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drugs are an important cause of liver injury and manifestations may range from asymptomatic elevation of liver enzymes to fulminant hepatic failure and may account for 20 to 40% of all instances of fulminant hepatic failure . more than 900 drugs , toxins , and herbs have been reported to cause liver injury . in the united states drugs are the most common cause of acute liver failure and 39% are due to acetaminofen and 13% are idiosyncratic reaction due to other medications . knowledge of commonly implicated agents and high degree of suspicion are essential for an accurate diagnosis . a seventy six years old male developed anorexia , nausea and right upper quadrant pain following intake of azithral ( azithromycin ) 500 mg per day for three days along with rantac ( ranitidine-300 mg / day ) and calpol ( acetaminophen-500 mg ) for upper respiratory tract infection . it was followed by passage of high color urine , jaundice , pruritis and gradual sleep disturbance and after four days he was admitted through emergency with altered sensorium and restlessness . no history of dyspnea , orthopnea , paroxysmal nocturnal dyspnea or edema could be elicited . he was non - alcoholic and was not suffering from any hepatic , cardiovascular or respiratory diseases and he took no other drugs within last three months . at presentation he was restless , confused and blood pressure was 110/70 , pulse 90/min and respiratory rate was 24/min . jugular venous pulse was not elevated . laboratory testing revealed normal serum urea , creatinine , fasting blood sugar , electrolytes and blood counts . liver function test ( lft ) showed total/ conjugated hyperbilirubinemia ( 7.0/4.1 mg% ) , markedly elevated alanine aminotransferase ( alt -1640 iu / l ; normal range 9 to 40 iu / l ) , aspartate aminotransferase ( ast-930 iu / l ; normal range 10 to 35 iu / l ) , alkaline phosphatase ( alp-1894 iu / l ; normal range 30 to 120 iu / l ) and a normal lactate dehydrogenase ( ldh-330 iu / l ; range 105 - 333 iu / l ) level . prothrombine time ( inr-2.2 ) and serum ammonia ( 83 mol / l ; normal range 10 - 40 on chest x - ray , the cardiothoracic index was augmented with clear lung fields . the patient was treated conservatively and showed improvement of signs and symptoms and lft within 14 days . acute hepatocellular injury , whether due to viral hepatitis , hepatic ischemia , or drug hepatotoxicity , results in elevated levels of serum aminotransferases ( ast and alt ) . in viral and drug - induced hepatitis , the ast and alt levels steadily increase and peak in the low thousands range within seven to 14 days . in ischemic hepatitis serum ldh is reported to be markedly elevated and a ratio of serum alt to ldh of < 1.5 , and serum alp remains normal . drug induced hepatotoxicity is mainly due to intrinsic/ predictable drug reactions or idiosyncratic and the risk factors are race , older age , female sex , pre existing liver disease , genetic factors , other co - morbidities and long acting drug formulation . azithromycin has a long half - life and has been demonstrated to reach high liver concentrations , exceeding the serum levels by 50 folds . the early liver injury could be hypersensitivity - mediated and rare cases of cholestatic hepatitis , and severe iatrogenic hepatitis requiring hepatic transplantation , has been reported . our patient developed features of hepatocellular toxicity and hepatic encephalopathy one week after the last dose of azithromycin with markedly elevated alt , ast , alp and serum ammonia levels . elevated aminotransferase , conjugated hyperbilirubinemia and prolonged p- time are suggestive of subfulminant or fulminant necrosis . at presentation the patient was haemodynamically stable with a normal serum ldh level and there was no evidence of other organ dysfunction . absence of clinical or radiological evidence of decompensated heart failure raises the possibility of an ischemic hepatitis unlikely . the diagnosis of azithromycin induced hepatotoxicity was considered because of the temporal relationship between drug intake and onset of clinical signs and symptoms and absence of other causes of liver disease . the naranjo et al probability scale ( score - six ) and who causality assessment scale , indicated azithromycin as the probable / likely cause of the adverse drug associated hepatocellular toxicity in this case . awareness and early reconition of azithromycin induced hepatocellular toxicity could be life saving and rewarding while prescribing this commonly used macrolide derivative .

azithromycin is a widely used macrolide derivative and has generally been considered to be a very safe medication . though gastrointestinal symptoms and reversible hearing loss are common , potentially serious side effects including angioedema and cholestatic jaundice occurred in less than one percent of patients . we report a case of asymptomatic dilated cardiomyopathy with azithromycin induced severe hepatocellular toxicity and hepatic encephalopathy .

a 74 year old male presented to his family physician with intermittent right sided headaches of 2 months duration . there was no history of trauma , migraine and no associated neck pain . otherwise , his general health was very good . clinical examination was unremarkable , therefore , no further investigations were instigated and the patient was discharged with simple analgesia . four months later , he returned to his family physician with worsening symptoms , namely , the headaches became more intense , persistent and were associated with slurred speech . clinical examination revealed atrophy of the right side of the tongue and deviation to the right on protrusion - right hypoglossal nerve palsy ( fig . his baseline blood tests which included a whole blood count , urea and electrolytes , serum calcium and glucose were all normal . a computed tomography of the brain showed skull base sclerotic metastases , subsequently , a magnetic resonance imaging of the brain revealed a focal abnormality of the right petrous bone with involvement of the hypoglossal nerve ( fig . bone metastases are commonly associated with thyroid , lung , breast , prostate and renal cancer , prostate cancer differs from the others by nature of its ' sclerotic bone metastases . therefore , in addition to the chest x - ray , ultra sound scan of the renal tract , a serum prostate specific antigen ( psa ) was requested , this was found to be elevated at 101 ng / ml . he was then referred to a urologist with suspected prostate cancer . he denied suffering from lower urinary tract symptoms and there was no history of back pain . subsequently , prostate gland biopsies confirmed a well - differentiated adenocarcinoma , gleason score 3 + 3=6 . although , there has been no recovery of the hypoglossal nerve palsy following a bi - lateral scrotal orchidectomy , his recent psa level remains low at 3.2 ng / ml . at 32 months of follow - up skull base metastatic cancer is often silent ; however , as the disease advances it commonly results in cranial nerve palsies . a combination of computed tomography and magnetic resonance imaging of the head is used to diagnose skull base metastases . although rare , cranial nerve palsies are associated with advanced prostate , breast , lymphoma and lung cancers . collet - sicard syndrome is caused by a lesion that involves the lower 4 cranial nerves . it results in the paralysis of vocal cords , palate , trapezius and sternocleidomastoid muscles . clinically , it results in anaesthesia of the larynx , pharynx and soft palate . as described in our patient , unilateral occipital headache with ipsilateral hypoglossal nerve palsy is termed occipital - condyle syndrome . although , sclerotic bone metastases are commonly associated with prostate cancer , other cancers with bone metastases must be excluded ; such as thyroid , lung , breast and renal cancer . skull base involvement of metastatic prostate cancer is almost invariably associated with known hormone - refractory disease . cranial neuropathy as the presenting feature is extremely rare , and although , there is one reported case of hypoglossal nerve involvement as the presenting feature , this was associated with involvement of multiple cranial nerves at the time of presentation . to the best of our knowledge , we report the first case of solitary hypoglossal nerve palsy as the presenting feature of advanced prostate cancer . neurologists , neurosurgeons and otolaryngologists may be the first clinicians to see such a patient ; therefore , prostate cancer should be amongst the differential diagnoses considered in middle - aged and elderly men presenting with a cranial neuropathy and evidence of skull metastasis . furthermore , if a psa test is elevated then the patient should be referred to the urologist .

prostate cancer is the most frequently diagnosed solid organ cancer in men and is the second leading cause of cancer - related deaths in men in the united kingdom . commonly , it metastasizes to bones and lymph nodes , however , in advanced hormonerefractory disease it may involve the skull base leading to associated cranial nerve palsies . cranial nerve palsy as the presenting feature of advanced hormone - sensitive prostate cancer is extremely rare . to the best of our knowledge , we report the first case of solitary hypoglossal nerve palsy as the presenting feature of advanced prostate cancer . neurologists , neurosurgeons and otolaryngologists may be the first clinicians to see such a patient ; therefore , prostate cancer should be amongst the differential diagnoses considered in middle - aged and elderly men presenting with a cranial neuropathy and evidence of skull metastasis .

retroperitoneal sarcomas are relatively uncommon tumors , constituting only 1015% of all soft tissue sarcomas ( sts ) [ 1 , 2 ] . patients usually present in their fifth decade of life , although the age range is wide . males and females are equally affected [ 4 , 5 , 6 ] . the most common histological types of retroperitoneal sts are liposarcomas and leiomyosarcomas followed by pleomorphic undifferentiated sarcoma and malignant fibrous histiocytoma . a variety of other histological types exist but they are much less common in the retroperitoneum than in other primary sites . , we describe a patient who presented with a large mesenteric root leiomyosarcoma that was treated surgically with favorable outcome . a 65-year - old male presented to our department complaining of recurrent epigastric and upper right abdominal pain radiating to the back for the last 3 months . his family history was consistent with a father who suffered lung malignancy and a mother who expired due to hepatoma . an ultrasound performed prior to his admission revealed a hypoechoic 4 4 cm lesion close to the pancreatic head . on admission , abdominal examination revealed a soft , nondistended abdomen with local tenderness in the upper right quadrant . abdominal tomography revealed a 5 5 cm , rounded , soft density lesion adjacent to the root of the superior mesenteric artery ( sma ) and pancreatic head ( fig . the patient underwent endoscopic ultrasound examination that demonstrated a hypoechoic - heterogeneous solid lesion behind and adjacent to the sma and superior mesenteric vein . 2 ) . pathology obtained by fine needle aspiration from the lesion revealed fragments of mesenchymal tissue that was positively stained for c - kit and actin . laparotomy revealed a large , 7-cm , hard tumor adherent to the medial border of the pancreatic uncinate process laterally , to sma medially , posterior to the portal vein and anterior to the inferior vena cava and left renal vein ( fig . he received radiotherapy , and at 4 years of follow - up , the patient is healthy and has no recurrence . local recurrence is the primary cause of mortality after resection in these pa - tients . low tumor grade and smaller tumor size are both well - established prognostic factors and are significantly associated with improved survival . the therapeutic aim of surgery in patients with sts is complete macroscopic resection , ideally with negative microscopic margins . this may oblige the decision to resect the surrounding tissue by the surgeon involved or adhere to the tumor . however , because of the large size of these tumors and the intraoperative difficulty in accessing all involved margins , this goal is difficult to achieve , often resulting in the presence of positive microscopic margins . tumors that are located in a strategic anatomical location , as presented here , are difficult to manage , and the surgeon needs to decide whether the surrounding vital structures are involved in the tumor or can easily and safely be dissected away from the tumor . the pseudocapsule consisting of surrounding tissue to the sarcomatous tumor dictates occasionally unblock resection . in proximity to strategic and vital organs ,

high mesenteric root sarcomas are difficult to manage due to their proximity to the superior mesenteric vessels . resection of these tumors along with the blood vessels may lead to a complicated and protracted convalescence for the patient . resection remains the main treatment modality for these tumors . during operation on high mesenteric root sarcomas , sound clinical judgment is needed for the decision not to sacrifice vital blood vessels .

acute thermal injuries to the esophagus are uncommon causes of esophageal disease . a candy - cane appearance is an endoscopic feature of thermal injury to the esophagus from hot liquid ( 1 , 2 ) . however , the clinical course of such a finding from solid food is not well documented . we treated a patient that presented with a 2-day history of odynophagia and foreign body sensation after an acute thermal injury of the esophagus from solid food ( prawn ) . here a 53-yr - old man was admitted to the hospital with a two - day history of odynophagia and a foreign body sensation . he had no medical history , and previously denied any esophageal symptoms such as dysphagia , odynophagia , or chest discomfort . two days before admission , the patient began to experience odynophagia and a foreign body sensation in the chest after swallowing several extremely hot pieces of prawn in haste . on arrival , endoscopy revealed a huge longitudinal ulcer , typical of friable hyperemic mucosa with necrotic debris with a tendency for easy to touch bleeding along the full length of the esophagus ( fig . the patient was treated with a parenteral nutrition regimen and intravenous pantoprazole to prevent injury from gastroesophageal reflux . the symptoms gradually improved over eight days after the initial event . at eight days after the initial event the patient was started on liquids and progressed to a soft diet , and was then discharged on oral pantoprazole for 1 months . eight weeks after the event , endoscopy showed normal esophageal mucosa with the rim of the previous ulcer scar ( fig . here we present the clinical course of serial endoscopy of an acute thermal injury of the esophagus caused by extremely hot solid food . there is only one prior similar report with the endoscopic and histological characteristics of an injured esophagus due to hot liquids ( 3 ) . however , there is no same case due to solid foods reported in the medical literature . although candy cane esophagus with alternating pink and white linear bands of esophageal mucosa is well known feature of esophageal thermal injury , most of the prior caustic agents were hot liquids . in our case , the typical candy cane appearance was not observed during the clinical course . most early endoscopic findings of the initial injury during the first week showed a predominant whitish pseudomembrane ( 3 ) . however , our findings , 2 days after the initial event , showed hyperemic areas with marginal necrotic debris , which may have resulted from rupture of bullae . we assume that the appearance of the candy cane esophagus was due to the flow of hot liquid whereas that of burn or ulcer was due to the pressure effect of hot solid . therefore the different causes of thermal injury might make the different endoscopic findings and the endoscopic image of a candy cane appearance may not be characteristic of an acute esophageal thermal injury due to hot solid foods . although most reported series are case reports , conservative management with anti antisecretory treatment such as a proton pump inhibitor ( ppi ) or histamine2-receptor antagonist ( h2ra ) to prevent further injuries from gastric acid was underwent without severe complications ( 3 - 6 ) . most cases were treated for 1 months except for only one case for 14 days ( 6 ) . in conclusion , with the history of hot food ingestion , esophageal symptoms , a foul odor on examination , and deep linear ulcers on the posterior aspect of the esophagus the diagnosis of an acute thermal injury of esophagus should be considered .

