in most cases , percutaneous retrieval techniques of fractured guide wires are recommended , there have been several reports of fragments being left in place without complications.1 - 4 ) we present the case of a 78-year - old female patient who was diagnosed with non - st segment elevation myocardial infarction ( nstemi ) and treated with pci . the patient had remnant guide wire filaments in the left anterior descending artery ( lad ) and aorta but did not experience any serious complications during a one - year follow up period . a diagnostic coronary angiogram showed diffuse significant stenosis from the proximal to middle lad and first diagonal branch ( d1 ) ( fig . we initially treated the patient with a single paclitaxel - eluting stent ( 2.7532 mm taxus , boston scientific , natick , ma , usa ) . four days later , two coronary angioplasty 0.014 guide wires were inserted { one hi - torque balance middleweight ( bmw ) universal coronary guide wire ( abott vascular , santa clara , ca , usa ) into the lad , and one high - torque whisper coronary guide wire ( abott vascular ) into the d1}. an intravascular ultrasound after predilatation with a 2.520 mm voyager balloon ( abott vascular ) revealed a large plaque burden at both the lad and the d1 . we deployed two overlapped sirolimus - eluting stents at the proximal and middle lad : a 2.7533 mm cypher at the middle lad and a 2.7518 mm cypher at the proximal lad ( cordis corporation , miami lakes , fl , usa ) . when we exchanged the guide wires to perform kissing balloon angioplasty , a fracture occurred at the distal tip of the bmw guide wire ( fig . 1 ) . another guide wire was inserted to perform a beaded wire rotation , and distal balloon inflation retrieval was attempted , in order to remove the fractured guide wires . finally , we used a goose neck loop - snare ( microvena corporation , st . multiple forward and backward movements of the snare , combined with distal balloon inflation retrieval , successfully removed most of the fractured guide wires ( fig . 2 ) but we later observed retained filaments during echocardiography ( figs . 3 and 4 ) . the patient declined surgical intervention for removal of these stray filaments and was discharged from our hospital , with triple anti - platelet medication and no complications . the patient did not experience any thrombotic or embolic events and did not suffer from any subjective symptoms over the one year of clinical follow up . guide wire fractures during pci are very rare , occurring in approximately 0.1 - 0.2% of cases.5 ) guide wire remnants could lead to life threatening complications such as thrombosis , emboli , and perforation . therefore , in the event of failed percutaneous retrieval and persistent signs of ischemia , patients should be urgently referred for surgical intervention . there are several methods recommended for the management of fractured guide wires , including emergent surgery , loop snare removal , two- or three - wire rotation , stenting over the retained wire , and conservative treatment.6 - 8 ) surgical extraction is strongly recommended in cases of protrusion of the guide wire into the ascending aorta.9 - 11 ) however , guide wire segments retained within the coronary circulation may remain benign for a long time , particularly if they are entrapped within a distal part of the vessel and do not have accompanying total coronary occlusions.3 ) vascular endothelial cell covering over the guide wire fragments may render them immobile and non - thrombogenic . hi - torque bmw guide wires consist of a distal core and a stainless proximal shaft , facilitating treatment of multiple lesions and tortuous vessels . however , guide wire fractures may occur if the distal core and stainless proximal shaft are separated by either the trapping of the distal tip or by vascular resistance . because the fracture in the lad developed after stent deployment at the main branch , we could not determine the mechanism of fracture in this particular case . however , trapping of the distal tip of the bmw wire , or stent deployment over a severely angulated guide wire are two possible explanations . in conclusion , even though the most ideal management option for remnant guide wires is their removal , conservative treatment with the fragments left in situ may be successful in cases in which patients remain asymptomatic and hemodynamically stable . however , life - long administration of intensive anti - platelet medications and close observation are recommended for these patients .

guide wire fractures during percutaneous coronary intervention ( pci ) are very rare , but when they do occur they may lead to life - threatening complications , such as embolization , thrombus formation and perforation . in cases when percutaneous retrieval has failed , surgical extraction of the remnant fragments is recommended . we present a case of remnant guide wire filaments that remained in place without complications , over a one - year clinical follow up period .

a couple that is unable to get pregnant after one year of unprotected intercourse , usually ends up at the gynaecology department of a hospital . therefore the man has to collect his semen in a special container and deliver it within one hour of collection to the hospital . the parameters usually determined with a semen analysis are the concentration and the motility of the spermatozoa in the semen . the haemocytometer is the gold standard for concentration determination , but this labour intensive method is in larger laboratories replaced by an expensive computer assisted semen analysis system ( casa ) . another way that gives an estimation of the spermatozoa concentration uses flow cytometry [ 2 , 3 ] , while antibody binding and fluorescence labelling are used to determine the concentration of progressive motile spermatozoa ( > 5ms-1 ) . none of these approaches assess the concentration of spermatozoa without the use of an expensive system , labour intensive handling and sample preparation . furthermore , due to intra - individual variations , the results of a single test are not reliable and at least three tests have to be done . a better alternative for the current procedure is a portable system that enables the man to perform several objective and reliable measurements at home . today a few at - home tests to determine the fertility of the man exist , but these rely on subjective interpretation by the man and only give qualitative information about the semen quality . the small reagent- and sample volumes needed , together with the possibility to integrate several steps in one single device , provides the opportunity to improve the semen analysis . therefore we focus on the development of a microfluidic chip for the assessment of the semen quality . such disposable microfluidic chip will be ultimately used in combination with a handheld measurement system and management software ( see figure 1 ) . in this manuscript our recent efforts for improvement of the fertility chip are summarized . almost twenty years ago , kricka and co - workers showed that a microfluidic chip can be used to separate motile sperm from a semen sample . to our knowledge , they were the first who used microfluidics for andrology applications . subsequently more studies have been published which focus on the use of microfluidics for ( part of the ) semen analysis or sperm selection and purification . in our first approach , microfluidic impedance cytometry has been used to determine the concentration of spermatozoa in semen . with cleanroom fabrication techniques a glass - glass chip has been made ( see figure 2 ) , which comprises an 18 m deep microfluidic channel . at the tapering of the microfluidic channel to a width of 38 m two platinum electrodes the electrical impedance is measured at a specific frequency between those electrodes and when a cell passes the electrode pair , it changes the average dielectric properties of the measurement volume , resulting in an impedance change . in this way since the value of the impedance change of each event is also dependent on the size of the cell passing the electrode pair , we were able to distinguish between hl-60 cells , spermatozoa and 6 m polystyrene beads . to determine the concentration of spermatozoa in semen , we used a comparable method as used in conventional flow cytometry . a known concentration of polystyrene beads was added to the semen sample and by flowing them through the chip by means of applying a hydrostatic pressure , we showed that we were able to determine the spermatozoa concentration of boar semen in the range from 210 to 6010ml . another parameter that is important to assess the semen quality is the motility of the spermatozoa . for the purification of the best spermatozoa out of a semen sample for assisted reproductive technologies ( e.g. in - vitro fertilisation , intracytoplasmic sperm injection ) cho and co - workers developed a microfluidic approach [ 11 , 12 ] . in this approach two microchannels combine to one separation channel , where the two laminar flows from both channels join . only motile spermatozoa have the ability to cross the flow barrier and will end up in the other channel , thereby creating a sample of spermatozoa with sufficient motility for further use . for the determination of the motility we use the same principle as mentioned before and we combine this with the electrical detection of spermatozoa at the two outlet channels ( see figure 4 ) . the detection of the spermatozoa in both outlet channels is done with the same configuration as used for determining the concentration on - chip . we propose a new model for the determination of the separation efficiency of motile spermatozoa from the semen sample and compare these simulated results with experimental data , which shows a good agreement . in this way we were able to distinguish between samples with motile and immotile spermatozoa . parameters of the semen quality that are normally determined in the hospital laboratory can be measured with microfluidic devices in an objective way making point - of - care diagnostics possible . with microfluidic devices a shift toward at - home analysis can be made , thereby reducing the costs and making it more patient friendly . additionally , more measurements can be performed over a period of time such that a better statement of the semen quality is obtained . this information can lead to a better treatment decision of the gynaecologist , thereby improving the care of the couple that is childless by default . this research is supported by the dutch technology foundation stw , which is an applied science division of nwo , and the technology program of the ministry of economic affairs . , et al . , a. lab - on - a - chip technology for clinical diagnostics : the fertility chip .

the gold standard of semen analysis is still an manual method , which is time - consuming , labour intensive and needs thorough quality control . microfluidics can also offer advantages for this application . therefore a first step in the development of a microfluidic chip has been made , which enables the man the semen analysis at home . in this article recent efforts to determine the concentration and motility using a microfluidic chip are summarized .

in a differential diagnosis of a wide complex tachycardia ( wct ) , prior to which a 12-lead surface electrocardiogram ( ecg ) was taken , a comparison of qrs morphology between the sinus rhythm and the wct is helpful . an identical qrs morphology between sinus rhythm and wct strongly suggests supraventricular tachycardia ( svt ) whereas a contralateral bundle branch block ( bbb ) morphology during tachycardia with a preexisting bbb strongly suggests ventricular tachycardia ( vt).1 ) contrary to this rule , we present a case of svt with left bbb ( lbbb ) aberration but right bbb ( rbbb ) during sinus rhythm . a 45-year - old woman with a 30-year history of palpitations presented herself for an electrophysiologic ( ep ) study and a catheter ablation . her present arrhythmia was a lbbb morphology tachycardia ( lbbb - t ) at 200 beats / min which was converted into a sinus rhythm with intravenous adenosine . during the ep study , multipolar catheters were placed in the high right atrium ( hra ) , his - bundle region ( his ) , right ventricle ( rv ) , and coronary sinus ( cs ) . at the beginning of the ep study , the surface ecg did not show any bbb or intraventricular conduction delays ( fig . 1a ) , and the baseline conduction intervals were within normal limits . the ah interval was 72 msec , and the hv interval was 54 msec . however , an rbbb occurred due to mechanical trauma during his - bundle catheter placement ( fig . the baseline ep study showed ventriculo - atrial ( va ) conduction was present through both the atrioventricular ( av ) node and the concealed accessory pathway ( ap ) in the left posterior , which was blocked by 250 msec pacing with an av wenckebach cycle length of 310 msec . the clinical lbbb - t ( cycle length : 330 - 350 msec ) was easily induced by catheter - manipulation and spontaneous premature atrial complexes ( fig . lbbb - t has several possible mechanisms including orthodromic atrioventricular reentrant tachycardia ( ort ) with an lbbb aberration using a concealed ap , antidromic atrioventricular reentrant tachycardia ( art ) using various types of right - sided aps anterogradely , rv vt , and bundle branch reentry vt . 2 shows that the lbbb - t terminated spontaneously and was followed by a sinus beat with a rbbb . the lbbb - t terminated without any following atrial activation ; therefore , vt with 1:1 retrograde conduction was ruled out . the his - bundle activation during the tachycardia preceded the beginning of the qrs complex , which ruled out an art . the site of the earliest atrial activation during the lbbb - t was in the mid - cs rather than in the his - bundle . delivery of premature ventricular stimulus during the his - bundle refractory terminated tachycardia without atrial activation . this confirmed that the tachycardia was an ort using a concealed left posterior ap . after ablation , va conduction was present through the av node only , but a va conduction block occurred at the vh level with a wenckebach pattern ( fig . 3 ) , which suggested a conduction abnormality in the his - purkinje system or between the his - purkinje system and the ventricle . bundle branch block aberrancy during svt in the presence of pre - existent contralateral bbb is extremely rare , even in the presence of a his - purkinje system dysfunction . a functional or anatomical block at one or more levels in the conduction system can cause lbbb.2 ) it can occur at the his bundle level ( dedicated fibers to lb ) before its bifurcation , the left bundle branch level , the left fascicle level ( due to variation in the anatomy of fascicles3 ) ) , or diffuse disease of the very distal ramifications of the left bundle . burst pacing at 280 msec revealed a conduction delay between the his and bb resulting in an infra / intra hisian block ( wenckebach type ) . the interval following a non - captured beat allowed recovery of the left bundle , and this resulted in the re - appearance of the rbbb qrs morphology similar to that of baseline conduction . early - coupled atrial extrastimuli caused a progressive delay within the his bundle or between the his and bb , and the rb potential to the qrs interval became longer and fixed during the lbbb morphology . 4 showed that the lbbb did not recover from previous stimulation , but the interval from his to rb became longer by a premature stimulation without a change in lbbb morphology . this implies that a certain amount of conduction delay between the his and bundle branch may be the cause of manifestation of lbbb in this case . we propose that conduction delay between his and bundle branch may be the possible mechanism of the lbbb aberration with svt during preexisting rbbb .

a contralateral bundle branch block ( bbb ) aberration during tachycardia with a preexisting bbb strongly suggests the presence of ventricular tachycardia . we report on a middle - aged , female patient presented with wide qrs tachycardia . the patient had orthodromic atrioventricular tachycardia with a left bbb aberration in the presence of a preexisting right bbb due to an abnormal his - purkinje system . we learned that the contralateral bbb aberration with supraventricular tachycardia could be seen when the his - purkinje system was abnormal .

in the previous issue of critical care , ma and colleagues report a meta - analysis of the randomized , clinical trials of clazosentan and tak-044 in patients with aneurysmal subarachnoid hemorrhage ( sah ) . the endothelins ( ets ) are a family of three ( et-1 , et-2 and et-3 ) 21-amino - acid peptides that act on several receptors , principally eta and etb receptors in the vasculature . experimental data as well as the results of this meta - analysis show that this system is important in the pathogenesis of angiographic vasospasm after sah . a variety of et receptor antagonists have been developed . clazosentan is a heteroarylsulfonamido pyrimidine that was specifically developed to be a relatively water - soluble , small - molecule , highly - selective eta receptor antagonist for prevention of angiographic vasospasm . their meta - analysis gives the same results as the trials , which at least for the four largest studies all had basically the same results . the pooled relative risk ( rr ) of angiographic vasospasm with et antagonist treatment was 0.66 ( 95% confidence interval ( ci ) = 0.57 to 0.77 ) , so these drugs effectively reduce vasospasm . the main consequence of vasospasm , delayed cerebral ischemia ( dci ) , was defined in the last three clazosentan studies as delayed ischemic neurological deficit . the current meta - analysis reports delayed ischemic neurological deficit and dci , but dci is defined as infarction on computed tomography ' only attributable to cerebral vasospasm and dci ' , which is a partly circular definition . these varied definitions lead to confusion since the definitions vary in the studies and the terminology of ma and colleagues does not match that recommended by vergouwen and colleagues . interestingly , and not unexpectedly , there was a significant reduction in delayed ischemic neurological deficit ( rr = 0.77 , 95% ci = 0.66 to 0.90 ) and a trend towards reduction in dci ( rr = 0.87 , 95% ci = 0.74 to 1.03 ) . despite these improvements thus , considering the pathway from angiographic vasospasm to ischemia ( dci by most definitions ) , to infarction , and to poor outcome , the benefits of et antagonists diminish at each step . the findings of ma and colleagues are virtually identical to a meta - analysis conducted by vergouwen and colleagues . vergouwen and colleagues , however , also reported data from a subset of the studies showing that there was no significant reduction in vasospasm - related cerebral infarction ( rr = 0.76 , 95% ci = 0.53 to 1.11 ) although the rr is reduced , in keeping with the analysis of ma and colleagues . et antagonists did not seem to have any effect on all new cerebral infarction ( rr = 1.04 ; 95% ci = 0.91 to 1.19 ) . this is an important finding since cerebral infarction is one of the most important prognostic factors for outcome after sah . why is there a substantial effect on angiographic vasospasm , less effect on infarction judged to be due to vasospasm and no effect on all delayed infarcts and clinical outcome ? this theory predicts that reducing angiographic vasospasm may not be adequate to reduce infarction and improve outcome . under this theory , the vasospasm - related and any new infarction incidences should be the same . strictly speaking , they are the same - although , as noted above , the trends in the odds ratios seem different . one alternative theory is that side effects of the drugs , such as hypotension and pulmonary complications , counteract the beneficial effects of reducing vasospasm so that there is no overall beneficial effect on outcome . indeed , both meta - analyses report virtually identical and significant increases in lung complications , hypotension and anemia in the patients treated with et antagonists . to fit the data , this theory would require those side effects being sufficient to cause infarctions so that the overall infarction rate is about the same . one could argue that the data , while not conclusive , favor the second theory . another fundamental issue is that patients in the placebo groups of these studies are administered rescue therapies for dci in a higher percentage of cases than in the drug - treated groups . if rescue therapy is efficacious , then this also could reduce the difference between the groups in cerebral infarction and overall clinical outcome . the strengths of the current analysis are that it is rigorous and follows preferred reporting items for systematic review and meta - analysis ( preferred reporting items for systematic reviews and meta - analyses ) guidelines . the results of this meta - analysis are not surprising , given that the results for all of the individual studies are the same - which is not a weakness but a comment . another issue is the inclusion of drugs of different chemical classes and with different known pharmacologic actions in these sorts of meta - analyses . multiple doses and methods and timing of administration of different drugs are combined into single treatment groups , which makes no sense biologically . what does the future hold for et antagonists in sah ? since all of the studies are only recently completed , obtaining the individual patient data from the sponsors may allow further analysis to guide further studies . this collation is obviously being done , since actelion ( allschwill , switzerland ) sponsored all of the clazosentan studies , have the data and have invested heavily in clazosentan . according to vergouwen and colleagues , actelion did not provide individual patient data or data that would enable an intention - to - treat analysis . the latter missing data , however , given the small number of patients involved , are not going to change the overall findings . actelion , however , must be complimented for supporting development of clazosentan and for conducting these studies that would not have occurred if we waited for funding from peer - reviewed granting agencies . the studies they have conducted have been fundamentally directed at improving the outcome of patients with sah and there can not be any question about their motivation to develop a drug that will address this . in summary , the authors ' conclusion is that future studies of et antagonists should be ' more carefully formulated and designed ' . input into the design of these studies would be welcome , given that all of these studies were already very carefully formulated and designed . my opinion is that some method of reducing the side effects of et antagonists , primarily hypotension and pulmonary complications , is the key to the future of these drugs . ci : confidence interval ; dci : delayed cerebral ischemia ; et : endothelin ; rr : relative risk ; sah : subarachnoid hemorrhage . rlm is a consultant for actelion pharmaceuticals , chief scientific officer of edge therapeutics inc . , and holds patents related to the prevention of delayed cerebral ischemia after subarachnoid hemorrhage . rlm receives grant support from the physicians services incorporated foundation , the brain aneurysm foundation , the canadian institutes of health research and the heart and stroke foundation of canada .

in the previous issue of critical care , ma and colleagues perform a meta - analysis of five randomized , clinical trials of endothelin antagonists in patients with aneurysmal subarachnoid hemorrhage . there are four trials using clazosentan and one trial with tak-044 . these studies show that endothelin plays an important role in the genesis of angiographic vasospasm . the benefit of these drugs is less on delayed cerebral ischemia and nonexistent on overall clinical outcome . why the drugs reduce vasospasm but do not improve outcome could be because of side effects such as hypotension and pulmonary complications that are more common in patients treated with endothelin antagonists or because rescue therapy , which is used more in the placebo groups , improves outcome in these patients to the same extent as the endothelin antagonists . as the authors conclude , future studies of these drugs will need to consider these and other factors in their design .

the source of the microbial inoculum was primary wastewater collected from the waternet wastewater treatment plant , amsterdam west ( the netherlands ) . the bacterial growth medium ( 1 l ) contained acetate ( 10 mm ) , sodium phosphate buffer ( 20 mm ) , nh4cl ( 6 mm ) , kcl ( 4 mm ) , trace metals ( 12.5 ml ) , and vitamin solutions ( 12.5 ml ) having the composition described by kim et al . all solutions were purged with n2 before biofilm growth . for primary biofilm formation , 5 ml of wastewater per 1 l of bacterial growth medium were inoculated in a sealed electrochemical cell incubated at 35 c under anaerobic conditions , operating in batch mode . a constant potential of + 0.15 v versus sce ( amel , italy ) was applied to the working electrode ( graphite rods , mersen , france ) by using a autolab potentiostat ( metrohm , utrecht , the netherlands ) to promote biofilm formation . afterwards , the primary biofilm enriched in geobacter species scraped from the carbon electrode under anaerobic conditions was used as inoculum for the secondary biofilm formation , following a similar procedure on homemade ag disks ( purity > 99.99 % , diameter=2.5 mm ) at the applied potential of 0.085 v versus . these polycrystalline ag electrodes have a removable tip , allowing for fast and leakage - free tip exchange , which could rapidly be fixed under the microscope for optical measurements ( smartip electrodes , vu university ) . immediately before biofilm formation , the ag electrodes were polished as described elsewhere . after biofilm formation , the ag electrodes were quickly transferred from the cell to the spectroelectrochemical cell operating in flow mode . electrochemical measurements on the microbial biofilm were carried out in a homemade spectroelectrochemical cell , operating in a three - electrode configuration and controlled by a pgstat101 potentiostat ( metrohm , utrecht , the netherlands ) . the cell was equipped with a flow system controlled by a hplc pump k-501 ( knauer , germany ) , allowing for fast exchange of the solution in contact with the biofilm . current densities are expressed with respect to the projected electrode area of the working electrode . biofilm growth was performed in a thermostated glass vessel , using a pt coil and a sce as the counter and the reference electrodes , respectively . all potentials provided in the manuscript are referred to the sce reference electrode ( + 0.244 v vs. she ) . optical measurements where performed on a renishaw raman setup ( wotton - under - edge , united kingdom ) equipped with a leica light microscope with 5 air objective and a renishaw ms 20 encoded stage 100 nm motorized stage . the ca traces were fitted to the exponential decay using an origin pro software ( originlab , northampton , ma ) , applying built - in non - linear curve fitting routines . the source of the microbial inoculum was primary wastewater collected from the waternet wastewater treatment plant , amsterdam west ( the netherlands ) . the bacterial growth medium ( 1 l ) contained acetate ( 10 mm ) , sodium phosphate buffer ( 20 mm ) , nh4cl ( 6 mm ) , kcl ( 4 mm ) , trace metals ( 12.5 ml ) , and vitamin solutions ( 12.5 ml ) having the composition described by kim et al . for primary biofilm formation , 5 ml of wastewater per 1 l of bacterial growth medium were inoculated in a sealed electrochemical cell incubated at 35 c under anaerobic conditions , operating in batch mode . a constant potential of + 0.15 v versus sce ( amel , italy ) was applied to the working electrode ( graphite rods , mersen , france ) by using a autolab potentiostat ( metrohm , utrecht , the netherlands ) to promote biofilm formation . afterwards , the primary biofilm enriched in geobacter species scraped from the carbon electrode under anaerobic conditions was used as inoculum for the secondary biofilm formation , following a similar procedure on homemade ag disks ( purity > 99.99 % , diameter=2.5 mm ) at the applied potential of 0.085 v versus . these polycrystalline ag electrodes have a removable tip , allowing for fast and leakage - free tip exchange , which could rapidly be fixed under the microscope for optical measurements ( smartip electrodes , vu university ) . immediately before biofilm formation , the ag electrodes were polished as described elsewhere . after biofilm formation , the ag electrodes were quickly transferred from the cell to the spectroelectrochemical cell operating in flow mode . electrochemical measurements on the microbial biofilm were carried out in a homemade spectroelectrochemical cell , operating in a three - electrode configuration and controlled by a pgstat101 potentiostat ( metrohm , utrecht , the netherlands ) . the cell was equipped with a flow system controlled by a hplc pump k-501 ( knauer , germany ) , allowing for fast exchange of the solution in contact with the biofilm . current densities are expressed with respect to the projected electrode area of the working electrode . biofilm growth was performed in a thermostated glass vessel , using a pt coil and a sce as the counter and the reference electrodes , respectively . all potentials provided in the manuscript are referred to the sce reference electrode ( + 0.244 v vs. she ) . optical measurements where performed on a renishaw raman setup ( wotton - under - edge , united kingdom ) equipped with a leica light microscope with 5 air objective and a renishaw ms 20 encoded stage 100 nm motorized stage . the ca traces were fitted to the exponential decay using an origin pro software ( originlab , northampton , ma ) , applying built - in non - linear curve fitting routines . as a service to our authors and readers , this journal provides supporting information supplied by the authors . such materials are peer reviewed and may be re - organized for online delivery , but are not copy - edited or typeset . technical support issues arising from supporting information ( other than missing files ) should be addressed to the authors

the study of electroactive microbial biofilms often requires knowledge of the biofilm thickness . unfortunately , this parameter is , nowadays , only accessible through expensive microscopic techniques . this work overcomes this limitation by presenting a new strategy , exploiting the use of chronoamperometry ( ca ) alone . a mixed - culture biofilm is exposed to an o2-saturated solution during anode respiration to suppress its catalytic activity . assuming that inactivation of the electrocatalytic process is caused by o2 diffusion through the biofilm , a simple relation allows the use of the time constant extracted from the fitting of the curve of the ca trace during inactivation for the straightforward and quantitative determination of biofilm thickness . the biofilm thickness obtained with this method obeys the expected trend reported for biofilm growth and is in agreement with optical measurements . contrary to the techniques usually employed to determine biofilm thickness , this new strategy is very rapid , nondisruptive , inexpensive , and may become a convenient alternative with respect to expensive and time - consuming microscopic techniques .

etizolam is a thienodiazepine anxiolytic and is said to have low tolerance and dependence liability than benzodiazepines . we report a case of etizolam dependence in a young male with social anxiety disorder to highlight the abuse and dependence potential of etizolam . we present a case of 23-year - old male who presented to the outpatient department with 3 years history of feeling anxious in social situations , feeling scrutinized and focus of attention in social situations and marked avoidance behavior . for past few months the patient also had pervasive sadness of mood , lack of interest , ideas of hopelessness and worthlessness . the patient was earlier on treatment with paroxetine up to 12.5 mg , escitalopram 10 mg and sertraline up to 50 mg / day before coming in our contact . there was a history of progressive increase in dose of etizolam taken by the patient . basis when he would face any social situation . gradually , he started taking etizolam regularly , and his intake increased to 2.5 mg / day over a period of 1 month . the patient would have palpitations , tremulousness , impaired sleep , would feel agitated on taking lower dose of etizolam resembling the characteristic benzodiazepine withdrawal symptoms . he continued to self - medicate himself with etizolam even after the physician had stopped prescribing the same . hence , the patient was found to have tolerance and compulsion to take the substance and experienced withdrawal symptoms for etizolam and thus fulfilled the criteria for dependence syndrome as given by the international classification of diseases-10 ( icd-10 ) classification of mental and behavioral disorders . the patient was prescribed paroxetine up to 25 mg / day with clonazepam 3 mg / day . the patient showed marked improvement in depression and social anxiety but continued to take etizolam . he continued his etizolam intake despite being aware that etizolam might be harmful to him and is not to be taken on long term basis . although a thienodiazepine , etizolam is clinically regarded as a benzodiazepine because of its mode of action via benzodiazepine receptor . the potency and efficacy of etizolam for allosteric potentiation of -aminobutyric acid evoked cl current mediated by recombinant 1 2 2s receptors is lower than those of classical benzodiazepines which has been proposed as a reason for a reduced liability of etizolam for the development of tolerance and dependence . the claim of low dependence potential of etizolam has led to it being prescribed liberally in the markets where it is available for a long time , like japan . this myth is being realized now after it has become the most frequently prescribed benzodiazepine there . perhaps , this is the reason for its nonavailability in developed markets of united states of america and europe . it was approved for use in india on october 29 , 2007 and perhaps because of late entry , remains one of the least used benzodiazepine in india . etizolam has been occasionally associated with skin lesions and blepharospasm . however , the literature about its abuse and dependence potential is sparse . the rapid relief of anxiety by ultra - short - action and feeling of anxiety after the action wears off may lead to dependence by both positive and negative behavioral reinforcement . the case described in this article developed dependence on etizolam after experiencing relief in his anxiety symptoms with its therapeutic use . five ( a , b , c , d , and f ) out of six criteria for establishing dependence syndrome ( f13.2 ) as per icd-10 , against a diagnostic threshold of three were present in this case in context of etizolam use . paroxetine has proven efficacy for social anxiety disorder , depressive episode and for tapering benzodiazepine use and successfully resulted in remission of former two conditions in this patient . however , the patient was finding it difficult to taper etizolam use and dropped out of follow - up . this case report highlights the fact that the same caution be applied while prescribing etizolam with respect to dependence potential as for any other benzodiazepine . in the case of development of dependence , treatment of the primary disorder , substitution with longer - acting benzodiazepines , selective serotonin reuptake inhibitors and psychotherapy are various options that can be exercised .

etizolam is a thienodiazepine anxiolytic which is said to have lower dependence potential than other benzodiazepines . we report a case of etizolam dependence in a young male with social anxiety disorder and moderate depression . this case report highlights the fact that the same caution be exercised while prescribing etizolam with respect to its potential to cause dependence as with any other benzodiazepine .

endocardial fibroelastosis ( efe ) is a disorder of fetuses and infants of unclear etiology that is characterized by deposition of collagen and elastin , and that leads to ventricular hypertrophy and diffuse endocardial thickening.1 ) however , a recent study has shown that even in adult heart recipients , efe is a relatively frequent finding in histological samples of explanted hearts.2 ) the basic feature of the disease is the formation of fibrous tissue on the endocardium in the inflow tract of the right or left ventricle or both , leading to partial obliteration of the ventricle with decreased ventricular distensibility and impaired diastolic filling.3 ) in korea there were no reports of a case of efe in adults . therefore , we now report the case of a 57-year - old woman with efe confirmed by histological examination of her explanted heart after heart transplantation . she had been diagnosed with restrictive cardiomyopathy secondary to endomyocardial fibrosis when she was 38 years old . afterward , she had remained in good functional status until she was 53-years - old . when the patient was admitted to our hospital , she complained of dyspnea on exertion { new york heart association ( nyha ) functional class 3 } and abdominal distension over the last several months . the initial blood pressure was 112/56 mmhg , the heart rate 67/minute , the respiratory rate 18/minute , and temperature 35.9. on physical examination , increased jugular venous pressure with kussmaul 's sign and decreased breathing sounds in both lower lung fields were observed . in addition , there were a shifting dullness on her distended abdomen and peritibial pitting edema ( grade 3 ) . laboratory findings showed anemia ( hb 7.9 g / dl ) , hypoalbuminemia ( 2.0 g / dl ) , and elevated n - terminal pro - b - type natriuretic peptide level ( 359.0 pg / ml ) . the electrocardiogram showed no specific abnormality . on the chest x - ray , bilateral pleural effusion the echocardiogram showed severe diastolic dysfunction ( grade 4 ) with normal ventricular size and normal systolic function . coronary angiography was performed and showed normal coronary arteries . on cardiac catheterization , mild pulmonary hypertension ( pulmonary arterial pressure 40/13 mmhg ) , diastolic equilibrium of four chambers , and dip and plateau configuration of ventricular pressure were observed . on cardiac mri , a contrast - enhanced delayed myocardial image demonstrated endocardial hyperenhancement in diffuse area of both ventricles ( fig . finally , the patient received a heart transplantation 5 months later because of progressive heart failure . histological examination showed irregularly thickened endocardium with fibrosis and elastosis in the left ventricle , compatible with the diagnosis of efe ( fig . her one - year follow - up echocardiography and cardiac biopsy showed normal cardiac function and no allograft rejection . efe usually occurs in infants and young children who present with signs of congestive heart failure . efe is an adverse prognostic factor for children and adolescents with dilated cardiomyopathy.4 ) there have been many reports about efe presenting in fetuses , infants and children including a korean report , in which efe was proved by autopsy after sudden unexpected death of the infant.5 - 7 ) there was a korean paper about idiopathic restrictive cardiomyopathy in children , but the pathologic diagnosis was not investigated.8 ) several cases with efe in young adults have also been reported in other countries.4)9 ) interestingly , however , our patient showed an unusually benign course despite extensive fibroelastosis and remained in good functional status until her 50s . . it may be secondary to congenital heart disease , mainly left ventricle obstructive malformations and hypoplastic left ventricle . as for primary efe , different pathogenetic mechanisms have been suggested , such as genetic factors , viral infections , carnitine deficiency , or transplacental crossing of maternal antibodies ( anti - ro , anti - la ) . it has also been suggested to be a nonspecific response to chronic myocardial dysfunction.4 ) in our case , we could not find any etiology for the efe . the diagnosis of efe is difficult to establish because clinical symptoms , electrocardiographic findings and even echocardiographic findings are nonspecific.10 ) there have been papers that concluded that cardiac mri and ct could be useful in establishing the presence of efe.10 - 12 ) stranzinger et al.10 ) reported that , on mri , efe manifested at the endocardial surface as a rim of hypointense signal in the perfusion sequences and as a rim of hyperintense signal in the myocardial delayed - enhancement sequences . on mri for our case , we also noticed a hyperintense signal along the endocardium in the contrast - enhanced delayed myocardial image . the mri image was obtained using a balanced turbofield echo technique after injection of gadobutrol . as the gross specimens of other reported cases showed,4)13 ) we could see the typical efe finding referred to as a whitish fibrous tissue lining the endocardium.14 ) in summary , we report , for the first time in korea , the case of a 57-year - old woman with primary efe presenting as heart failure . we observed very similar findings in her mri image and in the examination of her explanted heart with previous cases of efe reported in other countries .

endocardial fibroelastosis ( efe ) is characterized by deposition of collagen and elastin leading to ventricular hypertrophy and diffuse endocardial thickening . here we report ( for the first time in korea ) the case of a efe presenting with heart failure . the patient was a 57-year - old woman who had complained of dyspnea on exertion { new york heart association ( nyha ) functional class 3 } and abdominal distension at the time of hospital admission . echocardiography showed severe diastolic dysfunction with normal systolic function . on mri , the contrast - enhanced delayed myocardial image demonstrated hyperenhancement in the endocardium . owing to progressive heart failure , the patient was transplanted . histological examination of the explanted heart showed irregularly thickened endocardium with fibrosis and elastosis in the both ventricles , compatible with the diagnosis of efe .

a 65-year - old woman was referred to our department because of a recently diagnosed left atrial ( la ) mass . she presented with a five - month history of fever , malaise , and myalgia and had been diagnosed with ventricular septal defect ( vsd ) two years earlier . on physical examination , two - dimensional transthoracic echocardiography showed an la cyst ( 2423 mm ) that was attached to the interatrial septum and detected the trace of blood flow at the margin of the cyst ( fig . 1 ) . the vsd was a small perimembranous type and the pulmonary blood flow to systemic blood flow ratio ( qp / qs ) was 1.2 . the patient underwent surgical treatment . the cystic mass attached to the left side of the interatrial septum was white - pink - yellowish and oval in shape . the cystic mass was widely excised with the atrial septum , leaving the defect in the atrial septum , and the small vsd was closed with two pledgeted sutures without a patch . the defect on the atrial septum was closed with an artificial patch ( polytetraflouroethylene , gore - tex patch ; wl gore & assoc , flagstaff , az , usa ) . histologically , the mass consisted of myxoid cells in abundant loose and myxoid stroma , and the tumor cells were round or polygonal with eosinophilic cytoplasm ( fig . la myxoma is usually a solid , round or polypoid mass without a cystic structure attached to the interatrial septum . the size of the mass ranges from 1 to 15 cm and is usually about 5 to 6 cm . the mass has solid content with a consistency varying according to the amount of collagen it contains . the preoperative diagnosis of a cardiac mass has been enabled by echocardiographic examination . in this case , it was difficult to establish the diagnosis of the mass preoperatively because of its cystic structure without any content . however , we believed that it was not a simple cyst and that surgical excision was needed because she had had constitutional symptoms . myxomas originated from the mesenchymal cells of the septal endocardium and can present as villous , papillary , sessile or pedunculated pattern and were usually divided into round and polypoid type and the majority of them are solid . the types of cystic masses that can appear in la are as follows : myxoma , hydatid cyst , and interatrial septal aneurysm [ 5 - 8 ] . owing to their many structural similarities , it is difficult to establish an accurate diagnosis using preoperative echocardiography . major complications like stroke , rupture , and hemodynamic problems may develop if they are not removed . therefore the surgical excision of an la cyst is reasonable for establishing a definitive diagnosis and preventing sequelae .

cardiac myxomas are the most common primary benign tumors of uncertain etiology . they usually present as polypoid or oval - shaped masses projecting into a heart chamber from the interatrial septum and have a soft , gelatinous consistency without a cystic structure . we report a case of left atrial myxoma with a single cystic form .

the dermal sinus tract is a potential communication between the skin and the deeper neural structures and present with a variety of clinical features . benign lesions of embryological origin may occur anywhere along the neuraxis , however congenital occipital dermal sinus with an underlying dermoid is rare.[112 ] a 15-year - old girl presented with 7 months history of intermittent occipital headaches that increased on walking , standing and was relieved by rest . there was no postural variation . she also gave a history of sustaining a road traffic accident 6 months prior to presentation after which she was apparently alright and from which she recovered uneventfully . she did not sustain any injury to the occipital region at that time . on examination , she had a small sinus in the region of the occipital protuberance with no active discharge or swelling underneath . neurological examination was within normal limits and she did not have any cerebellar signs . mri brain ( magnetic resonance imaging ) [ figure 1 ] showed a well defined lesion in the region of the vermis - hypointense on t1w , hyperintense on t2w with a patchy contrast enhancement and causing compression on the vermis . a thin tract was seen to extend from the skin surface , coursing downwards and entering the bone just to the left of midline at the level of the torqula . it was seen to be entering the dura just below the torqula and entering into the lesion beneath . the external surface of the lesion had a smooth , pearly appearance with small lobulations . the plane between the cyst and the surrounding structures was relatively good and total resection of the cyst with the sinus tract could be achieved . post - operatively she recovered well without any fresh deficits , seizures or aseptic meningitis . post - operative ct scan ( computed tomography ) showed no residual lesion [ figure 2 ] . histopathological examination of the excised cyst wall revealed a thin fibro collagenous wall with overlying stratified squamous epithelium and focal areas of bone , dystrophic calcification , cholesterol clefts and foreign body giant cells . the cyst lumen showed keratin flakes and hair shafts , suggestive of a dermoidcyst [ figure 3 ] . axial ( a and b ) , saggital ( c and d ) and coronal ( e and f ) non - contrast mri images showing a vermian lesion which is hypointense on t1w ( a , c and e ) and hyperintense on t2w ( b , d and f ) . a faint outline of the occipital dermal sinus tract may be made out on saggital t2w image ( d , circled area ) post - operative ct showing resection cavity ( white arrow ) and fourth ventricle ( ) ( a ) and bone windows showing craniectomy defect ( b ) . x - ray cervical spine showing no klippel - fiel deformity ( c ) tissue resected shows cyst wall lined by flattened , focally stratified squamous epithelium ( a ) adherent to underlying gliotic cerebellar folia . there are foci of calcification , xanthogranulomatous response with giant cells , and cholesterol clefts in the cyst wall ( c ) . focally multinucleated giant cells are seen enclosing hair shaft ( d , asterix ) a : h and exobj.10 , b - d : h7exobj.20 dermoid tumors are not true neoplasms but are inclusion cysts composed of ectodermal elements . they are uncommon lesions , accounting for approximately 0.04 - 0.6% of all brain tumors[1315 ] and are thought to arise as a result of they typically enlarge slowly and accumulate thick , yellowish to viscous greenish brown material that comprises of desquamated epithelium , sebaceous gland secretions , lipid metabolites , fat , oil , and whorls of hair . the presence of hair follicles and sebaceous and sweat glands in the cyst wall distinguishes dermoid from epidermoid cysts . in wright 's review of 127 cases , one fourth of the sinuses were located in the cranium and three fourths in the spine . in an elaborate review of congenital dermal sinuses by french , 85% of all cranial dermal sinuses were located at the occipital protruberance , 11% at the nasion and 5% at the posterior parietal region . of the spinal dermal sinuses , 41% were lumbar , 35% were lumbosacral , 10% were thoracic and a mere 1% were located at the cervical region . inclusion cysts associated with dermal sinus tract ended at or superficial to the dura in 18% of the cases and extended to the subdural or deeper planes in the rest . dermoid cysts have a characteristic non - homogenous appearance on imaging due to its contents . they are usually hypodense on plain ct scan and may have a negative hounsfield unit due to the presence of fat . , the fat content is seen strongly hyperintense on t1w while the other contents appear hypointense . additionally , curvilinear hypointense elements may be seen if the lesion contains hair.[113171921 ] the sinus tract may not be demonstrable on mri in all cases , thus adding to the uncertainty of diagnosis pre - operatively . despite the rarity of lesion , the diagnosis becomes certain if a communicating tract is demonstrated on mri , as in the present case . occipital dermal sinus associated with a dermoid cyst may present with recurrent infections leading to meningitis or cerebellar abscesses , or with obstruction of csf(cerebrospinal fluid ) pathways due to an inclusion cyst compressing the fourth ventricle . despite the proximity , intra - iv ventricular inclusion cysts have only been rarely reported . they may however , rarely present acutely with rupture manifesting as severe headaches , seizures , acute hydrocephalus , visual loss , aseptic meningitis or with focal neurological deficits . imaging in such a case would demonstrate disseminated fat droplets in the sub - arachnoid space or rarely fat - fluid levels in the ventricles . some of the above features may also be seen after partial surgical removal of the cyst wall- a safe strategy to be adopted when there are dense adhesions of the capsule to the surrounding important vascular/ parenchymal structures , injury to which may lead to catastrophic complications . in contrast to partially resected epidermoids , recurrence rates in partially resected dermoids are significantly less . our case presented with non - specific headaches , probably related to minor infections in the sinus tract . intra - operatively , there were no major adhesions and total resection of the cyst and the sinus tract could be achieved .

congenital occipital dermal sinus with an underlying dermoid is a rare , benign lesion of embryological origin and may occur anywhere along the neuraxis . we present a case of a 15-year - old girl with a vermian dermoid and an occipital dermal sinus . gross total resection of the lesion was done and post - operative period was uneventful . a detailed review of the literature is also covered .

it may have vascular , immune - mediated , neoplastic , or metabolic toxic causes . epc is a particular form of epilepsy that is different from common epilepsy because it does not have the tendency to spread . the most frequently used clinical definition1,2 describes it as : epc is spontaneous regular or irregular clonic muscular twitching affecting a limited part of the body , sometimes aggravated by action or sensory stimuli , occurring for a minimum of 1 hour , and recurring at intervals of no more than 10 seconds . epc is spontaneous regular or irregular clonic muscular twitching affecting a limited part of the body , sometimes aggravated by action or sensory stimuli , occurring for a minimum of 1 hour , and recurring at intervals of no more than 10 seconds . characteristic semiological features enable epc to be diagnosed and distinguished from other movement disorders . additional electrophysiological studies , such as an electroencephalogram ( eeg ) , can contribute to enhance the degree of certainty . however , in recent years some unusual manifestations have been described : vukadinovic et al described a case of lingual epc in 2007,3 and espay et al described a case of hemifacial spasm.4 in our case , we report an unusual case of epc presenting with shoulder joint - trunk - hip joint rhythmic jerk , which has not been reported before , in order to bring awareness for clinicians during clinical diagnosis . written informed consent was obtained from the patient for publication of this case report and any accompanying images and this case report was approved by the first hospital of jilin university s research ethics board . a male chinese patient , 33-years - old , was admitted to our hospital after unconsciousness and seizure onset . a family member of the patient reported that the patient had presented with fever a week before , then gradually fell into unconsciousness during which time the patient experienced three seizures . at admission , the patient s body temperature was over 39c , mental symptoms including hallucination and talking nonsense and strange seizures occurred , such as left shoulder - trunk - hip rhythmic jerks , which made diagnosis difficult . a lumbar puncture was done on the fifth day and the cerebrospinal fluid ( csf ) examination found that increased cell numbers of 51 cells raised igg protein to 24.7 mg / dl , and antibodies against the herpes simplex virus was positive . it was suggested that he should take a scalp video - eeg ( high frequency filter at 70 hz , low frequency filter at 0.3 hz ) and a 3.0 t magnetic resonance image ( mri ) . however , after several examinations of the scalp video - eeg , his eeg showed a time - locked abnormal discharge synchronized to the rhythmic jerk ( figure 1 ) , seen as a sharp - slow wave located in the right central - parietal lobe . the patient s mri was normal . on the basis of the current clinical syndrome and the examination results , a diagnosis of encephalitis however , can the recent abnormal movement be interpreted as epc ? based on the detailed functional anatomical analysis , we found that the location of the shoulder joint was close to the hip , which is connected to the trunk in the brodmann 4 area . after such analysis , we treated the patient with experimental antiepileptic medication , such as levetiracetam at 1.0 g / day . after 3 days , the abnormal rhythmic jerk of the shoulder - trunk - hip decreased and gradually disappeared once the dose was increased to 1.5 g / day . the combined functional anatomical analysis , the synchronized abnormal eeg , and clinical therapy allowed us to make a final diagnosis of epc and encephalitis . epc is a kind of clinical syndrome defined as continuous spontaneous jerking , confined to one part of the body , sometimes aggravated by action or sensory stimuli , occurring over hours , days , or even years without spreading to other body regions . some authors have broadly defined epc on clinical ( semiological ) grounds , whereas others have demanded additional electrophysiological evidence regarding the cortical origin of the phenomena to be considered.5 typical clinical signs of epc are : repetitive myoclonic jerks with hemiparesis or with other cortically - generated deficits ; monomorphic , simple , brief excursions of the affected limb ; regular or irregular occurrence of the jerks ; and involvement of distal rather than proximal muscle groups . additionally , electrophysiological studies of time - locked discharge can contribute to an enhanced degree of certainty.6 however , in some complex situations , clinical symptoms and detailed functional anatomical analysis of the brodmann 4 area seem to be much more important to take into account as in our case . as shown in figure 2 , the shoulder , trunk , and hip are located in a certain area of brodmann 4 , epileptic discharges can lead to synchronized abnormal movement of shoulder joint - trunk - hip joint , and regular occurrence of the jerks can be interpreted as a clonic seizure . with antiepileptic treatment , the symptoms disappeared , and the seizures stopped . however , in some special cases , scalp eeg can not capture the discharge due to the smaller range of electrical activity , weaker epileptic potential , or a different position of the electrode . reported elsewhere , other methods have been applied to confirm epc , such as jerk - locked back - average analysis or functional mri ( fmri ) , and so on . espay et al reported an epc case of hemifacial spasm which was diagnosed by applying the eeg - fmri technique in 2008,7 which may be our limitation . additionally , we should pay attention to the etiology of epc . in 1993 , schomer8 reported that in childhood , the most frequent cause of epc is rasmussen encephalitis . at older ages , metabolic , toxic , and other immune - mediated causes account for most of the remaining cases . however , recently some other special epc cases have been reported : hemb et al9 presented an epc case of dysplasia ; lv et al reported an epc case accompanied by dystonia caused by schizencephaly;10 karkare et al showed an epc case of mitochondrial encephalopathy;7 li et al presented an epc case of alpers - huttenlocher syndrome;11 and chhabra et al reported an epc case of hypocalcemia.12 in this epc case , positive antibodies against herpes simplex virus in the csf was found . in addition , antiepileptic drugs or surgery may be the alternative choice according to the different etiology . our report expands the clinical presentation of epc and provides the detailed anatomical and functional correlation to shoulder joint - trunk - hip joint abnormal movements . although the abnormal movement presented in our case has not been described before , our case should call for the attention of clinicians to the potential epileptic seizure .