a 53-yr - old man presented with a two - day history of odynophagia and a foreign body sensation . two days before admission , the patient began to experience odynophagia and a foreign body sensation in the chest after swallowing several extremely hot pieces of solid food ( prawn ) in haste . endoscopy revealed a huge longitudinal ulcer , typical of friable hyperemic mucosa with necrotic debris along the full length of the esophagus in the posterolateral region . here we present the clinical course of serial endoscopy of an acute thermal injury of the esophagus caused by solid food .

the authors report a unique case of malignant mesothelioma with distant metastasis to the brain . pleural mesothelioma was thought to spread directly to local structures with distant metastasis found only on autopsy . the authors present this case to demonstrate that mesothelioma can have distant metastasis and that surgery can improve both survival and quality of life . we report a case of a 62-year - old gentleman who presented with shortness of breath and right - sided chest pain over the period of 12 months . a chest x - ray showed a right pleural plaque that subsequently caused a right pleural effusion ( fig . 1 ) . he declined chemotherapy or radiotherapy , although he was having regular follow - up by the oncologist . he confirmed being exposed to asbestos , having worked for 20 years in aluminum and margarine factories . eighteen months after his initial presentation , he experienced progressive left - sided weakness and left - sided homonymous hemianopia . an mri scan of his brain showed extra - axial right occipitoparietal enhancing mass ( 43 43 47 mm ) with surrounding vasogenic oedema . it was isointense to grey matter on t2 and abutting the falx cerebri with midline shift and effacement of the right lateral ventricle ( fig . 2 ) . the lesion was approached through a right occipital craniotomy and entirely removed in a piecemeal fashion . at surgery , it appeared as a greyish - white firm vascular mass with a clear cleavage plane with the surrounding brain . the patient had good recovery and was discharged home . on 6-week follow - up , the patient continued to improve with significant improvement in his quality of life . figure 2:mri image of brain with gadolinium contrast showing enhancing mass in the right occipital lobe . mri image of brain with gadolinium contrast showing enhancing mass in the right occipital lobe . section from the intraoperative specimen showed a large cell - epithelioid malignancy composed of markedly pleomorphic epithelial cells with large hyperchromatic nuclei . immunoperioxidase stains demonstrated in fact that the cells expressed vimentin , calretinine , ae1/ae3 and cam 5.2 as in the previously biopsied pleural lesion . histologically mesotheliomas may be purely epithelioid ( 50% ) or of mixed histology ( 30% ) . more than 80% of tumors arise from the pleura ; however , primary mesothelioma of the peritoneum , pericardium and tunica vaginalis have also been reported . the risk of developing mesothelioma after asbestos exposure is 8% , depending on the duration and intensity of exposure . malignant pleural mesothelioma usually presents between the fifth and seventh decade of life and can be difficult to diagnose due to the vagueness of the presenting symptoms including dyspnea and nonpleuritic chest pain . the median survival is only 9months from diagnosis with death usually due to thoracic disease . this rapid progression may have contributed to the belief that mesothelioma rarely has distant metastasis . reviewed 171 cases of malignant mesothelioma at autopsy and discovered that over 54% of patients had distant metastases . the sites most commonly affected were the liver , adrenal glands and kidneys ( 56 , 31 and 30% , respectively ) . wronski and burt also reviewed the post - mortem findings and they concluded that the incidence of distant metastasis from pleural mesothelioma is around 50% and the incidence of cerebral metastasis around 510% . although there are numerous reported cases of cerebral metastasis from malignant pleural mesothelioma , the majority of cases were post - mortem findings . furthermore , only eight patients had neurological manifestation of cerebral disease at the time of diagnosis [ 3 , 6 , 8 ] . the case we report is interesting for the presentation of the intracranial pathology 18months after the initial presentation , well beyond the reported median survival for this lesion . the good postoperative neurological recovery also emphasizes the role of surgery to extend survival in the presence of locally controlled primary disease . to the best of our knowledge , this case represents the third report of symptomatic cerebral metastases from malignant mesothelioma that was treated by surgical excision via craniotomy , where ante - mortem histological diagnosis was obtained . with an increasing incidence of mesothelioma , the treatments available are also expanding . in the past , single - modality therapy alone ( surgery , radiotherapy and chemotherapy ) has failed to improve survival significantly . furthermore , several new therapeutic techniques , such as photodynamic therapy , immunotherapy and intracavitary chemotherapy , are increasing survival and retarding disease progression . we present this case to demonstrate that metastatic mesothelioma can have distant metastasis to the brain . as a direct result of improvements in treatment , the survival of patients with malignant mesothelioma will continue to improve , and more patients are likely to present with metastatic disease . as we have demonstrated in this case , surgical excision of cerebral metastases can provide symptomatic relief , and surgical treatment may therefore be justified in enhancing the patient 's quality of life .

malignant mesothelioma is an uncommon , highly invasive tumor derived from the mesothelial cells of pleura or peritoneum characterized by poor outcome . mesothelioma was thought to metastasize locally only via direct invasion and not have distant spread . distant metastases were discovered mostly on post - mortem examination . the authors present a case of 62-year - old man with pleural mesothelioma and brain metastasis .

pleural effusion and pneumothorax are common conditions presenting to secondary care and accounted for over 29 000 admissions in the period 20112012 within the national health service in england . first line management is usually conservative , needle aspiration or by medical teams utilizing small bore seldinger intercostal chest drains . small bore tubes are more comfortable for patients and can be therapeutically equivalent to larger drains . the national patient safety agency issued a rapid response report in 2008 due to concerns about the risks associated with chest drains . this case demonstrates that damage to intercostal drains can occur during difficult insertion and that appropriate checks of equipment during clinical procedures can avoid the a gentleman in his 80s presented to hospital with a 3-week history of chest pain and shortness of breath brought on by an episode of sneezing . he had a notable past medical history of previous right anterior thoracotomy and wedge resection of a lower lobe nodule that was found to be benign . on assessment , he was found to have a right - sided pleural effusion and a right - sided 18 fr seldinger drain was inserted for diagnostic and therapeutic purposes . at this point , it was noted that the tip of the drain was missing . the patient was informed about this , retrieval of the foreign object was not attempted and the event was clearly documented . a new seldinger drain was placed and the missing drain tip was visible on chest radiograph , see fig . 1 . cessation of fluid output prompted drain removal and a computed tomography ( ct ) scan of the thorax was performed to further assess the pleural disease ; this showed a large persistent multiloculated effusion . the patient was transferred to a specialist thoracic surgery unit and proceeded to urgent right thoracotomy and decortication for the loculated effusion with removal of the foreign body . video - assisted thoracoscopic surgery ( vats ) was not possible due to the presence of adhesions from previous surgery . the 1-cm drain tip was identified medial to the 12th rib in the posterior cardiophrenic angle and removed . the patient required transfusion of two units of packed red cells for a low haemoglobin post - operatively but otherwise made a good recovery . iatrogenic foreign bodies in the chest have been formally reported as early as 1964 when a rubber chest drain was retained in the pleural space . it was believed at this time that management should usually be that of thoracotomy and decortication and a further case series confirms that surgical removal is almost always performed [ 3 , 4 ] . with the advent of vats , it is usually possible and indeed preferable to retrieve a foreign body before pleural sepsis occurs , averting thoracotomy ; however , surgery is still likely to be necessary . the retained foreign material following seldinger chest drain insertion has been reported once before and the patient required surgery to remove the item , in the form of a vats decortication . in this paper , the distal portion of the drain had sheared off , most likely due to repeated withdrawal and advancement of the drain over the guidewire . correct insertion technique is important in preventing damage to the drain and avoiding inadvertent introduction of free foreign bodies into the pleural cavity , specifically repeated insertion and withdrawal of a seldinger drain over a guidewire . surgeons and physicians should perform a count of instruments during clinical procedures that they undertake in ward or clinic environments . should a foreign object be retained inside a patient then prompt recognition , as occurred in our case , is important for patient safety . a plan for further management , including whether to remove the object can then be made . unusual problems may be encountered during procedures but a retained foreign object that is not recognized would constitute a never event . chest drains inserted at the end of cardiothoracic procedures commonly require removal of the proximal end prior to connection with the drainage system ; we now also include these drain ends in the instrument count for operative cases . patients with chest drains should be cared for on a ward where specialist staff are trained in their management . these staff should be familiar with the normal appearance of equipment upon removal ; any discrepancies at this point are a further step in ensuring patient safety . review of a chest radiograph after drain insertion or removal is a routine step that should enable prompt identification of a foreign body in correlation with review of any equipment which is causing concern .

pleural effusions are commonly drained with seldinger intercostal drains . one uncommon but serious risk of drain insertion is that of a foreign body being retained in the pleural cavity following removal . we report a case in which the tip of the drain was retained in the pleural space following difficult insertion of a seldinger intercostal drain in a district general hospital . prompt recognition and clear patient communication are important at the occurrence of an unusual complication . surgical removal of the foreign body was performed following transfer . we report this case to raise awareness that insertion and withdrawal of drains over the guidewire during insertion may damage the drain and highlight the need for doctors who insert chest drains to perform a count of instruments during ward or clinic - based procedures as well as those performed in theatres . we now include removable parts of chest drains in our theatre instrument count .

fixed drug eruption to ornidazole has been infrequently reported . fixed drug eruption ( fde ) is a special variety of allergic drug reaction where the reaction areas become reactivated with well - demarcated erythematous area whenever the same drug is administered . the lesions may be multiple and may occasionally be surmounted by a bulla in the center . in the majority of cases brocq in 1894 was the first to coin the term fixed eruption to describe a pattern of skin eruption due to antipyrine . since then , numerous drugs including pseudoephedrine , trimethoprim , tetracycline , barbiturates , salicylates , phenolphthalein , ibuprofen oxyphenbutazone , fluconazole , azithromycin , levofloxacin , levamisole , and colchicine have been implicated among many others as a causative agent . fde due to ornidazole , a relatively new 5 nitro - imidazole derivative has been very infrequently reported , though it is very commonly used for amoebic dysentery in developing countries . a 56-year - old male developed pain , redness , and tenderness of his right index finger since 2 days for which he had been treated elsewhere with cephalexin 500 mg twice daily ; ofloxacin 200 mg twice daily ; and ornidazole 500 mg twice daily orally . by third day , when i first saw , the infection in the index finger improved but he developed an ulcer on his glans penis [ figure 1 ] and the mucosae of his upper and lower lips . at this juncture , all the medicines were discontinued and he was started on dexamethasone 2 mg daily orally which led to the clearance of all the lesions during the next 3 days . superficial ulcer of fixed drug eruption on glans penis one week later , oral provocation test was started after obtaining informed consent by giving one drug each day in full therapeutic dose . there was no reactivation of the lesions with cephalexin , ofloxacin , ciprofloxacin , tinidazole , paracetamol , diclofenac sodium , amoxicillin and clavulanic acid . however , he developed reactivation of itching , redness and occasional erosions on his glans penis , upper and lower lips 4 hours after taking ornidazole 500 mg . he was immediately started dexamethasone 2 mg orally twice daily with clearance of all the symptoms and lesions during the next 24 hours . recurrence of pruritus , erythema and occasional erosions on the lips and glans penis 4 hours after administration of 500 mg ornidazole confirm that the reaction was due to ornidazole and not due to the other medicines used in the provocation test . among the nitro - imidazoles , fde seems to be a form of delayed hypersensitivity reaction mediated by cd8 + t cell . the causative drug is supposed to act as hapten which binds to basal keratinocytes resulting in the release of lymphokines and antibodies which damage the basal cell layers . on drug intake , cd8 + cells are reactivated to release interferon and cytotoxic granules into the local micro - environment . mast cells are also believed to contribute to the activation of intraepidermal cd8 + cells through the induction of cell adhesion molecules . provocation tests are still the only reliable method to find the causative agents and are often essential or even mandatory in the patient 's interest . though provocation is very safe especially in fixed eruption , if history suggest severe reaction , then it may be safer to start with half the dose on first day , followed by full therapeutic dose on the next day if there is no reaction to the first dose .