epilepsia partialis continua ( epc ) is a particular type of epilepsy which is distinguished from common epilepsy by its characteristic semiological features . however , unusual manifestations should be described in order to give awareness at clinical diagnosis . in this case report we describe a rare epc case not previously reported , in which left shoulder joint - trunk - hip joint jerk was present for 1 week . abnormal electroencephalogram and cerebrospinal fluid results supported a diagnosis of viral encephalitis . antiepileptic treatment seemed effective . our report emphasizes that a detailed functional anatomical analysis and synchronized electroencephalogram discharge should be done to avoid misdiagnosis in patients with synchronic shoulder - trunk - hip jerk symptoms .

though gastrointestinal symptoms are relatively common in bd , ulcerative change of the intestine is not that frequent . these include rectovaginal fistula , vesicovaginal fistula , aortoatrial fistula and postoperative complication such as aortoenteric fistula and enterocutaneus fistula . our patient who presented with massive bloody diarrhea and severe pain in rla had a large deep cavitating ileocecal ulcer along with a cecocecal fistula around the previous appendectomy site . a 38-year - old man presented with massive , bloody diarrhea and colicky pain in rla . he had been having recurrent oral ulcer , genital ulcer and erythema nodosum - like lesion for the past ten years . six years ago , he had an appendectomy done at a primary clinic . at that time , the multiple ulcers were noted in the ileocecal region and histology showed minimal inflammation in the appendix . he was referred to the university medical center and diagnosed as having an intestinal bd . after surgery , intermittent severe abdominal pain has occurred while he has been on medication on and off . on examination , he had a regular pulse of 120 beats / min , blood pressure of 70/40 mmhg and body temperature of 36.5c . the lungs were clear to auscultation . though his abdomen was soft , the abdominal examination revealed tenderness and rebound tenderness in rla . he had a hematocrit of 33.5% , a white blood cell count of 11800//mm and a platelet count of 185000/mm . even with enough saline and transfusion of packed red blood cells , he had persistent hypotension and severe abdominal pain . emergency ileocecal segmental resection was performed . pathologic examination revealed large cavitating ulcers(figure 1 ) , lymphocyte aggregates and lymphocytic vasculitis ( figure 2 ) in the ileocecal region . there was cecocecal fistula ( figures 3 & 4 ) presumably around the previous appendectomy site . he was started on oral prednisolone 10 mg / day , sulfasalazine 2 g / day and cyclophosphamide 100 mg / day in the sixth postoperative day . bd is a multisystemic disorder characterized by oral ulcer , genital ulcer , uveitis and skin lesions , most likely occurring with the underlying vasculitis . there is other organ involvement of joints , heart and lungs , as well as neurologic and gastrointestinal involvement . our case fulfilled the diagnostic criteria of the intestinal study group for behcet s disease . many patients complained of gastrointestinal symptoms such as nausea , vomiting and abdominal pain , but the ulcerative changes in the intestine were found in 1% or less of all patients with bd . the commonest sites for the ulcerative changes of intestinal bd were terminal ileum in 44% , followed by the ileocecal region in 34% and the cecum in 12% . the clinical manifestations of intestinal bd are similar to inflammatory bowel disease , especially crohn s disease . but lymphoid aggregates , submucosal fibrosis , no granuloma , and deep penetrating , easily perforating ulcer in behcet s colitis help to distinguish it from crohn s disease . histology in our case revealed lymphoid aggregates , no granuloma and deep penetrating ulcers in the ileocecal region . about 22% of the patients with intestinal bd developed symptoms mimicking appendicitis during the clinical course . because the most common sites of intestinal bd are the terminal ileum and the ileocecal region , some cases can be diagnosed as an appendicitis . we could speculate that vasculitis and ulcer necrosis , along with pathergy reaction by surgical trauma in our case , might have contributed to the fistula formation .

we describe a case of behcet s disease ( bd ) which showed the ileocecal ulcer and cecocecal fistula . this 38-year - old man had appendectomy six years ago because of colicky pain in the right lower abdomen ( rla ) . there are some reports on fistula formation in bd . in those , some are related to surgery and others are not . bd with cecocecal fistula , possibly associated with a past operation , has not been reported in the literature .

clustering genes by their expression profiles among samples and/or across time points is a useful approach to reducing data dimension and identifying co - expressed genes that may share common biological functions or regulatory networks.1 there are three typical experimental designs , under which gene expression data are collected : ( 1 ) multiple samples at one time point , ( 2 ) one sample at multiple time points , and ( 3 ) multiple samples each at multiple time points . data collected under each experimental design possess specific distributional characteristics to that design , which should be properly accounted for in data analysis . for the analysis of gene clustering , we have previously developed a model - based clustering method , called the clustering of regression models ( corm ) method , to accommodate data collected from various experimental designs while accounting for data distributional characteristics specific to each design.2 corm uses regression to model the expression of each gene and clusters genes that share similar regression coefficients to sample covariates . it applies an em algorithm to iteratively assign genes to clusters and estimate the regression coefficients for each cluster . we have implemented corm for the clustering of linear models ( clm ) method and the clustering of linear mixed model ( clmm ) method , with the former applied to cluster genes using cross - sectional data2,3 and the latter time course data with or without replicates.2,4 in this paper , we report an r package that we recently developed implementing the clm method and the clmm method , and for each method , we provide two distinct data examples illustrating their uses . the corm package is available at r cran and it can be imported once installed with the r code below : the clm method is implemented by the function fit.clm . the first example is to cluster genes using microarray data derived from a set of breast cancer samples , including 38 invasive ductal carcinoma ( idc ) and 21 invasive lobular carcinoma ( ilc ) samples.5 two indicator variables , one for idc and another for ilc , were used as the covariates in the regression model for clm . a set of 474 markers , which were selected based on their differential expression between the two breast cancer subtypes idc versus ilc , are grouped into nine clusters with genes in each cluster sharing similar expression levels in both subtypes.2 the second example is to cluster candidate target genes for a microrna named hsa - let-7f using their expression data derived from a set of normal and tumor tissue samples.6 three variables were used in the linear regression model for clm : ( 1 ) let-7f expression , ( 2 ) indicator of disease status , and ( 3 ) interaction between let-7f and disease status . a set of 178 markers , which were selected based on their significant association with let-7f expression , are clustered to look for genes that share similar association with let-7f and hence may be similarly regulated by let-7f.3 the clmm method is implemented by two functions : fit.clmm and fit.clmm.2 . the former can be used to cluster single - time course data or replicated time course data with replicate samples sharing the same time points . the latter can be used to cluster replicated time course with the samples belonging to two groups each having a different set of time points . a single - time course study examining yeast cell cycle is used to illustrate the use of fit.clmm.7 the fixed effects and random effects in the linear mixed effects model are both set to be the spline basis of time . a set of 256 cell cycle - dependent genes identified by zhao et al.8 were clustered into six groups . the expression profiles over time for genes in each group showed significant periodicity with similar peak time within each group and difference between groups.2 a replicated time course study assessing yeast cell cycle in two yeast samples of different genotypes is used to illustrate the use of fit.clmm.2.4 the two genotypes are wild - type yeast and single - mutant yeast with yox1 gene knocked out . the two samples were measured for gene expression at the same time points in the experiment ; however , each sample incurred bad time points at different times due to technical issues , which were removed from the clustering analysis . in order to accommodate the different time points for the two samples , separate arguments for the fixed and random effects are allowed for the two samples in fit.clmm.2 . the same list of 256 cell cycle - dependent genes is partitioned into eight groups using the wild - type and mutant yeast data to look for genes whose expressions are similarly regulated by the mutation.4 the first example is to cluster genes using microarray data derived from a set of breast cancer samples , including 38 invasive ductal carcinoma ( idc ) and 21 invasive lobular carcinoma ( ilc ) samples.5 two indicator variables , one for idc and another for ilc , were used as the covariates in the regression model for clm . a set of 474 markers , which were selected based on their differential expression between the two breast cancer subtypes idc versus ilc , are grouped into nine clusters with genes in each cluster sharing similar expression levels in both subtypes.2 the second example is to cluster candidate target genes for a microrna named hsa - let-7f using their expression data derived from a set of normal and tumor tissue samples.6 three variables were used in the linear regression model for clm : ( 1 ) let-7f expression , ( 2 ) indicator of disease status , and ( 3 ) interaction between let-7f and disease status . a set of 178 markers , which were selected based on their significant association with let-7f expression , are clustered to look for genes that share similar association with let-7f and hence may be similarly regulated by let-7f.3 the former can be used to cluster single - time course data or replicated time course data with replicate samples sharing the same time points . the latter can be used to cluster replicated time course with the samples belonging to two groups each having a different set of time points . a single - time course study examining yeast cell cycle is used to illustrate the use of fit.clmm.7 the fixed effects and random effects in the linear mixed effects model are both set to be the spline basis of time . a set of 256 cell cycle - dependent genes identified by zhao et al.8 were clustered into six groups . the expression profiles over time for genes in each group showed significant periodicity with similar peak time within each group and difference between groups.2 a replicated time course study assessing yeast cell cycle in two yeast samples of different genotypes is used to illustrate the use of fit.clmm.2.4 the two genotypes are wild - type yeast and single - mutant yeast with yox1 gene knocked out . the two samples were measured for gene expression at the same time points in the experiment ; however , each sample incurred bad time points at different times due to technical issues , which were removed from the clustering analysis . in order to accommodate the different time points for the two samples , separate arguments for the fixed and random effects are allowed for the two samples in fit.clmm.2 . the same list of 256 cell cycle - dependent genes is partitioned into eight groups using the wild - type and mutant yeast data to look for genes whose expressions are similarly regulated by the mutation.4 it can be applied to cluster gene expression data collected under various types of experimental designs and forms an integrative analysis framework together with regression models typically used to detect differentially expressed or time - dependent genes . table 1 lists the computing time spent for the aforementioned data examples as tested on a linux server ( intel xeon ) . in our experience , applying the corm method , the em algorithm typically converges in just a few iterations and is quite robust to the starting values when there are relatively well - separated clusters in the data . we would recommend applying corm to about 100500 genes to partition them into reasonably sized clusters .

we report a new r package implementing the clustering of regression models ( corm ) method for clustering genes using gene expression data and provide data examples illustrating each clustering function in the package . the corm package is freely available at cran from http://cran.r-project.org .

nephrotic syndrome may occur in a wide variety of clinical settings such as diabetes mellitus , amyloidosis , systemic lupus erythematosus , membranous nephropathy , focal glomerulosclerosis , as well as minimal change disease ( mcd ) . it is generally recognized that mcd accounts for up to 15% of all cases of adult nephrotic syndrome and is most often of idiopathic origin . the paraneoplastic minimal change nephrotic syndrome , generally defined by a close time relationship between the glomerular disease and the malignancy , is mainly secondary to haematological malignancies . occasionally , solid tumours are associated with mcd and therefore should be searched , especially in older patients . we report on a case of a woman who presented with acute kidney injury and nephrotic syndrome secondary to mcd as the inaugural manifestation of a breast cancer . the patient came off dialysis after a 4-week course of steroids combined with enalapril , and surgical removal of the breast tumour . a 79-year - old woman was referred by her family doctor for dyspnoea , ascites and lower limb oedema that appeared a few weeks previously and rapidly worsened . her past medical history consisted in essential hypertension well controlled by barnidipine and bumetanide , and osteoporotic fractures treated by alendronate . blood and urine tests demonstrated a functional acute kidney injury ( serum creatinine : 256.4 mol / l ; blood urea : 34.9 mmol / l , fractional excretions of sodium : 0.14% and of urea : 4.6% ) with hypoalbuminaemia ( 24 nephrotic syndrome was further confirmed on a 24-h urine collection with a protein / creatinine ratio at 1338 mg / mmol . serological studies for antinuclear antibodies , antineutrophil cytoplasmic antibodies , rheumatoid factors , antistreptolysin - o , hbc , hcv , hiv and complement levels were all negative . the renal doppler ultrasonography displayed normal - sized kidneys without any sign of obstruction or renal veins thrombosis . histopathological examination demonstrated optically normal glomeruli , mild tubular atrophy and the absence of complement or immunoglobulin deposits by immunofluorescence microscopy , consistent with a diagnosis of mcd ( figure 1a and b ) . drugs , infection , atopy and haematological malignancies were reasonably ruled out as possible causal factors of mcd on the basis of biological and clinical findings . ( a ) representative photomicrographs of renal biopsy showing glomerulus of the normal size and no segmental lesions . mild tubular atrophy is found , probably as a result of ischaemic and protein overload processes ( silver stain , 400 ) . ( b ) at higher magnification , the glomerular basement membrane is thin without any spikes ( silver stain , 1000 ) . , the patient 's outcome was marked by a pulmonary oedema uncontrolled by high doses of diuretics , and requiring haemodialysis . a few days later , the patient received prednisolone ( 1 mg / kg per day , orally ) and the angiotensin - converting enzyme inhibitor enalapril . a progressive reduction of proteinuria was observed and renal function parameters improved , allowing us to taper the steroid dosage ( figure 2 ) . time course evolution of renal functional parameters ( serum creatinine and proteinuria ) along with major clinical events . careful physical examination revealed a suspect mass ( 20 15 mm ) in the inner quadrant of her right breast that was further confirmed by mammography and ultrasonography . histopathological examination of a breast biopsy tissue sample demonstrated a moderately differentiated infiltrating ductal carcinoma ( grade ii ) expressing oestrogen and progesterone hormones receptors but not the erb-2 protein . the supraclavicular and axillar areas were free of enlarged lymph nodes and no distant metastasis was found . serum markers ca 15 - 3 and cea were at 27 u / ml ( < 25 u / ml ) and 6.2 ng / ml ( < 4.5 ng / ml ) , respectively . one month later , the patient was dialysis free and the surgical removal of the breast cancer was performed ( final staging pt1cn1cm0 according to the who classification ) . the immediate postoperative period resulted in the nearly complete remission of the renal disease with a serum creatinine level at 114.9 mol / l ( figure 2 ) . unfortunately , the patient developed a fulminant septic shock due to staphylococcus aureus and died 48 h later . the present case draws the physician 's attention to the possible presentation of mcd nephrotic syndrome and acute kidney injury as inaugural manifestations of solid tumour . cancer - related mcd is preferentially linked to haematological malignancies whereas membranous nephropathy is mostly associated with solid tumours such as respiratory and gastrointestinal tract adenocarcinomas . the association between mcd and solid tumours is extremely rare , especially those associated with breast cancer . in this case , the simultaneous presentation of the nephrotic syndrome and the breast cancer is in favour of an association between those two entities . moreover , alternative causes of mcd such as non - steroidal anti - inflammatory agents or antibiotics were excluded . rare cases of biphosphonate - induced nephrotic syndrome have been reported in the literature ; most of them were collapsing focal glomerulosclerosis due to pamidronate and exceptionally to alendronate . on the other hand , barry et al the term paraneoplastic glomerulopathy generally refers to a glomerular disease without specific aetiology and which develops in parallel with cancer evolution phases ( improvement , remission , recurrence ) . in about half of cases , the diagnosis of nephrotic syndrome precedes those of cancer while the simultaneous presentation of both diseases occurs in 30% . taking together , the firm causal link is often missing as in many similar cases , which makes the formal diagnosis of paraneoplastic glomerulopathies uneasy . finally , the beneficial effect of steroid therapy observed in our patient can not distinguish idiopathic form from cancer - associated mcd since pathophysiology of paraneoplastic glomerulopathies involves numerous immunological processes ( cytokines , growth factors or tumour antigens ) susceptible to be efficiently reduced by immunosuppressive treatment . in conclusion , the diagnosis of idiopathic mcd may be firmly assessed only after exclusion of all possible causes such as drugs , infections , allergies and neoplasms , among others solid tumours . our case highlights the fact that a cancer as common as a breast malignancy may have an uncommon inaugural manifestation such as a mcd nephrotic syndrome .

glomerular diseases may occur as primary manifestation of cancer , especially in patients older than 60 years . among glomerulopathies , membranous nephropathy is preferentially associated with respiratory and gastrointestinal tract adenocarcinomas , whereas minimal change disease is most often seen in haematological malignancies . though breast cancer is one of the most frequent malignancies in women , paraneoplastic glomerular disease is rarely observed . we describe the case of a 79-year - old female patient who presented with nephrotic syndrome and renal failure . breast cancer was found . pathological studies of kidney and breast biopsy revealed a minimal change disease and an infiltrating ductal carcinoma , respectively .

p3ht ( 9194 % regioregular , rieke metals ) was dissolved in chlorobenzene ( vwr chemicals ) with a concentration of 0.15 mol l and spin - coated ( 7080 nm ) on znse / pt crystal and glass / ito ( 15 sq , xinyan ) , respectively . quinacridone ( tci ) was purified by repeated temperature gradient sublimation and vacuum - evaporated ( 90100 nm ) on both substrates mentioned before . subsequently , a thin layer ( 40 nm ) of pva ( 99 + % hydrolyzed , aldrich ) solution , 7 mg pva dissolved in 1 ml deionized water , was spin - coated ( 900 rpm ; 3 seconds ) onto the pigment and polymer , respectively , and finally dried under air . the thickness of the pva layer was measured by a dektak profilometer ( bruker ) . pt served as a counter electrode ( ce ) and a silver wire coated with agcl as a quasi - reference electrode ( qre ) , see ref . for fabrication details . a glass / ito electrode covered with a thin film of the studied material , which was deposited as described above , has been used as working electrode ( we ) . in the case of p3ht , we used a concentration of 0.3 mol l. a solution of 0.1 m tetrabutylammonium hexafluorophosphate ( tbapf6 , 99 % , fluka analytical ) in acetonitrile ( roth ) was used as an electrolyte solution . the midpoint potential of the ferrocene / ferrocenium redox couple was found to be + 353 mv vs. ag / agcl ( for a description of non - aqueous reference potential determination see for example , ref . ) . the cyclic voltammograms were recorded at a scan rate of 10 mv s by sweeping the potential between 0 mv and 650 mv for p3ht and between 0 mv and 1400 mv for quinacridone . all spectroscopic measurements have been performed with an ifs 66/s spectrometer ( bruker ) using the atr - ftir technique . for the spectroelectrochemical cell , shown schematically in figure 1 , we used znse / pt / studied material as a we , pt electrode as a ce and an ag / agcl electrode as a qre . znse was covered with a thin layer of pt ( 7 nm ) serving as ir - transparent electrode for contacting the we . we used the same electrolyte solution as mentioned above , which flows through the cell during the measurement . we changed the potential for p3ht between 0 mv and 600 mv in steps of 100 mv and for quinacridone from 0 mv to 1300 mv , also in steps of 100 mv . we plotted the spectra as log(tox / tref ) , where tref is the spectrum obtained at 0 mv for quinacridone and p3ht , respectively , and all other related spectra during oxidation are denoted as tox . p3ht ( 9194 % regioregular , rieke metals ) was dissolved in chlorobenzene ( vwr chemicals ) with a concentration of 0.15 mol l and spin - coated ( 7080 nm ) on znse / pt crystal and glass / ito ( 15 sq , xinyan ) , respectively . quinacridone ( tci ) was purified by repeated temperature gradient sublimation and vacuum - evaporated ( 90100 nm ) on both substrates mentioned before . subsequently , a thin layer ( 40 nm ) of pva ( 99 + % hydrolyzed , aldrich ) solution , 7 mg pva dissolved in 1 ml deionized water , was spin - coated ( 900 rpm ; 3 seconds ) onto the pigment and polymer , respectively , and finally dried under air . the thickness of the pva layer was measured by a dektak profilometer ( bruker ) . pt served as a counter electrode ( ce ) and a silver wire coated with agcl as a quasi - reference electrode ( qre ) , see ref . for fabrication details . a glass / ito electrode covered with a thin film of the studied material , which was deposited as described above , has been used as working electrode ( we ) . in the case of p3ht , we used a concentration of 0.3 mol l. a solution of 0.1 m tetrabutylammonium hexafluorophosphate ( tbapf6 , 99 % , fluka analytical ) in acetonitrile ( roth ) was used as an electrolyte solution . the midpoint potential of the ferrocene / ferrocenium redox couple was found to be + 353 mv vs. ag / agcl ( for a description of non - aqueous reference potential determination see for example , ref . ) . the cyclic voltammograms were recorded at a scan rate of 10 mv s by sweeping the potential between 0 mv and 650 mv for p3ht and between 0 mv and 1400 mv for quinacridone . all spectroscopic measurements have been performed with an ifs 66/s spectrometer ( bruker ) using the atr - ftir technique . for the spectroelectrochemical cell , shown schematically in figure 1 , we used znse / pt / studied material as a we , pt electrode as a ce and an ag / agcl electrode as a qre . znse was covered with a thin layer of pt ( 7 nm ) serving as ir - transparent electrode for contacting the we . we used the same electrolyte solution as mentioned above , which flows through the cell during the measurement . we changed the potential for p3ht between 0 mv and 600 mv in steps of 100 mv and for quinacridone from 0 mv to 1300 mv , also in steps of 100 mv . we plotted the spectra as log(tox / tref ) , where tref is the spectrum obtained at 0 mv for quinacridone and p3ht , respectively , and all other related spectra during oxidation are denoted as tox . as a service to our authors and readers , this journal provides supporting information supplied by the authors . such materials are peer reviewed and may be re - organized for online delivery , but are not copy - edited or typeset . technical support issues arising from supporting information ( other than missing files ) should be addressed to the authors

spectroscopic measurements in the infrared range combined with electrochemistry are a powerful technique for investigation of organic semiconductors to track changes during oxidation and reduction ( p- and n - doping ) processes . for these measurements it is important that the studied material , mostly deposited as a thin film on an internal reflection element , does not dissolve during this characterization . in this study we introduce a technique that allows infrared spectroelectrochemical characterization of films of these materials for the first time . in many cases so far this has been impossible , due to solubility in the oxidized and/or reduced form . this novel technique is shown on thin films of quinacridone by adding a protection layer of poly(vinyl alcohol ) ( pva ) .

but the combination of nasogastric tube and double aortic arch ( daa ) , a rare congenital vascular abnormality , is known to cause fatal aortoesophageal fistula ( aef ) . moreover , daa had never been reported as a cause of superior mesenteric artery ( sma ) syndrome . a 19-year - old woman was admitted to our hospital for nausea and vomiting in april , 2009 . she had a past history of bronchial asthma in her childhood . as she was emaciated due to dysphagia and her unbalanced diet for 1 year , her body indices became low as follows : body height 153 cm , body weight 29.8 kg and body mass index 12.7 . computed tomography ( ct ) revealed that her stomach and duodenum were expanded to their limit , being filled with food , and that the third portion of the duodenum was stenotic between the sma and the abdominal aorta . a nasogastric tube was immediately inserted and over 5,600 ml of gastric contents were drained during the consecutive 4 days , and she became symptomless . esophagogastroduodenoscopy on the 5th hospital day disclosed extramural compression , smooth - surfaced stenosis with top ulceration that might be caused by the physical pressure of the nasogastric tube at the upper esophagus ( fig . a liquid diet was started on the 6th hospital day and the patient became better . suddenly , massive hematemesis appeared and she fell into shock on the 12th hospital day . a retrospective detailed clinical interview disclosed the fact that daa was pointed out in her childhood , although she quitted visiting a clinic since she had no symptoms . daa is a rare vascular congenital abnormality and forms a complete vascular ring tightly surrounding the trachea and esophagus . complete vascular ring is composed of a double aortic arch comprising the right aortic arch with the left ductus arteriosus and the aberrant left subclavian artery . most cases are diagnosed in infancy with only a few exceptions [ 1 , 10 , 11 ] . as symptoms are usually due to compression pressure to the surrounding organs such as the bronchus and esophagus , wheezing , stridor , noisy breathing and dysphasia are usual symptoms . thus , daa tends to be misdiagnosed as bronchial asthma or bronchitis in connection with wheezing and stridor , and as psychosomatic disorders in connection with dysphagia . our case is just such an example , as she was diagnosed with bronchial asthma in childhood and was strongly suspected of anorexia nervosa according to the diagnostic and statistical manual iv ( dsm - iv ) criteria at admission . tracheal development when growing up had gradually hidden the symptoms due to the compression of the trachea and bronchus . actually , adult cases of daa complain of swallowing difficulty rather than respiratory symptoms . both dysphasia due to daa and anorexia nervosa recently , 3d - ct is reported to be more useful for the diagnosis of daa than other modalities . the only therapy for daa is operation , decompressing bronchus and esophagus by dividing the non - dominant arch . the outcome of operation is good and it provides symptomless status in almost all cases . aef that is caused by intubation into the esophagus is reported to be a fatal complication in daa patients , although only 1 case has been reported in adults . as both an inserted tube and the vascular ring together compress the esophageal wall , necrosis and ulceration develop and often result in aef accompanied with massive hematemesis . once exsanguine hemorrhage occurs in daa patients under intubation , aef is a most probable complication , and a sengstaken - blakemore tube ( sb tube ) is only a choice of emergency actions in such instances , controlling hematostasis through its balloon effects , and emergency operation should immediately be taken into consideration . thirteen cases of aef caused by nasogastric tube insertion in daa have been reported so far ( table 1 ) , in which all but 1 case were non - adults . almost all cases had respiratory symptoms that might be related to weakness and immaturity in the bronchus . the duration of intubation with nasogastric tubes spanned 4 to 60 days , which means that intubation periods have no relation to an occurrence of aef . it is crucial to start the treatment quickly , since 3 cases in whom the sb tubes were inserted immediately after the diagnosis of aef were alive . endoscopic observation was performed in 4 cases , but the bleeding point of aef could be revealed in only 1 patient . based on these observations , it may be concluded that endoscopy is less effective in both diagnosis and therapy of aef . the compression of the third portion of the duodenum by the aorta and sma causes the syndrome . as our case showed an extremely dilated full stomach , a nasogastric tube was inserted to drain the gastric content . the patient immediately became symptomless ; thus , the nasogastric tube was removed after 4 days . as a result , aef was abruptly revealed . in this context , our case is extremely special because daa indirectly causes sma syndrome in adults , since dysphagia due to daa may decrease the amount of oral intake and it may in turn result in a marked emaciation that is a major cause of the syndrome . firstly , drainage is apparently needed for sma syndrome , although intubation is a contraindication in daa . secondly , an emergency operation should always be considered whenever aef due to esophageal ulceration is found because endoscopic hemostasis is very difficult , or even impossible . only the sb tube insertion may temporally be effective for a short duration . in our case , operation would have been indicated immediately after the esophageal ulceration was found by esophagogastroduodenoscopy , although in fact we could not imagine in how far it was important . in this context , our alternative proposal is to perform intubation and drainage of the gastric content as soon as possible , and thereafter the repair operation for daa should be indicated , since the operation is inevitable because the symptoms due to daa were already present , one of which was sma syndrome , which must be treated by nasogastric tube insertion . in conclusion , all of us should pay attention to the fact that nasogastric tube insertion is a contraindication in sma syndrome that is caused by daa , since it may cause very serious complications such as aef . whenever massive hematemesis occurs in daa patients under nasogastric tube intubation , sb tube is a possible temporary choice of action , and following emergency operation is mandatory . thus , we believe that before intubation for sma syndrome a detailed clinical interview clarifying whether a past history of daa exists is mandatory to avoid aef .

double aortic arch ( daa ) is a rare vascular congenital abnormality . since a vascular ring surrounds bronchus and esophagus , any oral or nasal intubation can physically cause fatal aortoesophageal fistula ( aef ) . we report herein the first case of association of daa and superior mesenteric artery ( sma ) syndrome and the second case of aef caused by nasogastric intubation in an adult with daa . a 19-year - old woman visited our hospital for nausea and vomiting . she was diagnosed with sma syndrome by computed tomography ( ct ) . nasogastric intubation relieved her symptoms in 4 days . extramural compression with top ulceration was found in esophagogastroduodenoscopy on the 5th hospital day . she suddenly showed massive hematemesis on the 12th hospital day . aef was found by ct . soon , she died despite of intensive care . retrospective interview disclosed the fact that daa was pointed out in her childhood . we conclude that intubation must be avoided in daa and a detailed clinical interview about daa is mandatory to avoid aef .

fat embolism syndrome ( fes ) is more common following severe injuries with multiple fractures and fractures of long bones but can also occur in orthopaedic procedures , most commonly during intramedullary nailing of the long bones or hip or knee replacements [ 1 - 3 ] . most cases do have certain predisposing factors like fat patient , longer injury surgery interval , reamed nailing etc . a 23 year old female was admitted to hospital 3 hours after being hit by motor cycle while she was crossing the road . the patient was lean & thin . the height of the patient was about 152 cm and weight of patient was 45 kg . she sustained closed short oblique fracture of tibia and fibula at middle third junction with no associated injury . elective surgery was done by unreamed tibial interlocking nail under spinal anaesthesia , 4 hours after admission . body temperature was 39 , and respiratory rate was about 40/min with pulse rate of 136/min . arterial blood gas analysis was done- po2 was 49.1 mmhg , pco2 was 33.8 mmhg , o2 saturation82.1% , s.na+-134 mmol/ l , s.k+--4.2 mmol / l . patient was diagnosed as a case of fat embolism and was heparinized in the dose of 5000 iu subcutaneously every 12 hourly . she was intubated , put on ventilator and was oxygenated . at the time of intubation , she had a respiratory rate of 42 / minute , sbp of 95 mm hg , peripheral pulse of 120 / minute , and o2 saturation of 82.1% . at clinical examination , patient was on ventilator for 3 days , was given cppv breathing for another 2 days and was then extubated without any problems . preoperative radiograph of left leg showing short oblique fracture of tibia and fibula at middle third junction with narrow canal . it develops in 0.5% to 2% of all patients with fractures of the long bones and has been associated with high morbidity and mortality . there is usually a latent period of 24 to 72 hours between injury and onset , but in this patient symptoms appeared within 16 hours after trauma & 4 hours after internal fixation . the onset is then sudden , with breathlessness & chest pain , high pulse rate , petechial rash present in conjunctivae . central nervous system symptoms , disorientation , confusion , renal - oligouria and drowsiness are common . for appropriate management of patient of fat embolism , embolism should be diagnosed early and appropriate supportive measures started immediately . our patient was low risk for fat embolism but the unexpected event did occur in her . surgeon should always be conscious about such outlier occurrences and staff should be trained enough and be vigilant in post - op period till 4 days post - op . immediate postoperative radiograph showing internal fixation of the fracture by interlocking nail of the tibia .

incidence of fat embolism syndrome ( fes ) in fractures is about 16.3 but sometimes it is as high as 50% to 62% . the fat embolism is common in fatty bed ridden patients and in whom reamed interlocking is performed under tourniquet with prolonged injury - surgery interval . however in the case discussed here fes occurred under the exact opposite circumstances . in this 23 year lean and thin female with closed tibia fracture unreamed interlocking was performed without tourniquet & the operative procedure was done within 4 hours after trauma . her pre - operative investigation were within normal limit . we want to discuss by this case report to highlight that even when risk factors are absent outlier events of fes can occur in any case and symptoms should not be discounted

ivemark syndrome is a heterotaxy syndrome affecting multiple organs of the body , often presenting with congenital asplenia and cardiac problems [ 1 , 2 ] . commonly seen as right isomerism , typically there are two right - sided lungs and right - sided atria . the heart contains septal defects with right ventricular hyperplasia . additionally , the pulmonary venous return is irregular , long , and tortuous as it winds back to the heart . life expectancy is heavily reduced with 10% of cases dying within the first 24 h and 80% dying within the first year of life . these cardiac problems may include obstruction of pulmonary venous connections , seen in 48% of patients with heterotaxia and total anomalous pulmonary venous return ( tapvr ) . here , we discuss an unusual case of tapvr causing bronchial stenosis using cardiac ct angiogram to produce 3d functional figures displaying the anomalous pulmonary venous back to the left atrium . a 3-month - year - old male with total anomalous pulmonary venous connection , a double - outlet right ventricle , congenital stenosis of the pulmonary artery valve and heterotaxy syndrome with asplenia is one of twins who presented clinically stable . his right - sided pulmonary veins use an alternate route back to the heart as they drain into a right - sided vertical vein which passes under the carina and then back over the left main bronchus , joining the left lower lobe pulmonary vein to empty into the left atrium ( figs 1 and 2 ) . as a result , also , there is systemic venous communication with the left - sided vertical vein , left subclavian vein and the hemiazygos system ( figs 5 and 6 ) . the left venous vertical vein is shown passing over the left mainstem bronchus ( yellow ) as it enters the heart . multiple pulmonary vein branches are shown conjoining together to form the left - sided vertical vein ( white arrow ) . it dips under the carina and loops back over the left mainstem bronchus ( yellow ) . the left venous vertical vein is shown passing over the left mainstem bronchus ( yellow ) as it enters the heart . multiple pulmonary vein branches are shown conjoining together to form the left - sided vertical vein ( white arrow ) . it dips under the carina and loops back over the left mainstem bronchus ( yellow ) . additionally , there is a clockwise rotation of the aortic root , but the coronary arteries still originate from their respective sinuses ( figs 3 and 4 ) . there is no aortic insufficiency or stenosis , nor is there any aortic coarctation ( figs 5 and 6 ) . he also has both a large ventricular septal defect ( vsd ) with a septum primum atrial septal defect ( asd ) , with a double - outlet right ventricle and left ventricle hypoplasia ( figs 5 and 6 ) . figure 3:ct 3d showing anterior pulmonary arterial circulation ( blue ) . both left and right branches are nearly identical , characterized by the two right - sided lungs . the left - sided subclavian vein ( light blue ) brings blood to the right atrium ( light blue ) . the right ventricle ( dark purple ) provides outflow to both the aorta ( red ) and the pulmonary arteries ( dark blue ) . the multiple branches of the pulmonary veins ( pink ) can be seen coming together and wrapping over the left mainstem bronchus . the hypoplastic left ventricle ( white arrow ) can be seen small and shrunken slightly to the left of the large right atrium . this view focuses primarily on the anomalous branching and route of the pulmonary venous flow in relation to other vessels and airways nearby . the left - sided vertical vein can be seen traveling over the left bronchus ( white arrow ) . both left and right branches are nearly identical , characterized by the two right - sided lungs . ct 3d showing anterior heart and circulation . the left - sided subclavian vein ( light blue ) brings blood to the right atrium ( light blue ) . the right ventricle ( dark purple ) provides outflow to both the aorta ( red ) and the pulmonary arteries ( dark blue ) . the multiple branches of the pulmonary veins ( pink ) can be seen coming together and wrapping over the left mainstem bronchus . the hypoplastic left ventricle ( white arrow ) can be seen small and shrunken slightly to the left of the large right atrium . this view focuses primarily on the anomalous branching and route of the pulmonary venous flow in relation to other vessels and airways nearby . the left - sided vertical vein can be seen traveling over the left bronchus ( white arrow ) . ivemark syndrome is a unique form of heterotaxy , taking the right - sided form and thus resulting in no spleen development . many times it is associated with anomalous pulmonary venous return , with the newly oxygenated blood traveling a long or ambiguous route back to the heart . unfortunately , this kind of anomalous pulmonary venous return is different patient - to - patient contributing to the need for cardiac ct angiogram and subsequent 3d functional figures . the concurrent septum primum asd with corresponding vsd makes this issue very difficult to correct . due to the double - outlet right ventricle , there is a largely hypoplastic left ventricle and hyperplastic right ventricle . both the pulmonary and systemic circulation falls upon the pumping action of the right ventricle , when typically the left ventricle handles the systemic circulation and the right ventricle handles the pulmonary circulation . subsequently , the disuse of the left ventricle puts additional pressure on the right , increasing the pressure at which the right ventricle pumps out blood . typically , the pulmonary circulation has lower blood pressure due to the nature of the small capillaries the blood passes through . the left ventricle usually pumps harder in order to provide circulation throughout the entire length of the body . with the right ventricle now serving as pumps for both types of circulation , there is the possibility of pulmonary edema and poor blood perfusion throughout the body . without efficient oxygenation of all of the blood and the adequate circulation of oxygenated blood out of the heart , the patient will likely suffer from chronic poor perfusion and shortness of breath , as well . additionally , the pulmonary veins curve over the left mainstem bronchus causing it to narrow compared to the right mainstem bronchus . with the heterotaxy seen in this patient , both lungs are right - sided causing the same slight angle of entry into the lungs by both mainstem bronchi . the slight narrowing of the left mainstem bronchus could lead to problems with breathing and physical activity . as of yet , there have not been many attempts in permanently correcting these issues in ivemark patients . apart from a bidirectional glenn operation to shunt blood from the vena cava to the pulmonary arteries and therefore bypass the right side of the heart , these patients must be kept under close observation for visible distress due to the heart condition .

abstractivemark syndrome is a heterotaxy syndrome which affects multiple organs and affects roughly 1 in every 6000 deliveries . specifically , it can cause total anomalous pulmonary venous return and cardiac defects , which ultimately lead to decreased life expectancy . in order to better understand the nature of cardiac structures , ct angiogram has been heavily relied upon as it also allows for 3d reconstruction and optimal visualization of those features . this specific case presents with an anomalous venous return accompanied by multi - organ right isomerism that was reconstructed with 3d ct angiogram to better visualize and understand the cardiopulmonary system , as well as contribute to a fund of knowledge in hopes of discovering a solution to this condition .

cutaneous larva migrans ( clm ) also known as creeping eruptions and epidermatitis linearis migrans is caused by hookworm , most commonly ancylostoma braziliense and ancylostoma caninum . this acquired dermatosis is caused by infective larval form of the dog or cat hookworm which may accidentally penetrate the intact skin and then wander through the epidermis . a 2-month - old female child presented with a progressive rash over the left buttock of 4 days duration . initially the lesion started as a solid , raised swelling , which gradually progressed in a serpiginous manner in the left gluteal region . cutaneous examination showed an urticarial papule progressing to erythematous , tortuous , thread - like tract extending a few centimeters from the papule over the left gluteal region [ figure 1 ] . urticarial papule with serpiginous tract over left gluteal region a clinical diagnosis of clm was made . venereal disease research laboratory test , human immunodeficiency virus and hepatitis surface antigen were negative . baby was started on syrup albendazole 15 mg / kg body weight for three consecutive days . although clm is globally distributed , it is endemic in caribbean islands , africa , south america , south east asia and south eastern united states . it is a peculiar dermatosis caused by hookworm larvae such as a. braziliense , a. caninum , a. ceylonium , uncinaria stenocephala and bubostomum phlebotomus . other rare causes are strongyloides stercoralis , dirofilaria spp , gnathostoma spp and loa loa . it was first described in 1874 . people frequently visiting beaches , working in crawl spaces under houses , children especially playing in sand boxes are at high risk . a few reports of clm in infants of crawling age are reported . however , our patient was very young and unable to move . prolonged contact with contaminated soil either at home or at the parent 's work place was the probable route of spread , in our patient . these nematodes normally do not parasitize human skin , but the infective larval form of the dog or cat hookworm may accidentally penetrate the intact skin and then wander through the epidermis . the larvae secrete proteases and hyaluronidase , which facilitate the penetration and migration through epidermis . clinically , tingling or pricking sensation may be noted , followed by an erythematous , linear or serpiginous raised lesion that advances at the rate 2 mm3 cm per day . most common sites of involvement are feet ( interdigital spaces , dorsa of feet and medial aspects of sole ) , buttocks and hands . rarely anterior abdominal wall , penile shaft , perianal area , sole , oral cavity or breasts may be involved . secondary impetization , eczematization , bullous lesion , folliculitis or visceral larva migrans including loeffler 's pneumonia may complicate . differential diagnosis include larva currens , cercarial dermatitis , contact dermatitis , scabies and migratory myiasis . although a skin biopsy is of limited value , when taken ahead of the track , may show larva ( pas - positive ) suprabasally , spongiosis , intra - epidermal vesiculation and dermal eosinophilic infiltrate . epiluminescence microscopy , reflectance confocal microscopy and optical coherence tomography are other useful diagnostic tools . awareness , early recognition and treatment help in preventing complication . avoiding contact with contaminated soil helps in prevention .

cutaneous larva migrans or creeping eruptions is a cutaneous dermatosis caused by hookworm larvae , ancylostoma braziliense . a 2-month - old female child presented with a progressive rash over the left buttock of 4 days duration . cutaneous examination showed an urticarial papule progressing to erythematous , tortuous , thread - like tract extending a few centimeters from papule over the left gluteal region . a clinical diagnosis of cutaneous larva migrans was considered . treatment with albendazole led to complete resolution , confirming the diagnosis . this is to the best of our knowledge , the youngest age at which this condition is being reported .

coronary artery lesions are the most serious complications of kd ; they can lead to myocardial infarction , coronary artery dilatation and sudden death in the acute and subacute phases of the illness . there is no diagnostic test for kd , with the diagnosis being based on the clinical features . the diagnostic criteria for classic kd are : prolonged fever lasting longer than 5 days , diffuse mucosal inflammation , bilateral nonexudative conjunctivitis , dysmorphic skin rashes , indurative angioedema of the hands and feet and cervical lymphadenopathy . the potentially severe outcome of either classic or incomplete kd without therapy emphasizes the importance of the identification and treatment of all patients with the disease . a 6-year - old boy was referred to the department of ophthalmology , marmara university school of medicine , with the diagnosis of orbital cellulitis . four days prior to presenting at our department , he had been referred with complaints of irritation to an ophthalmologist . consultation with a pediatrician due to his fever resulted in a diagnosis of conjunctivitis and pansinusitis and he was treated with ampicillin - sulbactam and ceftriaxone 100 mg / kg / day . in the following 3 days , restriction of upgaze in the right eye and inflammation of the eyelids began and he was referred to us with a diagnosis of orbital cellulitis . an initial examination revealed normal visual acuity , bilateral conjunctivitis with excessive secretion , periocular inflammation and edema , right preauricular lymphadenopathy and right restriction in the upgaze and his lips were dry and cracked ( fig . his erythrocyte sedimentation rate on the first day of hospitalization was 55 mm / h and the c - reactive protein level was 22.4 mg / dl . laboratory findings included a white blood cell ( wbc ) count of 19,000 cells per mm , with 81.5% neutrophils , 15.0% lymphocytes , 1.2% monocytes and 0.4% basophils . after 10 days of hospitalization without a clear response to antibiotherapy , periungual desquamation of the fingers started ( fig . 3 ) . pediatric examination revealed a strawberry tongue . repeated laboratory tests revealed a total wbc count of 15,300 cells per mm with 63.8% neutrophils , an elevated platelet count ( 650,000 mm ) , an erythrocyte sedimentation rate of 52 mm / h and an elevated c - reactive protein level of 46.3 mg / dl following the algorithm defined previously , we concluded a diagnosis of incomplete kd ( table 1 ; online suppl . table 2 , see www.karger.com/doi/10.1159/000257258 ) . with the first echocardiography , no coronary artery lesions were detected . aspirin ( 100 mg / day ) was administered and by the third day of its administration , the orbital cellulitis and fever had regressed and the patient was discharged from hospital with oral antibiotics and aspirin . after 6 weeks , his control echocardiography revealed dilatation of the right and left coronary arteries and the diagnosis of incomplete kd was confirmed . he was treated with a single dose of intravenous immunoglobulin , 2 mg / kg over 10 h. incomplete kd should be considered in children who have unexplained fever for at least 5 days that is associated with two or three of the five diagnostic criteria for kd ( table 1 ) . although laboratory values are nonspecific and nondiagnostic , they are quite characteristic and may prove useful in reducing suspicion of incomplete kd . typically , there is an elevated wbc count , platelet count , esr and crp . kd results from an inappropriate immunological response to one or more infectious triggers in genetically susceptible individuals and fits between an infectious and an autoimmune disease on the spectrum [ 5 , 6 ] . in this particular case , unresponsiveness to antibiotics but a good response to aspirin may have been associated with orbital inflammation as a part of kd . although the existence of orbital lymphatics is controversial [ 7 , 8 ] , rowley et al . reported a characteristic , selective pattern of iga plasma cell infiltration in acute kd in vascular and nonvascular tissue . this iga plasma cell migration capability that manifests in kd may explain the peculiar presentation with orbital cellulitis . atypical kawasaki disease should be reserved for patients with complications that are generally not seen in kd . our case could therefore be defined as atypical kd . once previously , kd was reported as presenting with orbital cellulitis . this case is an interesting example showing that an orbital cellulitis unresponsive to antibiotherapy should be investigated for underlying kd . the consequences of kd may be mortality and serious morbidity , so ophthalmologists should always be careful when pediatric patients present with fever and orbital cellulitis .

a 6-year - old boy was referred to our hospital with orbital cellulitis . he had a history of 7 days of fever despite antibiotherapy . at first , he only had pharyngitis and conjunctivitis , but then an orbital mass evolved which restricted the movement of his right eye and there was also periorbital inflammation resembling orbital cellulitis . examination at presentation revealed conjunctivitis with secretion , periocular inflammation and edema , right - preauricular lymphadenopathy and restriction of upgaze in the right eye . laboratory findings included a white blood cell count of 19,000 cells per mm3 , with 81.5% neutrophils , 15.0% lymphocytes , 1.2% monocytes and 0.4% basophils . the erythrocyte sedimentation rate was 52 mm / h and the c - reactive protein level was 46.3 mg / dl . magnetic resonance imaging confirmed orbital cellulitis and pansinusitis . vancomycin ( 60 mg / kg / day ) and meropenem ( 100 mg / kg / day ) were administered , but desquamation on his fingertips and a rash appeared on the tenth day . a pediatric consultation resulted in a diagnosis of incomplete kawasaki disease ( kd ) . after administration of aspirin , the orbital inflammation regressed in 3 days . no coronary artery lesions were detected on the first echocardiography , but these did appear 6 weeks later . this confirmed the kd diagnosis .

a 35 year old woman presented with lower abdominal pain , vaginal bleeding , and dyspareunia . during gynecological diagnostic laparoscopy , a pelvic floor hernia was suspected , and a general surgical evaluation was sought . at a subsequent laparoscopy , the diagnosis of a left direct inguinal and a right obturator hernia was made . at follow - up at one and six weeks postoperatively , the patient 's complaints of pain had completely resolved . the usual presenting signs and symptoms are non - specific . without conclusive historical or physical findings , this entity , once diagnosed laparoscopically , can be repaired simultaneously via laparoscopic mesh technique . obturator hernia is an anterior pelvic floor hernia which occurs through the obturator canal , adjacent to the obturator vessels and nerve . obturator hernias are acquired lesions that are thought to result from progressive laxity of the pelvic floor which may be associated with multiparity , increasing age and chronically elevated intra - abdominal pressure . reported incidence of obturator hernia ranges from 0.05% to 0.07% of all hernias , making them the most common of all the rare pelvic floor hernias . previous authors have characterized the typical obturator hernia patient as an emaciated , dehydrated , multiparous female . although we may define characteristics of susceptible patients , symptoms of obturator hernia are often vague , making the preoperative diagnosis challenging . symptoms may include abdominal pain , vomiting , howship - romberg sign , recurrent bouts of intestinal obstruction , or a palpable upper thigh mass . for diagnosis and treatment , some authors advocate early use of laparotomy while others prefer preoperative non - invasive diagnostic methods such as ct5 , or contrast radiographs . we present a case of a relatively young woman with an atypically symptomatic obturator hernia diagnosed and repaired laparoscopically . a 35 year old , 72 kg , female presented to her gynecologist with a one year history of lower abdominal pain , dyspareunia , and vaginal bleeding after intercourse . hysteroscopy , fractional dilation and curettage ( d&c ) , and diagnostic laparoscopy were planned . anterior and posterior cul - de - sacs were clear , and both ovaries were normal . photographs of the pelvic floor were taken because of a suspicion of possible disruption in the continuity of the peritoneum . when the images were subsequently reviewed by the general surgeon , bilateral pelvic hernias without incarceration were identified . two additional 12 mm trocars were placed on either side of the abdomen at the umbilical level . the left direct inguinal hernia was treated by simple sac ligation utilizing 2 - 0 vicryl endo loops . the repair of the obturator defect was performed by incising the peritoneum of the anterior abdominal wall above the inguinal ligament , then medially to the right umbilical ligament , and laterally to the right inferior epigastric vessels . the peritoned flap was further developed down to the most caudal aspect of the obturator hernia . the skeletonized obturator defect was then closed by application of two pieces of 3 by 5 inch polypropylene mesh over the right obturator , femoral and inguinal areas . the mesh was stapled to the abdominal wall and cooper 's ligament , with care taken to avoid the epigastric vessels . the peritoneum was then closed over the mesh with staples . the abdominal wall fascial defects were closed with # 1 pds suture using an endoclose device . there were no complications ; the patient recovered uneventfully and was discharged on post - operative day one . at follow - up at one and six months , the patient 's symptoms had completely resolved . obturator hernias account for 1.4% ( 17 of 1178 ) of all hernias of the abdominopelvic wall . to date , approximately 743 cases of obturator hernia have been reported in the english language literature , eight of which were repaired laparoscopically . the majority of patients are between 70 and 90 years old at presentation - exceptionally , a patient as young as 32 days old has been reported . the female pelvis is wider and the obturator canal opening is more triangular with a greater transverse diameter , perhaps providing less resistance to herniation . it is postulated that with severe weight loss there is a decrease in the protective preperitoneal fat from the obturator canal . similarly , conditions associated with increased intra - abdominal pressure ( e.g. , chronic constipation , pulmonary disease , and ascites ) may also thin the preperitoneal fat and predispose patients to all types of hernias . pregnancy and chronic illness also predispose patients to hernia formation by increasing intra - abdominal pressure and relaxing the peritoneum . there are four classic features of an obturator hernia : ( 1 ) a palpable mass in the groin with the patient supine , and the thigh flexed , adducted and rotated laterally ; ( 2 ) intestinal obstruction ; ( 3 ) previous attacks of bowel obstruction resolving spontaneously ; ( 4 ) the howship - romberg sign . the howship - romberg sign is medial thigh and hip pain exacerbated by adduction and medial rotation of the thigh and relieved by thigh flexion . the characteristic clinical profile of previously reported patients is that of an elderly , emaciated woman with concomitant medical illness , but without previous abdominal surgery , presenting with intestinal obstruction . our patient was young , of average weight , and had two prior pregnancies ( although one for twins ) . she had no abnormalities detected on physical examination , nor episodes of bowel obstruction , but had pain with intercourse as her most prominent symptom . although there is no consensus of opinion , previous authors have recommended the abdominal approach to suspected obturator hernias because one can establish the diagnosis , obtain adequate exposure , protect the obturator vessels , and identify and resect compromised bowel when necessary . an abdominal approach through a lower mid - line incision is most favored , although the inguinal approach and the cheatle - henry retropubic approach may also be used . we believe that a laparoscopic approach for suspected obturator hernia is superior to described open techniques . because variable symptomatology makes its preoperative diagnosis difficult , laparoscopy offers a relatively noninvasive method to identify and treat obturator hernias . no special skills are required beyond those now commonly in use for laparoscopic repair of inguinal hernias , and recovery should be shorter than after laparotomy . controversies regarding costs and operative time are analogous to those regarding groin hernias and will be ongoing . appropriate patient selection , sound surgical judgment , and adherence to established principles of laparoscopic repair of the pelvic floor are essential to success .

objective : review of international literature reveals eight reported cases of laparoscopic obturator hernia repair . non - specific signs and symptoms make the diagnosis of an obturator hernia difficult . laparoscopic intervention provides a minimally invasive method to simultaneously diagnose and repair these hernias.methods and procedures : a 35 year old woman presented with lower abdominal pain , vaginal bleeding , and dyspareunia . during gynecological diagnostic laparoscopy , a pelvic floor hernia was suspected , and a general surgical evaluation was sought . at a subsequent laparoscopy , the diagnosis of a left direct inguinal and a right obturator hernia was made . both were repaired laparoscopically with polypropylene mesh.results:at follow - up at one and six weeks postoperatively , the patient 's complaints of pain had completely resolved.conclusion:the diagnosis of obturator hernia is problematic . the usual presenting signs and symptoms are non - specific . without conclusive historical or physical findings , laparoscopy is an excellent method for diagnosing obturator hernia . this entity , once diagnosed laparoscopically , can be repaired simultaneously via laparoscopic mesh technique .

meckel 's diverticulum ( md ) is remnant by incomplete obliteration of the vitelline or omphalomesenteric duct around the seventh or eighth week of gestation [ 1 - 3 ] . it is a true diverticulum that usually arises from the antimesenteric border of the distal part of ileum and contains all layers of the normal intestinal wall . it is the most common congenital anomaly of the gastrointestinal tract , with an estimated prevalence of 2% ( 0.14% to 4.5% in autopsy studies ) . about 90% of mds occur within 60 to 100 cm of the ileocecal valve ( icv ) and mean distance from the icv varies with age and measures about 3 cm in length [ 4 - 6 ] . we report a case of radiographically diagnosed chronic inflammatory mass caused by adenocarcinoma arising from md in the ileum . a 19-year - old woman received an examination from the department of gynecology with complaints of pain in the left lower abdomen . laboratory test results included the following : carbohydrate antigen ( ca ) 125 , 38.75 u / ml ( normal , 0 to 35.0 u / ml ) ; ca 19 - 9 , 2,038.0 u / ml ( normal , 0 to 36.10 u / ml ) . a sonography by the gynecologist revealed a right ovarian cyst ( 8.2 cm 7.4 cm ) but computed tomography ( ct ) revealed a chronic inflammatory mass ( abscess from unknown etiology , 6.7 cm 6.4 cm 6.3 cm ) with severe inflammatory infiltrations into adjacent mesentery , sigmoid colon and small bowel loops and magnetic resonance imaging indicated the same findings ( fig . 1 ) . positron emission tomography ( pet)-ct revealed a malignant tumor in the pelvic cavity abutting the small bowel and rectum ( fig . 2 ) . colonoscopy revealed erythematous masses like external indentations on the distal descending colon ( 50 cm from anal verge ) and sigmoid colon ( 15 cm from anal verge ) ( fig . she underwent laparoscopic exploration . during operation , a 6 cm - sized mass in the antimesenteric border of the ileum was noted , approximately 40 cm proximal from the icv . intraoperative frozen biopsy was performed and the temporary pathologic report showed metastatic adenocarcinoma , probably originating from the colon or endometrium . intraoperative endometrial biopsy was performed by the gynecologist and a frozen biopsy showed no tumor on endometrium . the final pathological diagnosis was adenocarcinoma , moderately differentiated ( 6.0 cm 4.0 cm ) from md with serosa invasion and one regional lymph node metastasis ( t4n1m0 , stage iiia according to the 7th american joint committee on cancer classification ) . in 1598 , wilhelm fabricius hildanus , a german surgeon , first described the presence of a diverticulum of the small bowel occurring in the distal part of the ileum , which later came to be called by the last name of the german anatomist , johann friedrich meckel who first described its embryological origin in 1809 . the total lifetime risk of complication in patients with a meckel 's diverticulum is not greater than 4% with a high male predominance ( male - to - female ratio ranging from 1.8:1 to 3:1 ) . acute or intermittent intestinal obstruction is the most common complication in adult patients and incidence rates of obstruction varied from 22% to 50% . neoplasms arising from meckel 's diverticulum are uncommon and quoted to be 0.5% to 3.2% with carcinoids as the most common malignant tumors occurring in this site . other reported cases include sarcomas , adenocarcinomas , benign mesenchymal tumors , melanoma , and lymphoma . a pubmed search was performed for all articles with the following words in the title , abstract , or keywords : " meckel 's diverticulum " , " adenocarcinoma " . since 1992 , 30 people with adenocarcinoma were reported with nine people having been additionally reported so far . in the surveillance , epidemiology and end results ( seer ) program in the united states from 1973 to 2006 , 18 people have been reported . it may arise mainly from heterotopic tissue within the diverticulum , including pancreatic tissue , duodenal , jejunal , colonic and gastric mucosa . in the few cases described so far , prognosis has been reported as very poor . it is extremely difficult to diagnose , preoperatively , malignancies in a meckel 's diverticulum . the suspicion of its malignancies is often difficult at the initial stage of patient management . when malignancies are suspected or diagnosed as malignancies before surgery , it is more likely to be advanced stage . there were some reports about the coincidence of meckel 's diverticulum with intestinal malrotation in children . ford et al . had reported the coincidence of meckel 's diverticulum up to 11% in children diagnosed with intestinal rotation . in adults , there are few reports about meckel 's diverticulum associated with intestinal malrotation ; especially , no report associated with malignant tumor . in our case , the patient had chronic inflammatory mass on the left lower abdomen that was suspected as a malignant tumor in the pelvic cavity by pet - ct . during operation , we found a 6 cm - sized meckel 's diverticulum in the antimesenteric border of the ileum with malrotation of the midgut incidentally at exploration . , our case demonstrates that adenocarcinoma arising from meckel 's diverticulum is difficult to diagnose preoperatively and has poor prognosis . we accidentally found an intestinal malrotation in this case , first reported in the literature .

meckel 's diverticulum ( md ) is a true congenital diverticulum that is remnant by incomplete obliteration of the omphalomesenteric duct . it is the most common congenital anomaly of the gastrointestinal tract , with an estimated prevalence of 2% ( 0.3% to 3% in autopsy studies ) . about 90% of md occurs within 100 cm of the ileocecal valve . a primary malignant tumor arising within an md is extremely uncommon . malignancies are reported to account for only 0.5% to 3.2% of the complications . carcinoids are the most common malignant tumors occurring in md . adenocarcinomas are extremely uncommon and very poor prognosis has been reported . we report a case of radiographically diagnosed chronic inflammatory mass caused by adenocarcinoma arising from md in the ileum with malrotation of the midgut incidentally discovered at exploration .

non - hodgkin lymphomas ( nhl ) are a spectrum of neoplastic diseases arising from lymphatic germ lines . the definition of primary extranodal lymphoma remains a controversial issue and the different definitions impact on incidence and prognosis . most of them originates from the gastrointestinal tract , but other common sites are skin , orbit and salivary glands ; less frequently they have been found in the lung , thymus , breast , brain , bone and soft tissue . a 63 year - old caucasian woman presented to the emergency department at wonford hospital , exeter , uk , with gradual onset abdominal pain in the upper right quadrant and in the suprapubic region , nausea and malaise . her past medical history was of a single episode of sigmoid diverticulitis , which was treated conservatively , and she was not on regular medications . on presentation laboratory blood tests revealed a normal white cells count ( 10.910/l ) and mildly raised c - reactive protein ( 54 mg / l ) , while renal and liver function parameters were within the normal range . computed tomography ( ct ) scan of the abdomen showed a thick - walled gallbladder containing large calcified stones , suggestive of chronic cholecystitis . symptoms improved promptly with intravenous antibiotics and the patient was discharged home after five days with a three days course of oral antibiotics . the intraoperative findings were of grossly inflamed thick walled gallbladder , and dense adhesions between the greater omentum , the liver and the gallbladder . the patient was sent home the same day of surgery and the following postoperative course was uneventful . routine histological examination of the gallbladder showed findings in keeping with a low grade small lymphocytic lymphoma ( sll / cll ) . the macroscopical examination revealed several stones up to 15 mm diameter in the gallbladder , which measured 703020 mm . the mucosa was focally pale , partly inflamed and the wall up to 4 mm thick ( figure 1 ) . microscopic examination found out a thickened gallbladder wall with denuded surface and a dense underlying follicular lymphoid population which abutted the serosa . there was an underlying cd21 positive follicular architecture with a mainly perifollicular distribution of small round lymphocytes with occasional blasts and a few plasma cells . this population showed positive reactivity with cd20 , cd79a , cd23 and bcl2 , although cd5 and bcl6 were negative . the cystic duct lymph node retrieved has not been examined with immunohistochemistry ( figure 3 ) . in conclusion , all the features were in favor of sll / cll ( low grade non - hodgkin s lymphoma ) . as per the multidisciplinary team meeting discussion , the patient underwent staging ct of the neck , thorax , abdomen and pelvis , which did not show any evidence of lymphomatous dissemination . the patient then had been taken over by the hematology team who kept her under surveillance as no further treatment was deemed as necessary . primary nhl of the gallbladder , defined as a disease confined in the gallbladder with or without involvement of contiguous lymph nodes is uncommon and less than 50 cases have been reported in literature . eight of these were nhl ( 4 lymphocytic lymphomas and 4 reticulum cell lymphomas , respectively ) . , described only one case of gallbladder nhl out of a total of 1452 histopathological examination of routine cholecystectomy specimens . according to the last world health organization ( who ) classification ( 2016 ) , the spectrum of lymphomas observed in the gallbladder reflects that of gastrointestinal tract lymphomas , with predominance of mucosa associated lymphoid tissue ( malt ) type and diffuse large b cells type ( dlbl ) . it has been suggested that malt lymphomas of the gallbladder may occur in the context of chronic cholecystitis with cholelithiasis or bacterial infection . the mechanism based on the chronic inflammatory process would be similar to that described previously in the stomach ( helicobacter pylori infection ) and conjunctiva . bisig et al . have described a case of gallbladder malt lymphoma with t(11;18 ) ( q21 ; q21 ) similar to that seen in the stomach . it mainly occurs in women and , if localized in the gallbladder only , cholecystectomy alone is considered curative with an excellent prognosis in the majority of the cases . it s an aggressive form with a high grade of malignancy , showing a marked tendency to systemic dissemination . it commonly occurs in the brain and spinal cord ( cns ) , eye , thyroid , waldeyer s ring , breast , liver and genitourinary tract . state that dlbcl of gallbladder is a de novo tumor , with different clinical and histo - pathologic features and a younger onset age . follicular lymphoma type is the third most common primary lymphoma of the gallbladder , although it tends to occur more frequently in the duodenum . less than 10 cases have been described in the literature and it has been regarded as a slow progression disease . other types of lymphoma include the b - lymphoblastic , t - lymphoblastic , angiotropic or intravascular , low grade b - cell , poorly differentiated lymphocitic , lymphosarcoma and reticulum cell sarcoma . to the best of the authors knowledge , no case of primary sll / cll of the gallbladder has been reported in literature so far . according to de rossi et al . , cd5-negative b - cll can be considered as an infrequent subtype of b - cll , 7 to 20% , as no significant differences have been observed in terms of clinical features and response to the conventional therapy . patients with primary gallbladder lymphoma usually present with long standing mild right upper quadrant pain or onset of biliary colic or thorough signs of cholecystitis . the radiological features of gallbladder lymphoma depend on the hystopathological types : high - grade lymphomas , such as dlbl , have a tendency to form a solid and large mass in the gallbladder or may present with marked and irregular gallbladder wall thickening , whilst most of the low - grade lymphomas , such as malt , follicular lymphomas or as in the case we presented , sll / cll , show mild thickening of the gallbladder wall . however , preoperative diagnosis is rare and in the majority of the cases , is made after surgery with histo - immunological study . gallstones are present up to 40% of cases and regional lymph nodes involvement has been noted in 30% of patients while local contiguous invasion of surrounding tissues is rather rare . on pathology examination is an exceedingly rare condition , but it should be added to differential diagnosis of gallbladder mass in addition to carcinoma and metastases . although rare , the authors feel such a case may support the arguments in favor of the routine histological examination of gallbladder specimens .

primary gallbladder lymphoma is an extremely rare disease . we report a case of a 63 year - old woman who has been admitted with gradual onset abdominal pain in the upper right quadrant and in the suprapubic region , nausea and malaise . according to the computed tomography scan of the abdomen , which was suggestive of chronic cholecystitis , she was treated conservatively . a laparoscopic cholecystectomy was performed 5 months later and the histological examination of the gallbladder showed a low grade small lymphocytic lymphoma . the patient has been taken over by the hematology team who kept her under surveillance as no further treatment was deemed as necessary . the purpose of this paper is to report a rare case of primary gallbladder lymphoma and to demonstrate that a laparoscopic cholecystectomy may be a valid treatment for this disease .

when the intervention occurred , she was 40 years old ( 5.5 years after stroke ) and had severe paralysis in her left hand with no residual movement . she had received conventional therapy for two years and no significant functional improvement had been observed before her participation to this study . she participated in 10 recoverix training sessions at the rehabilitation hospital of iasi , romania . we recorded patients sensorimotor rhythm using 45 active eeg electrodes ( g.ladybird , g.tec medical engineering gmbh , austria ) . fpz was used as ground electrode , and a reference electrode was placed on the right earlobe . eeg signals were transmitted to an biosignal amplifier ( g.hiamp , g.tec medical engineering gmbh , austria ) , which then delivered the data to a computer for further processing required in online bci . after preprocessing , common spatial patterns ( csp ) was applied to transform the data to a new matrix with minimal variance of one class and maximal variance of the other class , which is represented by a transformation matrix , w in equation ( 1 ) . the transformed matrix reflects the specific activation patterns of the data during motor imagery of left or right hand in this study . the decomposition of a trial equation ( 1 ) x is described by z = wx the variance of x was projected onto the rows of z. the variance for one class is largest in the first row of z and decreases in each subsequent row due to the transformation matrix , w. the optimal number of csps is four to classify the left or right trials . only first and last two rows ( p=4 ) of w were used to process new input data x. next , the variance ( varp ) was calculated . these values were normalized and log transformed according to the formula : equation ( 2 ) where fp ( p=1.4 ) were the normalized feature vectors and varp was the variance of p - th spatially filtered signal . the patient was seated in a comfortable chair in front of a monitor that presented cues and feedback ( see figure 2 ) with fes pads placed over the forearm of the affected side . the patient was instructed to imagine the movement of either left or right hand while an arrow was presented on a monitor indicating its movement site and cue . after a delay of 0.5 seconds a blue bar moved and updated every 4 ms to the left or right indicating both the direction and magnitude of the motor imagery as visual feedback . the fes would activate with 50 hz updating rate if the user was imagining hand movement of instructed side . the muscle contraction by fes was sufficient enough to cause movement in the affected hand . the feedback period lasted four seconds , and the inter - trial interval was two seconds . when the intervention occurred , she was 40 years old ( 5.5 years after stroke ) and had severe paralysis in her left hand with no residual movement . she had received conventional therapy for two years and no significant functional improvement had been observed before her participation to this study . she participated in 10 recoverix training sessions at the rehabilitation hospital of iasi , romania . we recorded patients sensorimotor rhythm using 45 active eeg electrodes ( g.ladybird , g.tec medical engineering gmbh , austria ) . fpz was used as ground electrode , and a reference electrode was placed on the right earlobe . eeg signals were transmitted to an biosignal amplifier ( g.hiamp , g.tec medical engineering gmbh , austria ) , which then delivered the data to a computer for further processing required in online bci . after preprocessing , common spatial patterns ( csp ) was applied to transform the data to a new matrix with minimal variance of one class and maximal variance of the other class , which is represented by a transformation matrix , w in equation ( 1 ) . the transformed matrix reflects the specific activation patterns of the data during motor imagery of left or right hand in this study . the decomposition of a trial equation ( 1 ) x is described by z = wx the variance of x was projected onto the rows of z. the variance for one class is largest in the first row of z and decreases in each subsequent row due to the transformation matrix , w. the optimal number of csps is four to classify the left or right trials . only first and last two rows ( p=4 ) of w were used to process new input data x. next , the variance ( varp ) was calculated . these values were normalized and log transformed according to the formula : equation ( 2 ) where fp ( p=1.4 ) were the normalized feature vectors and varp was the variance of p - th spatially filtered signal . the patient was seated in a comfortable chair in front of a monitor that presented cues and feedback ( see figure 2 ) with fes pads placed over the forearm of the affected side . the patient was instructed to imagine the movement of either left or right hand while an arrow was presented on a monitor indicating its movement site and cue . after a delay of 0.5 seconds a blue bar moved and updated every 4 ms to the left or right indicating both the direction and magnitude of the motor imagery as visual feedback . the fes would activate with 50 hz updating rate if the user was imagining hand movement of instructed side . the muscle contraction by fes was sufficient enough to cause movement in the affected hand . the feedback period lasted four seconds , and the inter - trial interval was two seconds . figure 4 presents bci classification accuracy across 10 sessions . the patient reported that she actively participated in motor imagery tasks as instructed . the accuracy in the first two sessions is slightly over the chance level of 50% , and the accuracy of the remaining eight sessions was substantially higher than that of the first two sessions ( see figure 4 ) . the accuracy dropped to 82.5% in the session number 8 because of the lack of sleep during the previous night . this result means that the classifier distinguished two different tasks between left mi and right mi in the most training sessions other than the first two sessions . the visual and proprioceptive feedback was not properly provided to the patients with incorrect classification ( in the left side of figure 5 ) , and both feedbacks were presented with correct classification during feedback period ( in the right side of figure 5 ) . event related desynchronization plot also showed that the patients was able to perform the mi tasks and here are two examples of the first and last sessions . erd is observed in both sessions and the statistical comparison between two erd plots is necessary in the future . after ten training sessions , the patient was able to voluntarily relax and extend the wrist of her paretic side seen in figure 6 . we showed that the patient could follow the left or right hand motor imagery instructions . the higher bci accuracy and lda values of later sessions implies that the patients learned to use the bci . this chronic stroke victim did not have any residual movement of her paretic hand even after several conventional physiotherapy sessions , but she regained her partial control of the affected hand after recoverix training . it was not possible to practice the nine - hole peg test ( 9-hpt ) and measure the electromyogram ( emg ) due to complete paralysis of her left hand before the session started , and alternative behavioral measurements are not available in this pilot study . the recoverix system and current training paradigm will be examined with higher number of patient population in comparison with control group for meaningful statistical outcomes . figure 7 presents our new g.estim device ( g.tec medical engineering gmbh , austria ) , which will replace the current fes device . the new g.estim is developed mainly for bci applications , and we are currently developing ce and fda clearance . in addition , the bar feedback will be replaced with an avatar of patients upper limbs , and eeg will be wirelessly transmitted to a computer by g.nautilus ( g.tec medical engineering gmbh , austria ) , as seen in figure 8 .

conventional therapies do not provide paralyzed patients with closed - loop sensorimotor integration for motor rehabilitation . paired associative stimulation ( pas ) uses brain - computer interface ( bci ) technology to monitor patients movement imagery in real - time , and utilizes the information to control functional electrical stimulation ( fes ) and bar feedback for complete sensorimotor closed loop . to realize this approach , we introduce the recoverix system , a hardware and software platform for pas . after 10 sessions of recoverix training , one stroke patient partially regained control of dorsiflexion in her paretic wrist . a controlled group study is planned with a new version of the recoverix system , which will use a new fes system and an avatar instead of bar feedback .

sweat gland carcinomas are rare malignant tumors of the skin.15 one entity is the aggressive digital papillary adenocarcinoma . these tumors are capable of aggressive local invasion resulting in a high recurrence rate , and are characterized by predominantly digital location . as the tumor is slow - growing , painless , and clinically inconspicuous , the diagnosis is often missed or delayed . we report two cases of aggressive digital papillary adenocarcinoma , including clinical course , pathological findings , and therapeutic approach , and review the present literature . a 52-year - old man presented with a 12-month history of a swelling of the distal phalanx of the right middle finger without prior trauma or infection ( figure 1 ) . intraoperatively , we observed a cystic brown tumor with a soft consistency ( figure 2 ) . a computed tomographic scan of the chest , ultrasound of the abdomen , and bone scintigraphy showed no evidence of metastasis . we chose an aggressive surgical approach consisting of amputation of the middle phalanx and regional lymph node dissection . a 54-year - old man presented with a 11 cm solid painless tumor on the dorsal side of the middle phalanx of the right middle finger . the histologic report disclosed an aggressive digital papillary adenocarcinoma with margins not free of tumor ( figures 36 ) . physical examination at our institution showed a bland scar on the middle dorsal phalanx with full function of the hand . x - ray imaging of the hand , magnetic resonance imaging , and a computed tomographic scan of the chest and abdomen were not suspicious for tumor spread . the defect was covered with a full - thickness skin graft ( figure 7 ) . postoperative wound healing was very good , and function of the right hand was not impaired . staging procedures , including colonoscopy , bronchoscopy , gastroscopy , and ultrasound of the thyroid gland revealed no further tumor localization . aggressive digital papillary adenocarcinoma is a rare cutaneous malignancy.19 it was first described in 1984 by helwig et al , who used the term eccrine acrospiroma . the term aggressive digital papillary adenocarcinoma was introduced decades later by duke et al,2 although it is a low - grade rather than a high - grade malignancy . histologically , tumor features include a grenz zone , fibrocollagenous stroma , a mixed tubuloalveolar and papillary pattern , and focal squamous metaplasia.10 the differential diagnosis comprises apocrine adenocarcinoma , adenoid cystic carcinoma of the sweat glands , and mucinous eccrine carcinoma . large series published about this entity are rare . there is one initial retrospective clinicopathological study published by kao et al , which included 57 patients.7 the authors reported a local recurrence rate of 47% and a 41.2% rate of distant spreading . patients with metastases died 520 years after diagnosis , indicating the low - grade malignancy of the tumor . authors classified subgroups as aggressive digital papillary adenomas and aggressive digital papillary adenocarcinomas based on histological criteria . currently , it is recommended to avoid the term aggressive digital papillary adenoma , as all such tumors possess metastatic potential.2 other authors report lymph node and lung metastases developing in up to 14% of cases.6,8 there is no effective treatment for widespread disease . another follow - up study of aggressive digital papillary adenocarcinomas from the same institution was published in 2000 by duke et al.2 sixty - seven cases were included in this study . these authors found subsequent radical excision to be imperative to prevent local recurrence . in this series , only 5% recurrence occurred when the tumor was treated with subsequent excision or digital amputation , compared with 50% recurrence when not so treated . interestingly , none of the clinical or histological features described above was predictive for local recurrence or metastasis . the findings of a recent study from 2012 that included 31 patients are in accordance with the results described above.11 these authors recommended wide excision or amputation as treatment , and reported a local recurrence rate of 16% thereafter . the metastasis rate was reported to be 19% , and 16% of metastases were located in the lung . concerning the clinical appearance , the lesion often presents as a nonspecific mass in the fingers or toes , which gradually enlarges over years.7,9 dorsal localization , as in our second case , is very uncommon , but should be taken into consideration . the typical age of patients with aggressive digital papillary adenocarcinoma is the fifties to seventies , with a predominance of male over female patients.7,11 the history in both our cases was very similar , ie , a painless tumor with slow growth . the histology of our cases showed partly solid and partly cystic tumor tissue with papillary epithelial proliferation . due to the slow growth and absence of symptoms , the patient and the physician in charge often trivialize the findings . the tumor can be easily confused with infection , a ganglion , or a cyst , which can lead to wrong or delayed therapy . in accordance with recommendations given in a previous study,12 we propose an exact diagnosis followed by a radical excision of the tumor ( excisional biopsy plus subsequent radical excision ) and staging of the regional lymph nodes , lung , and abdomen . the benefit of sentinel lymph node biopsy is still controversial.13 we recommend a clinical follow - up period of 10 years . digital papillary adenocarcinoma is a rare but life - threatening malignancy , and the diagnosis is easily missed or delayed . physicians in charge should be aware of their potential existence and confirm the diagnosis by biopsy in suspicious cases . in the event of a confirmed diagnosis , excision biopsy should be followed by radical excision and patient follow - up for a period of 10 years .

aggressive digital papillary adenocarcinomas are rare malignant tumors often located on the digits of the hand . due to lack of pain , slow growth , and an inconspicuous appearance , diagnosis is often missed or delayed . we report two cases and review the present literature to give recommendations for diagnosis and treatment .

heartworm ( dirofilaria immitis ) is a roundworm parasite that is spread to dogs by mosquito bites , causing heart failure in the definitive host canine . the nematode is found throughout the world and in the united states is endemic to the east , southeastern seaboard , and the southern coast . in the event that a human is bitten by an infected mosquito , the nematode travels from the subcutaneous tissue into the vessels , and eventually enters the right ventricle . the majority of patients are asymptomatic , however non - specific signs and symptoms that have been reported include cough , hemoptysis , chest pain and wheezing . although dirofilaria is a parasite , peripheral eosinophilia is only found in about 6.515% of the cases , . in the right clinical setting , these lesions are presumed to be neoplastic and require the appropriate workup . we describe a 48-year - old gentleman with a 30 pack - year smoking history who was admitted for refractory hypoglycemia secondary to a suspected insulinoma . biochemical work up proved positive warranting imaging studies with computed tomography ( ct ) chest / abdomen / pelvis to look for an underlying insulin - secreting tumor . his complete blood count showed a white blood cell count of 9.9 10/l , hemoglobin of 13.8 g / dl , platelet count of 442 k/l with an absolute eosinophil count of 0.1 k/l . complete metabolic panel revealed a mildly low sodium level and a glucose level of 34 mg / dl but was otherwise unremarkable . his insulin level was elevated at 133 miu / ml , as well as pro - insulin of 46.5 pmol / l , random cortisol of 129.1 mcg / dl , and c - peptide of 9.3 ng / ml . his vitals signs were normal and he was afebrile . imaging studies revealed multiple pulmonary nodules , the largest measuring 1.4 cm 1.2 cm in left lung ( fig . further serologic work up was negative for fungal and mycobacterial causes of pulmonary nodules as antibodies for histoplasma , aspergillus , coccidioides , and blastomyces were negative by immuno - diffusion and complement fixation . a ct guided core needle biopsy of the largest lung mass was done to rule out neoplasm and revealed a necrotic granuloma on microscopy ( fig . this is not pathognomonic for parasitic disease in this case so other infectious etiologies were considered . the specimen was sent for fungal and mycobacterium culture which were negative at 4 and 6 weeks respectively . no sputum cultures or smears were performed on this patient in the acute setting , this is one of the limitations of our workup . further inquiry of patient 's social history revealed that the patient has three dogs , one of which was ill with fatigue , weight loss , and hair loss . the patient denied any travel history to suggest tropical disease and granulomatous diseases such as granulomatosis with polyangiitis and sarcoidosis were ruled out based on the appearance of the biopsy and the absence of any systemic signs or symptoms consistent with inflammatory disease . there were no fevers throughout his hospitalization and lab testing for autoimmune disease was not performed during the workup . while there was not a confirmatory test or obvious parasite on biopsy , clinically the patient was diagnosed with an indolent infection secondary to d. immitis . the patient was still experiencing repetitive , symptomatic episodes of hypoglycemia while on maximum medical therapy and was transferred to a quaternary care center for management of his biochemical insulinoma . in the united states , heartworm infection in dogs and humans are endemic in the east and southeast regions . it is believed that the organism is inoculated into humans via a mosquito bite . from there they then migrate into the heart via the capillary system in order to mature for another 6 months . the human body is an unsuitable environment for heartworm and as the nematode dies it embolizes the pulmonary vessels causing infarction and eventual nodule formation that can present as a solitary or multiple pulmonary nodules . the first case of human dirofilariasis was documented in a brazilian boy in 1887 by de magelhaes when he discovered a filarial worm in the left ventricle of the patient . the majority of patients infected with d. immitis are asymptomatic and most commonly present with a solitary pulmonary nodule incidentally found on chest radiography . occasionally there can be multiple pulmonary nodules mimicking metastatic disease or fungal or mycobacterial infection . regardless of the number of nodules , these asymptomatic nodules should be evaluated for possible underlying malignancy . in our patient , given his significant smoking history , invasive testing was necessary in order to prove his lesions were not neoplastic . diagnosis of dirofilariasis can be made by a dirofilaria - specific antibody , through enzyme - linked immunosorbent assay ( elisa ) . in addition , the elisa assays are not known to be particularly accurate with problems of cross - reactivity between d. immitis and other filariases . the majority of cases are diagnosed by microscopy which shows a central core of necrosis surrounded by a granulomatous zone of tissues . one feature we would typically expect to see in patients with invasive parasites is peripheral eosinophilia . however , as in our case , many other cases have not shown any eosinophilia . it is believed that the incidence of eosinophilia in infected patients is between 6.5% and 15% , . few of the case reports also document eosinophils on microscopy as part of the inflammatory process . it is not known if there is a trend in the eosinophil level throughout the infectious process or if it trends either way . based on previous case series , other risk factors include the size of the dog population in the area , the prevalence of d. immitis infection in those dogs , the density of the mosquito population and the degree of human exposure to bites by said mosquitoes . it is possible , though , that the patient 's dog was sick due to d. immitis infection without treatment . we hypothesize , therefore , that the patient was exposed to a mosquito that also bit this dog . one of the limitations of our study was the lack of elisa antibody testing to help establish a diagnosis . in addition , the fine needle aspiration ( fna ) that was performed showed only necrotizing granuloma consistent with a parasitic infection but did not show the actual parasite . however , we are confident in our diagnosis in that we have ruled out other granulomatous infections and conditions . in conclusion , human pulmonary dirofilariasis should be considered as a differential diagnosis in patients presenting with asymptomatic solitary or multiple pulmonary nodules in the appropriate epidemiologic and clinical setting . we determine the right clinical setting to be one that has a high rate of d. immitis infected dogs ( both stray and domesticated ) in addition to having a high mosquito population in order to be able to transfer the parasite from canines to humans .

canine heartworm , dirofilaria immitis , is a nematode parasite that infects dogs by way of mosquito bite . rarely , humans play accidental hosts to this parasite and are not a suitable environment for the nematode to live . as the parasite dies in the pulmonary vessels it embolizes the vessels causing infarction and eventual nodule formation in the lungs . in the right clinical context , a nodule can be considered malignant prompting invasive tissue sampling . we describe a case of a 48-year - old man who was found to have multiple asymptomatic scattered pulmonary nodules during imaging workup for an insulinoma . fine needle biopsy of the largest nodule revealed a necrotic granuloma , lab testing and culture ruled out fungal and bacterial causes . clinically , this picture was consistent with d. immitis infection .

echinococcosis is a parasitic disease that affects both humans and other mammals , such as ruminants , sheep more receptive , dogs , rodents , and horses . humans are accidental intermediate hosts that become infected by handling of soil , dirt , or animal hair contaminated with eggs . kidney involvement in echinococcosis is extremely rare ( 2 - 3% ) , being third commonest organ involved after the liver and the lungs . kidney involvement by hydatid disease is very rare , constituting only 1.9 % of all cases . a 6-year - old female patient presented with right side loin pain of 4 months duration . the ultrasonography ( usg ) and contrast - enhanced ct scan of the abdomen showed a large exophytic cyst ( 10 8 8.4 cm ) involving mid and lower pole of right kidney with no solid component or calcifications [ figure 1 ] i.e. type 1 cyst according to gharbi classification . ivu revealed a space - occupying lesion involving mid and lower pole of right kidney causing displacement of collecting system superiorly [ figure 2 ] . the patient was explored under general anesthesia through right sub - costal incision , and the diagnosis of a hydatid cyst was confirmed . right nephrectomy was done , because cyst was involving almost whole of the kidney including hilum , sparing only a small portion of upper pole . contrast - enhanced ct scan of the abdomen showing a large exophytic cyst ( 10 8 8.4 cm ) involving mid and lower pole of right kidney with no solid component or calcifications intravenous urogram ( ivu ) revealed a space - occupying lesion involving mid and lower pole of right kidney causing displacement of collecting system superiorly the liver is the most common site of echinococcal infestation ( 54% to 77% ) , because the liver acts as the initial filter for the organisms . those larvae that escape the liver are next filtered by the lungs ( 9% to 30% ) . the spleen , ( 0.9% to 8% ) , kidney ( 2% to 3% ) , and brain ( 1% ) are other organs involved . some may present with a mass palpable in the loin , and rarely some present with a history of passing whitish material also called as the grape skin , the scolices , in the urine . pre - operative diagnosis of hydatid cysts can be made by ultrasound and confirmed by a ct scan . caliceal distortion is the predominant finding on ivp , followed by caliectasis and non - functioning kidney , possibly caused by the mass effect of cystic lesions . hypointense rim and multicystic appearance is distinctive in magnetic resonance imaging ( mri ) scan , which also delineates the anatomy well . serology that consists of immuno - electrophoresis , immuno - hemagglutination test , western blot , and complement fixation test is helpful when diagnosis is in doubt . the preferred surgical procedure is represented by the pericystectomy or resection of the protruding dome after injection of a scolicidal solution and partial or total nephrectomy in cases with significantly destroyed renal parenchyma . however , renal - sparing surgery with only cyst removal may be an alternative . recurrence is a significant problem in the late post - operative period , with an incidence ranging between 10% and 30% . although the isolated renal hydatid cyst is very rare and is even rarer in children , high suspicion of this disease is justified in any cystic mass of kidney in children , especially in endemic regions . arif hussain sarmast : substantial contributions to the conception or design of the work ; or the acquisition , analysis , or interpretation of data for the work . afak yusuf sherwani : drafting the work or revising it critically for important intellectual content . sajad ahmed dangroo : substantial contributions to the conception or design of the work ; or the acquisition , analysis , or interpretation of data for the work ; and drafting the work or revising it critically for important intellectual content . arif hamid : agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved .

isolated involvement of the kidney is rare in hydatid disease and is even rarer in children . we present a case of primary right renal hydatid cyst in 6-year - old female child who presented with pain right flank of 4 months duration . the patient was managed by nephrectomy .

in late august 2003 , local , state , and federal health officials began an investigation to determine the risk factors associated with an outbreak of cryptosporidiosis and to develop interventions to control it . the epidemiologic investigation resulted in 96 laboratory - confirmed cases of cryptosporidium infection and > 600 clinical cryptosporidiosis cases . brfss is an established nationwide population - based telephone survey system that primarily measures behavioral risk factors associated with leading causes of death . it is currently the largest continuous telephone survey in the world ; it expanded to all 50 states in 1993 ( http://www.cdc.gov/brfss ) . in kansas , the health risk studies program conducts the brfss in - house and provides the capacity and expertise to design and implement special surveys . during this outbreak investigation , kdhe , the lawrence - douglas county health department , and the centers for disease control and prevention ( cdc ) used the brfss infrastructure , which consisted of a fully networked , computer - assisted telephone interviewing system ( wincati sawtooth technologies , northbrook , il , usa ) to conduct a case - control study . we conducted a matched case - control study to identify specific risk factors for infection . clinical cryptosporidiosis patients were identified during the case ascertainment portion of the study , by surveying households of elementary school children and persons who had sought healthcare for diarrheal symptoms . all laboratory - confirmed patients were enrolled , as were a random selection of clinical cryptosporidiosis patients within 4 age strata . two controls were matched to each patient , and each control was asked the same questions for the specific exposure period of the patient to whom they were matched . a maximum of 1 case - patient or control - patient per household was enrolled . the cati system relies on a networked central server with both interviewer and supervisory stations ( figure 1 ) . the system allows for questionnaire programming , record management , scheduling of calls , and monitoring the disposition of calls . telephone numbers for patients were programmed into the cati system ; controls were identified by random digit dialing . telephone numbers , which included all telephone exchanges represented in the 100,000-person county , were purchased from a commercial survey research sample provider . this sample was prescreened to remove both business and nonworking numbers but did include unlisted numbers . all residential numbers in the community were eligible , and the cati system released the telephone numbers randomly . frequency matching controls to patients was performed by inquiring for a person at the residence within a certain age range . the questionnaire was programmed into the cati system by using both range and logic checks , to minimize data entry errors , as well as skip patterns , which allow the respondent to answer only those questions that pertain to them . twenty brfss personnel were trained in two 1-hour training sessions on the use of the outbreak instrument and conducted pilot testing of the questionnaire for appropriate wording and skip patterns . kansas health risk studies program computer - assisted telephone interview ( cati ) system architecture for case - control study . approximately 11,400 telephone calls were made , and 770 interviewer hours were used in a 41-day period to complete 151 case - patient and 302 control interviews . the average interview length for completion of the case questionnaire was 28 minutes , and the average interview length for completion of the control questionnaire was 16 minutes ( table ) . data from the investigation showed multiple risk factors associated with cryptosporidium infection , including exposure to several recreational water venues . this study highlights the feasibility and potential benefits of a coordinated effort between chronic and infectious disease sections at local , state , and federal public health agencies in responding to an acute infectious disease outbreak . we used existing infrastructure and resources in the chronic disease division of a state health department to conduct a communitywide case - control study . to our knowledge , this is the first time a cati system based at a state health department has been used to respond to an acute infectious disease outbreak . the brfss program at kdhe has facilitated the development of the internal expertise and infrastructure necessary to design and implement large - scale and complex telephone surveys . this program includes providing a cohort of trained interviewers who could efficiently collect data to allow a comprehensive assessment of the risk factors associated with cryptosporidium infection in this outbreak . with the wincati system , interviewers were able to enter questionnaire data directly into the computerized system in real time , thus creating a database that could be easily converted into a variety of statistical programs for data analysis . the questionnaire was programmed to require certain data before proceeding ( logic checks ) or to warn the user of an incorrect entry ( data checks ) , thus decreasing the possibility of missing or including incorrect data . use of an existing infrastructure did not require immediate recruitment and training of volunteer interviewers , the traditional method for outbreak investigations , but provided a trained interviewing staff . additionally , this mechanism liberated the professional public health staff to focus their efforts on the multifaceted public health interventions required in a communitywide outbreak . the use of existing cati systems may be of value in several circumstances . as demonstrated here , in large , communitywide outbreaks , cati systems can provide substantial resources and personnel capacity that may substantially enhance investigation efforts in responding to a public health threat . additionally , cati systems , similar to brfss , are well - suited for performing long - term studies , for on - going studies attempting to determine the source of sporadic infectious disease cases , and for public health surveillance . they can also provide a practical means of obtaining controls for case - control studies . nevertheless , several limitations should be noted about the use of population - based telephone surveys in responding to acute outbreak scenarios . unlike traditional communicable disease control programs , community telephone survey efforts , such as brfss , were not created for immediate response , and therefore their use in this context has some limitations . these include the time required to program the questionnaire into a cati system and the organization of professional staff time in an outbreak situation . the preprogramming of generic infectious disease outbreak questionnaire modules ( e.g. , demographics , clinical symptoms , or foodborne or waterborne exposures ) into a cati system may help decrease the start - up time required for questionnaire implementation . these include smaller focal outbreaks in which the use of many resources and lengthy start - up times would be disadvantageous ; particularly when these investigations are within the capacity of existing communicable disease programs . these include the following : selection bias , inclusion of only those who have a home telephone number ; and response bias . in addition , those who participate may be different from those unwilling to participate , and declining response rates have been noted among telephone surveys ( 12 ) . moreover , the regular use of a cati infrastructure , like brfss , for acute outbreak situations needs to be further assessed to prevent it from detracting from standard brfss activities . cati systems , therefore , may not replace existing disease investigation programs but have the potential to supplement these programs . using existing state - based infrastructure in the chronic disease arena should be considered as a potential response strategy for future public health emergencies , and state health departments should consider developing plans and identifying financial resources for implementing similar strategies when performing large - scale investigations . because many state health departments may contract with a survey research firm to perform population - based telephone surveys , including reference to special studies related to urgent public health needs using cati systems provides an innovative and potentially valuable adjunct to current outbreak investigation methods and should be considered as a viable addition or alternative for conducting acute outbreak investigations , particularly during large - scale , emergency situations when resources are limited .