a 56-year - old male developed an ulcer on his glans penis and mucosae of upper and lower lips 3 days after taking ofloxacin , cephalexin , and ornidazole . clinically , a provisional diagnosis of fixed drug eruption was made . the causative drug was confirmed by an oral provocation test which triggered a reactivation of all lesions only with ornidazole .

vertebral artery dissection ( vad ) is among the most common identifiable etiologies of stroke in young adults aged 1845 years , with an estimated annual incidence between 1 and 1.5 per 100,000.1 compared to carotid dissection , detection of vad is challenging due to nonspecific symptoms and substantial variability of imaging results . intramural pathology can be captured by noninvasive techniques such as fat - saturated magnetic resonance imaging ( mri ) and duplex ultrasound . although duplex ultrasound provides hemodynamic information in real - time , the technique is limited by the low rate of clear findings suggestive of intramural hematoma in patients with vad.2 here , we present a case of unspecific neck pain as isolated symptom of bilateral vad with unusually compelling evidence on duplex ultrasound . a 28-year - old woman with a history of amyotrophic neuralgia one year ago with electroneurographic evidence of neurogenic paresis of the right serratus anterior muscle experienced acute neck pain radiating in both shoulders . an elective cervical mri was performed 21 days later which showed no radiculopathy but suspicion of left vad . neither physical examination nor medical and family history revealed any indications of connective tissue disease or trauma . duplex ultrasound showed luminal narrowing of the left vertebral artery ( va ) along its extracranial course and hypoechoic thickening of the vessel wall suggestive of intramural hematoma ( figures 1 and 2 ) fat - saturated t1 mri confirmed dissection of the left va and additionally showed dissection of the right extracranial va ( figures 3 and 4 ) . antiplatelet therapy with oral aspirin ( 100 mg / day ) was initiated and the patient was discharged . at follow - up visit duplex ultrasound showed a patent left va with only slight residual luminal narrowing and decreased blood flow velocity of its intracranial segment compared to the contralateral va . aspirin was prescribed for another six months after which another follow - up visit was scheduled . our report of isolated pain in the neck as the sole symptom of spontaneous bilateral va dissection has two clinically relevant implications . first , the absence of any neurological symptoms in our patient highlights the necessity of considering cervical artery dissection in patients presenting with unspecific symptoms such as neck pain , even if isolated.3 second , our image of intramural hematoma on duplex ultrasound has educational value , as pathology is captured in an unusual , clear and distinct fashion and can be a useful supplement to other neurovascular reference images in the clinical assessment of patients with a suspicion of cervical artery dissection . while in our patient , dissection of the left va was clearly detected on both duplex ultrasound and mri , contralateral vad was missed by duplex ultrasound most likely due to its distal manifestation . direct b - mode imaging of the v3-va is challenging , and stenotic lesions caused by intramural hematoma are commonly suspected on the basis of upstream flow disturbances ( eg , high - resistance pulsatile flow ) . thus , we may speculate that luminal narrowing of the right v3 segment was too slight to produce corresponding pre - stenotic flow changes . in concordance with best available evidence , our patient was prescribed antiplatelet treatment.4 improving accuracy in detection of vad is important , since patients have an increased risk of acute ischemic stroke and early recurrent stroke due to embolism from thrombus formation at the dissection site.57 data from observational and nonrandomized studies indicated efficacy of oral anticoagulation therapy applied for three or six months after dissection to prevent recurrent stroke , an observation which has been widely translated into clinical practice.8 although this treatment regimen has been recommended by the american heart association ( aha ) guidelines , similar evidence was found for antiplatelet therapy , which is why these guidelines also acknowledged that the relative efficacy of anticoagulation versus antiplatelet therapy remained unknown at the time of publication.9 a recent multicenter trial compared the two treatment forms in a randomized fashion but was stopped prematurely due to failure of recruitment . however , subsequent analysis showed no difference between the antiplatelet and anticoagulant treatment arms in preventing stroke and death in patients with symptomatic cervical artery dissection.4 although the rate of strokes was slightly lower in the group of patients receiving anticoagulant therapy than in the antiplatelet group , this difference was counterpoised by one severe subarachnoid hemorrhage in the anticoagulant group . our clinical case of vad with unusually clear evidence on duplex ultrasound , confirmed by fat - saturated mri , and presenting with neck pain as the only symptom does not only highlight the diagnostic value of ultrasound as supplement to fat - saturated mri but also emphasizes the importance of thorough clinical assessment in patients with nonspecific symptoms such as neck pain .

vertebral artery dissection ( vad ) is among the most common identifiable etiologies of stroke in young adults and poses a diagnostic challenge due to nonspecific symptoms and substantial variability of imaging results . here , we present a case of unspecific neck pain as isolated symptom of vad with unusually compelling evidence on duplex ultrasound . this observation has clinical relevance as the absence of any neurological symptoms in our patient highlights the necessity of considering cervical artery dissection in patients presenting with unspecific symptoms such as neck pain , even if isolated . furthermore , our image of intramural hematoma on duplex ultrasound has been captured in an unusual , clear and distinct fashion and might therefore be a useful reference image in the clinical assessment of patients with a suspicion of cervical artery dissection .

the rarely described cytological features of chondroid syringoma included a mucoid aspirate , abundant chondromyxoid matrix material and epithelial components . chondroid syringoma or cutaneous mixed tumors are rare benign skin adnexal tumors accounting for only about 1% of commonly encountered skin tumors . it is now widely accepted that fine needle aspiration cytology ( fnac ) is useful in diagnosis of skin adnexal tumors . a mucoid aspirate , abundant chondromyxoid matrix material , and epithelial components were suggested as diagnostic criteria . the reported case is one of chondroid syringoma confirmed by histopathology , the fnac of which yielded thin fluid - like material and microscopy revealed epithelial clusters with admixed smaller myoepithelial cells , background cyst macrophages , and only scanty chondromyxoid stromal elements . a 31-year - old male patient presented with a solitary 3 cm 2.5 cm slowly growing , non - tender , cystic left supraorbital swelling [ figure 1a and b ] . fnac yielded a thin fluid - like aspirate from which leishman and pap stained smears were prepared . microscopic examination revealed moderately cellular smears composed of cohesive clusters of medium - sized epithelial cells with moderate to abundant amount of cytoplasm , peripheral cytoplasmic processes , and bland appearing monomorphic centrally placed or slightly eccentric nucleus with fine chromatin . smaller hyperchromatic myoepithelial cells were seen intimately admixed with the epithelial cells in most of the clusters [ figure 2 ] . fair number of cyst macrophages , a thin proteinaceous material , and only rare chondromyxoid stromal fragments were detected in a predominantly clean background . a cytological diagnosis of benign cystic neoplasm possibly benign skin adnexal tumor was made and excision biopsy suggested . ( b ) left supraorbital swelling ( closer view ) epithelial myoepithelial cell clusters in a clean background of thin proteinaceous material and cyst macrophages ( inset ; seen elsewhere ) ( pap ; 100 ) excision biopsy was performed 2 weeks later . low power showed multiple well - circumscribed cystic spaces lined by tissue having biphasic growth pattern [ figure 3 ] with epithelial elements in the form of non - branching bilayered tubules as well as solid nests embedded within a predominantly fibrous and focally chondromyxoid stroma . differential diagnoses included eccrine hydrocystoma and syringocystadenoma papilliferum both of which lacked the distinctive chondromyxoid stromal element . well - circumscribed cystic spaces lined by tissue having biphasic growth pattern ( h and e , 100 ) . the term chondroid syringoma , introduced in 1961 , may be preferred to the alternative designation - mixed tumor of the skin because of the recognition that the tumor is epithelial with merely secondary changes in the stroma . the world health organization has defined chondroid syringomas as benign adnexal tumors of skin composed of epithelial and stromal elements with a wide spectrum of patterns histologically analogous to mixed tumors of the salivary gland . they most commonly occur as solitary asymptomatic slowly growing nodules on the head and neck of adults , although other sites may be affected . there is a male predilection and most lesions are between 1 and 3 cm in diameter , although examples as large as 10 cm have been reported . it is generally accepted that there are both apocrine and eccrine variants of mixed tumors . ultrastructural studies confirm that myoepithelial cells surround the epithelial cells and appear to produce the stromal components of the lesions . histologically , two types of chondroid syringomas can be recognized : one with tubular and cystic , partially branching lumina and the other with small tubular lumina . the former type is much more common than the latter and shows marked variation in the size and shape of the tubular lumina ; it also shows cystic dilatation and branching . embedded in an abundant stroma , the tubular lumina are lined by two layers of epithelial cells : a luminal layer of cuboidal cells and a peripheral layer of flattened cells . among the published literature on cytological features of chondroid syringomas , predominance of chondromyxoid elements and presence of only epithelial cell clusters the present case had extensive cystic changes which according to the published literature is unusually seen in cytology but consistent with the more common histological type . the cystic change and presence of both epithelial and myoepithelial cells including the cytological features of the present case among the diagnostic criteria for cytodiagnosis of chondroid syringomas might increase the chances of a definitive preoperative diagnosis and help in planning the extent of surgery .

chondroid syringoma is a rare benign skin adnexal tumor , the cytological features of which have been published very rarely in the literature . a mucoid aspirate , abundant chondromyxoid matrix material , and epithelial components were suggested as diagnostic criteria . the reported case is one of chondroid syringoma confirmed by histopathology , the fine needle aspiration cytology of which yielded thin fluid - like material and microscopy revealed epithelial clusters with admixed smaller myoepithelial cells , background cyst macrophages , and only scanty chondromyxoid stromal elements . including these cytological features of the present case among the diagnostic criteria for cytodiagnosis of chondroid syringomas might increase the chances of a definitive preoperative diagnosis and help in planning the extent of surgery .

endometriosis is a clinical entity characterised by the presence of functional endometrial tissue in an anatomical location outside the uterine cavity . this condition is sometimes seen in the scars of caesarean section where it can be confused with incisional hernia . it is rarely ( 0.2% of ectopic endometrium ) seen in the perineum where it is usually localised in episiotomy scars . a 35-year - old lady presented as an emergency to different hospitals on three occasions with a history of severe pain in the perianal area . there was no change in the severity of symptoms in relation to the menstrual cycle during the first two episodes . she had had two deliveries , the first one a normal delivery without episiotomy and the second one caesarean section . at the time of first consultation she was noted to have a 2 cm tender nodule in the perianal area at the 2 o'clock position which was thought to be a perianal abscess . this was incised and drained and as no pus was seen , she was treated as suffering from cellulitis . she presented with similar symptoms a few months later to a different hospital and was treated for recurrent perianal abscess . during her third presentation some blood clots were seen in the nodule and hence an excision biopsy was done which showed endometrial tissue ( fig . her white blood cell count was normal and c - reactive protein was mildly elevated . she was further investigated with flexible sigmoidoscopy and an mri scan of the pelvis and perineum which did not show any pelvic endometriosis . she was referred to a gynaecologist for hormonal treatment as nothing was shown on mri scan . it is rarely suspected by the clinician as a differential diagnosis of perianal problems , and the characteristic cyclical pain is uncommon in endometriosis . as perianal sepsis is more commonly dealt with by junior surgeons , unusual presenting features of this condition may not be recognised . a high degree of suspicion is the key to diagnosis , particularly when a patient presents with recurrent perianal pain and no pus is found . anal endosonography can help to know the precise anatomical location and involvement of the external anal sphincter . involvement of senior surgeons and biopsy of unusual lesions in patients presenting with symptoms of recurrent perianal pain would establish the diagnosis early . wide local excision sparing anal sphincter cures the condition and hormonal treatment can be used when it involves multiple sites or when excision is not possible . painful perianal lesions / swellings raise the suspicion of perianal abscess . in cases of recurrence of such lesions and fistulation , crohn 's disease is often suspected . in females such lesions can be endometriosis , particularly when no pus is found or the problem is cyclical .

endometriosis of the perianal region is an extremely rare condition usually seen in episiotomy scars and can involve the septum separating vagina and anal canal . the clinician is unlikely to suspect it if there is no scar in the perineum and patient the does not give a history of episiotomy . moreover it is difficult to suspect when the patient does not report cyclical pain and therefore it is likely to be treated as perianal sepsis . we report the rare case of a 35-year - old woman who presented with recurrent painful nodule of endometriosis of the perianal area without previous episiotomy .