in august 2003 , a communitywide outbreak of cryptosporidiosis occurred in kansas . we conducted a case - control study to assess risk factors associated with cryptosporidium infection by using the telephone survey infrastructure of the behavioral risk factor surveillance system . using existing state - based infrastructure provides an innovative means for investigating acute outbreaks .

imaging findings , even with computed tomography ( ct ) , of such tumors are rarely described in literature . f-18 fluorodeoxy glucose positron emission tomography / computed tomography ( f-18 fdg pet / ct ) is emerging as a useful modality in assessment of genito - urinary malignancies . f-18 fdg pet / ct findings in penile leimyosarcoma have not been reported in literature . we present here a case of penile leiomyosarcoma with emphasis on findings on f-18 fdg pet / ct with histopathology correlation . a 47-year - old male presented with a palpable penile mass , with rapid growth over a period of 1 month . he was examined at an outside center and an incision biopsy of the tumor was done that revealed penile leiomyosarcoma . he was later referred to our institute , a tertiary care center , for further management . on examination of the patient at our institute , the patient was found to have 2 2 cm a typical nodular lesion in the proximal penile shaft . review of the histopathology examination after biopsy revealed tumor composed of spindle cells with hyperchromatic nuclei , inconspicuous nucleoli , and frequent mitoses . tumor cells also stained positive for smooth muscle antigen ( sma ) consistent with diagnosis of leiomyosarcoma of penis [ figures 1c and 1d ] . as a part of staging , the patient was subjected to f-18 fdg pet / ct examination 2 months after the biopsy ( this delay was due to late reporting of the patient to our institute from the peripheral center ) . the ct scan revealed moderate fdg uptake in the periphery of an ill - defined heterogeneously enhancing soft tissue lesion 2.9 2.2 cm in size involving corpora cavernosa on the left side of the distal penile shaft . this mass showed slightly thick , peripheral rim enhancement on the contrast - enhanced ct images corresponding to an area of increased f-18 fdg uptake , with an internal homogeneous region of low density , compared to the adjacent normal shaft of the penis , representing residual disease [ figures 1a and 1b ] . taking into consideration possible microscopic lymph node metastases total penectomy and bilateral inguinal lymphadenectomy was planned and the patient was counseled . however , the patient refused to undergo lymphadenectomy and only total penectomy was done . on follow - up after 8 months , the patient was found to be disease free . ( a ) contrast - enhanced axial ct through the penis demonstrates a low attenuating lesion in the corpora of the penis with peripheral enhancement . ( b ) f18-fdg pet image fused with corresponding ct demonstrates increased fdg uptake in the periphery of an ill - defined lesion within the corpora of the penis . ( c ) histopathological examination shows tumor composed of spindle cells with hyperchromatic nuclei , inconspicuous nucleoli with frequent mitoses ( d ) histopathological examination shows positivity for smooth muscle antigen penile cancer is a rare neoplasm and accounts for approximately 0.4% of all male malignancies . the most common primary malignant neoplasm of the penis is squamous cell carcinoma , constituting more than 95% of cases , followed by metastatic neoplasms of the prostate , bladder , rectum , kidney , and testis , as well as those spreading by direct extension from the adjacent structures . it accounts for 1020 % of all malignancies in males in asia , africa , south america , and it has a prevalence of only 1% in western countries . predisposing factors are phimosis , cigarette smoking , and human papilloma virus ( hpv ) infection . other tumors of the genitourinary tract include sarcoma , melanoma , basal cell carcinoma , and lymphoma . sarcomas are uncommon penile neoplasms , which include epithelioid sarcoma , kaposi sarcoma , leiomyosarcoma , and rhabdomyosarcoma . in general , very little literature exists that discusses the management of penile leimyosarcoma , due to the rarity of disease . role of routine lymphadenectomy is controversial as few authors have suggested that regional lymph node dissection is usually not indicated , since nodal metastases are uncommon . in our case lymphadenectomy was planned ; however , patient refused to undergo lymphadenectomy and was managed only with total penectomy . the ct findings of penile leiomyosarcoma are also rarely reported in literature in which the tumor may appear as a mass showing a relatively thick peripheral rim enhancement with internal regions of homogeneous low density , compared to the adjacent normal shaft of the penis , ( similar to findings in our case ) or as a soft tissue mass . fdg uptake has been described in penile squamous cell carcinomas and f-18 fdg pet / ct has been shown to be useful in detection of lymph nodal and distant metastases in penile carcinoma . f-18 fdg uptake has also been described in leiomyosarcomas and tumoral f-18 fdg uptake correlates well with the grade of the tumor in case of leiomyosarcomas . f-18 fdg pet / ct plays an important role in diagnosis , staging , treatment response monitoring , and follow - up in patients with sarcomas . this is the first case demonstrating f-18 fdg pet / ct findings in a case of penile leimyosarcoma .

penile cancer is a rare entity accounting for only 0.4% all male malignancies . penile leiomyosarcomas are even rarer with only around 35 cases reported in literature . we report a rare case of penile leiomyosarcoma illustrating f-18 fluorodeoxy glucose ( fdg ) positron emission tomography / computed tomography ( pet / ct ) features and histopathology correlation .

the causes of pulmonary embolism can be venous thromboembolism , and nonthrombotic embolism like septic , fat , air , amniotic fluid and tumour embolism . tumour embolism to lungs can arise from cancers of breast , stomach , liver , kidney and rarely from choriocarcinoma . choriocarcinoma is a malignant , trophoblastic cancer , belonging to the malignant end of the spectrum in gestational trophoblastic disease , which can occur following molar pregnancy , ectopic pregnancy , abortion and even normal pregnancy [ 2 , 3 ] . choriocarcinomas spread via blood and lymphatics with early haematogenous spread to lungs , resulting in pulmonary embolism , pulmonary oedema , pulmonary hypertension or acute respiratory distress syndrome . in a young female presenting with persistent shortness of breath , cough and chest pain , the possibility of metastatic pulmonary embolism should be considered as surgery and chemotherapy can cure the choriocarcinoma metastasizing to the lungs . a 25-year - old lady was admitted in the pulmonology ward with the diagnosis of pneumonia . the patient had presented with a history of progressive shortness of breath , chest pain and persistent cough with occasional haemoptysis . she had a history of being treated with antibiotics and anti - tb drugs in outpatient basis . since her symptoms were persistent and her general condition was deteriorating , she was admitted to the ward . on examination , she had crepitations in bilateral chest and an oxygen saturation of only 80% . cect chest was done , which revealed pulmonary embolus occluding the main pulmonary artery , and right and left pulmonary arteries ( fig . 1 ) . serum beta - human chorionic gonadotrophin ( hcg ) level was found to be significantly high . she was managed further with chemotherapy ( emaco regimen ) with excellent response to the treatment . figure 3:histopathological image showing the trophoblastic elements . a ct scan image showing thrombus in the pulmonary artery . women in the reproductive age group with lung metastasis present with dyspnoea , chest pain , cough and haemoptysis . as the diagnosis can always be misleading and patient might be treated in the line of pneumonia or tuberculosis , it is very essential to have a high index of suspicion . surgery is indicated in patients with haemodynamic instability and those with massive tumour burden occluding main pulmonary and branch pulmonary arteries . so , chemotherapy should be initiated as soon as the diagnosis is strongly suspected or confirmed . pulmonary embolism due to choriocarcinoma should always be suspected in a reproductive age woman presenting with intractable shortness of breath .

pulmonary embolism carries a significant morbidity and mortality . metastatic choriocarcinoma presenting as pulmonary embolism is a rare event . here , we report a case of a 25-year - lady with a history of worsening shortness of breath for 4 months who was treated as a case of pneumonia and tuberculosis . owing to the worsening condition , she had a contrast enhanced computed tomography ( cect ) chest done and was diagnosed to have pulmonary embolism . she underwent pulmonary embolectomy . the histopathological examination of the embolus revealed it to be metastatic choriocarcinoma . she showed a good response to chemotherapy . metastatic choriocarcinoma should be considered as a differential diagnosis in females presenting with pulmonary embolism .

several studies have been conducted citing the neuropsychological consequences regarding non - lethal hanging of adults . the primary findings are described as memory deficits and anterograde - retrograde amnesia . however , isolated memory disturbances can occur , though rarely , without other cognitive dysfunctions accompanying them . other cognitive deficits such as visuospatial impairment , expressive language deficits , behavior and personality changes are usually associated with memory disturbance . in post - anoxic states , post - anoxic burst - suppression electroencephalography ( bs - eeg ) implies a poor prognosis . it is rare to encounter case reports in medical literature about cognitive improvement in patients with bs - eeg . we have documented our evaluation of a patient 's cognitive recovery following bs - eeg after his attempted suicide via lethal suspension . the patient was admitted with a glasgow coma scale ( gcs ) score of 3 , his brainstem reflexes were absent , and he exhibited contracted , non - reactive pupils . eeg electrodes were placed according to the international 10 - 20 system . the burst suppression pattern ( bs ) was observed during the first 3 hours of eeg [ figure 1a ] . intravenous valproic acid ( 2 400 mg per / day ) was used and myoclonic jerks ceased within 2 days . the bs pattern was diagnosed as previously described : high - voltage bursts of slow waves with sharp or spiked transients occuring against a depressed background . bs - eeg continued in the second eeg recording , in the first 24 hours [ figure 1b ] . in the third eeg recording on day 6 , temporal relationship between consciousness and eeg findings are demonstrated in [ table 1 ] . on day 10 , the patient was responding to painful stimuli with flexor motor response in his extremities and he was extubated on day 13 . in the last eeg recording [ figure 2b ] , generalized low amplitude alpha and fast beta activities were revealed and the gcs score increased to 15 . generalized periodic sharp wave paroxysms and background activity was highly suppressed [ 3 hours after injury ] number of paroxysms increased and suppression continued [ 24 hours after injury ] widespread high - amplitude slow wave activity in the frontal region [ 6 days after injury ] fast rhythm activity in the frontal region and alpha rhythm in the parieto - occipital region during the resting state nearly similar to the physiological limits [ 13 days after injury ] temporal relationship between consciousness and eeg findings neuropsychological evaluation was applied for the first month after hospitalization . a total of 10 tests were selected to cover major cognitive domains : wechsler memory scale - iii [ wms - iii , the verbal fluency , dual similarities , clock drawing test , luria drawings , benton face recognition test , famous faces test , benton judgment of line orientation test , hooper visual organization test , boston naming test . also , mild dysfunction was detected in some executive functions like working memory , planning , cognitive flexibility , and inhibitory control . a total of 10 tests were selected to cover major cognitive domains : wechsler memory scale - iii [ wms - iii , the verbal fluency , dual similarities , clock drawing test , luria drawings , benton face recognition test , famous faces test , benton judgment of line orientation test , hooper visual organization test , boston naming test . the outstanding findings were memory deficits , deterioration in the attention . also , mild dysfunction was detected in some executive functions like working memory , planning , cognitive flexibility , and inhibitory control . hanging is one of the most commonly used methods of suicide among both men and women . the impact of lethal suspension on cognitive functioning is dependent on the length of asphyxiation time . enhancing initial diagnoses with eeg and cognitive tests can provide important information in determining the prognosis . post - anoxic bs - eeg implies a poor prognosis as shown in previous related studies . wijdicks et al . reported a repeat eeg in nine patients with bs - eeg on the day of resuscitation . persisting bs - eeg was seen in six patients and transition to alpha coma pattern was seen in three patients . reported 24 consecutive patients who developed bs - eeg within 24 hours after cardiopulmonary resuscitation . in this progression , with only one exception , bs - eeg was followed by another eeg pattern within 1 day , mainly a reactive eeg , isoelectric eeg , generalized continuous epileptiform discharges and eeg . in our patient , bs - eeg continued for 24 hours , followed by different wave patterns on the eeg , which were associated with generalized slow wave patterns and low amplitude alpha activity . parallel to the clinical improvement , the eeg of our patient underwent a dramatic improvement and bs - eeg disappeared completely . post - anoxic bs - eeg and subsequently evolving eeg patterns most probably reflect different forms of dysfunction of severely damaged cortical neurons . earlier studies have demonstrated that patients with myoclonic jerks accompanying post - anoxic bs - eeg exhibit a poor prognosis and anticonvulsant drugs are usually ineffective . medication was not the cause of bs pattern in our case , as the eeg was performed prior to the use of any medication . they revealed that amnesia is not detected in all cases of hypoxic - ischemic injury ; it rarely exists as the only deficit . brain imaging methods as ct , magnetic resonance imaging ( mri ) , single photon emission tomography ( spect ) is useful in showing brain damage . , neuropsychological test battery identified mild memory deficits with an impairment of attention . bs pattern following lethal suspension has been reported for the first time . our case is highly promising as it shows a good prognosis although burst - suppression pattern was perceived in eeg .

lethal suspension ( hanging ) is one of the most common methods of attempting suicide . spinal fractures , cognitive and motor deficits as well as epileptic seizures can be detected after unsuccessful hanging attempts . introduced here is the case of a 25-year - old man exemplifying the clinical observations stated hereafter , who was conveyed to our emergency room after having survived attempted suicide by hanging , with his post - anoxic burst - suppression electroencephalography ( bs - eeg ) pattern and clinical diagnoses in the post - comatose stage . the patient 's state of consciousness was gradually improved over a period of time . his neuropsychiatric assessment proved that memory deficit , a slight lack of attention and minor executive dysfunction was observed a month after the patient was discharged . although the bs - eeg pattern indicates severe brain dysfunction , it is a poor prognostic factor ; rarely , patients survive with minor cognitive deficits and can perform their normal daily activities .

the term ethics has obtained linguistic citizenship , especially in relation to biomedical research , including clinical and institutional scientific projects . in view of the common misunderstandings , ethics can not be meaningfully defined by etymology ( derived from the greek for good life ) , and needs instead a semantic definition , such as:1 ethics is an overall term for the immaterial values and attitudes , which are prevalent in a country or culture , which lie behind the country s or culture s concept of man , the derived laws and codes , and which on this basis determines citizens personal lives , their lives with each other , and with the legal and private institutions of the society . from a global perspective , ethics also include a responsibility for the ecologic balance between the planet earth , its soil , water , and air , and the diversity of its flora and fauna . in the nordic cultural and historic context , the most important nonmaterial values underlying ethics include solidarity with one s fellow man , equality , truth , justice , responsibility , freedom , and professionalism.1 however , even using existing contemporary semantic definitions of ethics ( which are few ) , there are substantial variations between cultures , national politics , and languages that are substantial , leading to highly variable interpretation by international readers and multicenter project participants . the increasing globalization of research now requires definitions that are understandable and transparent , in both the geographical universe and the multidisciplinary social universe , eg , between epidemiological researchers and the pharmaceutical and biomedical industries . since the mid 20th century , the controlled clinical trial has moved from being conducted in existing patients in the departments of the researchers to being based often on randomized cohorts from large and fully representative samples , based on pretrial epidemiological work . development of the controlled clinical trial and its original ethical perspectives after the second world war has , during the decades since , needed to supplement the original ethical demands in human biomedical research with several new ethical demands.2 these include : firstly , researcher ethics , ie , the integrity of the individual scientist in carrying out the project and presenting its results , to prevent fraud and dishonesty ; secondly , societal ethics , ie , dealing with patients as the ultimate target group in a globalized perspective , not the drug industry or the ambitious scientist ; thirdly , distributional ethics , ie , the democratic distribution of clinical research results to the patient groups in need of them . from the european perspective alone common definitions and control systems either lack uniformity or do not exist . based on a few existing national initiatives , eg , the nordic countries , united states good clinical practice , and european union initiative , the european forum for good clinical practice annual conference at prague in 2009 concluded that common european definitions and coordinated control systems are very much needed . fortunately , this work has already started in the form of a european union working group . biomedical and scientific journals are coming to reflect the strong public interest in , and demand for , an influential debate leading to progress in the ethics of biomedical research , thereby strengthening the interests of patients and society . the spectrum of participating parties is wide , comprising control agencies , professional medical associations , the drug industry , clinical and epidemiological researchers , and health care researchers from developing countries . garattini and chalmers3 in particular have addressed the interests of patients and the public in relation to evaluation of drugs in controlled clinical trials . they state that the drug industry has an image problem , and big changes are needed to restore public confidence . their reasons for this statement are that industry research agendas are distorted by priorities that are important to industry but not to patients.4 garattini and chalmers have considered the economic aspects of new drugs from the cambrium of basic research , the costs of which are met mainly by the public , and concluded that patients and health services are getting a poor return on this investment . although drug development and evaluation are not the only components of project collaboration between academia and industry , they have yet to be addressed fully in ethical analyses of unbalanced collaboration . garattini and chalmers have also assessed the transparency of drug testing by the european medicines evaluation agency and by the us food and drug administration , and found both to be inadequate , with the european system being the least transparent . their recommendations are for stronger involvement of patient interests in therapeutic research agendas , transparency in drug evaluation enshrined in law , independent drug evaluation , and demonstration of added value for all new drugs.4 a number of influential us authors from professional medical associations , including academia and journal editors , have also investigated their financial relationships with pharmaceutical and medical device companies , and have requested stronger guidelines for controlling conflicts of interest , because the present policies are not uniform and often lack stringency.5 a recent thought - provoking personal analysis by one clinical scientist strongly supports the conclusions of the professional medical associations , and puts the dilemmas and problems of conflicts of interests into the context of flesh and blood , recognizable to all clinical scientists and members of national ethical control systems.6 particular ethical dilemmas appear in collaboration between industries from developed countries and scientists from both developing and developed countries . a publication by the nuffield council on bioethics in 20027 dealt thoroughly with such problems , compared national guidance in denmark and uganda , and also presenting a survey of international guidelines for transparency of ethical dilemmas . in 2010 , the singapore statement on research integrity , comprising four principles and 14 responsibilities , now enables readers to put this ethical subtopic into an overall perspective.8 instead of providing a detailed description of contemporary project examples with ethical dilemmas , the present commentary concentrates on basic principles which can be practically applied when industries and academic researchers plan to work together on individual projects . these principles aim to balance the rights , interests , and duties of participating patients , volunteers , industry representatives , and biomedical scientists in an equitable manner . the protocol must provide a thorough description of : intended authorship order independent of any hierarchic titular order a fixed schedule and key agenda for project meetings any chairperson shifts and obligatory detailed reporting of project meetings and agreements on project plan changes any future members of the author group , balanced between disciplinary groups equal distribution , blinding , and collation of all project data for all disciplinary groups a fixed plan for exchange of manuscripts at the proofing stage with the aim of agreement and common authorship a contractual description of procedures , if agreement on the final content of the manuscript can not be reached , eg , a reflection period of three months , and after this , the right for both groups to publish their own version , with due consideration of any patenting issues ; if a national independent board for investigation of scientific dishonesty exists , and if suspicions of dishonesty have arisen , the possibility for one of the collaborators to involve such a board must exist role of all members of the project group must be listed and signed by all authors before the final manuscript is submitted to the editor of the intended journal for publication .

ethics in biomedical research can not be defined by etymology , and need a semantic definition based on national and contemporary values . in a nordic cultural and historic context , key values are solidarity with one s fellow man , equality , truth , justice , responsibility , freedom , and professionalism . in contemporary medical research , such ethics are further subgrouped into research ethics , researcher ethics , societal ethics , and distributive ethics . lately , public and academic debates have addressed the necessary strengthening of the ethical concerns and interests of patients and society . despite considerable progress , common ethical definitions and control systems still lack uniformity or indeed do not exist . among the cooperative partners involved , the pharmaceutical industry have preserved an important role . the same is true for the overall judgments reflected by the european forum for good clinical practice , leading peer - reviewed journals , the nuffield council on bioethics for developing nations , and the latest global initiative , the singapore statement on research integrity . to help both institutions and countries , it will be valuable to include the following information in academia industry protocols before starting a project : international authorship names ; fixed agendas and time schedules for project meetings ; chairperson shifts , meeting reports , and project plan changes ; future author memberships ; equal blinding and data distribution from disciplinary groups ; an equal plan for exchange of project manuscripts at the proofing stage ; contractual descriptions of all procedures , disagreements , publishing rights , prevention , and controls for suspected dishonesty ; and a detailed description of who is doing what in the working process .

carbon monoxide ( co ) is known as a silent killer , because it is an odorless , colorless , and non - irritating gas . myocardial infarction related to co poisoning has been frequently reported in the literature ; however , an st elevation myocardial infarction ( stemi ) due to coronary occlusion is a very rare presentation.1 ) although an increased tendency for thrombogenesis during co poisoning has been reported,2 ) the precise mechanism and treatment of stemi related to co poisoning remain uncertain . here , we report a rare case of acute stemi complicated by increased thrombogenicity secondary to acute co poisoning and complete revascularization after anti - thrombotic treatment . a 47-year - old male presented to the emergency department with prolonged chest pain , which developed during underground mining . upon arrival at the emergency department , his vital signs were blood pressure , 158/119 mm hg ; heart beat , 68/min ; respiratory rate , 12/min ; body temperature , 36.5 ; and o2 saturation , 100% . initial laboratory data revealed the following : carboxyhemoglobin ( cohb ) , 2.6% ; troponin - i , 3.06 ng / ml ; myoglobin , 321 ng / ml ; and creatine kinase ( ck)-mb , 22.9 ng / ml . electrocardiography ( ecg ) revealed an st elevation in leads ii , iii , and avf ( fig . transthoracic ecg , which was performed when the patient arrived at hospital , demonstrated hypokinesia of the inferior wall and preserved systolic function ( ejection fraction=50% ) . coronary angiography revealed total occlusion of the posterior descending ( pd ) branch of the right coronary artery ( rca ) with a large occlusive thrombus burden ( fig . far from the distal site of the rca , we decided to closely observe the patient in the coronary care unit and administer anti - thrombotic medications including heparin , aspirin , and clopidogrel . an electrocardiogram obtained 8 hours after admission showed normalization of the st segment elevation , q wave , and t waves in leads ii , iii , and avf ( fig . 3 ) . cardiac enzymes were elevated , with a ck - mb of 153.9 ng / ml and troponin i of 30.3 ng / ml on the first admission day . three days after admission , a follow - up coronary angiography was normal ( fig . carbon monoxide is one of the leading causes of poisoning - related deaths in the united states . co binds to hemoglobin with greater affinity than oxygen and forms cohb , which leads to impaired oxygen transport and subsequent tissue hypoxia.3)4 ) after exposure to co , several cardiac manifestations have been reported , including arrhythmias and electrocardiographic alterations,5 ) acute myocardial infarction , pulmonary edema , and cardiogenic shock.6 ) patients with coronary artery disease are more susceptible to co - induced cardiotoxicity.7 ) inhaling even relatively small amounts of co can lead to hypoxic injury , neurological damage , and possibly death . additionally , even if the initial cohb level is not very high , acute co poisoning can still lead to severe cardiovascular complications in high cardiovascular risk cases.8 ) toxicity also increases due to several factors , including increased activity and ventilation rate , preexisting cerebral or cardiovascular disease , reduced cardiac output , anemia or other hematological disorders , decreased barometric pressure , and high metabolic rate.9 ) myocardial ischemic changes often reveal t - wave inversion or st depression in patients with co poisoning . some cases reported with an st elevation had normal coronary arteries while undergoing coronary angiography.1 ) however , hsu et al.8 ) reported a case of co poisoning complicated with stemi , which had total occlusion of the left anterior descending artery and underwent primary percutaneous coronary intervention . the proposed mechanisms of myocardial damage are myocardial stunning as a result of co poisoning or unmasking of underlying coronary arterial disease by creating a myocardial demand / supply mismatch.10 ) furthermore , hematocrit , blood viscosity , and platelet function have been implicated as very important pathophysiological mechanisms in patients with acute myocardial infarction but normal coronary arteries . an increasing thrombotic tendency secondary to platelet stickiness and polycythemia has been reported in patients with co poisoning.11 ) a cohb level > 3% in nonsmokers or > 10% in smokers confirms exposure to co.12 ) in our case , even if the initial cohb level was not very high , emergency coronary angiography revealed total occlusion of the pd branch of the rca . however , the follow - up coronary angiography revealed a normal coronary angiogram after anti - thrombotic treatment , unlike other cases . the present case was unique in that the mechanism leading to the stemi in the co poisoned state was illustrated by coronary angiography , and complete revascularization was performed after anti - thrombotic treatment without percutaneous coronary intervention . in conclusion , this case highlights that anti - thrombotic treatment is the most essential therapy for co poisoning complicated by stemi in some specific cases .

carbon monoxide ( co ) is a well - known chemical asphyxiant , which causes tissue hypoxia with prominent neurological and cardiovascular injury . after exposure to co , several cardiac manifestations have been reported , including arrhythmias , acute myocardial infarction , and pulmonary edema . however , an st elevation myocardial infarction ( stemi ) due to co poisoning is a very rare presentation , and the treatment for stemi due to co poisoning is not well established . here , we report a rare case of stemi complicated by increased thrombogenicity secondary to acute co poisoning and complete revascularization after antithrombotic treatment .

posterior urethral valves ( puv ) are the commonest cause of lower urinary tract obstruction in male infants [ 13 ] . the incidence of this congenital anomaly in our setting is unknown , although reports from unites states and europe indicates that it occurs in about 1 : 8000 and 1 : 25,000 male live births [ 1 , 3 , 4 ] . prolonged and unrelieved lower urinary tract obstruction leads to back pressure effects on the kidneys resulting in obstructive uropathy with renal impairment . puvs are also a common cause of chronic renal failure in children if treatment is delayed [ 68 ] . late presentation in patients with puv is associated with urosepsis , uremia , and anemia and these form the bulk of patients seen in our centre . early diagnosis and prompt commencement of treatment is therefore germane to the overall outcome of these patients [ 9 , 10 ] . this is particularly important in a resource limited environment like ours where facilities for renal replacement therapy in children is not readily available . the aim of this study is to document the pattern of presentation in our centre and outcome of management . . records of patients with puv at the university of nigeria teaching hospital ( 19972004 ) and enugu state university of technology teaching hospital , both in enugu from [ 2005 to 2009 ] were reviewed . inclusion criteria were all patients who had radiological diagnosis of puv with voiding cystourethrogram and renal ultrasound . late presentation is defined in this study as patients presenting to our centre four or more weeks after the onset of symptoms . data such as age at presentation , symptoms and duration of symptoms , complications , investigation , and initial management instituted were collated . the patients mean age at presentation is 2.75 + 3.67 years while the mean duration of symptoms is 2.59 + 3.56 years . clinical findings at presentation include voiding anomaly ( 100% ) ; recurrent fever ( 90.5% ) ; ballotable kidneys ( 71.4% ) ; palpable bladder ( 76.2% ) ; failure to thrive ( 28.6% ) ; other symptoms like urinary incontinence , polyuria , and enuresis ( 47.6% ) ( table 1 ) . complications at presentation were renal failure ( 71.4 ) ; urinary tract infection ( 90.5% ) ; anemia ( 57.2% ) ; high blood pressure ( 47.6% ) . escherichia coli accounted for 66.7% of the urinary tract infection ( uti ) while 14.3% did not grow any organism . pseudomonas aeruginosa was found in 4.8% of the urine culture of patients with uti while 14.3% also grew klebsiella . only one ( 4.8% ) of the patients had vesicoureteral reflux on the voiding cystourethrography . of these , 62% required renal replacement therapy but only 19.05% were able to receive the therapy during the study period ( figure 2 ) . initial management instituted were continuous bladder drainage by urethral catheterization in 76.2% and cutaneous ureterostomy in 23.8% and none had vesicostomy . the outcome of the patients showed that 31% survived on dialysis ( 23% received peritoneal dialysis and 8% received hemodialysis ) . the remaining 69% were lost to followup or presumably died for inability to access required management for profound renal impairment . posterior urethral valve is the commonest cause of obstructive uropathy in children [ 11 , 12 ] . posterior urethral valves and other congenital obstructive uropathy accounted for 1.46.4% of all renal diseases in most of the centers in nigeria [ 1315 ] . all ( 100% ) our patients presented with one form of voiding abnormality or another . most of them presented with poor urinary stream while some others presented with straining during micturition . it is important to have a high index of suspicion of puv in any child presenting with the above symptoms and refer to a specialist early for appropriate intervention . furthermore , most of our patients presented late with features such as ballotable kidneys and palpable bladders . while the diagnosis of puv can be made prenatally [ 1618 ] , none of our patients was diagnosed prenatally . negative attitude , long distances to service providers , considerably heavy financial cost , long waiting periods , and unsatisfactory previous scan experience are major barriers to prenatal ultrasound in a study from nigeria , and these barriers had indirectly made prenatal diagnosis of puv intricate in our setting . the presence of ballotable kidneys suggests back pressure effect of the lower urinary obstruction with attendant hydronephrosis . this predisposes to stasis of urine and colonization by bacteria with attendant urinary tract infection and fever which was present in over 90% of our patients . in addition , majority of our patients also presented with complications including high blood pressure , urosepsis , and renal failure . elevated serum creatinine level has been shown to be associated with poor prognosis in puv patients [ 2022 ] , and this may not be reversed even with the relief of the obstruction . another possible reason is the ignorance that a poor urinary stream could be a transient event and that the baby will improve with time . a situation in which general practitioners do not refer patients to specialist for early diagnosis of the cause but rather they treat only the symptoms should be discouraged . the maxim should be that any child presenting with poor urinary stream should see a specialist for a second opinion . several studies have shown better preservation of renal function with early intervention and relief of obstruction [ 9 , 23 , 24 ] . therefore , with early presentation , diagnosis , and treatment the outcome the survival figure of 31% in this study is low compared to other centers in africa ( 87.5% ) and western world ( 96.2100% ) [ 2528 ] . medical education programs to improve the awareness among general practitioners should be encouraged by the health ministry . mothers presenting with oligohydramnious to the obstetricians should have their neonates screened for puv when born . patients presenting with features of urinary tract infection should have a full workup to rule out underlying urogenital anomaly . in conclusion , this study has shown that there is delayed presentation of patients with puv in our setting . efforts at improving awareness and early diagnosis among the health team should be made to stem the tide .

delayed presentation of patients with posterior urethral valve with complications like severe urosepsis , uremia , and anemia are seen in our setting . renal replacement therapy which should have been offered to these patients is not readily available for children in our country . the aim of this study is to determine the pattern of late presentation and outcome of management of posterior urethral valve in a resource - limited setting . a descriptive retrospective study ( 19972009 ) was conducted . data including pattern of presentation , duration of symptoms , complications , and outcome of initial management were analyzed . twenty - one patients were seen . the median age was 3 years ( 2 days13 years ) . the mean duration of symptoms before presentation was 2.6 years . nineteen patients ( 91% ) presented with urosepsis while 8 patients ( 36% ) presented with significant renal insufficiency . laboratory findings varied from - mild - to marked elevation in serum creatinine . radiological findings confirmed the diagnosis of posterior urethral valve . we concluded that late presentation is common in our setting . this is associated with high morbidity and mortality rates . efforts at improving awareness and early diagnosis among the health team should be made to stem the tide .

numerous short and thick hairs set obliquely in the fibers of orbicularis oculi , corrugator and frontal part of occipito frontalis are inserted in the dermis of eye brows . the head of the eyebrows overlies the frontal sinus and the tail is usually in the region of zygomatiocofrontal suture . it is an appendage of the hair bearing scalp rather than an extension of facial tissue . the head of the eyebrows overlies the frontal sinus and the tail is in the region of the zygomaticofrontal suture . the female eye brow is more arched and rest slightly higher than male eyebrow , which usually rests at the level of superior orbital rim . male eye brows are more irregular . the natural direction of hair of the eyebrow is varied . inferoateral hair direction is found in the upper and lateral parts . in medial and lower eyebrows play an important function in facial identification and may be at least as important as the eyes . human beings have a single eye brow above each eye , but this article presents a case report of a child with double eye brows on the left side . the present case report is about a 6-year - old girl presented to department of pediatric and preventive dentistry , guru nanak institute of dental science and research , kolkata for routine dental check - up . there was no relevant medical history with normal built , gait and intelligence . on facial examination , there was no gross asymmetry of face or any abnormal swelling . dermatological examination revealed that the eyebrows on the both the sides were sparser on the medial sides when compared with the lateral sides . the eye brows were free from any pathology except a double layer of eyebrow was present above the left eye . second layer of eye brow was just present above the first layer [ figures 1 and 2 ] . family history revealed no systemic disease or any extra layer of eye brow in either of maternal or paternal individual . no cosmetic / aesthetic or therapeutic treatment has been received by the child for double eyebrow . routine laboratory tests ( complete blood count , liver function test , urine analysis , abdominal ultrasound ) were all normal . considering the clinical features , a diagnosis of double eyebrow was concluded . the eyebrow is a transverse elevation of hair , which starts medially just inferior to the orbital margin and ends laterally above the orbital margin . they are formed by the transverse elevation of the superciliary ridge of the frontal bone . the superficial muscles of the head develop as mesodermal laminae which begin at the second branchial arch . from infraorbital lamina orbicularis , oculi , corrugator , these laminae join above the eye and form the interdigitating muscular structure of the brow . at 8 - 10 week of fetal development formation of primitive hair starts as a focal crowding of basal cell nuclei in the fetal epidermis . when the basal cell germ enlarges it becomes asymmetric and extends obliquely downward as a solid column . contracting the orbital sections of orbicularis oculi lowers the eyebrows and contracting the corrugators supercilia muscle draws the eyebrows together medially . there are three types of hair found in the eyebrow : ( 1 ) fine vellus hair ; ( 2 ) slightly larger and lightly pigmented hair and ( 3 ) large terminal hair known as the supercilia . the fine hairs form an effective moisture barrier to keep sweat from running downward into the eye . main function of eyebrows is to protect eyes and prevent flowing of salty sweat to eyes . the position and curvature of the eyebrow allows it to shields the eyes from bright light and it is an effective barrier to liquids running from the forehead into the eye . abundant sensory innervations are present in the large hairs of the eyebrow , which are very sensitive to tactile stimulation . the eye brows also function to depict the expression of an individual , like the depression of the medial portion of the eyebrow depicts anger or concern . eye brows abnormalities have a close relation with genomic disorders . in facial esthetics , sexual dimorphism , emotional expression and nonverbal communication eyebrows recent research suggests that eyebrows play an important function in facial identification and may be at least as important as the eyes . main physical function is to prevent flowing of salty sweat to eyes ; henceforth protection of eyes is the main function of eyebrows . eyebrows variation found in various syndromes such as chr1p36.33 microdeletion syndrome , chr2q21 - 23 microdeletion , mowat - wilson syndrome , chr3q26.3-q27 microdeletion , with sparse and broad - based eyebrow , chr7p15.3 duplication : extreme sparseness of the lateral portion of the eyebrows , chr9q34.3 terminal deletion , arched eyebrows and synophrys , chr10q22.3 - 23.2 duplication , with medial flaring eyebrows etc . ip 36.33 microdelation has a close relationship with deep - set eyes and horizontal eyebrows . eye brows abnormalities are useful diagnostic aids of chromosomal phenotype syndrome along with syndromic learning disability and developmental delay . suggested are diagnostic sign of genomic disorder . according to them array based comparative genomic hybridization cause multisystemic developmental diseases in human beings along with learning disability and developmental delay along with learning disability and developmental delay are responsible for most genomic disorder along with craniofacial skeletal and behavioral changes . the study done by berkenstadt et al . observed partial duplication of the eyebrows with other anomalies in a 7-year - old son . there was excess hair on the forehead and long eyelashes as well as excessive wrinkling of the periorbital skin when the eyes were closed . he had bilateral syndactyly involving the second to the fourth fingers and the second and third toes . gross - kieselstein and har - even also observed the same disorder in brother and sister of north african jewish descent . we could not detect any systemic disorder in our case with physical and laboratory investigations . it is clear that , new reports are still needed to enhance our knowledge about this rare entity .

eye brows are essential for esthetic and functional purposes . various kinds of eye brows are found in human species . protective function is one of the important functions of eye brows . double eye brow is a very rare condition found in human . this case report describes one of the rare cases of double eye brow .

to demonstrate a case illustrating meridional lenticular astigmatism as a result of renal cell carcinoma uveal metastases . clinical findings and diagnostic testing of a patient with acquired meridional lenticular astigmatism are described . the refraction revealed best - corrected visual acuity of 20/201 od ( 2.50 + 0.25 090 ) and 20/50 os ( 8.25 + 3.25 075 ) . bilateral concurrent renal cell carcinoma metastases to the choroid and ciliary body are demonstrated by utilizing ultrasonography , ultrawidefield fluorescein angiography , and unique spectral - domain optical coherence tomography . spectral - domain optical coherence tomography , ultrawidefield fluorescein angiography , and ultrasonography have roles in delineating choroidal metastases . renal cell carcinoma ( rcc ) , a common malignant renal tumor , often metastasizes to the lung , bones , liver , and brain , and rarely to the eye.1 common sites of intraocular metastasis within the eye include the choroid , iris , and ciliary body.2 we report an unusual case of meridional lenticular astigmatism with bilateral concurrent rcc metastases to the choroid and ciliary body , and describe spectral - domain optical coherence tomography ( sd - oct ) , ultrawidefield fluorescein angiography , and ultrasonography findings in the evaluation of the tumor . a 63-year - old african american male presented with blurred vision of 6 months duration in his left eye . his medical history was significant for type 2 diabetes mellitus , coronary artery disease , hyperlipidemia , hypertension , and rcc . he was on renal dialysis secondary to chronic renal insufficiency , a consequence of nephrectomy , chemotherapy , and radiation for his rcc . his best - corrected visual acuity was 20/201 od ( 2.50 + 0.25 090 ) and 20/50 os ( 8.25 + 3.25 075 ) . slit - lamp biomicroscopy revealed few keratic precipitates for os , mild 1 + nuclear sclerotic cataract , and a lesion posterior to the lens ( figure 1 ) . gonioscopy revealed 3 clock hours of angle crowding temporally , which was confirmed on anterior segment oct ( slit - lamp oct , heidelberg engineering , heidelberg , germany ) . fundoscopy of the right eye revealed a hypopigmented elevated lesion at the inferior disc margin ( 4.5 mm 4 mm ) . fundoscopy of the left eye revealed an elevated circumscribed lesion anterior to the equator encroaching on the ciliary body , with crowding of the angle at the 9 oclock meridian . the right peripapillary lesion measured 7.06 mm 7.10 mm 3.06 mm on ultrasound . a second mass located nasally measured 5.53 mm 6.06 mm 2.33 mm . fluorescein angiography revealed few scattered microaneurysms , with mild focal leakage and staining that extended over the disc in the right eye . sd - oct of the right eye demonstrated a peripapillary lesion with a dome - like elevated retina , areas of thickened nerve fiber layer , subretinal fluid , and retinal pigment epithelium hyperplasia ( figure 2 ) ( spectralis hra + oct , heidelberg engineering ) . the left ciliary body lesion measured 6.06 mm 5.53 mm 2.23 mm by ultrasonography . wide - angle angiography ( with staurenghi 230 slo retina lens , spectralis hra + oct ) revealed an irregularly staining hyperfluorescent lesion anterior to the equator in the temporal region ( figure 3 ) . the anterior edge of the mass crowded the angle and induced lenticular astigmatism ( 8.25 + 3.25 075 ) . rcc , the most common renal neoplasm , often metastasizes through lymphatic and venous routes to the lung parenchyma ( 50%60% ) , bone ( 30%40% ) , liver ( 30%40% ) , and brain ( 5%).3 ocular metastasis from primary rcc is extremely rare.1 to date , only 34 cases of uveal metastases were reported ; only two were bilateral and none was concurrent.2,4,5 bilateral simultaneous uveal involvement and associated anterior meridional lenticular astigmatism make our case unique . ciliary body metastasis induced a myopic shift and meridional lenticular displacement ( refractive error from 2.50 sphere to 8.25 + 3.25 075 in 12 months ) . this astigmatism , not explained by keratometry , indicates that the ciliary body mass is causing tilting of the lens and induced astigmatism . clinicians discovering new astigmatism and myopic changes should consider occult metastasis in their differential diagnosis . the lesion had irregular hyperfluorescent staining and was located anterior to the equator in the temporal region . sd - oct may offer an important method of following choroidal metastasis compared with traditional b - scan ultrasonography and previous - generation oct as the resolution continues to improve . time - domain oct of different choroidal metastasis revealed retinal and retinal pigment epithelial changes with overlying subretinal fluid.6 the high quality of sd - oct scans demonstrates the lesion s position relative to the optic nerve , dome shape , size , and associated subretinal fluid . we report a unique case of simultaneous bilateral uveal metastases of rcc with a concurrent ciliary body metastasis that induced myopic shift and meridional astigmatism from displacement of the crystalline lens .

purposeto demonstrate a case illustrating meridional lenticular astigmatism as a result of renal cell carcinoma uveal metastases.methodscase report with images.resultsclinical findings and diagnostic testing of a patient with acquired meridional lenticular astigmatism are described . the refraction revealed best - corrected visual acuity of 20/201 od ( 2.50 + 0.25 090 ) and 20/50 os ( 8.25 + 3.25 075 ) . bilateral concurrent renal cell carcinoma metastases to the choroid and ciliary body are demonstrated by utilizing ultrasonography , ultrawidefield fluorescein angiography , and unique spectral - domain optical coherence tomography.conclusionsmetastatic disease should be included in the differential of acquired astigmatism . spectral - domain optical coherence tomography , ultrawidefield fluorescein angiography , and ultrasonography have roles in delineating choroidal metastases .