vagal schwannomas are benign , rare peripheral nerve sheath tumors in the head and neck region . some physicians opt to closely observe cases of schwannoma of the neck on an outpatient basis rather than to perform radical surgery . however , there is a possibility , albeit rare , of malignant transformation of a benign schwannoma . here , we are reporting the first case from the indian subcontinent , which was transformed into the angiosarcoma from benign vagal schwannoma over a long period . a 47-year - old male patient presented with a left sided neck swelling since last 12 years , insidious in onset , and slowly progressive . in last 2 months , there was a firm , nodular , well - defined , nontender swelling of approximately 6 cm 6 cm size , in the left lateral part of the neck . fine - needle aspiration ( fna ) cytology revealed paraganglioma and magnetic resonance imaging ( mri ) demonstrated a tumor thought to be a vagal schwannoma with its morphology , and its relation to the surrounding structures [ figure 1 ] . contrast - enhanced magnetic resonance imaging , t1-weighted fat saturated coronal image shows a large isointense signal intensity mass admixed with hyperintense signal intensity during surgery , the tumor was found to be arising from the vagus nerve and adherent to the common carotid artery through the artery was unaffected by the tumor . pathologic findings showed a solid gray - white tumor with large areas of hemorrhage , necrosis , and cystic changes . microscopic examination showed verocay bodies ( antoni a region ) , focal admixed hypocellular areas with edematous vascular stroma and haphazardly arranged tumor cells ( antoni b region ) . multiple areas revealed a vasoformative tumor composed of numerous , irregular , anastomosing vascular spaces with dissecting pattern and with high mitotic activity , and the presence of atypical mitosis . the vascular channels were lined by pleomorphic , endothelial cells showing large ovoid nuclei , heterogenous chromatin , and prominent nucleoli [ figure 2 ] . section showing a well - encapsulated benign spindle cell tumor with characteristic verocay bodies , consistent with schwannoma ( h and e , 5 ) on immunohistochemistry - spindle cell tumor ( nerve sheath tumor ) component was positive with s-100 and negative for cd31 . ki-67 showed the high proliferation index in vasoformative tumor areas ( 4050% ) and was only about 1% in nerve sheath tumor areas . the final histopathological diagnosis was angiosarcoma arising in a benign schwannoma [ figure 3 ] . cd 31 positive staining of atypical endothelial cells in view of high - grade malignancy , whole body positron emission tomography - computed tomography was done , which revealed liver metastasis for which liver biopsy was done , which revealed angiosarcoma . the patient was given postoperative chemotherapy , but the patient died after 6 months of treatment due to distant metastasis . though rare but benign tumors have the potential for malignant transformation . angiosarcoma transformation in peripheral nerve sheath tumors usually such tumors transform into neurofibromas or malignant peripheral nerve sheath tumors , especially in von reckinghausen disease . the process of malignant transformation from schwannoma to angiosarcoma was postulated by rckert et al . although fna is clearly a good diagnostic tool that can be performed easily in the outpatient clinic once the mass had completely changed to malignant cells , fna for diagnosis of schwannoma is difficult and the accuracy reported was only 20% . thus , our physicians should be cognizant of the need for careful follow - up including mri and fna of benign neurogenic tumors of the neck because of this potential for transformation . the accumulation of more cases in the literature will help physicians decide on future diagnostic and treatment strategies . because neurogenic tumors sometimes undergo malignant transformation , we recommend that for neck masses suspected to be benign , surgery should be performed if possible . however , if follow - up observation is chosen , mri and fna should be regular , and patients should sign a statement acknowledging awareness of the potential for malignant transformation .

schwannomas are benign , rare peripheral nerve sheath tumors that occur in the head and neck region . some physicians opt to closely observe cases of schwannoma of the neck on an outpatient basis rather than to perform radical surgery . however , there is a possibility , albeit rare , of malignant transformation of a benign schwannoma . here , we are reporting the first case from the indian subcontinent which was transformed into the angiosarcoma from benign vagal schwannoma over a long period . a 47-year - old male patient complaining of left sided neck swelling since last 12 years , swelling was insidious in onset , gradually progressive very slowly . in last 2 months , the size of the swelling was suddenly increased . on examination , there was an approximately 6 cm 6 cm of size , firm , nodular , well - defined , nontender swelling in the left lateral part of the neck . fine - needle aspiration cytology ( fnac ) revealed paraganglioma and magnetic resonance imaging demonstrated very clearly a tumor , its morphology , and its relation to the surrounding structures , the tumor was thought to be a vagal schwannoma . surgery was done , and the whole of the tumor was removed in toto . on final histopathological diagnosis , the tumor was proved to be angiosarcoma developed from vagal schwannoma . postoperative chemotherapy was given but due to distant metastasis , the patient died . long standing neck masses can convert into malignancy as in our case , therefore , work up of the patient should be done properly . multiple fnac should be done because single fnac can give the false negative result as in our case . this was our diagnostic drawback not to do multiple computed tomography guided fnac .

a 37-year - old man was admitted to our hospital with long - standing , persistent , lone atrial fibrillation refractory to medical therapy and several attempts of cardioversion . the patient underwent a total thoracoscopic epicardial ablation without any intraoperative or postoperative complications , followed by a percutaneous postprocedural electrophysiologic evaluation that included confirmation of pulmonary vein isolation and a cavotricuspid isthmus block on the tenth postoperative day . two weeks after discharge , the patient was admitted to the emergency room with right - sided motor weakness and paresthesia of both upper and lower extremities . his fever reached 40c , and he had a white blood cell count of 17,690/l . chest computed tomography imaging revealed a collection of loculated air measuring up to 2 cm in diameter between the right side of the left atrium and the esophagus , with no definitive evidence of a fistulous connection ( fig . 1 ) . brain computed tomography revealed an acute - onset left middle cerebral artery infarction . an urgent surgical intervention was performed due to our high level of suspicion for a left atrial or pulmonary venous - esophageal fistula . the chest was opened through the fifth intercostal space via a right posterolateral thoracotomy under one - lung ventilation with a double lumen endotracheal tube . after anteriorly retracting the lung , a meticulous dissection of the posterior mediastinum between the esophagus , right upper and lower pulmonary veins , and left atrium was performed . a fistula 2 to 3 mm in diameter was discovered between the right lower pulmonary vein and anterior surface of the esophagus . surprisingly , there was no bleeding from the fistula on the side of the right lower pulmonary vein . the right lower pulmonary vein was repaired with a bovine pericardial patch , covered , and fixed with continuous poly - propylene sutures . after repairing the right lower pulmonary vein , we consulted our hospital s thoracic surgeon about repairing the fistula opening on the esophageal side . he decided to carry out a primary repair of this defect because the defect site was small and relatively clear . the fistula was carefully debrided and repaired with intermittent 4 - 0 black silk sutures . the patient s rhythm was converted to sinus rhythm and sustained after cardioversion one day after surgery . the patient became alert on the third postoperative day , and was extubated on the fifth postoperative day . he was discharged 39 days postoperatively , with a motor power score of three out of five on the medical research council scale after rehabilitation therapy . on his last outpatient visit , two and a half months after surgery , motor power was fully recovered without any sequelae . a hybrid procedure of a total thoracoscopic epicardial ablation and percutaneous transvenous radiofrequency catheter ablation for lone atrial fibrillation , performed either simultaneously as a single stage procedure or as a two - stage procedure , has been developed to overcome the limitations of each technique and result in better outcomes . the success rate of this therapy varies according to the specific goals of the intervention and the duration of atrial fibrillation ( paroxysmal or persistent ) . pison et al . reported conversion to sinus rhythm after a single stage procedure with a success rate of 83% after one year . muneretto et al . reported conversion to sinus rhythm after a two - stage procedure with a success rate of 91.6% at a mean follow - up of 30 months . after being performed for the first time in south korea at the samsung medical center in february 2012 , we have performed 50 staged hybrid procedures to date with a successful conversion to sinus rhythm in 48 out of 50 patients . unfortunately , we experienced a potentially fatal case of a fistula running from the pulmonary vein to the esophagus fistula despite the high success rate of conversion to sinus rhythm . we believe our case of a right lower pulmonary venous - esophageal fistula after thoracoscopic epicardial and transvenous catheter ablation to be the first reported in the literature . even though the radiofrequency catheter ablation was performed after the total thoracoscopic epicardial ablation in a staged procedure , we think that there may have been some degree of infection or edema at the ablation sites due to the short ( ten days ) interval between the components of the hybrid procedure . the most commonly reported esophageal complication after radiofrequency catheter ablation are left atrial - esophageal fistulas , with an incidence rate of up to 0.2% . these fistulas result from the usual anatomical relationship of the esophagus to the left atrium and pulmonary veins . however , unusual variations where the esophagus is situated rightward in the posterior mediastinum near the right pulmonary veins have been described , as in our present case . . a median sternotomy or a right or left thoracotomy with or without cardiopulmonary bypass is possible depending on the clinical situation and location of the fistula . surgical exposure in our case was achieved via a right posterolateral thoracotomy to expose the suspicious right pulmonary veins and left atrium . in light of this rare but potentially lethal event , we suggest the development of a better - defined consensus , based on further studies , on whether hybrid thoracoscopic epicardial and percutaneous catheter ablations should be performed simultaneously or as a staged procedure .

a case of a fistula running from the pulmonary vein to the esophagus after a staged hybrid procedure combining total thoracoscopic ablation and percutaneous radiofrequency catheter ablation has not been reported previously . we describe such a case in a 37-year - old man who was successfully treated by surgery .

to further evaluate the risk for cholera transfer through ballast water under existing management approaches , we applied the imo ballast water exchange depth and distance criteria to the caribbean region . buffers of 50 and 200 nautical miles were generated on the basis of the global self - consistent , hierarchical , high - resolution shoreline database ( version 2.1 ; www.ngdc.noaa.gov/mgg/shorelines/gshhs.html ) and overlaid on bathymetric data from the etopo1 global relief model ( www.ngdc.noaa.gov/mgg/global/global.html ) ( 10,11 ) . we acquired these datasets through the national oceanic and atmospheric administration s national geophysical data center ( www.ngdc.noaa.gov ) . mapping indicates that waters around haiti where the imo guidelines can be followed are extremely limited ( figure ) . to exchange ballast > 200 nautical miles from shore in water 200 m deep , ships must travel 280 nautical miles northeast of haiti ( figure , a ) or to the gulf of mexico ( figure , b ) . to exchange ballast at the minimum 50 nautical miles from shore in water > 200 m deep , ships must travel > 90 nautical miles northeast ( figure , c ) or 50 nautical miles south ( figure , d ) of haiti or conduct the exchange in an area < 45 nautical miles wide approximately equidistant from haiti , cuba , and jamaica ( figure , e ) . zones in the caribbean region where distance from shore and water depth meet international maritime organization guidelines for ballast exchange . to exchange ballast > 200 nautical miles from shore in water 200 m deep , ships must travel 280 nautical miles northeast of haiti ( a ) or to the gulf of mexico ( b ) . to exchange ballast at the minimum 50 nautical miles from shore in water > 200 m deep , ships must travel > 90 nautical miles northeast ( c ) or 50 nautical miles south ( d ) of haiti or conduct the exchange in an area < 45 nautical miles wide approximately equidistant from haiti , cuba , and jamaica ( e ) . light blue shading indicates distance from land is < 50 nautical miles and/or seawater depth is < 200 m. medium blue shading indicates distance from land is > 50 nautical miles but < 200 nautical miles , and seawater depth is > 200 m. dark blue shading indicates distance from land is > 200 nautical miles and seawater depth is > 200 m. after discussions with staff at cdc and the pan american health organization , the director general of the haitian ministry of health and population issued 2 memoranda addressing ballast water management . the first , issued november 10 , 2011 , asked ship captains not to exchange ballast water in haitian harbors . the second , issued november 15 , 2011 , reminded ship captains to adhere to imo guidelines for ballast water exchange . however , ships operating in the caribbean sea face practical difficulties in conducting ballast water exchange at the recommended distances without making large deviations from usual routes . the bwm convention recommends that designated ballast water exchange areas should be on or close to existing maritime routes and does not require that ships deviate course or delay voyages to comply with ballast water exchange guidelines ( 6 ) . ballast water exchange at sea also presents operational and safety challenges to ships and might not be completely effective in preventing spread of aquatic organisms ( 12 ) . as an alternative management measure , ballast water treatment systems are being developed to meet the bwm convention s numeric discharge standards , and several systems are available ( 13 ) . these systems combine filtration with nonchemical ( e.g. , uv light , shear , heat ) and chemical biocides to remove or kill organisms ( 14 ) . ballast water treatment systems are designed to achieve the bwm convention efficacy levels , and their future use in the caribbean region would likely be a more effective management approach than ballast water exchange . the haiti cholera outbreak spread to the neighboring dominican republic , and cholera cases associated with travel to haiti were recognized in the united states ( 7 ) , but there is no evidence that v. cholerae was transferred by ship ballast water in these instances . the wider caribbean region comprises 28 island and continental countries with coasts on the caribbean sea , the gulf of mexico , and adjacent waters of the atlantic ocean . this area is at elevated risk for transfer of contaminated ballast water because of the high volume of cargo trade in the region and has been prioritized by the global ballast water management program ( http://globallast.imo.org/index.asp ) , a program administered by imo , the global environment facility , and the united nations development program to assist developing countries implement ballast water management measures ( 15 ) . a comprehensive regional strategic plan has been developed to promote ratification of the bwm convention and to facilitate its implementation within the wider caribbean region through regional cooperation , training , communication , compliance monitoring and enforcement , and promotion of national - level legislation , task forces , action plans , and sustainable resources to support activities ( 15 ) . implementation of this plan will help protect public health by reducing the likelihood that v. cholerae and other pathogens will be transferred by ballast water .