chordomas are rare , slow - growing tumours that originate from ectopic notochordal remnants , found along the axial skeleton . ( 1 ) chordomas originate in the sacral ( 29.2% ) , cranial ( 32% ) and spinal ( 32.8% ) regions . ( 2 ) clival chordomas represent approximately half of cranial chordomas and they are more likely to occur in women and younger patients . ( 3 ) even though they are histologically benign , chordomas are highly invasive and locally - destructive . optimal surgical access and achieving complete resection often is constrained by the tumour s close proximity to vital structures . ( 4,5 ) even with adjuvant proton - beam radiotherapy , local recurrence rate is approximately 29% of skull base chordoma and is present in 95% of all treatment failure ( 6 ) . only three cases of a neck mass presenting as recurrence of the clival chordoma following implantation in the surgical pathway have been reported in the literature . here , past medical history was significant for clival chordoma resection and removal of a thyroglossal duct cyst . she had undergone resection 4.5 years prior via a transcervical , transparotid and transoral approach along with endoscopic intranasal exposure and a palatal split , followed by adjuvant radiotherapy . at the time of surgery , , she had a 3 cm , firm and horizontally mobile neck mass intimate to her cervical incision line in the left mid - sternocleidomastoid region . the patient underwent repeat staging with magnetic resonance imaging ( mri ) of the head and neck ( figure 1 ) , as well as computed tomography ( ct ) of the chest , abdomen and pelvis . ( axial , t1-weighted with gadolinium mr image ) . image obtained at the time of presentation with the neck mass , show a large , heterogeneous level iii neck mass ( 23 mm x 17 mm ) with infiltration throughout the sternocleidomastoid muscle without obvious invasion of the great vessels . contrast enhanced ct revealed some residual enhancement along the clival bone and left retropharyngeal area . she underwent left salvage modified radical neck dissection ( levels ii - v ) with sacrifice of the internal jugular vein and sternocleidomastoid , with preservation of the accessory nerve . the left neck mass was composed of nests of large physaliferous cells with vacuolated cytoplasm surrounded by abundant myxoid material , consistent with chordoma ( figure 2 ) . on immunohistochemistry , the tumour stained for low molecular weight keratin , high molecular weight keratin and epithelial membrane antigen . the tumour is composed of lobules of large cells with vacuolated cytoplasm admixed with a myxoid stroma . the main differential diagnosis at the time of our patient s presentation included distant metastasis , regional lymph node metastasis and surgical pathway recurrence . recurrence along the surgical pathway is a distinct entity defined as a relapse situated along the surgical access route that is separated from the primary site of disease and outside of the marginal zone . it must be differentiated from a marginal recurrence , which arises in the area bordering the initial tumour volume , but yet immediately external to the prescribed radiation dose region . ( 5 ) the rate of surgical pathway recurrence from a clival chordoma primary has been reported as 1.5% , and accounts for approximately 5% of all patients with chordoma recurrence after having undergone combined surgical and radiation therapy . ( 4 ) fischbein et al . ( 2000 ) suggested that four criteria should be met in order to apply the term surgical pathway recurrence : i ) disease found along the route of surgical entry to the original tumour resection ; ii ) presence of a minimum of 2.5 cm of normal intervening tissue between the disease and the site of the original tumour ; iii ) a minimum of 24 month interval between the time of surgery and recurrence ; and iv ) no evidence of perineural , lymphatic or distant metastases at the time of diagnosis . ( 4 ) in our patient s case , all of these conditions were fulfilled . using the aforementioned criteria for surgical pathway recurrence , only two other cases of clival chordomas with surgical implantation to the neck fulfilling these criteria have been reported . ( 2008 ) reported a case of recurrent clival chordoma presenting as a neck mass as a result of surgical pathway seeding after having undergone multiple resections and proton - beam irradiation for two local recurrences , where the primary resection involved insertion of harvested abdominal fat into the surgical bed with fibrin glue . ( 6 ) it has been suggested that the infrequency of surgical pathway recurrence may be attributed to tumour cell non - viability secondary to physical damage and absent blood flow once separated from the main tumour mass . ( 7 ) additionally , it has been suggested that with increased precision of radiation delivery to the tumour using more conformal proton - beams , the surgical pathway may not be covered by the radiotherapy delivered to the primary site . furthermore , the neck is excluded altogether from the radiation field . measures to prevent surgical implantation have been recommended including filling the operative tunnel with fibrin glue and cotton patties after completing the surgical approach , as well as changing instruments , gloves and contaminated towels and drapes prior to closure . ( 8) however , further investigation is required to determine the efficacy of filling the operative tunnel as a means of prevention . radiological follow - up assessment should include the surgical pathway relevant to the surgical approach in order to facilitate early detection of surgical pathway recurrence . should a soft - tissue lesion be identified along the surgical pathway , the differential diagnosis would include a foreign body reaction to operative materials , postoperative granulation tissue formation and surgical pathway recurrence . ( 9 ) definitive diagnosis would require tissue biopsy ; however , remarkable t2 hyperintensity on mri would be redolent of recurrence . controlling recurrent disease within the surgical route is best accomplished through fastidious surgical resection and postoperative radiation . even though surgical pathway recurrence may be controlled locally , since the majority of these cases experience primary or distant failure , they often have a poor prognosis .

chordomas are rare , locally - aggressive tumours with a high rate of local recurrence . recurrence along the route of surgical entry is an uncommon form of treatment failure . we report a case of a 59-year - old female who presented with a 3 cm neck mass in the left mid - sternocleidomastoid region . she had a history of a large clival chordoma resected via a transcervical , transparotid and transoral approach along with endoscopic intranasal exposure and a palatal split 4.5 years previously , followed by radiation to the primary site . biopsy of the neck mass confirmed the diagnosis of chordoma recurrence following implantation in the surgical pathway . this case illustrates that while surgical pathway recurrence is a rare entity , it requires a high index of suspicion and should be considered in the differential diagnosis of a patient with a history of chordoma resection presenting with a mass more than two years after undergoing initial treatment .

sequencing of a new genome is not a sensational event anymore : while the first genome sequences determined several years ago often made it to the front page of the new york times , nowadays even getting them published in major scientific journals is becoming increasingly difficult . the novelty of genomic data as such is certainly pass , but their usefulness remains intact , and perhaps is even increasing owing to virtually unlimited opportunities for comparative genomic analysis and large - scale data mining . at the same time , due to the sheer amount of genomic data currently available , the task of maintaining an up - to - date and complete genome analysis database represents a significant challenge . the mips group ( now institute for bioinformatics ) in munich began to provide exhaustive automatic analysis of all publicly available genomes in 1996 , when only five genomic sequences were published ( 1 ) . the main mission of the pedant genome database is to fill the gap between manually curated high - quality protein sequence databases , such as swiss - prot ( 2 ) or pir international ( 3 ) , and the enormous amounts of other protein sequences produced by genome sequencing projects at an ever increasing pace . for example , release 44.0 of swiss - prot contains 153 871 manually annotated proteins , while the total number of currently known protein sequences stands at roughly 2 500 000 . since the aforementioned gap is quickly growing , it is probably safe to say that the majority of protein sequences will never be subjected to in - depth annotation by human experts . we use the pedant software suite ( 4 ) for annotation of large amounts of protein sequences by a carefully selected set of established bioinformatics methods . exhaustive functional characterization of protein sequences includes similarity searches against the entire non - redundant sequence database , detection of motifs and patterns , automatic assignment of genes to functional categories and clusters of orthologous groups ( 5 ) , similarity - based prediction of enzyme classification , and extraction of keywords and superfamily information . structural characterization of gene products is based on similarity searches against the protein data bank ( pdb ) ( 6 ) database , sensitive recognition of structural domains using profile searches , secondary structure prediction , detection of transmembrane regions , and prediction of low complexity and coiled coil regions . by design , pedant provides protein sequence annotation in genomic context . the pedant genome browser enables the user to select functional or structural categories of interest , obtain the list of gene products from a particular organism assigned to this category , and then view detailed information on each protein presented as an integrated report page . advanced dna and protein viewers allow visualizing the positions of genes and other genetic elements on the chromosome , and predicted structural and functional information about proteins , respectively . facilities for searching the pedant annotation using text queries as well as blast ( 7 ) and pattern searches are provided . the pedant genome database is produced by systematically applying the automatic annotation pipeline described above to all genomic sequences that are being released in the public domain . the mips cpu resources make it possible to process a medium - size prokaryotic genome and make it available online essentially overnight.completeness . we seek to process all completely sequenced genomes as well as many incomplete genomes , which are being made available by sequencing centers . in many cases , pedant represents the only source of annotation for a given genome.standardization . automatic annotation of sequences follows a clearly defined protocol in terms of the particular set of bioinformatics techniques applied to each sequence and the values of pre - determined recognition thresholds used for individual methods ( e.g. blast e - values).documentation . since the results of automatic sequence analyses are inevitably afflicted by a large number of false assignments , we make available the raw output of each bioinformatics method used . this allows the user to make his own judgment on the validity of functional predictions appearing on each protein 's report page . the mips cpu resources make it possible to process a medium - size prokaryotic genome and make it available online essentially overnight . we seek to process all completely sequenced genomes as well as many incomplete genomes , which are being made available by sequencing centers . in many cases , pedant represents the only source of annotation for a given genome . automatic annotation of sequences follows a clearly defined protocol in terms of the particular set of bioinformatics techniques applied to each sequence and the values of pre - determined recognition thresholds used for individual methods ( e.g. blast e - values ) . documentation . since the results of automatic sequence analyses are inevitably afflicted by a large number of false assignments , we make available the raw output of each bioinformatics method used . this allows the user to make his own judgment on the validity of functional predictions appearing on each protein 's report page . over the past eight years , the number of analyzed genomes in the pedant database has grown steadily ( figure 1 ) and stands at 334 at the time of writing , including 228 completely sequenced and 106 unfinished genomic sequences from all three kingdoms of life ( figure 2 ) . however , the database also includes several genomes that were manually annotated and , in many cases , published by mips . those are saccharomyces cerevisiae ( 8) , thermoplasma acidophilum ( 9 ) , arabidopsis thaliana ( 10 ) , neurospora crassa ( 11 ) , parachlamydia uwe25 ( 12 ) , listeria monocytogenes egd , listeria innocuaclip 11262 and helicobacter pylori ke26695 . the total amount of data managed by pedant via a relational database system mysql , is 360 gb , more than one gigabyte per genome on average . to illustrate the functional and structural content of the pedant database , we calculated the coverage of all 1 240 000 annotated protein sequences by three selected popular categories : pfam sequence motifs ( 13 ) , scop structural domains ( 14 ) and mips functional role categories ( 15 ) . as seen in figure 3 , the coverage varies in a wide range from 64.3% by pfam to 34.5% by scop . only 15.2% of proteins possess all three attributes emphasizing the usefulness of applying many complementary bioinformatics techniques . the pedant database thus represents a valuable resource for large - scale association rule mining in automatically generated protein annotation . the mips functional catalogue ( funcat ) was developed in 1996 and used in the annotation of s.cerevisiae ( 8) . it comprises a hierarchically structured classification system , which at first only contained categories describing yeast biology . since then , it has been extended and used to annotate the following genomes : t.acidophilum , bacillus subtilis 168 , l.monocytogenes egd , l.innocuaclip 11262 , h.pylori ke26695 , n.crassa , a.thaliana and h.sapiens . the most recent version of the funcat ( v. 2.0 ; 16 ) is organism independent and consists of 28 main categories , covering features such as metabolism and cellular transport , as well as some more recently introduced categories ( e.g. development and organ localization ) . the main categories are branched into more specific categories , with up to six levels of increasing specificity ( e.g. 01.01.06.05.01.01 biosynthesis of homocysteine ) . the pedant software calculates automatic funcat numbers based on a gene product 's similarity to proteins in the manually annotated protein funcat database . although assignment of funcat numbers by homology alone is not always reliable , it may provide useful information in the absence of manual annotation . the automatic funcat tables for all pedant databases were recalculated using the new funcat version and updated manually annotated funcat database .

the pedant genome database ( http://pedant.gsf.de ) contains pre - computed bioinformatics analyses of publicly available genomes . its main mission is to provide robust automatic annotation of the vast majority of amino acid sequences , which have not been subjected to in - depth manual curation by human experts in high - quality protein sequence databases . by design pedant annotation is genome - oriented , making it possible to explore genomic context of gene products , and evaluate functional and structural content of genomes using a category - based query mechanism . at present , the pedant database contains exhaustive annotation of over 1 240 000 proteins from 270 eubacterial , 23 archeal and 41 eukaryotic genomes .

fungal endocarditis is an uncommon occurrence ; its incidence was reported as 1.3 to 6% of infective endocarditis cases ( 1 ) . aspergillus species contributes to approximately 25% of all cases of fungal endocarditis , second to the candida species in frequency . several conditions predispose patients to aspergillus infections including underlying cardiac abnormalities , prosthetic heart valves , indwelling central venous catheters , prolonged use of broad - spectrum antibiotics , and intravenous drug abuse ( 1 , 2 ) . we present a case of aspergillus endocarditis of a native valve , presenting as a femoral artery occlusion . four months previously , he underwent a pericardiocentesis for a fever and massive pericardial effusion ; no organism was found in the pericardial effusion . a precordial systolic murmur was heard during auscultation of the heart , and a right femoral artery pulse was not detected . the transthoracic echocardiography revealed severe mitral insufficiency with large mobile vegetations on the anterior and posterior mitral valve leaflets ( fig . the computed tomographic angiography showed an embolic occlusion of both common iliac arteries ( fig . the patient underwent emergency replacement of the mitral valve with a 29 mm prosthetic mechanical mitral valve ( sjm masters series , st . paul , mn , u.s.a . ) , and bilateral ilio - femoral artery thromboembolectomy with a fogarty catheter through both femoral arteries . gross findings in the surgical field revealed 1.51.5 cm round irregular vegetations on the middle portions of both mitral valve leaflets . culture of the valvular tissue on sabouraud dextrose agar confirmed the aspergillus species ( fig . anti - fungal medication was planned with intravenous amphotericin b for six weeks then oral itraconazole for 12 weeks . therefore , we started intravenous amphotericin b ( 5 mg / kg / day ) . a computed tomography showed multiple aneurysmal changes of the superior mesenteric artery ( sma ) , splenic artery , hepatic artery and left iliac artery despite amphotericin b treatment ( fig . 2 ) . the patient underwent sma aneurysmectomy and arterial reconstruction with bovine pericardium , and left iliac artery repair . amphotericin b was changed to oral itraconazole ( 800 mg / day ) at 6 weeks after the first operation . fifty - eight days after the first operation , the patient had hematochezia , and had a colonoscopy that revealed multifocal intestinal bleeding . the patient was discharged 78 days after surgery on oral itraconazole and warfarin . on follow - up , the itraconazole was discontinued 10 weeks later . aspergillus is a ubiquitous mold capable of causing several diseases in both healthy humans and immunocompromised hosts . aspergillus species endocarditis is an ominous condition and its prevalence is increasing in the hospital population . men are more commonly affected than are women with a peak incidence during the third to fourth decades of life ( 1 , 3 ) . previous valvular surgery is the most important risk factor , and was reported in 40% to 50% of patients diagnosed with aspergillus endocarditis ( 1 , 2 ) . aspergillus endocarditis of native valves is rare and experience in diagnosis and treatment is limited ( 1 , 4 ) . only 28 cases of aspergillus endocarditis were found in a medline search from 1995 to 2006 , and the mortality rate was reported to be higher than 90% despite aggressive surgical and anti - fungal therapies ( 1 ) . in most cases , predisposing factors were found including underlying cardiac conditions , prosthetic cardiac devices , central venous catheters , and previous antibiotic treatment . in 3.4% of cases with fungal endocarditis , , the patient underwent pericardiocentesis for pericardial effusion , but we could not find any predisposing factors . because of the ubiquitous nature of the organism , establishing a definitive diagnosis of disease caused by aspergillus is difficult ( 5 ) . recently , antigen detection methods and the polymerase chain reaction have been developed to improve the diagnosis of invasive aspergillosis ( 6 ) . the vegetations in aspergillus endocarditis are large and highly mobile and peripheral embolization is common in early stage disease ( 1 ) . in this case , the patient presented with iliac artery occlusions and with large mobile vegetations of the mitral valve . in general , the largest databases for aspergillosis treatment include amphotericin b and various surgical modalities ( 5 ) . in this case , we used a combination of amphotericin b , itraconazole and aggressive surgical treatment , but severe disseminated fungemia reappeared unexpectedly during the early postoperative period with a sma aneurysm and peripheral artery embolic occlusions . these complications may have been due to delay of antifungal treatment after surgery and dissemination by cardiopulmonary bypass before antifungal therapy was started . relapsing fungal endocarditis is a complication seen in as many as 30 to 40% of patients who have fungal endocarditis and who survive to complete short - term therapy ( 7 ) . thus , all patients who survive long enough to complete acute treatment are potential candidates for long - term suppressive antifungal therapy ( 1 , 3 , 8) . native valve aspergillus endocarditis is uniformly fatal without immediate and extensive surgical intervention combined with prolonged antifungal therapy .

systemic infection with aspergillus is an opportunistic disease that affects mainly immunocompromised hosts , and is associated with a high mortality rate . it typically occurs in patients with several predisposing factors , but aspergillus endocarditis of native valves is rare and experience in diagnosis and treatment is limited . we report a case of native valve endocarditis caused by aspergillus . a 35-yr - old male patient who underwent pericardiocentesis four months previously for pericardial effusion of unknown etiology presented with right leg pain and absence of the right femoral artery pulse . cardiac echocardiography revealed severe mitral insufficiency with large mobile vegetations , and computed tomographic angiography showed embolic occlusion of both common iliac arteries . we performed mitral valve replacement and thromoembolectomy , and aspergillus was identified as the vegetation . we started intravenous amphotericin b and oral itraconazole , but systemic complications developed including superior mesenteric artery aneurysm and gastrointestinal bleeding . after aggressive management , the patient was discharged 78 days post surgery on oral itraconazole . he was well at 12 months post discharge but died in a traffic accident 13 months after discharge .

since the introduction of highly effective immunosuppressive agents , organ transplant patients survive significantly longer and the number of patients with successful kidney transplantation is increasing worldwide . however , immunosuppressive therapies raise other distinct health problems that necessitate such patients visiting emergency departments ( ed ) with a variety of presentations . they are admitted to eds more frequently and with more complex issues ( 1 ) . lack of sufficient knowledge and experience of approach to renal transplant recipients in ed poses a major problem in management of these patients ( 2 ) . emergency physicians should be familiarized with major complications and ways to manage the emergent problems of the mentioned patients ( 2 ) . they may admit to ed for issues either related or not related to renal transplantation including acute rejection episodes , infections , cardiovascular diseases , side effects of immunosuppressive drugs , and the problems of renal transplant surgery ( 1 - 3 ) . it is important to distinguish transplantation related issues due to their vital importance in protection of graft . surprisingly , there are very few studies on the subject , most of which emphasize the importance of infections in renal , liver and heart / lung transplant recipients ( 2 , 4 , 5 ) . in a study , the causes of renal transplant patients death were found to be infections with 69.6% , cardiovascular diseases with 12.7% and acute rejection with 6.9% , respectively ( 6 ) . based on the above - mentioned , the aim of the present brief report is to determine the reasons of renal transplant patients ed visits and highlight the importance of preparedness for dealing with them . this retrospective case series study analyzed the reasons of renal transplant recipients admission to the ed of sanko university hospital , gaziantep , turkey . the patient data were collected from clinical files and electronic medical records via filling out the initially prepared checklist including demographic characteristics ( age , sex ) , ed presenting complaints , number of ed admissions , donor type , consulting services , as well as patient disposition and final diagnosis and outcome ( mortality , graft loss ) . the data were entered to a pre - designed database and analyzed with spss 13.0 statistical software . the researchers adhered to the principles of helsinki declaration and research ethics and kept patient information confidential . among which , 41(26% ) patients with the mean age of 40.63 10.95 years visited the ed at least once ( 60.9% male ) . the range of time interval between renal transplantation to ed admission was 1 - 36 months . the mean duration of ed stay was 2.1 0.69 ( 1.2 - 3.4 ) hours . table 1 presents the characteristics of studied patients . the most common ed presenting complaint was fever , followed by abdominal pain , nausea and vomiting . table 2 summarizes the final diagnosis of studied patients based on infectious and non - infectious causes . infections were the most common final diagnosis ( 28 ( 68.3% ) patients ) and the most common infection was acute gastroenteritis detected in 11 ( 26.8% ) patients . among non - infectious causes , the most common was acute renal failure observed in 4 ( 9.7 % ) patients . the mean time interval between ed presentation and disposition was 1.9 0.46 ( 1.1 - 2.3 ) hours and 73.2% ( 30 ) of the patients were hospitalized . in this retrospective case series , 26% of renal transplant recipients of the hospital visited the ed during 3 years . the most common reason for ed admission was fever , and infections were the most common diagnosis . acute gastroenteritis being the most frequent infection and among non - infectious problems , acute renal failure was the most frequent one . previous studies have declared infection as the most frequent cause of renal transplant patients ed visits ( 2 , 3 ) . the most common post - renal transplantation sources of infections are reported to be urinary tract , followed by muco - cutaneous and upper respiratory tract ( 2 , 3 , 8 - 10 ) . however , in the present case series gastroenteritis was the most frequent infection and about twice tokalak et al . this may be due to dietary habits of our patients or quality of food and water they used . pneumonia was diagnosed in two patients , pneumococcal in one case and atypical in the other . acute renal failure is a major risk factor of rejection among renal transplant recipients ( 11 ) . in our study , 4 patients were diagnosed with acute renal failure , 2of them were diagnosed with acute graft rejection and the other two with immunosuppressive drug toxicity . acute graft rejections were successfully treated and the patients blood urea nitrogen and creatinine values reversed to normal and for the two intoxicated patients , immunosuppressive dose adjustment was made . no case of graft loss and mortality one of the most important causes of mortality in renal transplant patients is cardiovascular diseases ( 2)(12 ) . the risk of cardiovascular disease in patients with renal transplantation has been reported to be 5 times higher than normal population ( 1 ) . in this study , one patient presented with chest pain and palpitations , which was diagnosed as supraventricular tachycardia and treated in the coronary intensive care unit . hospitalization rate of 73.1% in the present case series was high compared to previous studies ( 2 , 13 ) . the reason was the preference of studied center clinicians for inpatient management of renal transplant patients . this study has methodological restrictions , as it is a retrospective case - series with low sample size . in addition , some of the renal transplant patients of the hospital might have been admitted to the eds of other hospitals and were missed . despite the mentioned limitations , the findings of this study could be helpful in raising awareness regarding renal transplant complications among emergency physicians . the most common reason for ed admission was fever , and infections were the most common diagnosis . acute gastroenteritis being the most frequent infection and among non - infectious problems , acute renal failure was the most frequent one . all authors passed four criteria for authorship contribution based on recommendations of the international committee of medical journal editors .

introduction : renal transplantation are admitted to emergency department ( ed ) more than normal population . the present brief report aimed to determine the reasons of renal transplant patients ed visits.methods:this retrospective case series study analyzed the reasons of renal transplant recipients admission to one ed between 2011 and 2014 . the patient data were collected via a checklist and presented using descriptive statistics tools.results:41 patients with the mean age of 40.63 10.95 years were studied ( 60.9% male ) . the most common ed presenting complaints were fever ( 36.6% ) and abdominal pain ( 26.8% ) . infections were the most common final diagnosis ( 68.3% ) . among non - infectious causes , the most common was acute renal failure ( 9.7 % ) . 73.2% of the patients were hospitalized and no cases of graft loss and mortality were seen . conclusion : the most common reason for ed admission was fever , and infections were the most common diagnosis . acute gastroenteritis being the most frequent infection and among non - infectious problems , acute renal failure was the most frequent one .

lipoma is a common soft tissue tumor with several histopathological subtype , which occurs infrequently in the oral and maxillofacial region . one subtype is the spindle cell lipoma ( scl ) , which typically presents as a benign lipomatous neoplasm in the posterior neck and back of older males , and accounts for approximately 1.5% of all lipoma cases . in adult males , the most common location for classic oral and maxillofacial lipomas is the parotid region , followed by the buccal mucosa . however , oral scls are rare , and only about 40 cases have been reported . the histopathology of scl is characterized by a mixture of mature adipose tissue , bland spindle cells and wiry collagen in focal myxoid stroma . the differential diagnosis of such an oral lesion would include classic lipoma , myolipoma , schwannoma , myxoid neurofibroma , leiomyoma , myxoid solitary fibrous tumor and atypical lipomatous tumors . here , we report a case of scl localized to the mandibular mucogingival junction in a 68-year - old male , and the clinical , histopathological and immunohistochemical findings of this case are presented . a 68-year - old male presented to the dental clinic of riyadh colleges of dentistry and pharmacy ( riyadh , saudi arabia ) with a local region of swelling in his oral cavity that had persisted without pain over the past 3 years . clinical examination revealed a 2 cm1 cm sessile , soft tissue lump covered by intact oral mucosa ( figure 1 ) . an excisional biopsy was performed , and the patient did not exhibit evidence of recurrence during 12 months of follow - up . the specimen resected was routinely processed and stained with hematoxylin and eosin , as well as with anti - cd34 ( qb - end , 150 ; novocastra , newcastle , uk ) , anti - desmin ( der-11 , 150 ; novocastra , newcastle , uk ) , anti - bcl-2 ( bcl-2 - 486 , 1100 ; novocastra , newcastle , uk ) , anti - s-100 ( s-100 p , 140 ) and anti - smooth muscle actin ( sma , sm-1 , 150 ; novocastra , newcastle , uk ) antibodies . hematoxylin and eosin staining revealed the proliferation of diffuse mature adipocytes among spindle cells in a lobular configuration . the tumor cells were bland with inconspicuous nuclei within a fibroblastic stroma that exhibited focal myxoid changes . no mitotic activity or necrosis was observed , and few mast cells were detected ( figure 2 ) . tumor cells were positive for expression of cd34 and bcl-2 in immunohistochemistry assays ( figure 3 ) , while adipocytes , not spindle cells , were positive for s-100 . scl typically occurs as a solitary , painless and slow growing subcutaneous mass in the posterior neck or back of elderly males . moreover , a slight predominance for scl among males with an average age of 55 years has been observed . scl has also been reported to affect other sites such as limbs , the parotid gland and hypopharynx . the tumor rarely exceeds 5 cm in diameter , and with adequate local excision , recurrence is uncommon . in contrast , localization of scl to the oral cavity is extremely rare , and few case reports and small case series have been reported in the english literature . in these cases , scl has presented as a well - circumscribed mass that affects different anatomical locations within the oral cavity , including the buccal mucosa , tongue , floor of the mouth , hard palate and gingiva . furthermore , there have been only two case reports of scl in the gingiva and alveolar ridge mucosa . the histopathology of scl is characterized by the presence of mature fat cells admixed with spindle cells arranged into prominent collagen bundles in a lobular pattern . moreover for example , some tumors are predominantly composed of mature adipocytes and a few scattered spindle cells , while others contain mostly spindle cells and only a small number of mature adipocytes . in the current case , regarding lesions in the oral cavity , a differential diagnosis can include : conventional lipoma , myolipoma , schwannoma , myxoid neurofibroma , leiomyoma , atypical lipomatous tumor and myxoid solitary fibrous tumors . spindle cell and pleomorphic lipomas , which are now considered variants of the same lesion , are further characterized by losses on chromosomes 13q and/or 16q . expression of androgen receptors has also been documented for scls , suggesting a potential pathogenetic role for sex steroid hormones . however , for cases of oral scl , this correlation has not been well studied . furthermore , in one case report , no immunoreactivity to androgen , estrogen or progesterone receptors was demonstrated . although these findings might suggest that a different pathogenetic pathway is associated with a scl of the oral cavity , additional studies involving a larger number of cases are needed . previously , spindle cells have been found to express cd34 and bcl-2 , yet not s-100 . in the present case , tumor cells exhibited immunoreactivity for cd34 and bcl-2 , and not for sma and desmin . moreover , spindle cells were negative for s-100 , while mature adipocytes were strongly positive for . immunoreactivity to desmin has been found to vary and therefore , should be analyzed with extreme care . in particular , the expression of desmin by lesions with non - classical histological features , or those occurring in atypical locations , should be closely considered . overall , the clinical , histopathological and immunohistochemical profile of the present case supports a diagnosis of scl . therefore , complete surgical excision was performed , and the patient was monitored during a follow - up period , despite the low recurrence rates reported for scl . scl is a benign neoplasm that should be considered for tumors identified in the oral cavity that include a spindle cell component . in addition , a correlation between histological and clinical features is essential for establishing a definitive diagnosis of scl , in order to avoid a misdiagnosis .

spindle cell lipoma ( scl ) is a benign lipomatous neoplasm typically located in the posterior neck and back of older males . it presents as a well - circumscribed mass in the buccal mucosa , tongue , floor of the mouth or hard palate . there are only two case reports of scl in the gingiva and alveolar ridge . here , we report a case of scl in the mandibular mucogingival junction of a 68-year - old male . clinical , histopathological and immunohistochemical findings are presented . although oral scl is rare , it should be considered in the differential diagnosis of spindle cell neoplasms occurring in the oral cavity .

owing to its protected retroperitoneal location , pancreatic injury following blunt trauma is rare , with an incidence rate of < 2% . early and accurate identification of such injuries are imperative to avoid high morbidity and mortality associated with ductal injuries . however , proponents of early surgical intervention attributed to the delay in intervention to be related with increased rates of morbidity and mortality [ 13 ] . so , an early laparoscopic approach might play a role for the diagnosis and management of blunt pancreatic injuries . here , we report a case of traumatic pancreatitis following blunt abdominal trauma managed successfully using laparoscopic techniques . serum pancreatic amylase and lipase levels increased from108 to 456 u / l on admission to 404 to 764 an initial abdominal ct scan with iv contrast demonstrated pancreatic injury ( grade ii ) with peripancreatic fat stranding . two hepatic lacerations were noted in addition to minimal subhepatic and left subdiaphragmatic free fluid ( fig . 1 ) . initially , the patient was managed conservatively and kept on nil per mouth using nasogastric decompression , intravenous fluids , analgesics and serial clinical assessment . he continued to complain of severe generalized abdominal pain with diffuse tenderness and guarding that required exploration to exclude other intra - abdominal injuries namely hollow viscus . preoperative endoscopic retrograde cholangiopancreatography ( ercp ) and magnetic resonance cholangiopancreatography ( mrcp ) were not performed at this stage . cytology and culture from the fluid revealed no organism growth ; however , its pancreatic amylase level was 6062 u / l . severe pancreatic reaction with saponification was seen over the thickened and contused greater omentum and bowel loops . a thorough exploration revealed no associated intra - abdominal injuries . during exploration of the lesser sac , pancreas was found to be hemorrhagic and necrotic , and the ductal injury could not be identified . figure 2 shows the intraoperative extension of the pancreatic necrosis that involved the entire gland . two drains were inserted into the lesser sac and pelvis following which the procedure was terminated without conversion . figure 1:ct abdomen showing two hepatic lacerations in addition to minimal subhepatic and left subdiaphragmatic free fluid . ct abdomen showing two hepatic lacerations in addition to minimal subhepatic and left subdiaphragmatic free fluid . the high serum amylase and lipase levels were normalized within 2 days postoperative . on the third postoperative day , clinical examination and chest x - ray demonstrated left - sided pleural effusion ( fig . follow - up mrcp revealed complete transection of the pancreatic duct at the junction of pancreatic neck and body ( grade iii ) . output from the abdominal drains showed a gradual decline in the amount of drained fluid . on the 28th day a 6-month out - patient abdominal ct follow - up showed no fluid collection and the patient was asymptomatic . the clinical and laboratory findings of blunt pancreatic injury are nonspecific , and therefore accurate diagnosis in its acute phase is usually delayed [ 1 , 3 ] . computed tomography scanning may fail to delineate the pathology , especially in the initial stage . also , the ability for ct to demonstrate the integrity of pancreatic duct is limited ( 43% ) ; however , multiple detector computed tomography may have better result [ 1 , 4 , 5 ] . ercp seems the most reliable diagnostic tool to accurately define the continuity of the main pancreatic duct following pancreatic trauma with a 100% sensitivity and specificity . however , the need for a skilled endoscopist and the invasive nature of procedure may limit its use in unstable patients . suspicion of concomitant traumatic intra - abdominal injuries prompts the surgeon to choose exploration over ercp . pancreatic lacerations not involving the duct ( the american association of surgeons in trauma grade i and ii ) are considered minor injuries and are predominantly managed conservatively . grade iii v injuries usually necessitate surgical exploration depending on the degree of injury and its proximity to the mesenteric vessels ; where distal pancreatectomy is the most common approach . kantharia et al . studied 17 cases with pancreatic trauma and found that contrast - enhanced ct as the useful tool for diagnosis and grading of the pancreatic injuries . moreover , the majority of these cases responded well to the conservative treatment ; however , higher grade pancreatic injury required surgical intervention but with higher mortality . in patients with blunt pancreatic trauma , this is particularly compelling when ct scan is inconclusive and patients show signs suggestive of peritonism . intraoperative diagnosis of ductal injuries is seldom done owing to its complexity and retrograde pancreatography through a small duct is often difficult in trauma patients . necrotic and hemorrhagic pancreas precluded any intraoperative attempt to accurately characterize extent of ductal injury . looking retrospectively , we acknowledge that , if we were able to diagnose ductal transection pre / intraoperatively , our management would have drastically deferred towards distal pancreatectomy . in addition to being an exploratory , laparoscopy can be effectively used to characterize pancreatic injuries ( grading ) that informs the management with immediate drainage for the proximal pancreatic part or the resection of the distal injuries , whenever indicated . therefore , a laparoscopic approach provides a genuine alternative to the open abdominal surgery . in conclusion , the management of blunt pancreatic injuries should be tailored to individual situations . in selected patients with worsening symptoms , a prompt trial of laparoscopy although we chose a conservative drainage approach due to inconclusiveness on the integrity of pancreatic duct , we were able to achieve a favorable result . : data analysis and interpretation , drafting and manuscript review ; a.e.m . : data analysis and interpretation , drafting and manuscript review ; h.a.t . : study design , data interpretation and review manuscript .

the incidence of pancreatic injury following blunt abdominal trauma is rare . a timely accurate diagnosis of such injury is difficult and also the management remains controversial . here , we reported the successful use of laparoscopy to diagnose , characterize and treat blunt pancreatic trauma in a 28-year - old male patient involved in a motor vehicle crash . an abdominal computed tomography scan showed peripancreatic fat stranding suggestive of pancreatic injury . with persistent clinical signs of peritonitis and laboratory investigations suggestive of pancreatitis , the patient underwent laparoscopic drainage of the lesser sac . the patient had an uneventful postoperative course . the management of patients with blunt pancreatic injuries should be tailored to individual situations . our experience suggests that a timely laparoscopic management of traumatic pancreatic injury is safe approach in selected cases .

adrenohepatic fusion is a relatively common condition that has been reported in the literature and explained as a result of normal aging . however , the presence of a neoplastic process in the adrenohepatic fusion is relatively uncommon , especially when it is a malignant neoplasm . here , we present a patient with a malignant mass consisting of an adrenocortical carcinoma and hepatocellular carcinoma arising from an adrenohepatic union . a 48-year - old male presented with his ruq abdominal pain that is relieved by lying on the right side and sleeping . the patient had no past history of any disease , nor diagnosed of any chronic illnesses . the computed tomography ( ct ) scan for abdomen was done and showed large retroperitoneal mass of heterogeneous density , with heterogeneous contrast enhancement posterior to the liver ( fig . the mass measured 11 11 12 cm displacing the right kidney , and the right lobe of the liver and ivc anteriorly . there was focal invasion of the liver measuring 3.6 6.4 cm at segment 7 . the patient underwent an us - guided core biopsy of the mass that showed malignant cells consistent with both adrenocortical carcinoma and hepatocellular carcinoma ; however , the former diagnosis was favored based on the clinical picture . the patient went for a right hepatectomy with right adrenalectomy , cholecystectomy and excision of associated lymph nodes . the lesion and the excised structures were sent for histopathology that showed a right liver lobe mass attached to it measuring 17 10 7 cm , and the cut section of the mass showed nodular surface with multiple areas of necrosis . slicing of the liver showed a gray white mass measuring 5 5 3 cm , which is adherent to the mass and the remaining liver parenchyma appear unremarkable . the microscopic examination of the mass revealed a moderately differentiated hcc measuring 5 cm in diameter , confined to the liver , < 5 cm from resection margins and no lymph - vascular invasion ( fig . 2 ) , and a separate adrenocortical neoplasm measuring 17 cm in diameter , multiple foci of necrosis , no capsular or lymph - vascular invasion and resection margins were not involved by the tumor ( fig . 3 ) . excised lymph nodes included a single right portal vein lymph node , a gallbladder lymph node and seven para aortic lymph nodes . figure 1:sections of the ct showing a large retroperitoneal mass , focal absence of fat gland and an invasion into the liver.figure 2:section from the hepatic mass showing positive staining of the tumor cells with the hepar ihc stain confirming the hepatic nature of the liver mass.figure 3:section from the adrenocortical mass showing strong positive cytoplasmic staining with low molecular weight cytokeratin - cam 5.2 ihc stain . sections of the ct showing a large retroperitoneal mass , focal absence of fat gland and an invasion into the liver . section from the hepatic mass showing positive staining of the tumor cells with the hepar ihc stain confirming the hepatic nature of the liver mass . section from the adrenocortical mass showing strong positive cytoplasmic staining with low molecular weight cytokeratin - cam 5.2 ihc stain . adrenohepatic fusion is a relatively common observation during autopsies ; however , neoplasms arising from the union are very poorly reported . in our case , an adrenohepatic fusion was detected using a ct scan of the abdomen that showed focal areas of loss of fat gland between the retroperitoneal mass and the liver . dolan defined adrenohepatic union as the adhesion of the liver and the right adrenal cortex with the partial or complete absence of a fibrous capsule dividing the two organs . adrenocortical adenoma arising from an adrenohepatic union was reported in several cases ; however , we could not find a report that describes an adrenocortical carcinoma combined with a hcc from an adrenohepatic union in the literature as the case we present here . a differential diagnosis of hcc must be considered in such a case as the histopathology of the resected lesion shows mixed malignancies of adrenocortical carcinoma in the adrenal part of the lesion and a hcc in the hepatic part and several cases were reported in the literature of a primary hcc extending into the right adrenal directly , or to both adrenals as the first presentation of hcc metastasis , other reports mentioned cases where an hcc has developed in an ectopic liver tissue . on the other hand , an adrenocortical tumor that developed from an adrenal rest inside the liver with radiological findings of hcc okuda introduced a few cases of hcc presenting as pedunculated masses outside the liver most of which had dual blood supply of a hepatic and a suprarenal artery that might support the fusion phenomenon , furthermore , none of the masses were discovered in the left adrenal , which , again , supports fusion and invasion rather than hematogenous spread . core biopsy was reported in different similar cases to be of diagnostic value that changed the presumed diagnosis based solely on imaging modalities . in our case , after using a ct scan to diagnose the patient , a trucut biopsy was done to confirm the diagnosis of an adrenocortical carcinoma invading the liver ; however , an incidental histopathologic finding of co - occurrence of a hcc in the same lesion raised our suspicions , so we went to do a positron emission tomography scan cap to look for any focus of metastasis , which revealed negative results . the patient was followed up for 2 years after the operation without evidence of metastasis or recurrence .

abstractadrenohepatic fusion is a relatively common condition that has been reported in the literature and explained as a result of normal aging . however , the presence of a neoplastic process in the adrenohepatic fusion is relatively uncommon . a 48-year - old male presented with ruq abdominal pain with findings of a huge liver mass with adrenohepatic fusion in the computed tomography scan . histopathological studies revealed a mixed , although distinctly separated , adrenocortical carcinoma and a hepatocellular carcinoma within an adrenoheaptic fusion .

apoptosis and autophagy drive de novo lumen formation ( debnath et al . , 2002 ; mills et al . , 2004 ) . in the fly trachea and retina , secreted proteins draw fluid into the apical space ( husain et al . , 2006 ; endothelial cells are thought to extend and fuse vacuoles to form a central lumen ( kamei et al . , 2006 ) . understanding the mechanisms underlying lumen formation has been greatly aided by in vitro three - dimensional cultures that mimic their development . in general , this involves plating isolated cells in three - dimensional matrices such as matrigel . under these conditions , mammary epithelial cells grown in these conditions form a hollow ball of cells resembling the mammary gland . formation of this structure proceeds by apoptosis and autophagy , mimicking the in vivo process ( mailleux et al . , 2008 ) . recently , it was shown that fluid flow driven by ion transport is responsible for formation of the single intestinal lumen in zebrafish ( bagnat et al . , 2007 ) . although genetic and cell biological experiments in zebrafish have begun to dissect this process , the establishment of an in vitro system would be a great boon ( bagnat et al . , 2007 ) . to date , a robust three - dimensional cell culture system that models intestinal lumen formation has not been described . ( see p. 625 of this issue ) now show that intestinal epithelial derived caco-2 cells form cysts in three - dimensional culture . this is likely caused by the downstream activation of an apically localized cystic fibrosis transmembrane receptor chloride channel , although future studies will be needed to confirm this hypothesis . blocking na / k - atpase activity completely abrogates lumen formation , which is consistent with a role for ion flow in lumen enlargement . as this culture system is amenable to rnai , transfection , and pharmacologic perturbation , it should greatly aid in the understanding of intestinal lumen biogenesis . apical identity in the three - dimensional caco-2 cultures is established at the two - cell stage . after the first cell division , the site of the cytokinetic furrow is marked by atypical pkc , which localizes to the apical domain in mature polarized epithelia ( fig . this intriguing observation suggests that cell division acts as a symmetry - breaking event , allowing the establishment of cell polarity . what is perhaps most surprising is that the site of cell cell contact , usually occupied by adhesion molecules , may not be a homogeneously adhesive domain . although not examined in detail in this study , it will be interesting to determine whether tight junctions and adherens junctions encircle a nonadhesive apical core region at this polarized two - cell stage . this is not without precedent , as , after the first division of the xenopus laevis embryo , tight junctions form at the lateral margins of the cell contact zone ( cardellini et al . , 1996 ) . in the caco-2 three - dimensional cultures , it is not yet known whether polarized localization of transmembrane proteins occurs at the two - cell stage . thus , whether these cells are functionally polarized for secretion at this early time point remains to be determined . fluid flow increases lumen size . in cdc42-deficient cells , mitotic spindles do not localize correctly , resulting in formation of additional lumens . it is noteworthy to point out that in other model systems , a functionally opposite approach is used to generate cell polarity . in the caenorhabditis elegans embryo , as cells divide , the sites of cell cell contact exclude markers of the apical domain ( such as par6 ) , which become restricted to the peripheral plasma membrane ( hung and kemphues , 1999 ; anderson et al . , 2008 ) . an explanation for these differences is not clear at present , although it will be important to determine whether integrin / ecm - based signals coming from the matrix surrounding the caco-2 cells are necessary for correct polarization of these cells and collaborate with cell division to set up this polarity . to begin to understand how cells polarize and organize themselves into a hollow sphere , jaffe et al . this small gtpase is required for cell polarity in many contexts , including in some epithelial cells ( etienne - manneville , 2004 ; wu et al . , 2007 ) . , cdc42-null cells can still form a leading edge and migrate ( czuchra et al . , 2005 ) . in epithelial three - dimensional culture , knockdown of cdc42 in mdck cells results in a significant loss of cell polarity and an inability to form cysts ( martin - belmonte et al . , 2007 ) . individual cells polarize normally and have intact cell junctions , but the entire cyst lacks proper organization , with two or more lumens forming . the cell biological defect that gives rise to these multiple lumens appears to involve misorientation of the mitotic spindle . in simple epithelia , the spindle normally aligns itself perpendicular to the polarity axis and parallel to the underlying basal lamina ( jinguji and ishikawa , 1992 ; reinsch and karsenti , 1994 ; fleming et al . , 2007 ) . 1 ) . because the site of cell division becomes the apical membrane in these cells , this establishes a new apical membrane region , which is disconnected from the primary lumen . although cdc42 has been implicated in spindle orientation previously , this was thought to be secondary to its effects on polarity ( got ta et al . , 2001 ) . in this case , the two can apparently be separated . in the future , it will be important to determine not only the downstream effectors and pathways that cdc42 uses to influence spindle orientation but also how division sites specify apical membrane biogenesis in these cells . finally , it will be very exciting to determine whether cdc42 functions to maintain spindle orientation and single lumen formation in an in vivo context .

the formation of a single lumen is a necessary step in the formation of biological tubes . different tissues have developed diverse ways to form their lumens . in this issue , jaffe et al . ( jaffe , a.b . , n. kaji , j. durgan , and a. hall . 2008 . j. cell biol . 183:625633 ) report the development of an in vitro system for studying lumen formation that is driven by fluid transport , recapitulating intestinal lumen formation . effective ion and fluid transport requires both cell polarity and proper tissue organization . surprisingly , polarization of cells in this three - dimensional system does not require cdc42 . instead , cdc42 prevents formation of multiple lumens by orienting cell divisions and directing apical membrane biogenesis .

we first extended our recent cell culture studies to include porcine kidney 15 and human embryonic kidney 293 cells , which were the type of cells used by chung et al . human hepatocellular 7 carcinoma cells were also included because they are highly susceptible to virus infection , as are vero cells and several other cell lines we used in earlier studies ( 5,6 ) . infections with golv and hebv were performed at multiplicities of infection of 1 in doublets in all cell lines . cell culture supernatants were analyzed for viral rna after 0 , 3 , and 6 days by real - time reverse transcription pcr ( rt - pcr ) ( 5,6 ) . no replication of golv and hebv was detected , whereas vesicular stomatitis virus replicated to high concentrations ( figure 1 ) . infection of cells with vesicular stomatitis virus ( vsv ) , herbert virus ( hebv ) , and goulako virus ( golv ) . a ) porcine kidney 15 cells ; b ) human embryonic kidney cells ; c ) human hepatocellular 7 cells . the number of viral genome copies in cell culture supernatants were measured at 0 , 3 , and 6 days postinfection by real - time reverse transcription pcr . because cell culture experiments may not show the full host range of a specific virus , we tested serum samples collected in 2008 from sus scrofa domestica pigs in goulako , the rural village where golv and hebv were first isolated from mosquitoes in cte divoire ( 5,6 ) . the 28 tested samples represented nearly all the pigs kept in goulako at that time , all of which were constantly exposed to mosquitoes . we also tested 108 serum samples collected in 2011 from mosquito - exposed swine in kumasi , ghana , where mosquitoes were found to be infected with hebv ( 6 ) and golv ( s. junglen , unpub . all samples were tested for virus by real - time rt - pcr ( 5,6 ) and tested for antibodies against golv and hebv nucleocapsid proteins by recombinant immunofluorescence assay ( 10 ) . technical appendix figure 1 shows antigen controls and results from 1 representative swine serum sample . to compare the viruses found in pigs in south korea with viruses found in mosquitoes in africa , we replicated methods used by chung et al . ( 9 ) and amplified a region of the golv glycoprotein precursor gene from 27 golv strains in mosquitoes ( technical appendix ) . the viruses found in the pigs fell within the genetic diversity of viral strains of golv and hebv and did not constitute phylogenetic outliers ( figure 2 , panel a ) . the analyzed fragment had 6 aa exchanges , but they were insufficient for drawing conclusions about protein function because the fragment did not include domains putatively relevant for receptor binding ( technical appendix figure 2 ) . maximum - likelihood phylogenetic analyses of goulako virus ( golv ) and herbert virus ( hebv ) strains from mosquitoes in cte divoire , 2004 , and ghana , 2011 , and virus strains detected by chung el al . a ) analysis of the glycoprotein precursor gene of golv strains identified in mosquitoes collected in cte divoire and ghana and of strains detected in swine in south korea . b ) analysis of the rna - dependent rna polymerase gene of hebv strains from mosquitoes and swine . small rt - pcr fragments from the rna - dependent rna polymerase ( rdrp ) gene were presented by chung et al . for hebv . we performed phylogenetic analyses to compare these swine - derived sequences with sequences from all mosquito - derived viruses from which we could sequence the corresponding genome region ( figure 2 , panel b ) . comparison of swine - derived sequences with the phylogeny of mosquito - derived hebv strains , constructed on the basis of the third conserved region of the rdrp ( figure 2 , panel c ) , showed that the strains from south korea fell within the phylogenetic diversity of hebv strains identified in west africa . first , the viruses infecting swine in south korea may constitute variants of golv and hebv that can infect vertebrates . the presence of an nss protein in phleboviruses and orthobunyaviruses provides interferon resistance required to infect vertebrates efficiently ( 3,4 ) . because full genome sequences from swine viruses detected by chung et al . are not available , we have no information on the presence of ns proteins in these viruses . however , our rt - pcr assays have been shown to detect variant viruses , have been validated for sensitivity ( 100 viral genome copies per ml in liquid specimens ) , and provide high specificity by probe detection ( 5,6 ) . a concern regarding the results of chung et al . is the use of rt - pcr assays based on sybr green ( thermo fisher scientific , lithuania ) product detection , which , from our experience , is prone to yield nonspecific results because no probe is used in this assay . some sequences presented by these researchers contained stop codons in the hebv rdrp and the golv glycoprotein precursor genes , making it unlikely that these sequences represent replicating viruses . besides technical explanations , these sequences could represent viral genome fragments integrated in genomes of organisms , such as insects , that are eaten by pigs in the region . integration of rna virids derived from flaviviruses into the host genome has been described in insects ( 11 ) . testing food eaten by swine for insect dna or viral rna could yield insight . in addition , we may have collected serum when no active virus infections occurred in tested animals . however , past infections would have been shown by antibody tests . because bunyaviruses from all vertebrate - infecting genera induce antibodies against the nucleoprotein ( 1214 ) , we are confident about our choice of antigen in our assays . several technical issues in the study by chung et al . should be clarified further . first , rna concentration in tissue , as determined by rt - pcr , did not correlate with the success of probe - based immunohistochemistry in several organ samples ( 9 ) . second , supernatants from the virus isolate from south korea showed high cytopathogenic activity in cell culture ( 1010 cytopathogenic units / ml ) but low levels of concomitant viral rna by rt - pcr . because no antigen detection in cells was attempted , the cytopathogenic effect could have been caused by any other virus blindly isolated . one of the most infectious and deadly swine pathogens , the porcine reproductive and respiratory syndrome virus ( 15 ) , was co - detected in lung samples of dead pigs in south korea ( 9 ) . the finding of genome fragments of golv and hebv in swine in south korea needs to be more fully explored . however , with no further independent proof of infection of swine or other vertebrates , hebv and golv should not be considered epizootic pathogens or arboviruses . technical appendix . detailed methods and results of testing of serum samples from pigs for possible infection with goulako and herbert viruses , cte divoire , 2008 , and ghana , 2011 .

a recent report suggested that 2 novel bunyaviruses discovered in insects in cte divoire caused lethal disease in swine in south korea . we conducted cell culture studies and tested serum from pigs exposed to mosquitoes in cte divoire and ghana and found no evidence for infection in pigs .

subgingival fracture or fracture of a tooth below the gingival attachment or alveolar crest level presents esthetic , functional , and psychological sequelae . the time between the injury and the initiation of treatment , level of the fracture line , and stage of root development are some criteria to be considered when choosing a treatment approach for a complicated tooth fracture . in young permanent teeth , pulpotomy is classically performed to promote apexogenesis ; if this procedure ensures a tight seal , root canal treatment is not necessary . further , orthodontic extrusion , or forced eruption , is as an alternative to crown lengthening , which involves the removal of supporting alveolar bone and can compromise esthetics . a 10-year - old boy was referred to our dental clinic 12 h after he had slipped on the ground and injured his anterior tooth . he did not have a significant medical history , and the results of the extraoral examination were unremarkable . the patient had class ii deep bite , which increases susceptibility to anterior tooth injury . intraoral examination revealed horizontal fracture at the cervical margin of tooth # 9 extending toward the palatal side . all the incisors and canines except tooth # 9 responded normally to thermal and electric pulp testing , which signifies healthy pulp tissue . after removal of the loose fragment , the tooth margin was clinically visible on the labial side but not on the palatal side [ figure 2 ] . probing with a periodontal probe revealed that the tooth margin on the palatal side was located subgingivally and below the alveolar crest level . radiographic image of the fractured tooth ( # 9 ) occlusal view of the remained crown different treatment options were explained to the patient , and consent was obtained from his parents for the treatment chosen . vital pulp therapy with mineral trioxide aggregate ( mta ) and temporary restoration with glass ionomer cement ( gic ) were performed [ figure 3 ] . the orthodontic treatment consisted of forced eruption of the fractured tooth [ figures 4 and 5 ] . after 4 weeks of orthodontic treatment , a favorable response was observed , but adequate extrusion occurred after 9 weeks [ figures 6 and 7 ] . at this time , active orthodontic treatment was stopped , and the tooth was stabilized for 5 months to allow sufficient time for healing of the socket . thereafter , frenectomy and supracrestal fiberotomy were performed . eight weeks after crown lengthening , the tooth was finally restored with composite resin by using the acid etch technique [ figures 9 and 10 ] . periodic follow - up examinations were carried out : pulp sensitivity was tested and periapical radiographs were recorded to follow the root development . the periapical region appeared normal and the root apex completely formed during the treatment . two years later , hard bridge formation was evident under the mta dressing [ figure 11 ] . vital pulp therapy of the tooth # 9 using mta on the exposed pulp buccal orthodontic appliance bonded to # 9 lingual view of tooth # 9 on the first day of bonding orthodontic appliance buccal view at 9 weeks of extrusion radiographic view at 9 weeks of extrusion buccal view at 2 weeks after crown lengthening procedure restoration of the tooth # 9 with a composite resin using the acid etch technique palatal view of the restored tooth postoperative radiograph after two years showing apical end closure and intact lamina dura subgingival fracture of a tooth presents a challenging restorative problem and needs efficient assessment for treatment . extraction should not be the first choice of treatment for extensively damaged young permanent teeth in the anterior region ; instead , alternative treatment modalities must be considered . age is an important criterion for managing a tooth with pulp exposure , because older pulps are less cellular and more fibrous , and may have less blood supply , affecting the treatment outcome . in our case , we used white mta because of esthetic concerns . the main reason for forced eruption was to ensure sufficient tooth structure to create a ferrule effect over sound dentin . an alternative option is crown lengthening by removing the supporting alveolar bone ; however , this procedure further exposes sound tooth structure and produces a high gingival contour , hampering the soft - tissue esthetics and leading to additional bone resorption . in addition , the resultant crown root ratio may be unfavorable . in our case , orthodontic extrusion of about 4 mm the root length of the fractured incisor allowed the necessary amount of extrusion and still maintained a crown root ratio of approximately 1:1 , which is favorable for maintaining periodontal support . root canal treatment was not necessary because vital pulp therapy was performed within 48 h after the injury and a tight seal was achieved . in conclusion , the traumatized immature tooth was saved and restored by a multidisciplinary treatment approach with strict cooperation among specialists . the keys to long - term success in this case are efficient assessment , appropriate treatment , and reassurance and motivation of the patient throughout the course of treatment as well as regular recall examinations and careful prognostic evaluation .

this case report describes the multidisciplinary management of subgingival horizontal crown - root fracture of an immature permanent maxillary central incisor in a 10-year - old boy . after removal of the fractured fragment , pulpotomy was performed within 48 h from the injury to promote apexogenesis . the tooth was orthodontically extruded until the fracture line was located above the alveolar bone level . frenectomy , supracrestal fiberotomy , and crown lengthening were performed after adequate stabilization of the extruded tooth for 5 months . finally , the tooth was restored with composite resin by using the acid etch technique . this report highlights that a multidisciplinary treatment approach with strict cooperation among specialists to manage a complicated crown - root fracture can save and restore a traumatized immature permanent tooth .

a normotensive 68-year - old male who suffered from dementia without parkinsonism sign and symptoms , presented with hemiparesia without any decrease in level of consciousness . symptoms started since two weeks before admission with headache , nausea , vomiting and hemiparesia . the severity of headache and permanent weakness forced the patient and his relatives seeking medical care . past medical history revealed a progressive dementia since one year ago without history of hypertension or other related medical conditions . he did not have any history of trauma , but he had two attacks of transient hemiparesia and headache in previous year neglected as senile symptoms . other than hemiparesia , neurological examination at the first day and at the time of discharge revealed that cognition impairment was compatible with subcortical dementia . laboratory examinations , including : complete blood counts , electrolytes , liver and renal function tests , and coagulation tests were all within normal ranges . computed tomography ( ct ) showed three well defined hyperdense cortical lesions over the both parietal lobes and left insular lobe without mass effect or surrounding edema ( figure 1 ) . the further investigation using magnetic resonance imaging ( mri ) with administration of contrast agent revealed neither further enhancements nor additional information compared to ct scan ( figure 2 ) . spiral brain ct scan on admission brain mri with and without contrast agent on third day after 2 weeks , while the patient was hospitalized , we took another ct scan , and there was no evidence of previous lesions as shown in figure 3 . therefore , according to a documented multiple superficial intracerebral hemorrhage and other criteria , diagnose of probable caa was introduced . throughout the hospitalization , standard management of ich was done7 and finaly , the patient was discharged with the order of cognitive enhancer drugs and rehabilitation . dementia and ich are the main clinical presentations of caa.8 caa is the most frequent cause of lobar ich in the elderly.9 the condition is typically observed in normotensive adults over 60 years old.1310 in contrast to deep distributed ich resulting from hypertension , the location in caa is generally superficial.1011 caa is more often asymptomatic3 and in the brain autopsy of more than 40% of normotensive persons over the age of 70 , we can find amyloid changes.12 dementia may be seen earlier than symptomatic ich in 25 to 40% of patients and can be slowly progressive , similar to that seen in alzheimer disease.3 the most common type of caa is sporadic and associated with increasing age . sporadic caa can involve multiple lobes.9 angiography and mri are conventionally used for assessment , but the angiography is not useful.13 multiple regions of the signal void in gradient echo mri implys multiple distributed petechial hemorrhages and make the diagnosis of caa.3 for the standard diagnosis of caa , boston 's criteria36 were made in 1990 : --definite caa : full postmortem examination indicative of caa + lack of other diagnostic lesions --probable caa with supporting pathology : clinical data and histopathological sample ( evacuated hematoma or biopsy ) indicative of some degree of caa in the sample + lack of other diagnostic lesions . --probable caa : clinical data and mri or ct indicative of multiple hemorrhages limited to lobar , cortical , or corticosubcortical areas ( cerebellar hemorrhage allowed ) in subjects aged > 55 years . --possible caa : clinical data and mri or ct indicative of single lobar , cortical , or corticosub - cortical area hemorrhage in subjects aged > 55 . at present , there is no confirmed treatment to stop the progression of caa,9 but prevention from further hemorrhage and symptomatic treatment of seizures and related symptoms are recommended.1 caa usually has poor prognoses . each experience of hemorrhage brings the increasing risk of disability and dependence with permanent brain damage or even death.4 the management of ich related to caa is the same to the standard management of ich with particular attention for usage of anticoagulant , management of intracranial pressure , and preventing complications . when the ich causes a prominent mass effect and patient is impending to herniation , a prompt evacuation of hematoma can be life saving.4 recurrence of ich in caa is common.13 a history of hemorrhagic stroke before the index lobar hemorrhage can predict early recurrence of ich.4 occasionally , some medications such as those used to treatment of alzheimer 's disease may improve cognition and memory impairment . in summary , as the cerebral amyloid angiopathy is the most common cause of lobar parenchymal hemorrhage in elderly , we should be cautious and consider caa in normotensive patients presented with multiple or superficial intracerebral hemorrhage , particularly when the patient is demented with a history of hemorrhagic stroke .

cerebral amyloid angiopathy ( caa ) is the most common cause of lobar intracerebral hemorrhage . repeated bleeding may be presented with vascular dementia . we have reported a 68-year - old normotensive demented patient with probable caa presented with hemiparesia , headache and vomiting . according to the experience of this case , it is recommended to consider caa for normotensive elderly patients presented with multiple and superficial intracerebral hemorrhage .

a spinal subdural hematoma ( sdh ) is a rare clinical entity that accounts for only 4.1% of all spinal hematomas . it can be caused by major or minor trauma and iatrogenic injuries , such as those resulting from spinal punctures performed for diagnostic or anesthetic purposes5 ) . simultaneous intracranial and spinal sdhs are rare and may be a distinct subgroup , and only 12 cases have been reported in english literature1 - 3,6,7,9 - 14 ) . among them , only two cases of spontaneous concomitant cranial and spinal sdhs were reported in a patient receiving anticoagulant therapy who did not have a history of antecedent head or back injuries or lumbar spinal puncture3 ) . here , we report on a case of patient with a spontaneous nontraumatic spinal sdh that occurred with a simultaneous intracranial subacute sdh . the pathophysiological mechanisms of this uncommon entity are discussed , and the relevant literature is reviewed . a 67-year - old female who complained of back pain and both leg radiating pain was referred to our emergency room . she also complained of a severe bitemporal headache at the same time . during the previous 3 years she was treated with combined low dose aspirin and 75 mg clopidogrel bisulfate ( plavix ) per day . examination of blood tests had shown a platelet count of 14210/l , a prothrombin time of 10.4 sec ( range 9.4 - 12.5 ) , an international normalize ratio of 1.2 ( range 0.9 - 1.27 ) and partial thrombolplastin time of 40.2 sec ( range 28.0 - 44.0 ) . they were all within normal ranges . upon physical examination , she was alert and fully oriented in spite of the severe headache . the neurological examination revealed slight motor weakness ( grade iv ) and numbness in the lower extremities . an immediate magnetic resonance imaging of the brain and spine revealed a subacute sdh in the left fronto - temporo - parietal area that was 8 mm at its thickest point and a well - circumscribed intradural lesion , which was isodense with the dural sac , that measured 8 mm at its maximum diameter and compressed the cauda equina at l4-s1 . the intradural lesion showed high signal intensities on t1 weighted images and low signal intensities on t2 weighted images . no contrast enhancement was seen on fat - suppressed t1-weighted images ( fig . 1 , 2 ) . based on these magnetic resonance ( mr ) findings , the patient was diagnosed with concomitant cranial and spinal sdhs . the hematoma was evacuated under local anesthesia through one burr hole using a 5-l catheter 7 days after admission . the spinal sdh was treated conservatively . to distinguish this case from other conditions for differential diagnosis , the cerebrospinal fluid ( csf ) analysis revealed 190000 red blood cells / mm and 267 white blood cells / mm . a brain computed tomographic scan and lumbar spine mr images taken 14 days after admission revealed that the spinal sdh had completely resolved ( fig . 3 ) . the patient was in good health and free of neurological deficits during the 12-month follow - up period . unlike the cranial counterpart , the spinal subdural space lacks the bridging veins that act as an origin for a sdh . the lower incidence of sdh in the spine has been attributed to the protection of the spinal subdural space by the vertebrae and broad paravertebral muscles and to the rare passage of blood vessels , such as bridging veins , through the subdural space3,14 ) . moreover , a concomitant intracranial and spinal sdh is extremely rare , and , to the best of the authors ' knowledge , a total of 13 cases of the concomitant occurrence of intracranial and spinal sdhs have been reported so far in the english literature ( table 1 ) . among them , most cases were attributed to head injury or changes of csf hydrodynamics , and there has been only two reports , including our report , associated with anticoagulation in the absence of trauma3,4 ) . when using antiplatelet agents , the adp receptor antagonists prevent adp - induced fibrinogen binding to platelets , a necessary step in the platelet aggregation process . they would not influence the coagulation profiles of our patient , so the patient 's coagulation status remained normal . the exact etiology of the simultaneous occurrence of intracranial and spinal sdhs has not been clearly elucidated . initial hemorrhage in the subarachonoid space is thought to be the primary lesion that eventually dissects into the subdural space , and the subarachnoid hemorrhage is washed out by cerebrospinal flow3 ) . however , the causal relationship between cranial and spinal bleeding is not clearly documented by this theory . hung et al.2 ) hypothesized that a rise of intracranial pressure may also increase shearing force between spinal subdural and subarachnoid spaces so that the inner dura may tear and bleed . either high or low intracranial pressure has been proposed as a predisposing factor for this migration . raised intracranial pressure due to brain swelling the anatomic continuity between the intracranial and spinal subdural spaces can be observed using an electron microscope8 ) . a spinal sdh and rebleeding might have occurred in the cranial lesion before the onset because mr imaging of the brain suggested that the hematoma was in the subacute phase on admission . oral antiplatelet therapy and brain atrophy with aging may have facilitated the rebleeding and migration of the hematoma . the limitation of this study is that even though we discard the possibility of a minor trauma and thoroughly educate the patient , there is not enough to rule out the possibility of chronic subdural hematoma due to an accidental minor injury to the head . although rare , concomitant intracranial subacute sdh and spinal sdh should be included in the differential diagnosis of nerve root compression in a patient receiving anticoagulant therapy .

simultaneous intracranial and spinal subdural hematomas are extremely rare . in most cases , they are attributed to major or minor trauma and iatrogenic causes , such as those resulting from spinal puncture . to the best of the authors ' knowledge , there has been only two reports of spontaneous concomitant intracranial and spinal subdural hematomas in a patient receiving anticoagulant therapy who had an absence of evident trauma history . we report on a case of spontaneous concomitant intracranial and spinal subdural hematomas that occurred in association with anticoagulant therapy and present a review of the relevant literature .

we encountered a patient with renal failure in the setting of long - standing difficulty urinating , which he previously treated with intermittent self - catheterizations . this case illustrates the importance of taking a detailed history and the dramatic long - term effects of bladder calculi . urinary calculi are common , usually forming in the kidneys . less common are bladder calculi , which are more common in men and usually secondary to a pathologic condition such as a urethral stricture , benign prostatic hypertension , bladder neck contracture , flaccid or spastic neurogenic bladder , or foreign bodies in the bladder . however , some common complications of bladder stones include abdominal pain , infections , and hematuria . we report a case of a man with a long history of benign prostatic hypertrophy who was admitted for renal failure in the setting of using self - catheterization to relieve his urinary retention . a 58-year - old man with long - standing enuresis and positional difficulty with urination presented with shortness of breath . he was found to have a creatinine of 11.5 mg / dl , a blood urea nitrogen of 169 mg / dl , and a potassium of 6.5 mmol / l . urinary analysis was notable for a ph of 8.00 , > 180 white blood cells , and strongly positive leukocyte esterase . the urine culture grew pan - sensitive e. coli and he was started on antibiotics . renal ultrasound demonstarted bilateral hydronephrosis with ureterectasis , and computed tomography of the abdomen and pelvis revealed a large bladder calculus , measuring 5.3 4.3 cm and organized in concentric rings ( fig.1 ) . a computed tomography of the abdomen and pelvis showed a large bladder calculus , measuring 5.3 4.3 cm and organized in concentric rings . on further questioning , the patient described more than 10 years of difficult voiding . to relieve his urinary symptoms , approximately 5 years prior to admission he purchased plastic tubing from a pharmacy and used it to perform self - catheterizations intermittently over the course of 2 months . this provided only temporary relief and eventually urination required such significant intraabdominal straining that he suffered from frequent rectal prolapse . on hospital day 5 , he underwent cystolithotomy . a large , homogenous bladder calculi was removed and opened , demonstrating the presence of a plastic foreign body at the center ; thought to be a retained piece of plastic tubing ( fig.2a , b ) . the patient recovered from surgery uneventfully and was discharged with a stable creatinine of 4.5 mg / dl . ( b ) opened bladder calculus demonstrating the presence of a plastic foreign body at the center ; thought to be a retained piece of plastic tubing . bladder stones have been affecting human health for centuries and have even been found in egyptian mummies . in modern times , they account for only about 5% of urinary calculi and are often asymptomatic . while bladder outlet obstruction with resulting urinary stasis ( often from benign prostatic hypertrophy ) is the most common cause of bladder stones in developed countries , the presence of infection or foreign bodies are also risk factors . foreign bodies in the bladder may be iatrogenic in origin , resulting from retained catheter tips or sutures from bladder surgery . there are also reports of a wide array of self - inserted objects as diverse as light bulbs , pipe cleaners , wax candles , drinking straws , and even wrist watches [ 810 ] . any object that makes its way into the bladder can act as a nidus or scaffolding for stone formation . the formation of stones is a stepwise process that has been well described in the literature . first , once the solubility product has been exceeded , supersaturation begins as a metastable process with slow crystal growth . this continues until a critical limit of supersaturation is exceeded and the crystals spontaneously precipitate out on the initial small collection of crystals , acting as a nidus . in our patient , the retained piece of plastic tubing served as a nidus for stone formation with resulting supersaturation , aggregation , and proliferation of crystal growth around the foreign body . it is important to understand that there are several different types of urinary calculi differentiated by the chemical composition of the stone . starting with a plain abdominal radiograph is reasonable as approximately 90% of urinary calculi are radiopaque since they consist of calcium phosphate and calcium oxalate . less radiopaque stones include magnesium - ammonia - phosphate ( struvite ) and cystine , while uric acid and matrix stones are radiolucent . upon stone analysis it was determined that our patient had a carbonate apatite stone , a type of phosphate stone . it is rare for bladder stones to grow to a size large enough to cause renal failure . when this occurs , treatment involves cystolithotomy or endoscopic cytolithotripsy along with concomitant treatment of bladder outlet obstruction . after cytolithotomy and eventually transurethral microwave of the prostate , our patient had improvement in his renal failure . however , due to the long - standing nature of his outlet obstruction , he continues to have stage iv chronic kidney disease . bladder stones should be considered on the differential diagnosis in any patient with urinary symptoms as the presentation of bladder calculi is variable ranging from microscopic hematuria to severe renal failure as seen in our patient . it is important to remember that foreign bodies are one of the many risk factors causing bladder calculi . once the diagnosis of bladder calculi is made , it is necessary to treat the bladder calculi as well as the underlying problem that lead to the formation of the stone to prevent recurrent bladder calculi . as illustrated by our patient , prompt diagnosis and treatment must be pursued aggressively as significant complications can occur in long - standing , symptomatic bladder calculi .

key clinical messagewe encountered a patient with renal failure in the setting of long - standing difficulty urinating , which he previously treated with intermittent self - catheterizations . imaging showed a large urinary calculus in the bladder . this case illustrates the importance of taking a detailed history and the dramatic long - term effects of bladder calculi .

brucellosis is a highly contagious zoonotic disease caused by ingestion of unsterilized milk or raw meat from infected animals or in close contact with their secretions ; however , this disease is more prevalent in some parts in the world especially middle east , the mediterranean , mexico , and central and south america . isfahan has been one of the most important endemic areas of brucellosis in central iran for many years . most cases in the world are caused by b. melitensis , which is the most virulent subtype of brucella species . brucellosis has different clinical manifestations that mostly include : fever , sweating , low back pain , malaise , and arthralgia . two different clinical courses were recognized for this disease : acute brucellosis ( duration < 8 weeks ) and chronic brucellosis ( duration 8 weeks ) . the diagnosis of brucellosis should be considered in the setting of otherwise unexplained chronic fever and nonspecific complaints . moreover , brucellosis can cause different manifestations in eyes such as uveitis ( anterior uveitis , posterior uveitis , intermediate uveitis , panuveitis ) , conjunctivitis and neuro - ophthalmic defects ( papilledema , papillitis , third cranial nerve paresis ) . the history should include details regarding possible sources of exposure to brucella , including contact with animal tissues or ingestion of unpasteurized milk or cheese and raw meat . laboratory tests for diagnosis of brucellosis include specimen culture , serologic test , and polymerase chain reaction ( pcr ) . ideally , the diagnosis is made by culturing the specimen for detection of the organism . most of the serological studies for the diagnosis of brucellosis are based on antibody detection . it is generally agreed that a titer of > 1:160 in the presence of a compatible illness supports the diagnosis of brucellosis . treatment recommendations for children consist of combination therapy with a tetracycline ( for children 8 years ) or trimethoprim - sulfamethoxazole ( tmp - smx , for children < 8 years ) and at least one other drug including rifampin , gentamicin , or streptomycin , depending upon the site of infection . a 7-year - old girl was admitted to feiz hospital ( isfahan , iran ) with the chief complaint of decreased vision , pain and photophobia in right eye since last week . no afferent pupillary defect was detected but pupillary reaction to the light in right eye optic disc ( od ) was sluggish . in slit lamp examination , left eye was normal but right eye had ciliary injection , episcleritis , fine keratic precipitate ( kp ) on corneal endothelium , 2 plus flare , 4 plus cell reaction and 0.5 mm hypopyon in anterior chamber . iris was normal without nodules . however , vitreous had 4 plus vitritis and 2 plus haziness . optic disc and posterior pole were normal but at the periphery of retina some patches of choriretinitis were observed [ figure 1 ] . vitreous haziness in the first day in the medical history , she had wrist pain , fever and anorexia started since two months ago . we examined her some laboratory tests for ruling out certain diseases like juvenile rheumatoid arthritis ( jra ) and systemic lupus erythematous sarcoidosis , tuberculosis and syphilis . based on these evidences and the history of contact with sheep , some specific laboratory tests for brucellosis were evaluated . 2-mercaptoethanol ( 2me ) brucella agglutination test ( 1/160 ) , wright agglutination test ( 1/160 ) and combs wright ( 1/320 ) showed high titer of antibodies ; and the result of reponemal test , tuberculosis skin test and chest x - ray , the angiotensin - converting enzyme , rheumatoid factor ( rf ) and antinuclear antibody test ( ana ) were negative . after consultation , systemic treatment with rifampin and sulfadiazine / trimethoprim in concomitant with eye drops of betamethasone every 3 hours and tropicamide every 6 hours were administered for her . there after 5 days of systemic treatment , we started with systemic prednisolone 1 mg / kg ( oral ) and followed her weekly . after 2 weeks of the treatment , she started to show improvement , and 2 months later of systemic treatment and local steroid therapy , the signs and symptoms disappeared and her vision was back to normal ( final visual acuity was 20/20 ) [ figure 2 ] . no recurrence of ocular manifestations were detected during the follow - up period until now and thus we ruled out other problem like jra . decreased vitreous haziness after two weeks of treatment brucellosis presents with a various ranges and often with the presence of non - specific clinical signs and symptoms including ocular manifestations . in a cohort study performed in turkey , ocular involvements the most frequent manifestation was anterior uveitiis followed by choroiditis and panuveitis . in one study from peru , the most frequent manifestation of ocular brucellosis was reported to be uveitis , mostly posterior uveitis . in our case , furthermore , ocular damage occurs mainly in chronic phase of the disease , just as in this case . woods and rolando concluded , ocular brucellosis is a rare disease occurring among children ( 0.003% ) and our patient was seven years and further being a child . woods and rolando mentioned that the host - pathogen interaction of human and brucella species occurs through two mechanisms : direct invasion of the ocular tissue by the microorganism through sending septic emboli to the uveal tissue , and by formation of immunoglobulin and circulating complexes . in the above mentioned studies , improvement in visual acuity was seen with systemic steroid , which supports the interposition of immune components in ocular manifestations of brucellosis . it seems that in our present case , the second mechanism has the main role , since the signs and symptoms have started to disappear after steroid therapy . we conclude that uveitis may be a manifestation of the brucellosis and the treatment forthis systemic disease is needed for preventing systemic complications , and also examination of eyes in brucellosis patients must always be done by the clinicians working in this field . hence early treatment is very important for preventing permanent visual loss and the other complications of ocular brucellosis . all authors have contributed in designing and preparation of the first draft of the manuscript . all authors have read and approved the content of the manuscript and confirmed the accuracy or integrity of any part of the work .

brucellosis is a zoonotic disease with widespread prevalence . it presents with in various range and often with the presence of non - specific clinical signs and symptoms . brucellosis also may cause different manifestations in eyes such as uveitis , keratitis , conjunctivitis and neuro - ophthalmic defects . ocular brucellosis is rare among children . herein , we present a 7-year - old girl with systemic and ocular brucellosis . after treatment with systemic steroid and antibiotics , her signs and symptoms disappeared . since early treatment is important in preventing permanent visual loss and the other complications of ocular brucellosis , examination of the eyes in brucellosis patients must always be noticed by clinicians working in this field .

propranolol , a non - cardioselective -blocking drug , is considered the first - line treatment for complicated infantile hemangioma , which is associated with the potential compromise of vital functions , disfigurement , or bleeding . potentially harmful adverse effects , including bradycardia , hypotension , bronchospasm , and hypoglycemia , occur infrequently . common adverse effects include sleep disturbance and discoloration with cooling of the hands and feet [ 1 , 2 ] . here , we describe the case of an 18-month - old girl ( with no family or individual history of psoriasis ) who developed psoriasiform diaper rash , possibly induced by oral propranolol therapy for infantile hemangioma . an 18-month - old girl presented to the department of dermatology with a 3-week history of recalcitrant diaper rash . she had been successfully treated with oral propranolol for superficial and deep infantile hemangioma on the right cheek from the age of 3 months to the end of her first year of life . at 16 months of age , propranolol was reinitiated because the growth of the infantile hemangioma had rebounded , primarily in the deeper component of the tumor . she was initially diagnosed with irritant diaper dermatitis with secondary candida infection , based on a positive potassium hydroxide ( koh ) examination of skin scrapings . the rash did not respond to multiple topical therapies , including zinc oxide - based ointments , antifungal creams and low - potency topical corticosteroid ( desonide cream ) . a physical examination revealed well - defined erythematous scaly patches and plaque on the convex surfaces in the diaper area , with satellite lesions ( fig 1 ) . the patient was treated with a medium- to high - potency topical corticosteroid ( fluticasone propionate cream ) , and she experienced rapid and complete resolution ( within 1 week ) of the psoriasiform diaper rash ( fig 2 ) . one month later , the propranolol was discontinued because the hemangioma improved , and there was no recurrence of the psoriasiform diaper rash . with a prevalence of approximately 0.7% , psoriasis is a common chronic inflammatory cutaneous disease among children . psoriatic diaper rash , otherwise known as napkin psoriasis , is a special clinical variant that appears in young infants ( younger than 2 years of age ) and is characterized by sharply demarcated erythematous patches and/or plaque in the diaper area , which may be associated with satellite psoriasiform lesions . this clinical variant can be differentiated from irritant diaper dermatitis by its unique presentation and poor response to conventional diaper dermatitis treatment . these factors include trauma , infections ( e.g. , streptococcal pharyngitis or perianal streptococcal dermatitis ) , stress , and drugs . in the literature , few drugs have demonstrated a well - documented , strong causal relationship with the development of psoriasis or psoriasiform eruptions in the pediatric population . these therapeutic agents include tumor necrosis factor alpha inhibitors , imiquimod , growth hormone therapy , and rituximab . -blockers have been reported as the most common causative agents for drug - induced psoriasis in adults . however , to the best of our knowledge , there have been no well - described reports of psoriasiform eruptions due to -blockers in children . in adults , the latency period between starting -blockers and the appearance of psoriasis can vary from several days to 12 months , on average . the reasons for these variations remain unknown ; however , the influence of individual , genetic , and racial differences is implied . in addition , the occurrence of psoriasiform diaper rash temporally coincided with the re - administration of propranolol , suggesting a causal relationship between the drug and the skin eruption . moreover , our patient had no family history of psoriasis . in contrast , in a study of 1,262 pediatric patients , 71% of the patients with psoriatic diaper rash had a positive family history . it has been postulated that the blocking of epidermal -receptors by -blockers may decrease intraepidermal cyclic adenosine monophosphate ( camp ) levels , with a consequent increase of epidermal cell turnover as seen in psoriasis . indeed , the attachment of the normal -agonists to -receptors in the skin is necessary to increase cellular camp levels . camp , an intracellular second messenger , is part of a pathway that stimulates the proteins responsible for the differentiation and inhibition of epidermal cell proliferation . -blockers are now considered to be the first - line systemic therapy for complicated cases of infantile hemangioma . therefore , in recent years , its use has expanded in the pediatric population . to the best of our knowledge , here , we report the first case of psoriasiform diaper rash developing during propranolol therapy in a child with infantile hemangioma . this case also highlights the use of medium- to high - potency topical corticosteroids in treating this new potential adverse event . for physicians , awareness of this potential adverse event will facilitate its early recognition and prompt treatment .

propranolol , a nonselective blocker of -adrenergic receptors , has become the first - line treatment for complicated infantile hemangiomas . therefore , its use in the pediatric population has expanded in recent years . in adults , -blockers have been reported to be the most common causative agents for drug - induced psoriasis . in infants treated with propranolol for infantile hemangioma , the onset of psoriasiform diaper rash has not yet been reported . here , to the best of our knowledge , we report the first case of psoriasiform diaper rash possibly induced by oral propranolol in an 18-month - old girl with no family history of psoriasis .

radical generation can be triggered exogenously ( e.g. , uv and ionizing radiation ) and endogenously ( e.g. , mitochondrial respiratory chain and immune system ) , . an excess of free radicals due to increased formation or inadequate antioxidant mechanisms is harmful to the organism . because of their unpaired electrons and the associated instability and reactivity , radicals can cause damage in biological systems with the consequence of changing their structure and function . the undesirable effects include the inactivation of no by direct chemical reaction with reactive oxygen species ( ros ) , and oxidative damage to cellular components such as dna and proteins . these effects are possibly related to the development of cardiovascular diseases , neurodegenerative diseases , cancer , and aging processes , , . the antioxidant system is responsible for minimizing oxidative cell damage in the body caused by free radicals . ideally , it creates a balance which permits the beneficial effects of free radicals while preventing the harmful ones . the system includes enzymatic antioxidants ( e.g. , superoxide dismutase ) and non - enzymatic exogenous and endogenous antioxidants , which can be hydrophilic or lipophilic ( e.g. , ascorbic acid and glutathione , resp . ) . aop in urine and saliva can be determined by different methods , i.e. , photochemoluminescence ( pcl ) , . another method to determine the antioxidant status is the measurement of the -carotene content of the skin . the antioxidant balance of an individual is influenced by diet , sports , stress , among others , , . up to now , the aop in saliva , urine and skin were not determined in parallel in the same person . therefore , the focus of the study was to compare the aop of the 3 sampled media . nine psychology students ( 7 women , 2 men , 20 to 25 years old ) participated in the three - day study . every morning , fasting samples of spot urine and saliva from each participant were collected to determine aopsaliva and aopuurine . the samples were coded and then immediately frozen at 80c . while in saliva only the aop was analyzed , in the urine samples , both aopu and the creatinine content were determined , where the latter was adjusted for volume excreted . before analysis , the samples were allowed to thaw overnight in the refrigerator and were centrifuged after mixing briefly ( 5000 rpm ) in order to separate suspended matter . the centrifuged urine was diluted 1:10 and incubated for 5 min with uricase to eliminate uric acid . subsequently , the aop was measured by using photochem and the acw kit ( analytik jena , germany ) , . for all investigations , high - purity water was used ( reinstwasser - system , sg wasseraufbereitung und regenerierstation gmbh , barsbttel , germany ) . for creatinine , we used the creatinine - dri test detect ( micro genetics gmbh , passau , germany ) . the aop was calculated using the following formula : aop ( mg / g creatinine ) = aop ( mg / dl ) x 1000/creatinine ( mg / dl ) parallel to the daily sampling , we determined the -carotene content ( scale 010 ) of the skin by using biozoom ( opsolution nanophotonics gmbh , kassel , germany ) . the participants were instructed not to apply any skin cream in each morning before measurement . the parameters were intended for descriptive statistics , and pearson s correlation was calculated and tested for significance . the mean value of -carotene , 4.0 , was slightly lower than expected ( table 1 ( tab . 1 ) ) . the data analysis shows a significant positive correlation between the parameters aopuurine and aopsaliva at p<0.05 ( table 2 ( tab . , the values of -caroteneskin with those of aopuurine show a weak positive correlation , but this was not significant . the aopsaliva shows a slight negative correlation with the values of skin measurement , but the difference was not significant ( table 2 ( tab . antioxidant capacity was determined in materials which are non - invasively accessible , that is , in saliva , urine and skin . the ideal would be to collect 24-h urine . since this was not logistically realizable , spontaneous urine was used and normalized by creatinine content in urine ; this method has been proven in studies on iodine deficiency screening . influences of age , sex , lifestyle and nutrition were not considered in the pilot study , because the purpose was to compare the measured parameters . while urine is an excretion with accumulation of the excreted substances over time , saliva is a secretion , in which components can be exogenously influenced and endogenously metabolized , thus the composition can change quickly . this may explain the finding that the aopuurine is at least 10 times higher than aopsaliva . this result supports the hypothesis that urine and saliva are suitable for determining the aop . since saliva production is difficult to standardize and more susceptible to external influences than urine , the standard deviation in saliva is about 5.2 higher than in urine . this may be the reason why there is no positive correlation between -carotene of the skin and the aop of saliva and urine . our results suggest that in epidemiological studies , the aopuurine and , in parallel , the -carotene content of the skin are suitable for characterizing the antioxidative status , whereas the aopsaliva is dispensible . this work was supported by the project flex4work , sponsored by bmbf and esf ( fkz 01fh09127 ) . this work was supported by the project flex4work , sponsored by bmbf and esf ( fkz 01fh09127 ) .

aim : free radicals , oxidative stress and their possible consequences for health are becoming increasingly important in modern medicine . reactive species influence the organism , potentially causing oxidative cell damage . they can be produced by exogenous sources , or be a product of a variety of not only physiological metabolic processes , such as immune response , but also pathological processes . the antioxidant protection system protects the organism from oxidative damage caused by reactions producing an excess of free radicals . the analysis of antioxidant potential ( aop ) is therefore becoming increasingly important for the diagnosis of individual vitality.method : the photochemoluminescence method was used to measure the aop in urine and saliva , spectrometry was employed to measure the -carotene content of the skin . in addition , it was investigated whether the aopsaliva correlated with the aopuurine ( uric - acid independent aop ) as well as the -carotene content of the skin.results : the aop was significantly higher in urine than in saliva , and both values were significantly positively correlated with each other . however , there was no significant correlation to the -carotene content of the skin.discussion : the components of the aopuurine are accumulated over time ( night ) , whereas aop measurement in saliva is like a snapshot , which explains why aopuurine was significantly higher than aopsaliva , although the two parameters are correlated with each other . -carotene is a fat - soluble antioxidant , whereas in our study , only water - soluble antioxidants were determined in the urine . this explains why there is no positive correlation between -carotene of the skin and aop.conclusion : for the characterization of the aop in epidemiological studies , we recommend determining the aopuurine and parallel to this , the -carotene content of the skin .

it is well known that the main phenomenon of hypoxemia in acute lung injury / acute respiratory distress syndrome ( ali / ards ) is the high shunt fraction caused by the nonaerated areas of the lungs . during the disease process , the volume of extravascular lung water and the lung weight increase and promote the collapse of peripheral airways and lung parenchyma , mainly in the gravitation - dependent lung regions ( fig . the relationship between the nonaerated , poorly aerated , normally aerated and hyperinflated lung regions depends on the degree of heterogeneity of the ali / ards and the net result of the interaction of the pressure applied to the lung parenchyma ( airway pressure / end expiratory pressure ) and chest wall mechanics , as illustrated in the report by henzler and colleagues appearing in this issue of critical care . the most important force is not the airway pressure or tidal volume itself but the stress and strain that this airway pressure / tidal volume generates and the duration of these stresses and strains . at the bedside , the rough equivalent of stress is transpulmonary pressure , and the rough equivalent of the strain is tidal volume / end expiratory lung volume . this modern and complex mechanical ventilatory approach of ali / ards recruitment maneuvers and positive end - expiratory pressure ( peep)/tidal ventilation titration is a meshwork of interdependent but heterogeneously affected lung subunits that are behave according to different and multiple pressure volume envelopes of the respiratory system during mechanical ventilation , which in some cases can be represented by respiratory mechanics ( depending on the heterogeneity and etiology of the ali / ards and the net results of the mechanical configuration of the respiratory system and the applied inspiratory / expiratory pressure along the mechanical ventilatory support duration ) . in 1998 , a brazilian prospective , randomized and controlled trial of mechanical ventilation in patients with ards demonstrated that a lung protective ventilation strategy that used recruitment maneuvers ( a continuous positive airway pressure of 35 to 45 cmh2o ) for 40 s with a higher peep set 2 cmh2o above the lower inflection point of the pressure volume curve of the respiratory system and tidal volumes less than 6 ml / kg was associated with a 28-day intensive care survival rate of 62% . this contrasted with a survival rate of only 29% with conventional ventilation ( the lowest peep necessary for acceptable oxygenation with a tidal volume of 12 ml / kg without recruitment maneuvers - number necessary to treat = 3 , p < 0.001 ) . in a post hoc analysis , the same group stratified the 53 patients of the trial into quartiles according to peep levels and analyzed the 28-day survival rate . a peep of more than 12 cmh2o , and particularly greater than 16 cmh2o , was significantly correlated with an improved survival rate in these ards patients . ranieri and colleagues corroborated these results by demonstrating that a ventilation strategy involving higher peep / low tidal volume significantly decreased bronchoalveolar lavage and systemic blood levels of tumor necrosis factor- , il-8 and il-6 compared with low peep / high tidal volume ventilation . more recently , the same brazilian group showed that when an almost full recruitment is achieved and maintained by means of sufficient applied peep levels ( in ards patients this is about 18 to 26 cmh2o of peep ) , a partial arterial oxygen tension plus partial arterial co2 tension of more than 400 mmhg at a fraction of inspired oxygen of 100% is well correlated with less than 5% of lung collapse as shown on a thoracic computed tomography ( ct ) scan , ensuring more homogeneous ventilation ( fig . recruitment maneuvers , peep and tidal ventilation titration in ali / ards exert varied effects on airway caliber , the ventilation : perfusion ratio distribution , cardiac output and many as yet incompletely understood effects on the macromechanical and micromechanical properties of the diseased lung parenchyma [ 6 - 8 ] . the history of mechanical ventilation in previous breaths and the applied peep level strongly determine the working envelope in the present breath and the chances of promoting intratidal recruitment during mechanical ventilation in ards patients . overdistension and the opening and closing of alveoli during tidal ventilation are important issues in ventilator - induced lung injury . airspace collapse as shown by a thoracic ct scan is associated with hypoxemia in early ali / ards and can be reversed with a maximum lung recruitment strategy that can be applied to critically ill patients and may lead to 2 better pulmonary function at hospital discharge . so , careful studies of the mechanical , gas - exchange and hemodynamic consequences of mechanical ventilatory support in the experimental and clinical critical care settings of ali / ards are still necessary for a better understanding of the extremely complex issues involved in improving the prognosis of this still life - threatening clinical problem . more intriguing are the recent results showing that dead space fractions were elevated early in the course of ards patients and that the dead space fraction is an independent risk factor for death . corroborating these results are the observations that ali / ards patients who had a decreased partial arterial co2 tension during a prone - position protocol had improved survival compared with the nonresponders . so , respiratory mechanics , gas exchange and hemodynamic parameters as well as medical treatment for the etiology of ali / ards ( for example viral infections , bacterial infections , pancreatitis or gastric aspiration ) are important issues that have to be kept in the mind of the critical care physicians when treating a patient with ards in the intensive care unit . ali = acute lung injury ; ards = acute respiratory distress syndrome ; ct = computed tomography ; il = interleukin ; peep = positive end - expiratory pressure . thoracic tomography of two different models of acute lung injury / acute respiratory distress syndrome ( ards ) . ( a ) computed tomography ( ct ) scan of pigs after saline lung lavage before and after recruitment maneuvers with 45 cmh2o of pressure , maintaining a positive end - expiratory pressure ( peep ) of 10 cmh2o , showing some redistribution of ventilation . ( b ) ct scan of acute respiratory distress syndrome patients before and after a recruitment maneuver with 60 cmh2o maximal inspiratory pressure maintaining peep values of 20 and 25 cmh2o .