organisms , including vibrio cholerae , can be transferred between harbors in the ballast water of ships . zones in the caribbean region where distance from shore and water depth meet international maritime organization guidelines for ballast water exchange are extremely limited . use of ballast water treatment systems could mitigate the risk for organism transfer .

congenital adrenal hyperplasia ( cah ) is an inherited disorder in which adrenal glands produce excessive amount of androgens . . however non - classical cah are chromosomal females ( 46xx ) born with normal genitalia becoming symptomatic only during adolescence causing hirsutism , acne , menstrual irregularity and rarely gender dysphoria . the frequency of the classical disease has been estimated in europe and the united states , ranging from 1/5,000 to 1/115,000 . it is postulated that a general psychiatrist is unlikely to see more than one or two cases in lifetime . a young stocky built adult patient appearing in early twenties dressed in shirt and pant with a thick moustache and beard accompanied with parents walked inside psychiatry out - patient department ( opd ) with a referral from plastic surgery opd concerning gender affirmation surgery . t , a 21-year old female patient and expressed desire to be named as mr . t , in further conversation . on interview , parents reported patient to be their eldest daughter born of a non - consanguineous marriage following a full term normal vaginal delivery . parents reported since early childhood , patient was tomboyish , more comfortable playing with boys , watching wrestling and never showed interest in dolls or playing with younger sister or girls at school . patient used to wear shirt and skirt to school , but at home used to prefer wearing t - shirt and jeans . from adolescence onwards , patient started to gain weight , developed hirsutism and never attained menarche . patient started to develop strong disliking towards self being called as a female , withdrew self from female friends and interest in studies declined ; but never verbalised these feelings to anyone . thereafter , with parents consent patient started to dress as males , stopped removing facial hairs . from 18 years difficulties faced were using common urinals , feeling ashamed of getting the anatomical sex being disclosed and inability to study further or procure a white collared job because of high school certificate mentioning sex as female . despite these problems , patient was more comfortable in male gender role and since past 2 years , started seeking help for gender affirmation surgery . patient appeared to be of average intelligence and had no persistent aggressive , violent or criminal tendencies . external body habitus was of male and external genitalia was of female [ figures 1 - 3 ] . electrolytes , liver function test , lipid profile , thyroid function test , insulin , prolactin , follicle stimulating hormone , luteinizing hormone , estrogen , cortisol were within the normal limit . 17-oh progesterone and dehydro - epiandrosteine were elevated and showed complete suppression with low dose dexamethasone suppression test suggesting diagnosis of non - classical congenital adrenal hyperplasia . hirsutism , masculine body habitus and female external genitalia breast development : tanner stage iii female pattern pubic hairs : tanner stage iii ultrasound showing female internal genitalia gender identity describes psychological recognition of self as well as wish to be regarded by others as fitting into the social categories of male or female . these social categories generate expectations of gender roles that is how one is expected to behave in the society . gender dysphoria refers to persistent sense of one 's gender identity being in discord with anatomical sex and may be accompanied by gender discordant behaviour as was present in our case . without knowledge of ms . t 's intersexuality , presentation was most consistent with gender identity disorder of diagnostic and statistical manual - iv , text revision ( dsm - iv - tr ) . she had strong and persistent cross - gender identification , persistent discomfort with her natally assigned sex and clinically significant distress or socio occupational impairment . ms t was diagnosed with non - classical cah , a mild variant of one of the common causes of female pseudohermaphroditism . non - classical cah is an autosomal recessive genetic disorder due to deficiency of 21-hydroxylase enzyme , being more common in ashkenazi jews , hispanics and italians . it is also called attenuated , late - onset , acquired and cryptic adrenal hyperplasia . the age of 13 years is taken as an arbitrary dividing line between early and late onset cases to discriminate pre and post pubertal onset . non classical forms have more commonly been associated with hirsutism , acne , menstrual irregularities , but rarely with gender identity crisis as in our case . available research on cah focuses more on sexual orientation than gender identity . in a sample of 62 swedish females with cah , frisn et al . reported more male - dominant occupations ( 30% ) , greater interest in rough sports ( 74% ) , non - heterosexual orientation ( 19% ) whereas other psychosexual parameters assessed were comparable to controls . studied 82 women with non - classical cah and reported gender dysphoria in 2 and sex change in1 , rest all were comparable to controls in terms of gender identity . berenbaum et al . did not find any difference in gender identity of the 43 women with cah studied when compared to controls . in adults presenting with gender dysphoria it requires ( 1 ) a thorough medical history and physical examination , ( 2 ) karyotyping and ( 3 ) a thorough psychiatric examination . only after ruling out t 's case was by virtue of male external body habitus , no hormonal treatment was required along with gender affirmation surgery . however , post - operatively , ms . t will continue to face legal issues of change in name and sex on birth certificates , identity cards . tista das is currently the only transsexual in india to have a valid voter identity and ration card . indian laws regarding marriage , adultery , sexual offences , adoptions , succession and industrial laws will require modifications when dealing with these individuals . a social , legal and legislative change is the need of hour .

gender identity is the sense of belonging that one feels for a particular sex psychologically and socially , independent of one 's biological sex . there is much less systematic data on gender identity in females with congenital adrenal hyperplasia ( cah ) . we report a case of non - classical cah presenting as a case of gender identity disorder .

a 69-year - old woman was diagnosed with an intracardiac tumor during a preoperative work - up for sigmoid colon cancer . echocardiography demonstrated that there was a 2.52.6 cm mass in the left atrium , which had a relatively broad base at the interatrial septum . the mass was not highly mobile and did not result in any valvular dysfunction or hemodynamic compromise . cardiac magnetic resonance imaging ( mri ) also revealed a 2.4 cm mass located at the interatrial septum ( fig . 1 ) . the initial diagnosis was a myxoma or a bronchogenic cyst in the left atrium . only antegrade cardioplegia was used because the tumor was located very close to the coronary sinus . the tumor was not visualized from outside the heart . during palpation from the inferior side of the heart , a solid mass after aortic cross - clamping , a right atriotomy was performed and extended to the left atrial roof . the tumor had cystic features , and the diagnostic impression from the operative finding was a bronchogenic cyst . after excision of the mass , the empty interatrial space was filled with tisseel ( baxter healthcare co. , westlake village , ca , usa ) glue . the interatrial septum , left atrial roof , and right atrium were then anatomically reconstructed . 2 ) . the largest cystic nodule measured 2.01.51.2 cm and had a serous component . a microscopic section showed typical biphasic architecture with antoni a ( hypercellular ) and b ( hypocellular ) patterns ( fig . immunohistochemically , s-100 protein staining was strongly positive in most cells , which is consistent with schwannoma ( fig . currently , fewer than 15 cases of atrial schwannoma can be found in a pubmed search . further , to the best of our knowledge , there have been no reports on cardiac schwannoma located in the interatrial space . according to the previous case reports , patients with intracardiac schwannoma had various presentations , such as new - onset atrial fibrillation , recent shortness of breath , pleuritic chest discomfort , and chronic cough [ 25 ] . in our case , the diagnosis was made during a preoperative work - up for colon cancer surgery . even benign cardiac tumors should be completely excised , irrespective of the symptoms , because the tumors may grow and compress the cardiac chambers and cause thromboembolism , arrhythmia , or even sudden death . we think that the initial misdiagnosis could be attributed to the unusual anatomic location of the tumor . in fact , the tumor was located inside the heart but outside the cardiac chambers ; therefore , accurate preoperative characterization of the tumor was difficult , even with echocardiography and cardiac mri . although imaging studies did not suggest the possibility of metastatic cancer , one of our initial differential diagnoses was a metastatic tumor from the patient s colon cancer . in particular , the dissection of the inferior pole of the tumor was relatively challenging because the margin was immediately above the coronary sinus . we shaved the intramuscular portion of the coronary sinus wall . in conclusion , this case report describes a rare presentation of intracardiac schwannoma in the interatrial space . cardiovascular surgeons should consider schwannoma in the differential diagnosis of a low - mobility mass close to the interatrial septum .

we report the case of a 69-year - old woman who was diagnosed with intracardiac schwannoma without symptoms . preoperative echocardiography and cardiac magnetic resonance imaging showed a mass attached to the interatrial septum . the initial diagnosis was a myxoma or a bronchogenic cyst . the tumor was successfully excised under cardiopulmonary bypass . however , the pathology of the excised tumor was consistent with schwannoma . we suggest that cardiovascular surgeons consider schwannoma to be a possible differential diagnosis for a mass close to the interatrial septum .

the genus gasterophilus ( diptera : gasterophilidae ) includes nine species , six of which are reported to cause gastrointestinal myiasis in equid hosts ( wall and shearer 2001 ) . all species were originally restricted to the palearctic and afrotropical regions ( colwell et al . 2007 ) , but three major species g. nasalis , g. intestinalis , g. haemorrhoidalis have been distributed worldwide ( zumpt 1965 ) . the adult flies are not parasitic and do not feed ( wall and shearer 2001 ) . they are large , 1115 mm in length and their body is covered with yellowish hairs . the eggs are usually deposited on the hair of the host in a particular body region . after hatching , the larvae burrow into the tissue of the host , the first stage larvae hatch and moult to l2 , which can be present in different regions of the gastrointestinal tract , and in l3 remains attached to the mucosa for 810 months . the rounded body , hooked mouth - parts and spines enable the larvae to live in the gastrointestinal tract . species can be distinguished based on pattern of spines on the body ( wall and shearer 2001 ) . in g. intestinalis , the third instar larvae are relatively large , between 1.27 to 1.91 cm long and spines arranged in two rows ( zumpt 1965 , sweeney 1990 ) . here we report a type of gastric myiasis caused by g. intestinalis in an old lion in a zoo in sistan , southeast iran . the present case aimed to report the finding of g. intestinalis into the stomach of an old lion in a zoo in sistan , southeast iran . larvae were collected during a post - mortem examination of the digestive tract of lion for parasitological purposes ( fig . twelve larvae were collected from the stomach and preserved in 70% alcohol with 5% glycerin . samples were taken to the laboratory of parasitology , unit of the veterinary medicine , university of zabol , for morphological identification . all the collected larvae were identified under a stereomicroscope using the identification key ( zumpt 1965 ) . the isolated larvae were creamy - white in color , narrow at their anterior end and wide at their posterior end . gasterphilus larvae on the stomach mucosal membrane of a lion gasterophilus intestinalis collected from the stomach of a lion larvae of most gasterophilidae causing equine gastric myiasis have been recorded in southern italy ( otranto et al . gasterophilus intestinalis , g. nasalis , g. hemorrhoidalis , g. inermis , g. nigricornis and g. pecorum were detected in turkey ( gkcen et al . 2008 ) . khalifa et al . ( 2005 ) obtained g. haemorrohidalis from the stomach of egyptian equines . distribution of species of this genus also has been investigated in brazil and g. intestinalis reported to be responsible for the majority of myiasis cases ( felix et al . iranian equine myasis associated with gasterophilus spp . , have been reported on a few occasions , three species of g. nasalis , g. intestinalis and g. inermis were identified by tavassoli and bakht ( 2012 ) . aside from the higher incidence of infection by gasterophilus larvae in equid hosts , a few reports of infections in pigs , dogs and rabbits are provided by hall and wall ( 1995 ) and sayn ipek ( 2012 ) . besides veterinary importance , gasterophilidae larvae can be found in humans with at least three cases reported ( james 1947 , harwood and james 1979 , royce et al . 1999 ) . in wild animals has been reported rarely . only , kumar et al . gasterophilus involvement in the gastric myiasis of lion has not been reported , so the present study is the first report . further studies are recommended to complete the lack of data on parasite fauna of wild animals .

myiasis is the infection caused by a variety of dipterous ( fly ) larvae in vertebrate s tissue ( man and domestic or wild animals ) . species of gasterophilus are obligate parasite of horses , donkeys , zebras , elephants and rhinoceroses . there are records worldwide , but mostly , in tropical and subtropical regions . this case report describes a type of gastric myiasis caused by g. intestinalis in an old lion in a zoo in sistan , southeast iran . myiasis in lions is rarely reported and this is the first report of gastric myiasis in lion .