recruitment maneuvers and positive end - expiratory pressure ( peep)/tidal ventilation titration in acute lung injury / acute respiratory distress syndrome ( ali / ards ) are the cornerstone of mechanical ventilatory support . the net result of these possible adjustments in ventilatory parameters is the interaction of the pressure applied in the respiratory system ( airway pressure / end expiratory pressure ) counterbalanced by chest wall configuration / abdominal pressure along the mechanical ventilatory support duration . refinements in the ventilatory adjustments in ali / ards are necessary for minimizing the biotrauma in this still life - threatening clinical problem .

a 2-year - old boy presented to us with a reddish fleshy mass protruding from the inner side of the left eye for 8 months . he underwent an incisional biopsy at a local dispensary 2 months ago , following which there was an increase in the size of mass , spontaneous bleeding episodes , and epiphora . he was a diagnosed patient of classical lamellar ichthyosis and was using skin emollients . on local examination , a 15 mm 12 mm , strawberry - like polypoidal mass was observed in the left caruncular region [ fig . the inferior fornix revealed multiple , gelatinous , frond - like lesions originating from both forniceal and tarsal conjunctiva , along its entire length [ fig . the child was not cooperative for superior bulbar , palpebral , and forniceal conjunctival examination . ( a ) left eye shows reddish , strawberry - like mass in the caruncular region . the inferior orbital sulcus appears full with blood stained matting of temporal eyelashes indicating spontaneous bleeding episodes . ( b ) on inferior conjunctival examination , florid growth of similar lesions is observed along whole length of tarsal conjunctiva with an old blood clot present medially . ( c ) inferior sulcus pressure reveals massive involvement of forniceal conjunctiva with similar lesions . multiple pinhead - sized hemorrhages are seen on the surface a clinical diagnosis of diffuse , multifocal cp was made , and topical fortified eye drops of inf-2b ( injection zavinex , zydus cadila , india ) was started qid ( 1 million iu/1 ml ) . the child was kept under regular weekly follow - up for 6 weeks , but there was no mass reduction . however , the mass vascularity and spontaneous bleeding episodes reduced markedly after the topical treatment . in view of no reduction in mass size , a near - total surgical excision of the papillomas with cryo application at each site ( 2 freeze - thaw - freeze intraoperatively , similar lesions were noted at the superior tarsal and forniceal conjunctiva [ fig . the gelatinous exophytic masses were excised with westcott scissors , keeping its blades flush with the conjunctival surface . after cryo application , total 1 ml ( 3 million iu ) of inf-2b was injected subconjunctivally at multiple sites [ fig . 2c and d ] . ( a ) intraoperative double eversion of upper eyelid revealed multiple foci of similar gelatinous lesions over medial tarsal and forniceal conjunctiva . ( c ) after near - total excision with westcott scissors , application of cryo ( 2 freeze - thaw - freeze cycles ) is being demonstrated . ( d ) subconjunctival injection of interferon-2b being administered at multiple foci after the cryotherapy the histopathology of excised mass revealed multiple pedunculated papillomatous figures with central core of fibrovascular tissue covered by nonkeratinizing epithelium . there was no cellular atypia , and nuclear - cytoplasmic ratio was normal , ruling out any evidence of malignancy . postoperatively , topical 0.5% moxifloxacin ( qid ) and 1% carboxymethyl cellulose ( 2 hourly ) were prescribed along with topical fortified inf-2b ( 1 iu / ml qid ) eye drops . in the 1 postoperative week , the child had mild eyelid edema and nasal subconjunctival hemorrhage [ fig . 3a and b ] . topical steroid ointment ( hs ) was prescribed for 1 week to reduce cryotherapy - induced inflammation . at 14-month follow - up , the child is symptom - free ( no epiphora and spontaneous bleeding episodes ) , and there are no signs of local recurrence [ fig . ( a ) early postoperative period shows diffuse medial subconjunctival blood staining with no evidence of residual papillomas over inferior conjunctiva and caruncle . ( b ) superior tarsal conjunctiva is free from the papillomas with few subconjunctival hematoma spots . one small pinpoint hemorrhage presents temporal to plica semilunaris ( resolved in 1 week ) . ( d ) at 14-month follow - up , no recurrence of mass and the tumor epicenter appears normal . the infs are naturally produced glycoprotein molecules in our body secondary to viral infections and tumors . of late , these molecules have been employed with significant success in various human diseases , including cp , an uncommon ophthalmological condition . in children , due to the diffuse , multicentric nature , and inferior fornix predilection , the topical fortified inf-2b eye drops has a potential role . this drug has shown satisfactory results in primary and recurrent cp cases . in the past , many drugs such as oral cimetidine , 5-fluorouracil , mitomycin - c , local inf-2b ( topical or injection ) , and long - acting pegifn-2b have been used in the management of primary and recurrent cp . all these therapeutic agents mainly played the role of an adjunct to the surgical intervention than isolated therapeutic agents . no - touch technique , excisional biopsy cryotherapy , is the surgery of choice . surgical debulking not only provides instant relief but also reduces the viral load which is rather a difficult job for a short - acting , fortified drug such as inf-2b . hence , it is a good option in management armamentarium of surgeon handling recurrent cases . even after these treatment modalities , have described specific clinical tumor details which might be helpful in monitoring the treatment response , for example , tumor epicenter location ( clockwise and quadrant wise ) , basal dimensions and thickness ( in millimeters ) , configuration , pigmentation , and vascularity ( intrinsic and feeder vessels ) . on pubmed search with keywords - ichthyosis and cp , only single case report in literature is available from year 1988 though no association has been established . in our patient with classical lamellar ichthyosis and unilateral recurrent cp , the topical inf-2b eye drops mildly reduced the tumor vascularity which probably eliminated spontaneous bleeding but did not show any regression in tumor size . cp showed remission after near - total surgical excision and cryotherapy along with local subconjunctival injection of inf-2b . we postulate that the postoperative topical inf-2b eye drops prevent the dislodged viruses to establish and form a nidus at other conjunctival sites , which might lead to multifocal recurrences specifically in pediatric cp .

a 2-year - old boy presented with a recurrent strawberry - like reddish mass arising from the left caruncular region for 8 months . an incisional biopsy was performed elsewhere 2 months earlier , followed by an increase in size of mass , significant epiphora , and intermittent bleeding . on examination , exuberant exophytic gelatinous mass with multifocal origin was observed arising from inferior forniceal conjunctiva and caruncle . clinical differential of multifocal conjunctival papilloma was kept , and topical interferon alfa-2b ( inf-2b ) was started . no clinical reduction in mass or symptomatology was observed over 6 weeks . excision biopsy with cryotherapy and subconjunctival injection of inf-2b was performed over all foci . conjunctival papilloma was confirmed on histopathology , and topical inf-2b was continued in postoperative period for 3 months . at 14 months of follow - up , no recurrence , epiphora , or bleeding was noticed . we advocate a possible role of local inf therapy in managing and preventing recurrences of conjunctival papillomatosis .

a 49-year - old male presented with an incidentally detected right renal mass on a health examination . the patient had no symptoms or signs associated with the renal mass but presented with mild anemia ( hemoglobin , 11.6 g / dl ) and elevated alkaline phosphate ( 170 u / l ) . an abdominal ct performed in another hospital showed a 3-cm right renal mass with a homogenous pattern and slight enhancement compared with the common clear cell rccs ( fig . mri showed iso - intensity on the t1 weighted image and low signal intensity on the t2 weighted image . furthermore , an osteoblastic lesion on the right iliac bone was present , but we did not detect the lesion at that time ( fig . 1 ) . we suspected a hypovascular renal tumor such as papillary rcc and performed laparoscopic radical nephrectomy . the surgery was uneventful and the final pathology confirmed unclassified rcc of fuhrman grade ii , pt1anxmx ( fig . two months after surgery , the patient came to the emergency room with nausea , vomiting , and fever ( 38.7 ) . laboratory examination showed anemia ( hemoglobin , 8.6 g / dl ) and elevated alkaline phosphate ( 404 u / l ) , lactate dehydrogenase ( 657 u / l ) , and c - reactive protein ( 15.33 mg / dl ) . the patient 's coagulation profiles were prolonged ( activated partial thromboplastin time , 60.5 seconds ; prothrombin time , 15.3/75/1.20 sec/%/international normalized ratio ) . to find the fever focus , abdominal and neck ct was performed , which revealed multiple osteoblastic bone metastases and several enlarged neck lymph nodes . given that we had not previously detected the synchronous right iliac bone metastasis , we initially suspected a hematologic disorder such as multiple myeloma or myelophthisis . to rule these out subsequent review of the initial ct and mri revealed the synchronous bone metastasis . because the primary histology was the nonclear cell type , temsirolimus was offered to the patient for first - line therapy . the latest follow - up positron emission tomography showed newly developed liver and left adrenal metastases and increased bone metastasis ( fig . the proportion of small rcc ( < 4 cm ) is increasing because of the growing use of cross - sectional imaging such as ct and mri . however , several studies have shown that 5 to 7% patients with small rcc present with synchronous metastasis and that 5-year , cancer - specific mortality increases in a nonlinear sigmoidal relationship with tumor size . in the present case , the initial ct and mri were performed at another hospital , so we focused on the right renal mass and did not sufficiently review the other lesions . also , the european association of urology guidelines recommended that bone metastasis is symptomatic at diagnosis ; therefore , metastatic evaluation is indicated only if symptoms or laboratory signs are present . however , the patient did not manifest bone metastasis - related symptoms except for a mild elevated alkaline phosphate level ; therefore , we overlooked evaluation of bone metastasis . furthermore , we did not consider the possibility of distant metastasis because the renal mass was only 3 cm in diameter and there were no enlarged lymph nodes . recently , the 2004 world health organization ( who ) classification divided adult renal epithelial malignant neoplasms into 10 categories . among them , unclassified rccs represent 4 to 7% of renal tumors and the features to define this category of disease include composites of recognized types , pure sarcomatoid morphology without recognizable epithelial elements , mucin production , rare mixtures of epithelial and stromal elements , and unrecognizable cell types . tumors of unrecognizable cell or architecture types or those that are apparent composites of the recognized types are all included in the who classification scheme . microscopic findings of the present study showed no evidence of clear cells , papillary , or acinar structures . limited reported data suggest the clinical features of unclassified rcc are an aggressive form of rcc , mainly because most reports have been concerned with larger tumors with an advanced stage at presentation . reported that unclassified rcc was associated with larger tumors , increased risk of adrenal involvement and involvement of adjacent organs , and increased risk of metastatic involvement of the regional / nonregional lymph nodes and the bones compared with clear cell rcc . in addition , unclassified disease was associated with poor clinical outcomes . these clinical features were also reported by karakiewicz et al . , who also mentioned that unclassified disease was more likely to be associated with fuhrman grade iii or iv , nodal and distant metastasis , and higher mortality than was clear cell disease . reported that advanced clinicopathologic features were related more to unclassified disease , but that overall survival , cancer - specific survival , and distant metastatic - free survival were not different from clear cell histology in a matched analysis . in our case , although we missed a synchronous one - bone metastatic lesion in the initial images , the main renal mass was small ( 3 cm ) and had no regional lymph node involvement or adjacent organ invasion . recently , many studies have been published concerning systemically targeted therapies for the treatment of advanced rccs . for nonclear cell histology , temsirolimus has been shown to be beneficial in terms of overall survival and progression - free survival , regardless of age and risk group . although the neoadjuvant or adjuvant role of temsirolimus has not been well defined in nonclear cell metastatic disease , rodriguez faba et al . reported that neoadjuvant temsirolimus can downstage the t4n2m1 unclassified type rcc to t1bn0m0 and , after imaging , can be negative for recurrence . in our case , unclassified rcc presented extensive bone metastasis 2 months after surgery and , even though we missed a single bone metastatic lesion , temsirolimus was associated with 4.1 months of progression - free survival and 8.4 months of overall survival . in this regard , further studies are needed to clarify the efficacy of temsirolimus before and after cytoreductive nephrectomy . although the prevalence of this disease entity is rare , the final pathologic results show unclassified rcc after surgery for a small renal mass . thus , physicians should review the initial images and pay attention to metastasis , because unclassified rccs tend to rapidly progress and to carry a poor prognosis .

a 49-year - old man presented with an incidentally detected right renal mass on a health examination . the abdominal computed tomography and magnetic resonance imaging showed a 3-cm right renal mass suspected of being a hypovascular tumor , such as papillary renal cell carcinoma , and an osteoblastic metastatic lesion on the right iliac bone . however , we missed a bone lesion at the time of diagnosis . a laparoscopic radical nephrectomy was performed and the final pathology confirmed unclassified renal cell carcinoma . the follow - up imaging studies showed several neck lymph nodes and multiple bone metastases at the lumbar spine , right iliac bone , and left femur . thirteen cycles of temsirolimus were administered to the patient , but follow - up positron emission tomography showed newly developed liver and left adrenal metastasis and increased bone metastasis . it is important to note that t1a renal cell carcinoma can present with distant metastasis and thus demands scrupulous examination even though the tumor size may be small .

pancreatoenteric fistulas and pancreatic abscess are rare complications of severe acute pancreatitis1,2 and their traditional management which includes aggressive surgery or percutaneous drainage catheter placement is associated with increased surgery - related morbidity and mortality as well asa longer hospitalization.3,4 recently , a variety of occlusion methods of external or internal pancreatic fistula performed with minimally invasive techniques such as endoscopy and fibrin glue sealant.5,6 we here report a case of successfull closure of pancreatoenteric fistula , which remained open after the percutanous catheter drainage of pancreatic abscess , using vascular coil embolization and fibrin glue injection . this procedure is a less invasive , more effective and better tolerated strategy for the management of pancreatoenteric fistula in a selected group of high risk patients . a 79-year - old female patient with initial presentation of acute biliary pancreatitis and cholecystitis and subsequently underwent uneventful laparoscopic cholecystectomy . three days after the hospital discharge , she was admitted with epigastric pain and diarrhea . abdominal computed tomography ( ct ) scan on admission revealed a new air containing peripancreatic abscess , while the pancreas swelling and infiltration were significantly improved , when compared with her previous abdominal ct scan ( fig . the laboratory tests were unremarkable except elevated levels of white blood cell count ( 18,100/l ) and crp ( 13 mg / dl ) . during the process of inserting a percutaneous pigtail catheter to drain the abscess , we detected two fistulous tracts between a pancreatic abscess and the medial side of duodenum ( fig . the subsequent esophagogastroduodenoscopy ( egd ) confirmed a fistulous hole with pus draining into the duodenal wall ( fig . 3 ) and approximately 10 - 20 ml per day of yellowish pus drained through the catheter . after a week of catheter drainage , the follow - up tubography and abdominal ct scan indicated that the fistulous tract remained open while the size of abscess reduced significantly . we attempted to close the fistula tract initially with the injection of 1 : 1 mixture of tissue adhesive glue ( histoacryl ; b / braun , tuttlingen , germany ) and radiopaque fluid ( lipiodol ultra - fluide ; guerbet , aulnay - sous - bois , france ) using an 8-fr sheathed catheter and microcatheter without any success . at the third week of the catheter placement , when the drainage was decreased to 5 - 10 ml per day ( fig . 4 ) , a vascular occluding coil embolization ( nester embolization coil , 0.035 inch , 4 mm14 cm ; cook incorporated , bloomington , in , usa ) was carried out and , subsequently , 2 ml of fibrin glue ( greenplast ; green cross , seoul , korea ) as a filling was injected ( fig . 5 ) . the patient well tolerated the procedure without any complications . on the third day after coil embolization , the follow up tubography showed the successful closure of fistulous tract . the patient was discharged without catheter and monitored after discharge with ct scan and egd regularly up to 6 months ( fig . the conventional management of pancreatoenteric fistulas and pancreatic abscess with aggressive surgery or percutaneous drainage catheter placement are associated with increased surgery - related morbidity and mortality , and a longer hospitalization.3,4,7,8 though the peripancreatic abscess may be addressed by various drainage methods the complete closure of the entire fistula remains difficult . recently , a variety of occlusion methods of external or internal pancreatic fistula are reported with minimally invasive techniques such as endoscopy and fibrin glue sealant . recently , a long list of embolic agents , including blood clots , gelatin , silicon rubber plugs , various sponge materials , fibrin glue , metallic coils , have been introduced and the endobronchial vascular occlusion coils for control of a bronchopleural fistula has been reported.9,10 in the present case , we attempted to close the fistula tract initially by injecting tissue adhesive glue mixed with radiopaque fluid , which is generally used by interventional radiology field , however , we did not succeed . when the drainage was decreased 5 - 10 ml per day , we used metallic coils and fibrin glue as filler which is successfully closed the fistula tract . the present case is a rare example of a pancreatoenteric fistula which remained open after the percutaneous catheter drainage of pancreatic abscess is successfully closed by using vascular coil embolization and fibrin glue injection . we believe this is a less invasive , more effective , and better tolerated strategy for the management of pancreatoenteric fistula in a selected group of high risk patients , and needs further investigation .

the conventional management of pancreatoenteric fistulas and pancreatic abscess with aggressive surgery or percutaneous drainage catheter placement are associated with increased surgery - related morbidity and mortality , and a longer hospitalization . we report here a case of successful closing pancreatoduodenal fistula , which remained open after the percutaneous catheter drainage of pancreatic abscess , by using vascular coil embolization and fibrin glue injection . this procedure is a less invasive , more effective and better tolerated strategy for the management of pancreatoenteric fistula in a selected group of high risk patients and needs further investigation .

the association of posterior fossa lesions with syringomyelia has been described occasionally both for solid and cystic pathologies414 ) . few cystic lesions of posterior fossa have been found in association with syringomyelia , and even fewer have been reported in the huge retrocerebellar arachnoid cysts associated with syringomyelia918 ) . in the majority of these cases , development of syringomyelia was related to obstruction of cerebrospinal fluid ( csf ) flow caused by a downward invagination of the cyst itself or tonsillar decent within the foramen magnum1113 ) . the clinical features of syringomyelia are highly variable , usually with an insidious onset , a course that lasts for many years , and an unpredictable pace of progression19 ) . multiple treatment options for retrocerebellar arachnoid cysts have been introduced including cyst fenestration , cyst - peritoneal shunting , and foramen magnum decompression with complete or partial excision1415 ) . we describe the case of a patient with a huge retrocerebellar cyst associated with csf flow impairment in the foramen magnum and the resulting in syringomyelia . a 29-year - old man was brought into the clinic following a complaint of dizziness , gait disturbance , and shock - like pain occurring in both shoulders over the course of several months . upon neurological examination , the patient was fully conscious , and functioning of the cranial nerve was within the normal range . motor power was preserved in all four limbs , but paresthesia on the left side of the upper limb was noted . deep tendon reflexes were increased and abnormal reflexes ( e.g. , hoffman sign , ankle clonus ) were present . magnetic resonance imaging ( mri ) showed a large cystic mass at the posterior fossa with compression of the 4 ventricle and the brain stem with extension into the foramen magnum , which resulted in syringomyelia occurring from c1 to t10 and a mild dilatation of the lateral and the 3 ventricle ( fig . 1a ) . cine mri revealed that the flow of csf was present below only the foramen magnum(fig . the patient underwent a suboccipital craniotomy and c1 laminectomy with the removal of the arachnoid cyst 's walls . histopathological analysis of the excised tissues showed flattening of meningothelial cells attached to a loose fibrous wall with normal vessels ( fig . 3 ) . postoperative mri revealed a residual cyst , but the size and extent of syringomyelia had decreased ( fig . arachnoid cysts are benign intra - arachnoid fluid collections that develop as the result of an abnormal duplication of the arachnoid membranes during brain development . in patients with arachnoid cysts , neurological signs and symptoms reflect cyst size , anatomic distribution , and its impact on csf flow . there have been several other reports that have noted large arachnoid cysts associated with syringomyelia918 ) . one study postulated that syringomyelia results from obstruction of csf flow at the foramen magnum and the outlet of the fourth ventricle2 ) . obstruction of csf flow may lead to an increased pulsatile pressure within the spinal canal and forcing csf into the spinal cord17 ) . most posterior fossa arachnoid cysts result in cerebellar tonsillar herniation , consequently leading to compression of the spinal cord and syringomyelia resulting from the presence of the mass . the socalled " acquired " chiari malformation ( cm ) seems to be better understood . oldfield et al.16 ) propose that the descended tonsils obstruct the csf flow to and from the spinal compartment at the foramen magnum thus explaining the appearance of syringomyelia . however , as in our case it is extremely rare for a huge retrocerebellar arachnoid cyst at the foramen magnum to directly compress the spinal cord and result in syringomyelia . martinez - lage et al.12 ) identified 15 published cases of syringomyelia accompanying diverse cystic processes of the posterior fossa , such as congenital arachnoid cysts , dandy - walker malformation , blake 's pouch cyst , and posttraumatic csf pouches . in 14 of those cases , the obstruction of normal csf flow through the foramen magnum was due to blockage by the walls of the cyst itself . jain et al.8 ) documented one case of a giant posterior fossa arachnoid cyst extending into and compressing the spinal cord and resulting in syringomyelia . many patients with large posterior fossa lesions may have associated syringomyelia but no symptoms related to the syringomyelia . thus , it is important to image the entire length of spine in all the patients presenting with posterior fossa mass lesions . clinical manifestations of cm-1 malformation and syringomyelia associated with posterior fossa arachnoid cysts involved in foramen magnum obstruction are head and neck pain , retroocular pain , cerebellar signs , cranial nerve dysfunction , sleep apnea , and respiratory difficulty . furthermore , patients presenting with spinal cord compression may show a loss of fine movements , dysesthesia , dissociated sensory loss , sensory level , spasticity , scoliosis , or sphincter disturbances6 ) . various surgical options exist for the treatment of retrocerebellar arachnoid cyst according to the underlying pathogenic mechanism , including cyst fenestration , cyst - peritoneal shunting , and foramen magnum decompression with complete or partial excision1415 ) . removal of the underlying pathology and stablishing the normal csf flow at the foramen magnum is the main stay of treatment for syringomyelia9 ) . for cases of foramen magnum arachnoid cyst with direct compression of the spinal cord and syringomyelia , excision should be performed as much as possible with complete decompression of the posterior fossa , which should result in a satisfying outcome even if the arachnoid cyst is unable to be completely excised7 ) . we report here a case of patient who received decompression of the posterior fossa with a partial cyst excision , which markedly improved his symptoms . even though the post - ope rative mri showed a residual cyst , there was a reduction in the syrinx size . we feel that the surgical management of a huge retrocerebellar arachnoid cyst itself is attributed to syringomyelia , fenestration of the cyst and expansion of the fora men magnum , leading to restoration of the csf pathway . in addition , suboccipital craniotomy , with open cyst removal , offers the opportunity to explore the lesions and to relieve any arachnoid adhesions that may further restrict csf flow . our patient 's symptoms markedly improved after suboccipital craniotomy and c1 laminectomy with the partial removal of the arachnoid cyst 's walls . we briefly reviewed previous cases of syringomyelia associated with posterior fossa cysts . in this as in other types of posterior fossa lesions associated with syringomyelia , we recommend that the surgical management be used to address underlying hypothetical mechanism .

occasionally , a posterior fossa arachnoid cyst can induce compression of the spinal cord and cause syringomyelia . here , we report the case of a 29-year - old man with both progressive shoulder pain and gait disturbance , who was found to have a huge retrocerebellar arachnoid cyst associated with syringomyelia . accordingly , posterior fossa decompression and arachnoid cyst excision were performed . post - operative mri showed a marked reduction in the size of the arachnoid cyst and syringomyelia . the patient 's symptoms were clearly improved compared to before surgery . in our view , treatment in such patients should focus on decompressing the foramen magnum and include the removal of the coexistent arachnoid cyst walls , which appear to be the crucial factor in development of syringomyelia . in this report , we discuss the pathogenic mechanisms underlying syringomyelia - associated retrocerebellar arachnoid cyst and review the current literature on this topic .

however despite the introduction of more advanced surgical techniques , there remains a significant risk of complications and death from surgical procedures ( 1 ) . previous studies have shown that over 50% of surgical complications are avoidable ( 2 ) . in addition , the importance of effective teamwork has been established and been shown to improve outcome ( 3 ) . consequently , the world health organisation ( who ) developed the surgical safety checklist in 2008 ( 4 ) . following the introduction of the who surgical safety checklist , a large global multi - centre study demonstrated a 40% reduction in complications and death following surgery ( 5 ) . the use of this checklist is now recommended for all patients undergoing surgery in the uk by the national patient safety agency . a large number of invasive and interventional procedures are now performed outside the theatre environment . many of the factors contributing to surgical complications and serious untoward incidents are present when performing invasive procedures and/or administrating sedation in other environments . consequently , there is an increasing requirement to utilise safety checklists for all invasive procedures . the indications , guidelines and protocols for transoesophageal echocardiography are well established ( 6 , 7 , 8) . transoesophageal echocardiography is generally considered to be low risk but is occasionally associated with serious complications including oesophageal perforation , transmission of infection and death ( < 0.01% ) ( 9 ) . adherence to the british society of echocardiography ( bse ) guidance on toe probe cleaning and disinfection ( 10 ) is important to reduce the risk of transmission of infection between patients . in addition , the bse has produced guidance on the use of safe sedation during toe ( 11 ) . the incidence of complications may be further reduced by implementation and adherence to a safety checklist together with effective team working . the current who surgical safety checklist was designed for use within the theatre environment and hence is not directly relevant for use in toe . this document produced by the british society of echocardiography and the association of cardiothoracic anesthetists aims to outline a procedure specific safety checklist for toe ( who checklist , see section on who checklist given at the end of this article ) . the form is designed to be printed on a double - sided a4 page and can be filed in the patient medical records once it has been completed . however , the form can be adapted for use locally or converted into an electronic format for use in an electronic patient record if necessary . in keeping with the format of the who safety checklist , the procedure has been broken down into three phases , corresponding to patient checks , immediately pre - procedure and post - procedure checks . there is also an appendix to be completed if the toe is being performed under general anaesthesia . in order to complete the checklist effectively , it is important that one member of the team assumes responsibility for completion of each stage of the checklist . , it is important that the patient verbally confirms their identity and the intended procedure in their own words . during the time out phase , all team members should be present and should confirm their name and role . if the team is unchanged during a list , this stage can be performed at the start of the list but does not need repetition for each patient . immediately pre - procedure , the team should reconfirm that the correct patient is about to undergo the correct procedure and outline any anticipated difficulties for each patient . once the procedure has been completed , appropriate handover to the recovery team and any specific instructions should be given and all documentation completed . it is anticipated that the use of this checklist will ensure a consistent process is followed when performing toe . the authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this guideline . this guideline did not receive any specific grant from any funding agency in the public , commercial or not - for - profit sector .

the world health organisation ( who ) launched the surgical safety checklist in 2008 . the introduction of this checklist resulted in a significant reduction in the incidence of complications and death in patients undergoing surgery . consequently , the who surgical safety checklist is recommended for use by the national patient safety agency for all patients undergoing surgery . however , many invasive or interventional procedures occur outside the theatre setting and there are increasing requirements for a safety checklist to be used prior to such procedures . transoesophageal echocardiography ( toe ) is an invasive procedure and although generally considered to be safe , it carries the risk of serious and potentially life - threatening complications . strict adherence to a safety checklist may reduce the rate of significant complications during toe . however , the standard who surgical safety checklist is not designed for procedures outside the theatre environment and therefore this document is designed to be a procedure - specific safety checklist for toe . it has been endorsed for use by the british society of echocardiography and the association of cardiothoracic anaesthetists .

bazex syndrome or acrokeratosis paraneoplastica is a rare paraneoplastic syndrome that is characterized by acral psoriasiform lesions . this condition is a distinct skin phenomenon and can represent the first sign of a supra - diaphragmatic neoplasia , usually squamous cell carcinoma . patients typically present with asymptomatic and symmetrical acral erythemato - squamous psoriasiform eruptions involving fingers , hands , nails , ears , nose , and feet . the histological findings are not specific but include psoriasiform epidermal hyperplasia , hyperkeratosis with parakeratosis , and perivascular lymphocytic infiltrates in the dermis . here , we report a case of a 73-year - old woman with bazex syndrome , which was the first sign of a gastric cancer ( linitis plastica ) . a 73-year - old woman presented with symptoms of food aversion and dysphagia ( grade iii ) . she had no prior history of psoriasis or other skin diseases . however , 2 months before the first digestive sign , she developed nail and finger abnormalities that predominantly affected her left hand , but it also involved the right hand and her feet . she had lost 7 kg within 3 months and weighed 38 kg at the time of the consultation . her clinical examination was normal , except for the skin and nail lesions ( fig . 1 ) . she underwent an upper endoscopy and endoscopic ultrasound with biopsies that led to the diagnosis of gastric linitis , extending from the gastroesophageal junction to the antrum . her general status improved after 1 month of systemic chemotherapy , including an improvement of the bazex syndrome . this response lasted 6 months ; after that , her skin lesions , anorexia , and her performance status all worsened , and the development of ascites was detected . despite second - line treatment with a folfiri chemotherapy regimen , the outcome was fatal 10 months after her initial diagnosis . bazex syndrome is an infrequent paraneoplastic marker , but it is important to recognize its appearance . in a majority of cases , it may be caused by the production of epidermal growth factor by tumor cells or by cross - reactivity between epidermal and tumor antigens . in approximately 90% of all cases , the dermatosis follows the neoplastic course with an improvement after the effective treatment of the neoplasia and a recurrence when the tumor returns . a complete evaluation of the upper aerodigestive tract should be performed to identify the underlying malignancy .

we herein report the case of a 73-year - old woman who developed skin and nail disorders 2 months before her digestive symptoms started , which lead to the diagnosis of gastric adenocarcinoma . the lesions were diagnosed as bazex syndrome , usually seen in squamous cell carcinoma . under systemic chemotherapy , the cutaneous signs improved for some months before worsening when the disease progressed .

neurofibromatosis type i ( nf - i ) also known as von recklinghausen 's disease , is an autosomal dominant disorder that involves abnormal growth of neuroectodermal tumors in the peripheral nervous system . nf - i is due to mutations in the neurofibromin - encoding gene that is located on chromosome 17q11.2 with characteristic variable penetration . these mutations lead to the formation of neurofibromas of the peripheral nervous system with 50% of cases resulting from spontaneous mutations . spontaneous hemothorax is one of the uncommon complications of nf - i and is potentially fatal . the expected mediastinal tumor in von recklinghausen 's disease is a tumor of nerve sheath origin , namely , neurofibroma , and 4% of patients with this disease develop malignant schwannoma , which has been reported to cause massive hemothorax . we are describing a case of spontaneous hemothorax due to neurofibroma in a patient with a history of nf - i . a 49-year - old woman with a history of asthma , nf - i , and chronic smoking presented to the emergency room with chest pain . it was sudden onset of sharp , continuous pain in the right upper chest and radiating to the right lower chest , moderate in intensity , exacerbated with inspiration and cough . physical examination revealed the presence of decreased breath sounds at the base of the right lung . computed tomography of the chest confirmed the presence of a large amount of right pleural effusion with mediastinal shift [ figure 1 ] . computed tomography of chest showing large amount of right pleural effusion and mediastinal shift to the left thoracentesis was done without successful drainage . she underwent right thoracoscopy with evacuation of 2700 ml of blood . during the procedure , histology showed the segments of hyperplastic nerve tissue , consisting of cells that were s-100-positive by immunohistochemistry , confirming the diagnosis of neurofibroma [ figure 2 ] . the patient improved after surgery and she was discharged to home in stable condition . histology section showing the segments of hyperplastic nerve tissue consisting of cells that are s-100 ( + ) by immunohistochemistry two different types of vasculopathy have been described : stenosis or aneurysmal modifications of large intrathoracic vessels , most commonly the subclavian artery and the intercostal arteries ; and dysplastic alterations of small vessels in highly vascularized mesenchymal tumors . most commonly , tumor - related hemothorax is due to neurofibroma , and the most frequently involved artery is the intercostal artery . of the 11 published studies as shown in table 1 , nine patients underwent surgical exploration with two postoperative deaths . however , the sudden death without operation was also reported in two patients with nf-1 . sudden death occurred in a patient with spontaneous hemothorax due to neurofibroma causing a compression fracture of the thoracic vertebrae that in turn led to laceration of the aorta . in another case report , immediate death following spontaneous hemothorax during the postpartum period in a 37-year - old female with history of nf - i , due to rupture of right subclavian artery by infiltrating neurofibromas . in a review article by miura et al . , in 2005 , of seven patients with spontaneous hemothorax , the histology of tumors included five benign tumors ( one benign schwannoma and four neurofibromas ) and two malignant tumors ( one malignant schwannoma and one neurofibrosarcoma ) . previously published articles on spontaneous hemothorax due to bleeding from the vascularized mesenchymal tumors in the case report described by lim et al . , an 18-year - old male had partial excision of a large hemorrhagic mediastinal tumor and it was diagnosed as neurofibrosarcoma . another case presented with spontaneous hemothorax due to mediastinal tumor was also managed with excision and it was a benign schwannoma . managed their patient with exploratory thoracotomy , which showed continuous bleeding from tumor vessels ( confirmed as ganglioneuroma ) , and they were unable to achieve a stable hemodynamic status despite the transfusion of eight units of blood and they packed the area with three large laparotomy pads . three weeks later an uneventful re - thoracotomy showed the disappearance of the tumor perhaps due to the rupture and losing its vascular supply leading to necrosis or degeneration . reported by fedoruk et al . , there was disruption of the left subclavian artery and left internal thoracic artery junction , and exploratory thoracotomy revealed tissue masses and clots . as these vessels were friable and brittle , multiple attempts at a primary suture repair were made , and the artery was over sewn . faruque et al . described a patient with neurofibromatosis who developed massive hemothorax as a result of spontaneous rupture of the left vertebral artery and left subclavian artery due to invasion by neurofibromas . they successfully managed the patient with a combination of surgical and interventional radiology techniques , stapling of the left subclavian artery and endovascular embolization of left vertebral artery . another patient presented with spontaneous hemothorax due to an unknown source of bleeding as observed in our case , managed with recombinant - activated vii factor ( novoseven 90 /kg ) after an unsuccessful surgical attempt to stop bleeding . the patient 's bleeding was well controlled after the infusion of recombinant - activated vii factor for three times . we emphasize the importance of consideration of spontaneous hemothorax and mediastinal tumor in the differential diagnosis in any patient with a history of neurofibromatosis type i , who presents with chest pain and pleural effusion . spontaneous massive hemothorax in a patient with neurofibromatosis type i is due to erosion of thoracic vessels by tumor or from degeneration of a hypervascular neural tumor .

neurofibromatosis is generally a benign disease , but has the potential for rare and fatal complications , such as spontaneous hemothorax . we report a case of massive hemothorax due to neurofibroma in a 49-year - old woman with neurofibromatosis type 1 . the configuration of the radiological opacity and frank blood withdrawn on thoracentesis should suggest the diagnosis of hemothorax in a patient with neurofibromatosis . surgical treatment for hemothorax is limited by arterial fragility and the prognosis is relatively poor . any evidence of aneurysmal disease in the thoracic vessels should be aggressively managed percutaneously by coil embolization to prevent future rupture .

ameloblastic fibroma ( af ) is an extremely rare true mixed benign tumor that can occur either in the mandible or maxilla . it is frequently found in the posterior region of the mandible , often associated with an unerupted tooth . it usually occurs in the first two decades of life with a slight female predilection , causing delay in tooth eruption or altering the eruption sequence . small tumors are asymptomatic , while larger ones produce significant swelling of the jaws . on radiographs , smaller lesions are well circumscribed and unilocular with a sclerotic border , while larger ones are multilocular . histopathologically , af consists of odontogenic epithelium in the dental papilla - like background without dental hard tissue formation . similar lesions with hard tissue deposits are categorized as ameloblastic fibro - odontoma or odontoma depending on the degree of calcification . recently , there are few reports of this condition with high recurrence rates and malignant transformation . a 19-year - old female patient came to the department of oral medicine and radiology with a chief complaint of slowly progressive swelling on the right side of her lower posterior jaw . on intraoral examination , the right lower buccal vestibule was obliterated due to the expansion of the buccal cortical plate . the mucosa over the swelling was normal , except for slight blanching due to expansion of the buccal cortical plate . the lesion is seen extending from posterior aspect of first molar to the retromolar area , measuring 3 cm in size . on palpation , the swelling was slightly tender and no abnormality was detected in the adjacent teeth . panoramic radiograph showed a unilocular radiolucent area with well - defined borders , involving the posterior aspect of the right mandible . the lesion was measuring approximately 3.5 cm in size and was extending posteriorly from the distal aspect of the second molar to the retromolar area . microscopically , hematoxylin and eosin sections showed islands and strands of epithelial cells in a loose connective tissue stroma resembling primitive dental papilla [ figure 1 ] . the peripheral epithelial cells lining the islands and strands were low columnar , similar to the cells found in the peripheral layer of the follicle in ameloblastoma . the connective tissue resembled cellular fibroblastic tissue similar to the dental papilla in the developing tooth . hyaline - like tissue is also seen adjacent to the epithelial strands and islands [ figure 2 ] . it was interesting to note that both the epithelial islands and connective tissue stroma revealed high cellularity when compared with the conventional lesions of af . however , severe dysplastic features such as cellular and nuclear pleomorphism and increased number of abnormal mitotic figures were not observed . in this context , immunohistochemistry for ki-67 [ figure 3a ] proliferative marker along with proper positive [ figure 3b ] and negative [ figure 3c ] controls were performed . this had ruled out the diagnosis of a malignant tumor , confirming the diagnosis of af . photograph showing strands and islands of odontogenic epithelial cells in a loose connective tissue stroma resembling primitive dental papilla ( h and e 100 ) photograph showing the peripheral cells resembling ameloblasts with hyaline - like material surrounding the islands ( h and e 400 ) ( a ) photograph showing negative staining for ihc marker ki-67 antigen ( b ) photograph of positive control for ihc marker ki-67 antigen ( c ) photograph of negative control for ihc marker ki-67 antigen the histopathological finding of high cellularity in this lesion is uncommon as conventional afs show mild to moderate cellularity in a loose myxomatous connective tissue background . our case of af with high cellularity is unusual in the context of its histopathology .

ameloblastic fibroma is a rare odontogenic tumor comprising neoplastic epithelial and mesenchymal tissues . this lesion was previously considered to be a benign lesion with very limited recurrence rate and malignant transformation . however , recent reports have suggested that this lesion has the potential for recurrence and malignant transformation . in this brief report , we report a case of af in the context of its high cellularity on histopathological examination .

a 77-year - old woman with known spina bifida occulta presented to the emergency department with a 6-week history of severe low back pain and progressive paraparesis . she was able to walk only two to three steps and only with two helpers . she was previously asymptomatic and was aware of a hairy patch in the lower back since birth . her medical comorbidities included diabetes mellitus ( type ii ) , hypertension , increased body mass index , and mitral regurgitation . neurological examination of the lower limbs revealed proximal lower limb weakness of mrc ( medical research council ) grade 3 in l2 , l3 myotomes and grade 4 in l4 , l5 , and s1 myotomes . reflexes were brisk with upgoing plantars and three beats of clonus in the right foot . subsequent investigation with magnetic resonance imaging of the whole spine showed a low - lying tethered cord and a large disc prolapse at l2/3 causing cord compression with associated syringomyelia ( figs . 1 , 2 , and 3 ) . axial view l2l3 level . sagittal view t1-weighted image . sagittal view t2-weighted image . the initial operative plan was to perform an anterior decompression , which may have entailed a corpectomy with bone graft and fusion . however , her extensive medical comorbidities increased the risk of perioperative morbidity . consideration was given for posterior approach with the possibility of increased risk of wound infection due to the large lumbar pit and hairy patch , overlying the planned surgical wound . as posterior approach presented a significantly lower risk to the patient overall , a posterior decompression with a standard midline incision and laminectomy was performed at l2/3 under general anesthesia . following posterior decompression , the patient recovered full motor power in her lower limbs , and she could eventually walk unaided . in the early postoperative period , she had a deep wound infection , which was successfully treated with debridement , negative pressure therapy ( vacuum - assisted closure pump ) , and antibiotics . follow - up in outpatient clinic 6 months after surgery , she was walking unaided and the wound had healed satisfactorily . tcs was described in last 3 decades and was previously associated only with the pediatric population.4 now , however , there is good evidence that it can occur even in adults and is much more common than previously thought.1 adults with tcs are considered to belong to two groups : those who were healthy in childhood but symptoms developed in adulthood or those who had static neurological deficits or skeletal deformities that were diagnosed in childhood but remained well until the onset of new and progressive neurological deficits in adulthood.3 5 other classifications included grouping them on basis of extent of spinal dysraphism6 or surgical outcome following detethering of the cord.7 it has been shown that adults commonly present with varying neurological symptoms usually following a precipitating factor such as coughing , bending , or strenuous physical activity . it is thought that the mechanical longitudinal traction as a result of tethered cord causes these symptoms . many clinical series have found that these patients can present with a gradual , insidious onset of back pain , nondermatomal leg pain , burning pain in the buttocks and perineal region , and bowel and/or bladder dysfunction.1 2 4 7 they can mimic symptoms of lumbar disc disease or spinal stenosis . there are some reports of symptoms being aggravated due to disc disease.8 the recommended treatment is to detether the cord and excise any lesion.1 2 3 though the role of surgery is controversial , it has been shown that surgical detethering in the presence of neurological deterioration has been of some benefit . motor weakness and pain seem to resolve though the return of sensory deficit , and return of bladder function varies.4 some surgeons have even questioned the role of detethering in the absence of symptoms and whether it would alter the natural history of tcs.9 our hypothesis is that the neurological deficit in this patient was likely secondary to the prolapsed disc . owing to the natural lordosis of lumbar spine , posterior decompressive surgery may have allowed the spinal cord and neural elements to fall back and therefore relieved anterior cord compression . upper motor neuron signs and myelopathy are not usually seen with lumbar disc prolapse when the cord is in the normal position . however , in the presence of low - lying cord , this could result in signs of cord compression with resulting myelopathy or upper motor neuron signs . this is the first case we know of that describes the management of lumbar cord compression with progressive neurological deficit .

low - lying cord is an uncommon entity , and cord compression due lumbar disc disease is rarely encountered . we discuss our experience with a case of lumbar cord compression secondary to a large disc protrusion , which caused myelopathy in a low - lying / tethered cord . a 77-year - old woman with known spina bifida occulta presented with 6-week history of severe low back pain and progressive paraparesis . magnetic resonance imaging showed a low - lying tethered cord and a large disc prolapse at l2/3 causing cord compression with associated syringomyelia . medical comorbidities precluded her from anterior decompression , and therefore a posterior decompression was performed . she recovered full motor power in her lower limbs and could eventually walk unaided . she had a deep wound infection , which was successfully treated with debridement , negative pressure therapy ( vacuum - assisted closure pump ) , and antibiotics . six months after surgery , her oswestry disability index improved from 55% preoperatively to 20% . posterior spinal cord decompression for this condition has been successful in our case , and we believe that the lumbar lordosis may have helped indirectly decompress the spinal cord by posterior decompression alone .