cardiac myxoma usually develops in the atria and presents in the left atrium in more than 75% of patients and in the right atrium in only 15 - 20% of patients.1 - 9 ) only 3% to 4% of myxomas are detected in the left and right ventricle each.10 - 12 ) myxomas of the heart valves are rare,1)2 ) and primary cardiac valve myxoma is unusual , especially aortic valve myxoma.2 ) a 72-year - old man was referred to our cardiovascular center with previous history of hypertension for 5 years and a 2-month history of worsening dyspnea on exertion that motivated him to seek medical attention . atrial fibrillation was detected during a recent medical check up at a local clinic , and the patient was referred to our hospital and admitted for closer examination . two - dimensional transthoracic echocardiography ( 2d tte ) showed 1.040.87 cm nodular mass attached to the aortic valve . the echogenic mass originated from the ventricular side of the non - coronary cusp of the aortic valve ( fig . because of his old age and atrial fibrillation , scheduled surgery was performed to avoid systemic embolization . intra - operatory transesophageal echocardiography showed normal left ventricular outflow without regurgitation and no residual mass . the margin of the mass was irregular but was easily distinguishable from the normal valve tissue . the tumor consisted of plump gray purplish myxoid stroma and slender and long spindle stromal cells . fibrocollagenous bands of aortic valve tissue were also noted in the myxoid stroma ( hematoxylin and eosin ; 200 ) ( fig . the patient 's postoperative convalescence was uncomplicated and he has discharged on aspirin with regularly scheduled follow - up . myxomas are one of the most common cardiac tumors but usually confined to the atria , more commonly the left atrium , or the ventricles aortic valve tumors are rare and predominantly papillary fibroelastomas.13 ) the differential diagnosis of aortic valve myxoma includes vegetation , tumor , and degenerative changes ( lambl 's excrescence).14 ) 2d echocardiography may help differentiate thrombus , vegetation , and myxoma , because thrombus typically produces a layered appearance and in some myxomas an area of echolucency may be seen within the tumor . however , pathologic differentiation of cardiac tumor by image is very difficult . therefore , the size , shape , location , mobility , and attachment site of a cardiac mass as well as the clinical presentation usually can differentiate these masses . the most important clue to the diagnosis is their location . by far , the most common cardiac tumor of the heart is the myxoma , which is usually single and occurs in the atria . among tumors that affect the valves ( tumors arising from the heart valves are rare ) , papillary fibroelastomas are by far the most common . this tumor appears as a small mass attached to the mitral or aortic valve with motion independent from the normal valve and often locates on the downstream side of the valve by a small pedicle and are irregularly shaped with delicate frond - like surfaces . in case of our experience , a small spherical mass that showed a relatively round surface with central necrosis was attached to the cusp of non - coronary and was highly mobile without pedicle . unlike a typical fibroelastoma , according to tumor site , we speculated that the tumor was closer to fibroelastoma than other types of tumors . although aortic valve myxomas are extremely rare in clinical practice , we should at least suspect them in patients with unusual tumor characteristics.15 ) nevertheless , the clinical diagnosis of cardiac myxoma is often challenging , and distinguishing myxoma from a vegetation or thrombus by echocardiography is often difficult . our patient had an extremely rare aortic valve tumor as most aortic valve tumors are papillary fibroelastomas . a patient with atrial fibrillation and an aortic valve tumor is at an increased risk of systemic embolic events from a cardiac source . aortic valve myxomas are rare benign cardiac tumors , often discovered after embolization has occurred . although long - term results from surgical treatment of cardiac myxomas are not completely understood due to its rarity , the rate of recurrence of aortic valve myxoma appears very low.16 ) some reports have suggested that recurrence may be due to incomplete removal.16)17 ) therefore , complete resection of the tumor was performed in this patient , with regular follow - up by echocardiography to monitor the remote chance of recurrence .

myxoma of the aortic valve is an exceedingly uncommon condition . in this article , we report the case of a 72-year - old man with myxoma arising from the aortic valve . we extirpated the mass and repaired the aortic valve with the patient under cardiopulmonary bypass . the postoperative course was uneventful . histological examination confirmed that the mass was a myxoma .

osmotherapy is an option for the treatment of cerebral edema due to acute brain injury . it is used to prevent progression of ce and lower intracerebral pressure ( icp ) . mannitol and hypertonic saline ( hts ) are the drugs currently available for this purpose . mannitol would be inappropriate in a patient with end - stage renal disease ( esrd ) due to its accumulation in a patient without excretory function . hypertonic saline would be acceptable only as long as its accumulation and the excess extracellular volume generated by the resulting hypertonicity could be controlled . a patient with esrd is described who developed an ich with subsequent ce and was placed on continuous venovenous hemodiafiltration ( cvvhdf ) using fluids specially designed to maintain a hypertonic state with goal serum sodium of approximately 150155 meq / l . the patient is a 45-year - old male admitted after developing a headache , slurred speech , and left hemiparesis during his routine hemodialysis treatment . a ct scan of the brain showed a 4.4 2.5 cm area of hyperattenuation in the right basal ganglia area , moderate edema associated with the ich , and mass effect with a 2 mm right - to - left midline shift . the day after admission a repeat ct scan demonstrated that the edema and mass effect had increased and that the midline shift had increased to 10 mm . the standard protocol has a dialysate sodium of 117 meq / l and a predilution replacement fluid sodium of 135 meq / l . meq / l and a predilution replacement fluid sodium of 155 meq / l . in addition , shortly after the initiation of cvvhdf , the patient was given a 250 cc bolus of 3% saline followed by an infusion at 100 cc / hr to quickly elevate his serum sodium . the infusion was discontinued the next day , and the patient was maintained on hypertonic cvvhdf . minor adjustments to the solutions were made to keep the serum sodium near the goal of approximately 155 meq / l . after four days of cvvhdf , the decision was made to allow the serum sodium to slowly normalize . dialysate sodium of 147 meq / l was used for one hemodialysis treatment and then 145 meq / l was used for the next treatment . osmotherapy is an effective treatment option to control ce and reduce intracranial pressure in patients with acute brain injury . mannitol has been reported to cause a variety of electrolyte disturbances and acute renal failure . in an esrd patient who is anuric hts causes hypernatremia and extracellular volume expansion and can cause metabolic acidosis and hypokalemia among other side effects . hts has been shown to be effective in patients resistant to mannitol therapy [ 4 , 5 ] . hts may also have a beneficial effect on mortality in the treatment of raised icp when compared to mannitol . it has been reported that serum tonicity as high as 365 mosm / l can be safely achieved with hts therapy whereas mannitol therapy is limited to a maximum of 320 mosm / l . when hypernatremia , whether or not a consequence of osmotic therapy , was evaluated in patients in a neurologic icu , it was an independent predictor of mortality only when the peak serum sodium exceeded 160 meq / l . it has recently been suggested that continuous renal replacement therapy , due to greater cardiovascular and intracranial stability , is the preferred method to treat patients with acute brain injury and renal failure . our pharmacy does not use commercially prepared solutions but rather uses an automatic compounder to custom mix the ordered solutions . thus , it was straightforward for the pharmacy to mix the requested solutions for hypertonic cvvhdf . this simplified the patient 's regimen as the need for a constant hypertonic saline drip was eliminated . we observed no untoward effects from the hypertonic dialysis , and the serum sodium was readily maintained in the goal range . we are aware of only one similar report in the literature , that of hofmann et al . using continuous venovenous hemofiltration ( cvvh ) and we feel that hypertonic cvvhdf should be considered a reasonable treatment option for acute brain injury in patients with renal failure . cvvhdf with solutions designed to induce hypernatremia was used to treat an esrd patient with ce due to an ich . we were able to maintain the serum sodium at goal , and no adverse effects of the procedure were noted . we suggest hypertonic cvvhdf be considered an option in the treatment of esrd patients with ce due to acute brain injury .

continuous venovenous hemodiafiltration ( cvvhdf ) using solutions designed to maintain hypernatremia is described in an end - stage renal disease ( esrd ) patient with cerebral edema ( ce ) due to an intracerebral hemorrhage ( ich ) . hypernatremia was readily achieved and maintained without complication . cvvhdf should be considered as an alternative treatment option in esrd patients with cerebral edema who require hypertonic saline therapy .

in a study reported in this issue of critical care , van de leur and colleagues investigated the experience of critical illness and intensive care unit ( icu ) support from the patient 's perspective . although many workers have documented memories of a period spent in the icu , van de leur and coworkers attempted to relate memories of discomfort in icu to patients ' factual recall of the icu . good factual recall was associated with increased risk for having memories of physical and/or psychological discomfort . the relative frequency of hallucinations as a source of icu discomfort ( 32% ) appears greater than that found by others , although it must be highlighted that this is the percentage in the subset of patients with recollection of the icu a stratification not considered by other studies . recollections of pain , discomfort and other stressors suggest an undesirable experience in icu , and may be the origin of sleep disturbances and other ( post - icu ) problems that affect quality of life . a significant strength of the study is the early assessment of patients ( within 3 days of icu discharge ) using a structured questionnaire administered at a face - to - face interview . the methodology is further enhanced by the use of an assessment of factual recall in a matched control group of general ward patients . the fact that they were interviewed 3 days after hospital discharge by telephone rather than face - to - face is probably of little significance . the tool used to assess factual recall was simple and would be easily transferable between units . the authors acknowledge that a lack of objective sedation scoring was a weakness in the study . more detail on the relative balance between the sedation and analgesia received by study patients the finding that young patients have better factual recall and more memory of discomfort may be due in part to a decreased sensitivity to sedation / analgesia relative to older patients . it may also be , in part , a reflection that younger patients may be less intellectually impaired by a given physiological insult than more elderly patients . a measure of the intensity of the remembered discomfort would also be useful in a study of this type ( e.g. using a visual analogue scale ) . we might judge the recollection of occasional mild discomfort as a less worrying problem and might even view it as ( potentially ) unavoidable . illness severity in this study was moderate , as evidenced by the modest acute physiology and chronic health evaluation ii scores on day 1 , relatively short length of stay ( los ) in the icu , and the ability of almost all patients to complete a structured interview within 3 days of icu discharge . although this might be viewed as a weakness , it might in fact be a strength because such patients , when interviewed during recovery , may be expected to remember discomfort from a previous phase of illness more accurately than patients with high sickness severity scores with a long los in the icu . a cynical view after reading this study ( specifically the finding that lack of factual recall was associated with less recollection of discomfort ) might be that it is better to use deeper sedation in icu patients . however , such sedative practice has been shown to increase the duration of mechanical ventilation and los in the icu , which are known risk factors for nosocomial pneumonia [ 9 - 11 ] . absence of memory for a period may produce a condition similar to post - traumatic stress disorder . therefore , the use of high - dose sedation might be counterproductive in terms of post - icu psychological health . this appears to be a significant ' quality of life ' problem for many patients after discharge from the icu . the use of diaries completed by relatives and/or staff to reduce the memory deficit may be useful in this context . from this paper we may conclude that the ideal icu sedative regimen should produce good analgesia in a patient who is ' tranquil ' but who retains mental clarity . van de leur and colleagues previously suggested that discomfort due to the presence of a tube in the trachea may in fact be due to memories of tracheal suction . it is somewhat surprising that chest physiotherapy was not identified as a source of discomfort in postoperative surgical patients . we need to explore the use of suction regimens that are limited in terms of frequency or invasiveness in appropriate patients . the finding that more than 50% of patients who remembered the icu had memories of discomfort is disappointing . to evaluate this problem fully , we must study different patient populations , using similar methodology to that used in the study by van de leur and colleagues , but including an objective measure of sedation / analgesia and a means to quantify the degree of discomfort remembered .

many studies have documented patients ' distressing recollections of the intensive care unit ( icu ) . the study by van de leur and colleagues , conducted in a group of surgical icu patients with moderate severity of sickness , found that the frequency of such unpleasant memories was increased in those able to recall factual information about their stay in the icu . the study did not include sedation scoring but it did use a simple tool to assess factual recall . this tool appeared reliable and could be easily applied in any icu . previous work strongly suggests that abolishing memory of icu by using deep sedation would not be an appropriate response to these findings . rather , we need to work on strategies that reduce distress by improving analgesia , reducing noxious stimuli ( if possible ) and , potentially , using pharmacology to produce a calm patient with minimal sedation . achieving the latter is rarely possible today but it might become possible with future drug development .