isolated spontaneous dissection of the superior mesenteric artery ( sma ) without aortic involvement is a rare event . diagnosis may have been difficult in the past , but recent advances in imaging modality and knowledge of mesenteric arteries disease have rendered diagnosis easier.1 that is perhaps why this disease is much more common than we used to think . there is , however , no general consensus about the best treatment option.2 here we report a case of isolated spontaneous dissection of the sma , which we managed conservatively . a 48-year - old man was admitted to our hospital with a sudden onset of epigastric pain , nausea , and vomiting commencing three hours previously . he had no history of hypertension or diabetes , but he had smoked one pack of cigarettes daily for the previous ten years . he had a permanent pacemaker , implanted one year before because of symptomatic bradycardia . physical examination revealed a normal blood pressure ( 137/87 mmhg ) and mild tenderness over the epigastric area with no peritoneal signs . on admission in the emergency room due to left bundle branch block in the electrocardiogram ( figure 1 ) and epigastric pain , thrombolytic therapy was done on suspicion of acute myocardial infarction . the patient was transferred to the cardiac care unit ( ccu ) , where he continued to complain of severe abdominal pain , especially after eating . the patient was kept fasting , and a nasal gastric tube was , therefore , employed and enoxaparin , aspirin , and clopidogrel were continued . laboratory tests , including complete blood count , amylase , liver enzymes , and cardiac markers , were normal . coronary angiography was normal , but superior mesenteric angiography showed a dissected non - flow limiting lesion at the proximal part ( figure 2 ) . in ct angiography , the aorta and the other visceral vessels were normal and a dissection was detected at the proximal part of the sma , which extended only about two centimeters . the false lumen was occluded by a thrombus ( figure 3 ) . despite our recommendation , the patient refused to accept sma stenting and conservative therapy was , consequently , continued . the patient was kept fasting for five days ; at first , the epigastric pain decreased but was thereafter exacerbated by eating . as a result , he was kept fasting for one more week , at the end of which he started eating gradually . the patient was discharged after two weeks . in the first month , he preferred to have a low calorie , low volume diet to reduce the pain , but afterwards he became completely asymptomatic and was able to tolerate food normally . isolated spontaneous dissection of the sma is a rare occurrence even among spontaneous dissections of the peripheral arteries.1 bauersfeld first described dissection of the sma in 1947 in a series of patients with aortic dissection.2 when dissection is isolated to the sma , it usually begins 1.53 cm from the orifice of the sma , thereby sparing the origin of the artery.3 the etiology of spontaneous sma dissection in most reported cases and in our case is unknown , but it may include arteriosclerosis , fibromuscular dysplasia , congenital connective tissue disorders , mycotic infection , trauma , vasculitis - like giant cell arteritis , takayaso s arteritis , polyarteritis nodosa , and iatrogenic - induced dissections due to endovascular interventions . reported the risk factors to be high blood pressure and smoking.7 in most cases of the sma dissection , patients present in one of two ways : with vague abdominal pain due to the stenosis of the true lumen by the dilatation of the false lumen causing mesenteric ischemia,1 or with profound shock after the rupture of the dissection.5 as a result , it should be considered in the differential diagnosis of abdominal pain . upper abdominal bruit , which was not detected in our patient , is an important physical finding of this disease.8 spontaneous sma dissection used to be diagnosed via angiography ; more recently , however , ct scans have become the most reliable diagnostic modality . through dynamic ct , the lumen that appears with staining first is the true lumen and the lumen that shows delayed dark staining and continuous staining is the false lume.9 a previous report demonstrated that increased attenuation of the fat around the sma is a useful finding.10 there is no clear protocol for the treatment of the sma dissection . reported treatments include surgical treatment , endovascular repair , and conservative treatment.11 the mainstay of treatment of the dissection of the sma has been surgery.12,13 several authors have shown promising results for the stenting of the sma dissection.14,15 leung et al . have reported the first successful case of isolated spontaneous dissection of the sma treated via percutaneous stent placement.13 miyamoto et al . reported that 24 out of 55 patients with spontaneous sma dissection were treated conservatively.16 obstruction of the main sma trunk does not always result in bowel infarction because of the existence of the mesenteric marginal artery . according to the literature , it seems that endovascular stent placement is indicated in cases with short segment dissection , in cases without the signs of bowel ischemia or peritonitis , and in cases not improving on conservative therapy . the sma dissection can present with symptoms that are not specific ; highly clinical suspicion and early diagnostic modalities are , therefore , necessary .

isolated dissection of the superior mesenteric artery is a rare occurrence with a hitherto unknown exact etiology . patients may present with abdominal symptoms or hemodynamic instability.we herein present a case of spontaneous isolated superior mesenteric artery dissection in a 48-year - old man , who was admitted with epigastric pain . due to an undiagnosed paced rhythm on the electrocardiogram , he was given fibrinolysis treatment for acute myocardial infarction . on further evaluation , angiography revealed that the cause of pain was the dissection of the superior mesenteric artery . the patient s symptoms were diminished with conservative management , obviating the need for the angioplasty of the superior mesenteric artery .

a push - up is a common closed kinetic chain exercise for the upper extremity that is known to activate the scapulothoracic musculature1 . a closed kinetic chain exercise could facilitate the stability of an articular joint through muscle co - activation , which would then lead to enhanced dynamic stabilization of the shoulder girdle in patients with shoulder disorders1 , 2 . thomas3 reported that the hip adductor muscle is connected to the internal abdominal muscle through the iliacus , psoas major , and quadratus lumborum . kim and yoo4 reported that the muscle activities of the external oblique , internal oblique , and l5 paraspinal muscles increased during hip adduction using a visual feedback device . maenhout et al.5 reported scapular emg activity during knee push - up - plus ( kpp ) and six commonly used variations . when using a kinetic - chain approach during kpp , homolateral leg extension increased sa activity because the stress of the thoracolumbar fascia was transmitted to the heterolateral scapula5 . however , few studies have investigated the effect of hip adduction on shoulder muscle activation during a push - up exercise . so , we investigated the effect of push - up exercise with hip adduction on the cop deviation and sa and l1 spinal muscle activation . twelve males aged 2030 years and with a mean height and weight of 174.7 5.0 cm and 68.5 6.4 kg , respectively , participated in this study . the subjects had no history of musculoskeletal disorders or pain associated with the upper and lower extremities in the past 6 months . all participants gave their informed , written consent according to the protocol approved by inje university faculty of health science human ethics committee . the variance of the cop between hands was measured using a tekscan system ( tekscan inc . , all emg signals were amplified , band - pass filtered ( 20500 hz ) , and then sampled at 1,000 hz using the acqknowledge 3.9.1 software . we measured the serratus anterior ( sa ) and l1 level paraspinal ( l1 spinal ) muscles . a digital air - pressure sensor ( ap series pressure sensor , keyence , osaka , japan ) was directly connected to an air cushion and calibrated to the zero point during a no hip adduction exercise . we designed the air cushion to exert a continuous external load using the tension air cushion against the medial side of the thigh . all trials were started in the standardized push - up starting position with the hands one shoulder width apart and the participant 's middle finger under the acromioclavicular joint , as described in a previous study . participants performed 2 different trials : a push - up exercise with and without hip adduction . the trials were presented in a randomized order , and each participant was allowed to rest for 3 minutes between each trial . the statistical package for the social sciences ( spss , chicago , il , usa ) was used to perform the paired t - test to analyze the differences in cop deviation and sa and l1 spinal muscle activities during push - up exercise with and without hip adduction . the alpha level for statistical significance the cop deviation was significantly decreased during push - ups with hip adduction ( 5.6 2.0 mm ) when compared with push - ups without hip adduction ( 7.5 2.7 mm ) . the activity of the sa was significantly increased during push - ups with hip adduction ( 52.0 10.6% ) when compared with push - ups without hip adduction ( 48.3 12.9% ) . the l1 spinal activity was significantly increased during push - ups with hip adduction ( 36.5 9.1% ) when compared with push - ups without hip adduction ( 28.9 15.7% ) . this study investigated the effect of a push - up exercise with hip adduction on the cop deviation and sa and l1 spinal muscle activation . park et al.6 reported a negative correlation between serratus anterior activation and displacement of the cop . the cop deviation was significantly decreased during push - ups with hip adduction when compared with push - ups performed without hip adduction . in the present study , the sa showed greater activation with low cop deviation during a push - up with hip adduction . the hip adductor muscle contraction synergistically facilitates contractions of the pelvic floor and abdominal muscles7 . first , this co - activation of the hip adductor muscle , pelvic floor muscle , and internal abdominal muscle is necessary for the induction of intra - abdominal pressure , and it powerfully reinforces the multifidus muscles and contributes to spinal stability8 . we thought that a push - up exercise with hip adduction would increase the trunk stability . second , a previous study also showed that homolateral leg extension increased sa activity because the stress of the thoracolumbar fascia was transmitted to the heterolateral scapula5 . the muscles that originate from the thoracolumbar fascia , and that are superficially located , play a major role in transmitting the load of the trunk to the arms and shoulders3 , 9 . in the present study , the l1 spinal muscle activity was significantly increased during a push - up with hip adduction . our opinion was that a push - up exercise with hip adduction increased the trunk stability by co - activating the thoracolumbar fascia . finally , a push - up exercise with hip adduction increased the sa activity because the stress on the thoracolumbar fascia was transmitted to the scapula .

[ purpose ] this study investigated the effect of push - up exercise with hip adduction on the cop deviation and sa and l1 spinal muscle activation . [ subjects ] twelve males aged 2030 years were recruited . [ methods ] we measured the cop deviation and sa and l1 spinal muscle activities during push - up exercise with and without hip adduction [ results ] the cop deviation significantly decreased and the sa and l1 spinal muscles were significantly increased during push - ups with hip adduction when compared with push - ups without hip adduction . [ conclusion ] we thought that the push - up exercise with hip adduction might help to selectively strengthen the sa .

chordoid glioma ( cg ) of the third ventricle , a rare tumor with both glial and chordoid features , was described as a new pathologic entity in 1998 by brat et al . and accepted by world health organization ( who ) in 2000 as a distinct glioma with grade ii malignancy123 ) . various morphological and clinicopathologic aspects of cg have been depicted , but there may also be other unknown features due to its rarity5 ) . to this time , more than 70 cases of cg with different microscopic transcranial and transnasal approaches have been reported8 ) ; but , to the best of our knowledge , this is the first successful report of expanded endoscopic transnasal transplanum approach to this neoplasm . a 43-year - old woman presented to our clinic with a history of headache and somnolence since one year , and a decrease of her vision of 6 months duration . on presentation , she was oriented with a visual acuity of 7/10 and 2/10 in right and left eyes respectively . computed tomographic scan and magnetic resonance imaging ( mri ) showed a well circumscribed , oval mass without calcification , hypointense in t1-weighted and isointense in t2-weighted images , in the suprasellar area and the floor of the third ventricle . after the intravenous contrast administration , the mass enhancement was remarkable with the maximum diameter of 32 mm ( fig . the tumor was retro - chiasmatic and was extended from inferior border of chiasm into third ventricle . resection of proximal stalk was intended in the pre - operative stage ( because of involvement of proximal stalk and infundibulum ) . it was firm and non - suckable , so it was resected totally by micro - scissors with the aid of angled lens . dural defect was reconstructed with an overlay fascia lata graft , reinforced with standard nasal septal flap ; and lumbar drainage established for 7 days . her somnolence got aggravated during the first postoperative week ; but , improved dramatically with the administration of ritalin ( novartis , cambridge , ma , usa ) 20 mg per day . histopathologic examination disclosed a neoplastic tissue composed of eosinophilic epithelioid cells arranged in small sheets and cords , and in some areas with mucinous extracellular matrix and scattered lymphoplasmacytic infiltrates ( fig . 3a ) . also , the extracellular mucinous matrix was pas - diastase positive ( fig . immunohistochemically , the tumor cells were diffusely positive for glial fibrillary acidic protein , vimentin , cd 34 , and focally positive for ae1/ae3 , ck 18 , epithelial membrane antigen , and s-100 ( nuclear ) , and negative for carcino - embryonic antigen ea , nf , ck7 , ck 8 , ck 20 , estrogen receptor , progesterone receptor , and gross cystic disease fluid protein-15 ( fig . 3c - f ) . these findings were consistent with chordoid glioma . during the second week of her stay in hospital , she experienced a gram negative septicemia from the site of central venous catheter insertion which responded intravenous meropenem ( daana pharma co. , mashhad , islamic republic of iran ) and ciprofluoxacine ( samen pharma co. , mashhad , islamic republic of iran ) . prior to discharge , an mri was taken which revealed gross total tumor resection ( fig . there is a controversy over the best treatment strategy for cg : tumor biopsy / partial resection with subsequent adjuvant therapy , versus an aggressive gross total tumor resection7911 ) . traditionally , the surgical route to remove cg is transcranial and includes transventricular , transcallosal , and translamina terminalis approaches . lie et al.7 ) in a review of 64 cases of cg demonstrated in comparrison with transventricular and transcallosal approaches , the translamina terminalis corridor was associated with a significantly lower postoperative mortality and morbidity and they concluded that apart from the neurosurgeons ' experience and preferences , the translamina terminalis approach was better than the other approaches . in the usual transcranial approaches , the operative corridors through the interoptic , prechiacmatic and opticocarotid cisterns allow limited exposure , insufficient visualization , and inadequate accessibility to the infra- and retrochiasmatic regions110 ) . further , because cg is hidden behind an anteriorly displaced chiasm , it is often mandatory to open the lamina terminalis to access this lesion in the retrochiasmatic space ; therefore it could be an impressive corridor in experienced hands . however , the undersurface of the optic chiasm and optic nerves remain a blind location from the transcranial view . instead , the expanded endoscopic transnasal approach provides a direct view to these regions6 ) . selected suprasellar cases with various pathologic entities including craniopharyngiomas , pituitary stalk tumors , and basal hypothalamic lesions have been effectively approached using the expanded endoscopic transnasal technique4 ) . our endoscopic endonasal experience to deal with sellar and suprasellar lesions especially retrochiasmatic huge craniopharyngiomas triggered us to tackle this tumor via an endoscopic transnasal route with a successful complete tumor resection . the approach and technical nuances were similar to an approach to a retrochiasmatic craniopharyngiomas6 ) . to our knowledge , this is the first case ever reported in literature via the expanded endoscopic transnasal approach . this could be an alternative trajectory for the resection of cg ; albeit , it requires an added research and study . chordoid glioma is a very rare tumor which occurs predominantly in middle - aged women , with a characteristic appearance on radiology and histopathology . despite being classified as who grade 2 , it may have a poor clinical outcome because of its close vicinity to vital structures and hypothalamus . various transcranial approaches has been described with different rates of success . on the other side , excellent visualization of the undersurface of the optic apparatus and hypothalamus can be obtained in endoscopic transnasal approach to facilitate bimanual tumor dissection , to permit complete removal of these formidable lesions . for the first time , we present expanded endoscopic transnasal approach as an alternative route to tackle this unusual tumor with a favorable result .

chordoid glioma of the third ventricle is a rare and challenging tumor to surgery because of its unique anatomical location and its close juxtaposition to the neurovascular structures and hypothalamus . the authors report a case of chordoid glioma of the third ventricle in a 43-year - old woman , who presented with headache and somnolence . the tumor was approached by endoscopic transnasal technique with a favorable result . histopathologic examination disclosed a neoplastic tissue composed of eosinophilic epithelioid cells , mucinous , periodic acid schiff - diastase positive , extracellular matrix , and scattered lymphoplasmacytic infiltrates . the best treatment option remains controversial . customarily , the surgical route to remove chordoid glioma is transcranial ; however , the undersurface of the optic chiasm and optic nerves preclude an adequate surgical visualization . in contrast , an expanded endoscopic transnasal approach provides a direct midline corridor to this region without any brain retraction .

many different chemotherapy regimens were therefore developed.13 however , little is known on the feasibility and efficiency of chemotherapy for these cancer types in patients with severe renal failure.46 only case reports on the pharmacology of irinotecan in patients with colon or rectal cancer are available at present.711 we present the first case of combination chemotherapy in metastatic gastroesophageal cancer in a dialysis patient . a 73-year - old patient with a longstanding history of ischemic heart disease had been on dialysis for two years for vascular renal insufficiency . in september 2004 he was admitted for gastrointestinal blood loss . ca 19.9 was very high : 24925 u / ml ( nl < 37 u / ml ) . the patient was started on chemotherapy , the regimen consisting of l - leukovorin 250 mg / m , irinotecan 50 mg / m followed by 5-fluorouracil ( 5 fu ) 2 g / m/24 h , six weeks out of eight.1213 there was neither significant nausea nor diarrhea . dialysis was continued three times a week , ( the patient was on a monday wednesday friday schedule of dialysis ) and chemotherapy was given on the monday , just after dialysis . after four weeks of chemotherapy he also underwent a right carotid endarterectomy for an intercurrent transient ischemic attack in the right carotid region . six months after starting chemotherapy the ct scan of the liver showed a complete response of the numerous metastases . ( table 1 ) nine months after initiation of treatment , however , the liver metastasis and tumor marker were progressive again . doses of chemotherapy were based on a number of case reports on paclitaxel for ovarian cancer in dialysis patients.14,15 ct scan after two months showed further progressive disease . the increase in solid tumors in a patient undergoing dialysis poses specific problems,16 especially in the choice and pharmacology of anticancer drugs , bearing in mind that all of these drugs were developed in patients with normal liver and kidney function . for gastric cancer , 5fu has always been the backbone of treatment.1,2 in chronic hemodialysis , there are some data on dose reductions with 5fu weekly.17,18 for gastric cancer , combination chemotherapy is , however , necessary to obtain prolonged disease control and even for prolonging overall survival.1,2 combinations of 5fu + cisplatin and either docetaxel or epirubicin have therefore become standard chemotherapy regimens in gastric cancer.19,20 besides the aforementioned regimens , irinotecan - based combinations were shown to be active in first21 and second line gastric cancer.22 its equivalence ( in combination with 5fu ) in first - line metastatic gastric cancer was recently established in two studies , both comparing this regimen with a combination chemotherapy with cisplatin and 5fu.23,24 irinotecan is metabolized in the liver to its active metabolite sn-38 , followed by biliary excretion.6 there is no significant renal elimination . the drug was evaluated in patients with serum creatinin between 1.6 and 5 mg / dl and no unexpected toxicities were seen.25 there are a number of case reports on the use of irinotecan during hemodialysis , all of which are on patients with metastatic colon cancer . a first report mentions the use of irinotecan at a dose of 50 mg / m without significant toxicity.7 in two other case reports on dialysis patients , both patients were started with irinotecan at 50 mg / m . both reports mention that by increasing the dose , prohibitive diarrhea was the consequence.8,11 the worst outcome in higher irinotecan doses ( above 125 mg / m ) was demonstrated in two other dialysis patients , where these dosages led to extreme gi toxicities and even death.9 it can be concluded that irinotecan in terminal renal insufficiency should not be given at a dose above 50 mg / m . korean authors have made pharmacologic evaluations on the use of irinotecan in small - cell lung cancer patients during dialysis . they noted however that these doses were only feasible in patients of korean descent.26 there is a very recent case report on the combination of irinotecan at a dose of 50 mg / m weekly combined with fu1600 mg / m/24 h / week , leading to disease stabilization at six months in a dialysis patients with diffuse bone , cerebral and liver metastases of colon cancer.10 our case report builds on this knowledge of the use of irinotecan in metastatic colorectal cancer during dialysis . this case report discusses both the weekly dose of irinotecan and the 24-hour administration of 5fu in a gastroesophageal cancer patient . this is the first report on the efficacy of irinotecan- and fluorouracil - based chemotherapy in a dialysis patient with liver metastases of a gastroesophageal carcinoma . combination chemotherapy of irinotecan and fu was extremely well tolerated , without significant delays in administration . it produced radiographically complete remission of the liver metastases , and a normalization of ca 19 - 9 tumor marker , leading to a remarkable overall survival .

we present the first case report of a complete response of metastatic gastroesophageal cancer in a chronic hemodialysis patient with irinotecan - based chemotherapy . an elderly dialysis patient presented with diffuse liver metastases by a gastroesophageal adenocarcinoma . he received combination chemotherapy with 5 fluorouracil and irinotecan . after six months of chemotherapy , liver scans show complete remission . the principles , practice , and experience of chemotherapy with irinotecan during dialysis are discussed .

the massive global burden of heart disease in children , and the fact that it affects predominantly children from developing countries , requires a concerted collaborative effort . a spark of light in this effort was kindled recently by the cooperation of five organisations to provide life - saving intervention for an 8-year - old moroccan boy with congenital heart disease . his father works as a sandwich maker and his mother is a full - time homemaker . mustapha was a cheerful , intelligent boy growing up with his peers and acting as a source of great joy to his parents and family . this continued until the age of seven , when suddenly he started to complain of shortness of breath and tiredness . these symptoms were most unusual for the carefree boy , and worried his parents , who took him to the cardiology clinic in rabat to see the consultant paediatric cardiologist , dr layla zniber . dr layla volunteers for the chain of hope as the medical representative in morocco and has facilitated the treatment of dozens of critically ill cardiac patients through this link with la chaine de l'espoir in france , the chain of hope in the uk and now with chain of hope in qatar . mustapha was diagnosed as having a relatively rare complex heart disease , laubry - pezzi syndrome , consisting of a severe aortic regurgitation and vsd . with the leak in the valve worsening , the heart started to enlarge and fail which caused deterioration of his general condition and his parents were told that unless he underwent a complex heart operation , he would not live beyond his teens , which caused considerable anguish within the family . a multilateral agreement between qatar foundation , chain of hope , magdi yacoub research network , hamad medical corporation and the centre in morocco , provided unexpected hope for mustapha and his family with the prospect of rapid , corrective surgery . effective communication among the five organisations , culminated in mustapha and his family being flown to doha , qatar . during the journey , a moroccan flight attendant befriended the boy and his mother and her support and compassion ensured that the boy had constant round - the - clock support from the moroccan community in doha . in addition the family consulting centre in doha and the moroccan ambassador also rallied to support the family . mustapha was admitted to hamad general hospital on friday 13 july 2012 and on 15 july he underwent a ross procedure and vsd repair . this procedure is ideally suited for a pre - adolescent child and is designed to last for life . the operation was successful and within a few days he was a typical energetic youngster . in addition to the remarkable improvement in his health from the operation , the procedure presented a unique opportunity for training for the staff at the hospital . life since his operation has changed immeasurably for mustapha not only did he turn 9-years old on the day of the surgery , but the young boy is now attending school full time and is able , once again , to play with friends . he is particularly keen on football and hopes one day to emulate the stars of his favourite team . this is not only a happy ending for mustapha , but he has opened the door for many more children .

a case study in global cooperation between multiple charities and cardiac centers helped to save a 8-year - old moroccan boy suffering a case of laubry - pezzi syndrome with severe aortic regurgitation and ventricular septal defect . his recuperation was aided by the support of communities in both morocco and qatar .

most symptomatic patients present with postprandial fullness and gastrointestinal hemorrhage ; however , other patients present with an incidental submucosal filling defect on upper gastrointestinal contrast studies or a smooth effacement of gastric mucosa overlying a submucosal mass ( schindler 's sign ) on endoscopy . although leiomyoma is classically a submucosal lesion , intraluminal or extramural growth has been noted . open celiotomy with gastric wedge resection , partial gastrectomy , enucleation , and extended gastrectomy with en bloc resection of adjacent organs are various methods of treatment for gastric leiomyoma before the use of laparoscopy . with the progression of laparoscopic surgery beyond laparoscopic cholecystectomy , below , we describe a case of laparoscopic wedge resection and review the various laparoscopic techniques used to treat gastric leiomyoma . an upper endoscopy demonstrated a 2-cm lesion on the greater curvature of the stomach 6 cm from the gastroesophageal junction . the patient remained hemodynamically stable without any changes in her hematocrit . a contrast upper gastrointestinal series displayed a well - circumscribed mass in the region of the upper gastric body ( figure 1 ) . digital spot film from an upper gastrointestinal examination demonstrating the gastric mass located in the proximal stomach . the long white arrows show the bulging contour deformity on the external surface of the stomach . intraoperatively , a small , white , smooth , well - encapsulated nodule was noted on the greater curvature lying among the short gastric vessels . the short gastric vessels were divided by using the harmonic scalpel ( ultracision ethicon endo - surgery , cincinnati , ohio ) to completely free and visualize the mass ( figure 2 ) . a wedge resection of the mass with a rim of normal gastric tissue was performed with a laparoscopic stapling device ( figure 3 ) . postoperatively , the patient did well , was discharged the next day with oral pain medications , and was seen in the clinic in follow - up without any problems . the first gastric stromal tumor was noted at autopsy in 1762 , however , the first successful resection was performed over 100 years later . gastric stromal tumors are divided into 3 groups based on malignant potential : leiomyoma , leiomyosarcoma , and leiomyoblastomas . these methods have been applied to other benign gastric tumors ( eg , submucosal gastric lipoma ) as well as leiomyosarcoma . gastric resection without lymph node dissection in the treatment of malignant neoplasm ( such as leiomyosarcoma ) may be controversial although studies have demonstrated no benefit from the addition of systemic lymph node dissection or more extensive resection in the treatment of leiomyosarcoma . these results are important when considering the laparoscopic technique for any gastric stromal tumor resection because often the diagnosis of leiomyosarcoma versus leiomyoma may not be evident until after resection . in fact , biopsies from endoscopy yield the diagnosis in less than 60% of the time . although some authors feel that more extensive resections may be necessary for high - grade leiomyosarcoma , others believe that a wedge resection is sufficient for leiomyosarcomas . the choice of technique should be based both on size and location of the lesion . for easily accessible anterior lesions , a simple wedge resection is possible via an endostapling device although some have suggested the use of laparoscopic suturing as a more cost - effective method . we , like others , prefer the use of an endostapling device to reduce operative time as well as to avoid contamination from a gastrotomy . simple wedge resection has also been described for the use of posterior lesions via access through the lesser sac . because the lesion in our patient was on the greater curvature and easily accessible after dissection of the short gastric vessels , a wedge resection was the method we chose to use . lesions on the posterior wall , close to the gastroesophageal junction , or close to the pylorus may be difficult or impractical for a simple wedge resection . also , resection of a tumor close to the gastroesophageal junction or the pylorus may cause significant postoperative stenosis . thus , laparoscopic resection via an anterior gastrotomy has been described . with this technique , an anterior gastrotomy is first performed ; then , the mass is removed either with all layers of the posterior gastric wall or removed leaving the posterior gastric wall partially intact . closure of the defect can be performed via the anterior gastrotomy via laparoscopic stapling or suturing techniques . another method described is the combined use of laparoscopic , endoscopic , and intragastric techniques for the resection . this technique is ideal for lesions that are difficult to excise with a simple wedge resection . utilizing this method , the minilaparoscopic or needlescopic ( 2-mm ) ports do not usually require closure , which offers a specific advantage over standard laparoscopic ports . resection of the leiomyoma leaving the serosa intact is performed with visualization via the endoscope . some authors close the intragastric defect with intragastric suturing , while others leave the defect open . the seromuscular layers are dissected from the gastric mucosa to allow for enucleation of the leiomyoma . the utilization of this technique has significant drawbacks . because preoperatively , the distinction between leiomyoma and leiomyosarcoma is not always known , rupture of the tumor mass or incomplete resection would be inappropriate treatment . no matter which technique is used , intraoperative endoscopy is a useful adjunct especially when trying to localize small tumors . frozen section should always be considered in order to ( 1 ) exclude other possible diagnoses and ( 2 ) to assure clear margins . differentiating from high - grade and low - grade lesions by frozen section is not accurate however . postoperative recovery is short as demonstrated by our case with a 1-day postoperative hospital stay . this shorter stay should translate into a reduction in pulmonary and infectious complications related to extended hospital stays . another advantage is smaller incisions ( better cosmesis ) and thus subsequent decreased postoperative pain and narcotic requirement . laparoscopic surgery for gastric leiomyoma offers a safe and effective approach compared with open laparotomy .

gastric leiomyoma is a relatively rare gastric neoplasm . before the routine use of laparoscopy , various methods of treatment for gastric leiomyoma included open celiotomy with gastric wedge resection , partial gastrectomy , enucleation , and extended gastrectomy with en bloc resection of adjacent organs . below , we describe a case of laparoscopic wedge resection and review the various laparoscopic techniques for the treatment of gastric leiomyoma .

the annual occurrence of malignant melanoma has been dramatically increasing over the past few decades , and the exposure to ultraviolet light is assumed to be a major risk factor . other risk factors including the high number of typical melanocytic nevi , presence of atypical nevi , personal history of melanoma , and several genetic factors including increased frequency of cdkn2a mutations have been reported [ 2 - 4 ] . additionally , familial atypical multiple mole and melanoma syndrome are reportedly related with a higher incidence of malignant melanoma . typical melanocytic nevi occur at photo - exposed areas , where the risk of cutaneous melanoma greatly increases , and they are generally round with a uniform color and a diameter of 5 mm or less . are infrequently pigmented to the mucosa , and several cases of melanocytic nevus at the rectal mucosa have been reported [ 2 - 4 ] . however , there are no prior reports of the malignant transformation of rectal melanocytic nevus or its treatment . like melanocytic nevus of the skin , rectal melanocytic nevus thus , endoscopic resection of rectal melanocytic nevus might be an alternative treatment option . here , we report the first detailed case report of rectal melanocytic nevi resected using endoscopic submucosal dissection ( esd ) . a 70-year - old male without a medical history of remarkable illness visited our hospital for screening colonoscopy . the patient had no previous experience of colonoscopy and successfully underwent propofol - based conscious sedation . during the procedure , a 1.00.8 cm hyperpigmented and slightly elevated lesion was observed at the far distal rectum near from dentate line ( fig . a tiny piece of tissue was taken from the lesion , and the acquired specimen was tested under h&e staining and immunohistochemical staining for tumor proliferation using the ki-67 labeling index . the ki-67 labeling index was less than 1% , and the results of the hematoxylin - eosin - stain identified it as a melanocytic nevus ( fig . although there have been no previous written reports of the transformation of melanocytic nevus at the rectum to malignant melanoma , a large melanocytic nevus might have the potential for malignant transformation . the patient was recommended periodic colonoscopy or endoscopic resection , and he decided to receive therapeutic endoscopic resection after 10 months of colonoscopic examinations . the hyperpigmented lesion at the rectum showed no change in size , and under midazolam- and propofol injection - based sedation , standard esd was performed ( fig . the lesion was 0.70.7 cm , and hematoxylin - eosin staining and s-100 using immunohistochemical staining revealed many melanocytes and positivity for s-100 stain . therefore , the resected specimen was finally diagnosed as a melanocytic nevus with no malignant cells ( fig . melanocytic nevus has the potential for malignant transformation , and if malignant melanoma is developed on the colon or rectum , severe adverse effects such as diarrhea , rectal bleeding , constipation , and obstruction may occur . however , in many cases , such side effects may not be clear , making it difficult to diagnose malignant melanoma in the lower gastrointestinal tract . up to 1% of total melanoma cases are the anorectal type , the prognosis of which is known to be generally poor . considering the potential risk for malignant transformation , if melanocytic nevus is found on the rectum , a biopsy should be taken to confirm the presence of malignant cells . furthermore , either colonoscopic surveillance or resection should be considered despite a benign pathologic examination . however , there has been no case report of the malignant transformation of rectal melanocytic nevus , and the incidence of malignant transformation of rectal melanocytic nevus remains unknown . therefore , endoscopic resection using esd may be preferred if regular surveillance colonoscopy is unavailable or if the patients are younger or want to remove the lesion . to our knowledge , this is the first case in which esd was used to provide therapeutic resection of rectal melanocytic nevus . however , a treatment consensus should be established by future case reports and long - term follow - up data of endoscopic resection of rectal melanocytic nevus . in conclusion , rectal melanocytic nevus may have the potential for malignant transformation ; therefore , periodic monitoring via colonoscopy should be performed . however , colonoscopic surveillance requires patients to complete a cumbersome bowel preparation process and may increase their anxiety of malignant transformation during the long - term follow - up period . in such cases , removal of the rectal melanocytic nevus can be considered a definite treatment option , and endoscopic procedures including esd can be safe and feasible alternatives .

melanocytic nevus is the benign proliferation of melanocytes . the most common location of melanocytic nevus is the skin of the extremities ; however , there are few case reports of melanocytic nevus at the rectal mucosa . no prior case of malignant melanoma from melanocytic nevus at the rectal mucosa has been reported ; therefore , it is unclear whether resection should be performed or close observation is sufficient . however , the potential malignant transformation of melanocytic nevus should be considered , including melanocytic nevus on the rectum . melanocytic nevus of the skin can be removed by surgical excision ; however , due to rare incidence on the mucosa of the gastrointestinal tract , the optimal treatment for rectal melanocytic nevus remains controversial . here , we report the first case of melanocytic nevus on the rectal mucosa that was removed by endoscopic submucosal dissection . this case report provides useful information about the optimal management of rectal melanocytic nevus .

it can have a disabling effect because of pain and reduced mobility of the stroke survivor , which may limit the potential effect of rehabilitation . quality of life can affected by spasticity and can be highly detrimental to daily functional ability . spasticity can cause urinary incontinence , limit sexual ability , interfere with walking , sitting , and standing , and could generally reduce one 's ability of undertaking activities of daily living . a recent study showed that 39% of patients after first stroke are spastic after 12 months . a variety of techniques for the management of spasticity have been suggested , including positioning , cryotherapy , splinting and casting , biofeedback , electrical stimulation , and medical management by pharmacological agents . botulinum toxin a ( bta ) is now the pharmacological treatment of choice in focal spasticity . the aim of this review is gathering data about therapeutic usage of bta in the management of post stroke spasticity in respect of effect in spasticity and motor functions there are seven botulinum neurotoxinserotypes ( a , b , c1 , d , e , f , and g ) , all of which inhibit acetylcholine release at the neuromuscular junction . bta and botulinum toxin e cleave the c terminus of snap-25 , although bta has the longest therapeutic effect . there is not any general agreement that the extended action of bta is due to persistence of catalytic activity or prolonged blocking action by the cleaved snap-25 . for prolonged periods , cleaved snap-25 remains associated with the vesicle - docking protein syntaxin , indicating that it plays a continuous role in blocking vesicle fusion . the very long duration effect of bta results in the formation of temporary sprouts which replace for the paralyzed nerve terminal and can cause the wearing - off of clinical effect . a longer period of reinnervation for the parent terminal occurs finally as the sprouts die back . bta , by blocking acetylcholine release at neuromuscular junctions , accounts for its therapeutic action to relieve dystonia , spasticity , and related disorders . also , it has additional therapeutic advantages , not necessarily related to neuromuscular transmission ; first , blockade of acetylcholine release at autonomic nerve endings , and second , blockade of transmitter release at peripheral nerve endings which use other mediators . bta has effects other than peripheral action , indirect effects may also occur on the spinal cord and brain , which are caused by changes in the normal balance of efferent and afferent signals . side effects associated with administration of bta fall into three broad categories : ( 1 ) diffusion of the toxin can lead to unwanted inhibition of transmission at neighboring nerve endings , ( 2 ) continued blockade of transmission can cause some effects similar to anatomic denervation , such as muscle atrophy , ( 3 ) immunoresistance to bta is another undesirable side effect [ figure 1 ] . a detailed research was conducted in pubmed database during the time period from 1997 to december 2012 and 13,628 articles were identified concerning botulinum toxin . eighty - four studies were identified for inclusion in this review by search for botulinum toxin , post - stroke spasticity and finally , 40 articles were included in the review , among them eleven are review articles . the individual studies were categorized into the following subsections : lower extremity , upper extremity , and both upper and lower extremities . as of january 2008 , two botulinum toxin serotypes ( a and b ) are approved by food and drug administration ( fda ) for clinical use in the united states . botox is approved for the treatment of strabismus , blepharospasm , cervical dystonia , axillary hyperhidrosis , and glabellar lines ; and myobloc is approved for cervical dystonia . it is also approved in europe forfocal adult spasticity . bta is a superior treatment for post - stroke spasticity compared to other treatment options like oral therapies , such as diazepam , dantrolene sodium , baclofen , clonidine , gabapentin , and tizanidine ; intratechal drug therapies , like intratecha baclofen , morphine sulphate , and fentanyl ; focal treatments , such as ethyl alcohol and benzyl alcohol ( phenol ) . the results of previous studies indicated that bta is a treatment of choice in reducing tone and managing post stroke spasticity . also , compared to other pharmacological treatment options noted above , bta has higher efficacy and less adverse effects .

background : a variety of techniques for the management of spasticity have been suggested , including positioning , cryotherapy , splinting and casting , biofeedback , electrical stimulation , and medical management by pharmacological agents , botulinum toxin a ( bta ) is now the pharmacological treatment of choice in focal spasticity . bta by blocking acetylcholine release at neuromuscular junctions accounts for its therapeutic action to relieve spasticity.methods:a computerized search of pub med was carried out to find the latest result about efficacy of bta in management of post stroke spasticity.result:among 84 articles were found , frothy of them included in this review and divided to lower and upper extremity.conclusions:bta is a treatment choice in reducing tone and managing post stroke spasticity .

pandemic influenza h1n1 virus has been reported worldwide including the united states since 2009 . as the infection has been studied in more detail , , myositis has been described as a rare complication , which usually occurs in children as well as in the elderly . the classical presentation of myositis due to h1n1 virus is more diffuse and involves all muscle groups . we report a case of a 36-year - old male with pcr proven h1n1 influenza . the myositis involved only one group of muscles , while sparing all other muscles , leading to rhabdomyolysis and acute renal failure . a 36-year - old male came to the emergency room with 3 days of vomiting , fevers and left arm pain and swelling with restricted range of motion . he had been anuric for the past 2 days and had a fever of 101 f on presentation . the physical examination of the left upper extremity showed erythema with mild tenderness and swelling over the left upper extremity extending to the elbows and down the lateral chest wall . localized exam did not reveal injection site , insect bites , and trauma or open wounds . the initial laboratory examination showed a creatinine of 5.07 mg / dl and bun of 32 mg / dl . his transaminases were elevated with an ast of 2557 units / l and alt of 648 units / l . x - ray of the left shoulder was unremarkable and the ct scan of the left upper extremity without contrast showed stranding and edema of the soft tissues of the left shoulder , left abdominal wall and left upper extremity . patient was started on combination of piperacillin / tazobactam and linezolid for cellulitis and pneumonia after blood cultures were obtained . patient 's nasopharyngeal swab was sent for pcr analysis for influenza , which came back positive for influenza type a subtype h1n1 . antimicrobials were discontinued on day 4 because of negative blood cultures and absence of fever or leukocytosis . the patient continued to receive dialysis for 4 days as he remained oliguric with his creatinine trending down . the final diagnosis was rhabdomyolysis with acute renal failure due to isolated upper extremity myositis as a complication of influenza caused by h1n1 virus . patient 's urine output gradually started increasing and the patient was discharged home in 10 days with regular dialysis follow up till his acute renal failure resolved completely . we report a novel case of h1n1 infection complicated by isolated myositis of the left upper extremity causing severe rhabdomyolysis and acute renal failure . this is an unusual example of the localized myositis and severe myolysis after an influenza h1n1 infection . influenza a and b viruses have been documented to cause viral myositis with rhabdomyolyis , , , . all of these reported cases of myositis as a complication of influenza h1n1 virus have presented with diffuse muscle involvement and has not been described with an isolated muscle groups . in this patient the presentation was unusual because the myositis was limited in its distribution to the left upper extremity while sparing all other extremities and muscles . viral myositis presents with history of preceding upper respiratory tract infection followed by fever , anorexia and diffuse myalgias . medical attention is usually sought due to development of severe diffuse muscle pain , swelling or tenderness that interferes with function . both upper and lower the diagnosis of viral myositis as a cause of rhabdomyolysis is first suspected on a clinical basis . extreme elevation of creatine kinase can be seen in cases of acute viral myositis ranging from 10,000 viral myositis can occur from other viruses apart from the influenza virus including coxsackievirus , epstein barr virus , and echovirus . common causes of rhabdomyolysis include environmental heat illness and extreme physical exertion , , inherent metabolic myopathies and drug induced myopathies . other acute viral illnesses may also manifest as viral myositis and can cause complications like rhabdomyolysis and acute renal failure and fatal hyperkalemia . contrary to popular belief that viral myositis presents as generalized weakness involving all muscle groups with or without rhabdomyolysis , this atypical case highlights the fact that on rare occasions , viral myositis may present as an isolated myositis leading to severe rhabdomyolysis causing acute renal failure . there has been a reported case of orbital myositis in an infant with a severe h1n1 infection . it is thus important to note that influenza type a subtype h1n1 which has been famous for its respiratory manifestations can also cause viral myositis and can have extremely atypical manifestations as noted in this case and the infant with orbital myositis . it is essential to recognize this association and have a high index of suspicion for patients presenting with similar clinical presentation and flu like illness . this case also emphasizes influenza vaccination to prevent the flu and its life threatening sequelae . in conclusion , we report a novel case of influenza a subtype h1n1 complicated by rhabdomyolysis resulting from severe myositis of left upper extremity . this should alert the practitioners about the atypical presentations of influenza type 1-h1n1 and to its potential metabolic complications . on behalf of all authors , the corresponding author states that there is no conflict of interest . a copy of the written consent is available for review by the editor - in - chief of this journal on request .

acute viral myositis is a fairly rare condition and usually seen in recovery phase of illness , especially in pediatric or geriatric population . influenza type a , specifically h1n1 may present with generalized myositis and mild elevation of creatinine kinase in addition to usual manifestations . we would like to discuss an atypical presentation of type a influenza ( h1n1 ) in a middle aged male who was never immunized for influenza , presenting with fever , vomiting , anuria and acute severe left upper extremity pain . the most interesting presentation in our patient was that , it was limited to a single extremity , unlike generalized presentation , which was previously reported , acute renal failure warranting renal replacement therapy . this case serves as a reminder for clinicians about atypical manifestations of h1n1 and its threatening metabolic complications . hence the practitioners should be aware of this rare but possible presentation of certain strains of influenza virus . it also accentuates the importance of being immunized , reminding us of the old but golden adage prevention is better than cure .

an 1-month - old male infant , born at the gestational age of 35 weeks weighing 2,293 g was examined for the evaluation of retinopathy of prematurity ( rop ) . other metabolic or hematologic abnormalities were not detected and imaging of brain , orbit , chest and abdomen showed normal findings without evidence of trauma or tumor . ocular examination revealed normal anterior segments , but fundus examination was limited due to dense vitreous hemorrhage in both eyes . lensectomy was inevitably done in each eye during operation , because of the risk of damaging or severing retina . during vitrectomy the inner layer and unsupported vessels were excised to facilitate evacuation of intraschisis hemorrhage and to prevent postoperative bleeding . as intraschisis cavities were nearly cleared , the stump of inner layer with adherent intraschisis blood clot appeared . the outer layer of the schisis retina and non - schisis retina could be seen together on both sides of the stump as demarcation line . during surgeries , 1e - f).4 there was not any fibrovascular proliferation or tractional membrane . at 2 months after the last vitrectomy , all six exons and flanking regions in xlrs1 gene were directly sequenced , but known gene mutations were not detected.5 one 3-month - old male infant was referred with esodeviation of his left eye . fundus examination under general anesthesia revealed bilateral retinoschisis involving maculae with vitreous and intraschisis hemorrhage obscuring retina . the schisis involved the temporal retina in his right eye and nearly total retina except the nasal part in his left eye . the absorption of initial vitreous hemorrhage was observed during regular follow - up but recurred vitreous hemorrhage was detected at the age of 38 months . fundus findings were stationary without progression with partially remnant hemorrhage at the age of 42 months on the last follow - up ( fig . xlrs - related gene ( rs1 ) mutation ( c.544c > t , p.arg182cys ) was detected in the infant and his mother.5 an 1-month - old male infant , born at the gestational age of 35 weeks weighing 2,293 g was examined for the evaluation of retinopathy of prematurity ( rop ) . other metabolic or hematologic abnormalities were not detected and imaging of brain , orbit , chest and abdomen showed normal findings without evidence of trauma or tumor . ocular examination revealed normal anterior segments , but fundus examination was limited due to dense vitreous hemorrhage in both eyes . lensectomy was inevitably done in each eye during operation , because of the risk of damaging or severing retina . during vitrectomy the inner layer and unsupported vessels were excised to facilitate evacuation of intraschisis hemorrhage and to prevent postoperative bleeding . as intraschisis cavities were nearly cleared , the stump of inner layer with adherent intraschisis blood clot appeared . the outer layer of the schisis retina and non - schisis retina could be seen together on both sides of the stump as demarcation line . during surgeries , 1e - f).4 there was not any fibrovascular proliferation or tractional membrane . at 2 months after the last vitrectomy , all six exons and flanking regions in xlrs1 gene were directly sequenced , but known gene mutations were not detected.5 fundus examination under general anesthesia revealed bilateral retinoschisis involving maculae with vitreous and intraschisis hemorrhage obscuring retina . the schisis involved the temporal retina in his right eye and nearly total retina except the nasal part in his left eye . the absorption of initial vitreous hemorrhage was observed during regular follow - up but recurred vitreous hemorrhage was detected at the age of 38 months . fundus findings were stationary without progression with partially remnant hemorrhage at the age of 42 months on the last follow - up ( fig . xlrs - related gene ( rs1 ) mutation ( c.544c > t , p.arg182cys ) was detected in the infant and his mother.5 vitreous hemorrhage is uncommon in the first year of life , but could be seen in rop , shaken baby syndrome , intracranial hemorrhage , thrombophilic diseases , or retinal dysplasia.6 intraschisis or vitreous hemorrhage in xlrs results from rupture of unsupported retinal vessels or rarely from neovascularization . it usually occurs later in childhood and clears spontaneously.1 herein , we provided two infantile xlrs with vitreous hemorrhage and different clinical courses . in case 1 , although the genetic mutation associated with xlrs was not detected , clinical history and intraoperative findings of retinoschisis with vitreous hemorrhage strongly suggest xlrs , and exclude the possibility of other systemic and ocular causes except dic , which could be the cause of diffuse subretinal hemorrhage.4 among the clinically diagnosed xlrs cases , the gene mutation can not be detected in about 9%.5 case 2 showed typical fundus findings in xlrs and the gene mutation . we described two cases of xlrs in infants exhibiting the wider spectrum of disease expression . our report shows that xlrs could be demonstrated as massive vitreous hemorrhage even in early infants .

the authors report two cases of x - linked juvenile retinoschisis ( xlrs ) manifested as bilateral vitreous hemorrhage as early as in an 1-month - old infant and in a 3-month - old infant . the one - month - old male infant showed massive bilateral vitreous hemorrhage . during vitrectomy , thin membrane representing an inner part of schisis cavity was excised and intraschisis hemorrhage was evacuated . as intraschisis cavities were cleared , the stump of inner layer appeared as the demarcation line between the outer layer of the schisis retina and non - schisis retina . the other three - month - old male infant presenting with esodeviation also showed bilateral vitreous hemorrhage . typical bilateral retinoschisis involving maculae could be seen through vitreous hemorrhage in both eyes on fundus examination . spontaneous absorption of hemorrhage was observed on regular follow - up . xlrs could be manifested as massive hemorrhage inside or outside of the schisis cavity early in infancy .