rotator cuff tendon tears occur frequently , and surgical repair of the torn tendons is often necessary to relieve symptoms and restore function . approximately , 15 - 20% of the repairs may re - tear , and regular radiological monitoring may be necessary in post - operative period for early detection and treatment of these failed repairs . we describe a simple technique of radio - opaque marking of the rotator cuff margins using metal markers during surgical repair of the tears ; the markers can be monitored on simple radiographs , and on sonography , and failure in cuff repair integrity may be diagnosed at an early stage . the patient is positioned in the beach - chair position , and a standard posterior portal is used to evaluate the tear pattern and associated lesions . if a mini - open technique is used , a 2-inch incision is used along langers lines , and the deltoid muscle is split between its anterior and middle segments . . the footprint of the tendons along the greater tuberosity is prepared , and medial and lateral row anchors are placed . medial sutures are passed in a mattress configuration through the tendons , and lateral sutures are passed as simple sutures , or in a mason - allen configuration . prior to suture knot tying , the healthy tendon edge is marked with a metal marker . the marker may be prepared using a metal wire that may be passed through the tendon edge and twisted around to form a closed loop ; this is possible when a mini - open deltoid - splitting approach is utilized . alternately , titanium hemostatic clips may be used ; these may be clamped over the tendon edge using special forceps , and this may be performed as an arthroscopic procedure . secure placement of the marker is crucial to prevent post - operative dislodgement , and it is useful to test the security with a probe . thereafter , the medial and lateral sutures are tied ; the double - row repair configuration adds to the fixation of the marker , and this is now securely placed between the tendon and the rotator cuff footprint [ figure 1a - c ] . intraoperative images show the technique of radio - opaque marking of the torn cuff tendon . ( a ) a special forceps are used to grasp the titanium clip during the procedure , ( b ) the position of the clip is shown prior to tying the medial and lateral row sutures , ( c ) the final position of the clip is shown after tying the sutures from the medial and lateral row anchors . ( c : clip , s : supraspinatus , h : grasping forceps , f : rotator cuff footprint , a : sutures from anchors ) the post - operative rehabilitation protocol is similar to that of a double - row rotator cuff repair . in the immediate post - operative period , an anteroposterior shoulder radiograph is obtained with the shoulder in neutral rotation and the arm by the side , and the position of the metal marker is documented for future reference [ figure 2 ] . thereafter , a simple anteroposterior radiograph may be obtained at any time in the post - operative and follow - up visits to evaluate the position of the marker . the usual protocol is to obtain a true anteroposterior radiograph at 3 weeks and 6 weeks after surgery to detect early failures of repair that may be diagnosed in this period . thereafter , 3 - 6 monthly radiographs or sonography may be performed to monitor cuff integrity . the follow - up radiographs are compared to the immediate post - operative radiograph , and displacement of the marker from the medial edge of the greater tuberosity footprint is measured . significant displacement of the marker on early radiographs or progressive displacement on successive radiographs is indication for further evaluation and treatment [ figure 3a and b ] . revision surgery for failed repairs has shown that the marker remains attached to the torn tendon , and is easily retrieved without additional damage to the cuff [ figure 4a and b ] . immediate post - operative radiograph demonstrates the position of the metal marker ( c ) relative to the anchors ( a ) and humeral head ( h ) anteroposterior ( a ) and axillary - lateral radiographs ( b ) show the medialized position of the metal marker ( c ) , and are suggestive of failure of repair . ( h : humeral head , g : glenoid ) ( a ) arthroscopic evaluation of a failed cuff repair shows the torn tendon ( t ) of the supraspinatus ( s ) , and the metal marker ( c ) is seen attached to the torn edge of the cuff . ( f : cuff footprint , a : sutures from anchors ) , ( b ) arthroscopic retrieval of the metal marker ( c ) is shown prior to final repair . ( f : cuff footprint , a : sutures from anchors , s : supraspinatus , t : cuff tear ) surgically repaired rotator cuff repairs may fail to heal or re - tear in the post - operative and rehabilitation periods , and regular periodic imaging is useful to detect these failures . magnetic resonance imaging is the ideal modality ; however , this may not be available readily and costs involved are often prohibitive . ultrasonography is non - invasive , and may be the preferred mode of regular imaging of rotator cuff repairs ; however , ultrasonography is operator dependent , and useful in experienced hands . the radiographic technique described here is simple , and re - tears can be detected on simple radiographs that may be obtained readily . further studies are necessary to analyze the utility and cost - effectiveness of this technique in comparison to other modalities .

surgically repaired rotator cuff repairs may re - tear in the post - operative follow - up phase , and periodic imaging is useful for early detection . the authors describe a simple surgical technique that provides a visible clue to the tendon edge on an anteroposterior radiograph of the shoulder . the technique involves arthroscopic or mini - open radio - opaque tagging of the tendon edge using a metal marker , and followed by a double - row rotator cuff repair using suture anchors . serial post - operative radiographs may then be used to monitor the position of the marker . progressive or marked displacement of the marker suggests a failure of cuff repair integrity and should be evaluated further .

toxic neuropathies are often misdiagnosed as there are no easily available specific or biological tests for the diagnosis . toxic neuropathies are suspected on the basis of clinical examination and electrodiagnostic features . in india ayurveda , homeopathy , siddha and unani are practiced and serve as a source of poisoning and drug toxicity . we report a 30 year - old male who presented with numbness of palms and soles followed by weakness of upper limbs and lower limbs . the present case study emphasizes the need to consider heavy metal intoxication in patients presenting with acute demyelinating neuropathies and history of use of indigenous medications . numbness of palms and soles 5 daysweakness of upper limbs and lower limbs 4 daysdysphagia 1 day . numbness of palms and soles 5 days weakness of upper limbs and lower limbs 4 days this gentleman initially developed bilateral upper limb and lower limb numbness followed by progressive weakness of the lower limbs ascending to the upper limbs . there was history of swaying while walking , buckling of knees and loosening of slippers from foot . he developed nasal regurgitation , nasal tone on talking and dysphagia to liquids after 1 day . he had history of oral and genital ulcers three months ago which was evaluated and diagnosed as ? he was given ayurvedic medicines in the form of powders for 10 days following which he developed his present symptoms . on examination , he had bilateral lower motor neuron facial palsy along with bilateral vagal palsy . his blood samples and the ayurvedic drug samples were sent for toxicological analysis [ tables 24 ] . csf study done in the second week toxicological analysis of ayurvedic samples permissible limits of heavy metals in ayurveda / siddha / unani / homeo medicines with only herbal ingredients as per who / fda34 toxicological analysis of blood sample he was treated initially with intravenous immunoglobulin , but did not show much improvement . this gentleman initially developed bilateral upper limb and lower limb numbness followed by progressive weakness of the lower limbs ascending to the upper limbs . there was history of swaying while walking , buckling of knees and loosening of slippers from foot . he developed nasal regurgitation , nasal tone on talking and dysphagia to liquids after 1 day . he had history of oral and genital ulcers three months ago which was evaluated and diagnosed as ? he was given ayurvedic medicines in the form of powders for 10 days following which he developed his present symptoms . on examination , he had bilateral lower motor neuron facial palsy along with bilateral vagal palsy . his blood samples and the ayurvedic drug samples were sent for toxicological analysis [ tables 24 ] . csf study done in the second week toxicological analysis of ayurvedic samples permissible limits of heavy metals in ayurveda / siddha / unani / homeo medicines with only herbal ingredients as per who / fda34 toxicological analysis of blood sample toxic neuropathies are often misdiagnosedin a survey , 14 of the 70 herbal medical products available commercially were found to contain lead in 13 ( median concentration , 40 mg / g ; range , 537,000 ) , mercury in 6 ( median concentration , 20,225 mg / g ; range , 28104,000 ) , and/or arsenic in 6 ( median concentration , 430 mg / g ; range , 378130 ) . if taken as recommended by the manufacturers , each of these 14 drugs could result in heavy metal intakes above published regulatory standardsusers of herbal medical products may be at risk for heavy metal toxicity ; therefore , testing of ayurvedic drugs for toxic heavy metals should be mandatory . toxic neuropathies are often misdiagnosed in a survey , 14 of the 70 herbal medical products available commercially were found to contain lead in 13 ( median concentration , 40 mg / g ; range , 537,000 ) , mercury in 6 ( median concentration , 20,225 mg / g ; range , 28104,000 ) , and/or arsenic in 6 ( median concentration , 430 mg / g ; range , 378130 ) . if taken as recommended by the manufacturers , each of these 14 drugs could result in heavy metal intakes above published regulatory standards users of herbal medical products may be at risk for heavy metal toxicity ; therefore , testing of ayurvedic drugs for toxic heavy metals should be mandatory .

case : a 30 year old male presented with numbness of palms and soles followed by weakness of upper limbs and lower limbs of 5 days duration , which was ascending and progressive . three months back he was treated for oral and genital ulcers with oral steroids . his ulcers improved and shifted to indigenous medication . his clinical examination showed polyneuropathy . csf study did not show albuminocytological dissociation . nerve conduction study showed demyelinating polyneuropathy . his blood samples and the ayurvedic drug samples were sent for toxicological analysis . inference : acute toxic neuropathy - arsenic

dissecting ventricular septal hematoma ( dvsh ) after repair of ventricular septal defect ( vsd ) is a rare , potentially life threatening [ 2 , 3 ] complication initiated by surgical disruption of the coronary microcirculation . the resultant bleeding dissects along a plane beneath the endocardium resulting in a hematoma that bulges out into ventricular cavity . the following is a case report of the diagnosis and management of acute , severe , left ventricular outflow tract ( lvot ) obstruction caused by the development of a dvsh after vsd repair . a 7-week - old male infant was noted to be hypoxemic prior to repair of an inguinal hernia . a postoperative echocardiogram demonstrated a large membranous vsd and a long segment coarctation of the aorta . three months after repair of the coarctation the infant was in congestive heart failure and was brought to the operating room for vsd repair . preoperative transesophageal echocardiography ( tee ) demonstrated a large membranous vsd that extended into the inlet septum and a widely patent left ventricular outflow tract ( figure 1 ) . the echocardiographic findings were confirmed at surgery , and the vsd was closed in the standard manner using a dacron patch and 50 prolene pledgeted suture . the initial suture line was carried clockwise avoiding the crest of the ventricular septum . near the septal leaflet of the tricuspid valve the vsd was then closed in a counterclockwise fashion staying away from the crest of the ventricular septum , across the ventricular infundibular fold avoiding the aortic annulus , and eventually transitioning to the septal leaflet of the tricuspid valve . the remainder of the vsd underneath the septal leaflet of the tricuspid valve was closed by weaving in and out of the valve leaflet and the vsd patch . postoperative tee ( figure 2 ) , performed immediately after coming off of cardiopulmonary bypass , demonstrated an echo lucent region beneath the vsd patch that was surrounded by a thin membrane protruding into the lvot , findings consistent with a dvsh . during systole the anterior mitral leaflet / chordal apparatus came in contact with the dvsh resulting in severe lvot obstruction with a peak instantaneous doppler gradient between 7080 mmhg which was confirmed by direct pressure measurement . the patient was placed back on cardiopulmonary bypass and an oblique aortotomy was made allowing retraction of the aortic valve leaflets to inspect the ventricular septum . the hematoma was identified and the thin membrane overlying the hematoma was incised and evacuated . the remainder of the hematoma was unroofed and lvot patency was confirmed with a 9 mm dilator . postevacuation tee confirmed a widely patent lvot with no residual gradient ( figure 3 ) . although rare , dvsh has the potential to cause significant hemodynamic perturbations and may be life threatening . this process , initiated by surgical disruption of the coronary microcirculation , creates a form of myocardial rupture as blood dissects along the spiral planes of the cardiac muscle beneath the endocardium . the resulting hematoma bulges out into the right , left , or both ventricular cavities . this may lead to septal rupture which may create a vsd , extension of the hematoma onto the lv free wall with the potential for myocardial rupture , development of a communication between the ventricles across their inferior walls without septal rupture , cardiogenic shock , heart block , outflow obstruction , cardiac tamponade , abscess transformation , and death . dvsh after vsd repair can be readily diagnosed during intraoperative tee , and we agree with previous recommendations that intraoperative tee should be performed in all patients undergoing vsd repair . both the right and left sides of the ventricular septum must be thoroughly evaluated and the finding of an echo lucent region surrounded by a membrane ( the thickness of the membrane varies depending on the level of the hematoma , those deep within the septum have a very thick membrane while those close to the endocardium have a very thin membrane ) that protrudes into the cavity of the ventricle ( figure 2 ) should raise suspicion that there is a septal hematoma present . it must be remembered that since the hematoma is caused by disruption of the coronary microcirculation in a patient that is anticoagulated , small hematomas have the potential to enlarge and cause arrhythmogenic / hemodynamic abnormalities , even after the patient leaves the operating room . for this reason , any suspicious lesion should be thoroughly evaluated and a management strategy determined prior to the patient leaving the operating room . management strategies of dvsh include evacuation [ 13 ] or observation [ 5 , 8 ] of the hematoma . since conservative treatment of dvsh is associated with a mortality rate reported to be as high as 90% , we recommend immediate evacuation of the hematoma if the diagnosis is made in the operating room during intraoperative tee . because of the potential for reaccumulation of the dvsh if it is evacuated by needle aspiration , we recommend that complete unroofing of the hematoma be performed by placing the patient back on cardiopulmonary bypass . if the dvsh is diagnosed after the patient has left the operating room , serial echocardiograms should be performed until the size of the dvsh has stabilized and periodically thereafter until the hematoma has either resolved or is noted to be enlarging . if the hematoma enlarges , or causes any other complications , consideration should be given to surgically evacuating the hematoma .

dissecting ventricular septal hematoma ( dvsh ) rarely occurs after repair of a ventricular septal defect ( vsd ) but can lead to serious complications such as septal rupture , myocardial rupture , cardiogenic shock , heart block , outflow obstruction , cardiac tamponade , abscess transformation , and death . this paper describes the diagnosis and management of acute , severe , left ventricular outflow tract obstruction caused by the development of a dvsh after vsd repair .

cefepime is a broad - spectrum fourth - generation cephalosporin with enhanced coverage against gram - positive and gram - negative bacteria.1 cefepime is predominantly cleared from the body by renal secretion , therefore the elimination half - life is increased in patients with renal impairment.2 cefepime - induced neurotoxicity , including nonconvulsive status epilepticus ( ncse ) , has been reported especially in patients with renal impairment . we present a rare case of aphasic status epilepticus ( se ) mimicking acute stroke in a patient with nephrotic syndrome and urinary tract infection treated by cefepime . a 36-year - old right - handed man was admitted to internal medicine department with 3 months history of generalized edema and decreased urine output . he was diagnosed as nephrotic syndrome and urinary tract infection . because his urine culture demonstrated pseudomonas aeruginosa , intravenous cefepime 2 g his creatinine clearance calculated by modification of diet in renal disease ( mdrd ) formula was 49 ml / min/1.73 m , suggesting mild renal impairment . he was consulted to neurology department for acute onset global aphasia and right hemiplegia during admission . although he had a past medical history of intracerebral hemorrhage ( ich ) due to left middle cerebral artery ( mca ) aneurysmal rupture about 7 years ago , he did not have any language difficulties , hemiplegia , and seizures . at first , under the suspicion of acute stroke , an emergent brain magnetic resonance imaging ( mri ) with angiography was done . however , there were no acute lesions in brain imaging , except old encephalomalacia in left fronto - temporal area and clipping of left mca aneurysm ( fig . 1 ) . there was no significant alteration of perfusion status on perfusion - weighted mri . although right hemiplegia recovered completely within a few hours , motor aphasia was persistent . after ruling out acute stroke , we performed electroencephalography ( eeg ) due to the persistent aphasia . eeg revealed continuous 23 hz rhythmic spike - and - waves in left hemisphere , especially in fronto - temporal area ( fig . 2a ) , with clinical ictal phenomena ( aphasia ) during the eeg patterns , compatible with the working clinical criteria for ncse with focal onset.3 because he has been treated with high dose of cefepime since 2 days ago from the onset of neurological symptoms , we suspected cefepime - induced ncse , particularly aphasic se . 2b ) and clinical symptoms made a gradual recovery within 3 days after the discontinuation of cefepime . follow - up brain diffusion - weighted mri after 5 days from symptom onset also did not show the acute lesions . various antibiotics have been reported to be associated with se , and these drugs representatively include third and fourth generation cephalosporins and quinolones.4 patients with prior central nervous system ( cns ) disease , advanced age , and particularly renal impairment may be vulnerable.2,47 although there have been various case reports and series of cefepime - induced neurotoxicity , including ncse , aphasic se itself is a rare phenomenon , and cefepime - induced aphasic se proven by eeg has never been reported to our knowledge . although our patient had a past medical history of ich , there were no acute lesions in brain imaging and he has never experienced a seizure before the administration of cefepime . therefore the diagnosis of cefepime - induced ncse was more relevant than acute stroke or simple post - stroke seizures . our case was a high - risk patient having renal impairment and prior cns disease simultaneously . renal impairment may increase the concentration of cefepime in the serum , cerebrospinal fluid , and brain tissue.2,6 in addition , the increased permeability of blood - brain barrier ( bbb ) and decreased albumin binding of antibiotics in the presence of uremia , as well as the presence of endogenous uremic toxins might increase a patient s vulnerability to neurotoxicity.6 our patient s brain , especially the left hemisphere , might be particularly vulnerable because bbb was locally disrupted by the prior ich . the most widely accepted theory on the pathogenesis of seizures induced by beta - lactam antibiotics including cefepime involves the interference or inhibition of gamma - aminobutyric acid ( gaba ) binding to gabaa receptors.6 gabaa receptor inhibition can lead to increased neuronal excitability which can cause se . the focal - aphasic - se was thought to be the result of this hyperexcitability in the vulnerable brain area in our case . therefore focal ncse can be induced by cefepime in the presence of prior cns disease , although the most of previous reports of cefepime - induced ncse delineated generalized epileptiform discharges on eeg with decreased consciousness . in conclusion , as the use of cefepime is increasing , clinicians should be aware of various cefepime - induced neurotoxicity . when encountered with unexplained neurologic deficits , eeg should be considered to diagnose ncse in in patients receiving cefepime especially with renal impairment and prior cns disease .

cefepime - induced neurotoxicity , including nonconvulsive status epilepticus , has been reported especially in patients with renal impairment . however , focal nonconvulsive status epilepticus is very rare and cefepime - induced aphasic status epilepticus proven by electroencephalography have never been reported to our knowledge . we present an interesting case of aphasic status epilepticus mimicking acute stroke in a patient treated by cefepime .

rhabdomyomas are the most common primary cardiac tumors in childhood.13 this neoplasm may be associated with tuberous sclerosis tuberose sclerosis which is an autosomal - dominant disaese affecting the brain , skin , kidney , heart and characterised by infantile epilepsy , mental retardation , facial adenoma sebaceum . although the indication of surgical resection of symptomatic tumors is well established,4 medical follow - up is prefered unless critical obstruction or dysrhythmias are present.5 we describe a newborn with a huge cardiac rhabdomyoma in the left ventricular outflow tract that initially produced moderate obstruction , but resolved spontaneously . a male neonate aged four hours was admitted to cerrahpa?a medical faculty because of a heart murmur detected two hours earlier . physical examination was normal except for a grade 3/6 systolic ejection murmur which was heard maximally at the left sternal border in the third intercostal space . heart rate was regular at 126/min and blood pressure was 65 mmhg in the right arm . echocardiography showed normal chamber dimensions and anatomy , along with a spherical mass originating from the mitral valve , just below the aortic valve , interposed between the ventricular septum and mitral valve anterior leaflet . multiple additional masses were present within the left and right ventricular cavities ( figures 1 and 2 ) . the location , number and size of each tumor were : mass in right ventricular apex mass below septal leaflet of tricuspid valve mass on interventricular septum doppler showed turbulence within the aorta with a systolic gradient of 30 mmhg between left ventricle and aorta ( figure 4 ) . although there were no other signs of tuberose sclerosis , the baby was thought to have tuberose sclerosis presenting with heart disease , a common presentation.6 due to the asymptomatic nature of the condition , a conservative approach was taken . serial echocardiographic studies were undertaken and at one month of age , the subaortic tumor decreased to 7 by 6.8 mm and the outflow gradient fell to 22mmhg . left ventricular outflow tract obstruction caused by mass neurologic and radiologic features of tuberose sclerosis appeared , with convulsions and subependymal hamartomas at 6 month of age . but cardiologically the patient has remained asymptomatic . follow - up investigations showed spontaneous regression of the tumors within eight months and the outflow gradient disappeared completely ( figure 5 ) . a clinicopathologic study showed that such tumors are usually multiple ( 92% ) , often intracavitary ( 50% ) , and occur more frequently in the left ventricle than in the right ventricle ( 100 % vs 81 % ) .2 cardiac rhabdomyomas are frequently associated with tuberose slerosis,6 with a prevalence of 30- 80%.13712 the other primary heart tumours at this age ( hamartomas , myxomas and fibromas ) differ both clinically and ultrasonographically from rhabdomyomas . as most rhabdomyomas are multiple , the diagnosis is generally beyond doubt , and may be made even in the absence of histologic confirmation.13 multiple intracavitary tumours are considered as an important marker of tuberose sclerosis , even in antenatal period.14 multiple tumors , or a single tumor plus involvement of other organs ( e.g. central nervous system , kidney , skin ) that are compatible with the diagnosis of tuberose sclerosis , or a single tumor with positive family history of tuberose sclerosis , is highly suggestive of rhabdomyomas.1 cardiac rhabdomyomas may be asymptomatic , or may cause a variety of clinical symptoms depending on their size and location.315 in the majority of cases , symptoms occure at an early age or even before birth.614 the spectrum of clinical manifestation ranges from cardiac murmur to sudden death.5 the presenting symptom may be arrhythmia , cardiac murmur , complete or variable atrioventricular block , pericardial effusion , cardiomegaly , cardiac failure or sudden death.361017 the variety of symptoms can be explained on the basis of obstruction of blood flow , myocardial involvement and disturbance of the cardiac rhythm . the value of surgical resection of symptomatic tumours is well established.4 while most rhabdomyomas appear to regress spontaneously , some infants may benefit from surgery for obstructive lesions at an early stage.13 with surgery , it is possible to remove obstruction or an arrhythmogenic substrate . rarely , even heart transplantation may be indicated in patient with severe myocardial involvement.18 but surgical intervention is neither possible nor indicated in every child.19 consequently , a conservative approach is preferrable and useful in most cases . unless critical obstruction or dysrhythmias is present , medical follow - up should be preferred5 since these tumours demonstrate benign pathological characteristics and tend to regress over time.11213151920 the chance of spontaneous regression does not depend on the initial size , number or location of tumours.15 partial or complete spontaneous regression of rhabdomyomas has been reported in 54% of cases.1 this regression may take place in a period as short as three weeks.1 echocardiography is useful in determining tumour size , number and location . serial echocardiographic studies are both useful and safe in monitoring tumour size , and they provide acceptable follow - up information.21

rhabdomyomas are the most common primary cardiac tumors in childhood , and are often associated with tuberous sclerosis . we report a huge rhabdomyoma in an asymptomatic four hour old infant who presented initially with a murmur due to moderate subaortic stenosis . followup showed regression of the tumour . although the indications for surgical resection of symptomatic tumors are well established , medical follow - up should be the prefered treatment .

the juxtaoral organ of chievitz ( jooc ) is a normal anatomical structure considered of neuroepithelial origin with no known function is located within the soft tissue in the buccotemporal fascia on the medial surface of the ascending ramus . jh chievitz , a danish anatomist , first described jooc in 1885 while studying human embryos . however , this structure is not only unique for adults but also has been reported in some other species and in reptiles . this enigmatic vestigial structure has been designated with various other names depending on its embryologic origin as orbital inclusions , buccopharyngeal tract , buccotemporal organ and juxtaoral organ . as a matter of fact , the only practical importance of awareness of this structure lies in the potential of being misdiagnosed as perineural invasion in a patient with oral squamous cell carcinoma , which can be one of the most treacherous pitfalls in oral pathology . hence , the basic aim of this short communication is to reveal the importance about this organ and enlighten the oral pathologist about this histopathological structure , thus preventing extensive and unnecessary investigations . he was born on october 16 , 1850 , in svendborg which is a town on the island of funen in south central denmark . chievitz graduated in 1869 from soro , which is a town in region sjlland on the island of zealand in east denmark . he practiced a short time before he was employed in 1877 , in the anatomy under professor theodor schmidt ( 18251880 ) . in 1881 he noted it in 10-week - old embryos during his study on the development of salivary glands . originally thought to be of embryonic origin , jooc starts as an epithelial thickening of the stomodeum and invaginates into the subjacent mesenchyme . this epithelial bud then detaches from the oral epithelium and becomes innervated by a buccal nerve branch receiving vascular supply from the buccal artery . the jooc measures between 7 mm and 15 mm in length and between 1 mm and 2 mm in diameter . if it is more than 10 mm in diameter , then clinicians are likely to suspect submucosal tumor or hyperplasia of jooc . microscopically , the epithelial component consists of circumscribed nests of nonkeratinizing squamous , columnar and occasionally , basaloid epithelial cells with a definite glandular or organoid pattern with no keratin formation . three concentric domains of connective tissue encase the epithelial islands as shown in figures 1 and 2 . hand drawn illustration showing epithelial component with circumscribed nests of nonkeratinized squamous , columnar and basaloid epithelial cells with a definite glandular or organoid pattern with no keratin formation within loose connective tissue stroma representative of juxtaoral organ of chievitz . the juxtaoral organ of chievitz is composed of nests of epithelial parenchyma embedded in highly organized connective tissue stroma rich in nerve bundles ( courtesy : jerad m gardner , md , university of arkansas for medical sciences , usa ; daifullah al aboud et al . 2014 ) courtesy : arvind venkatesh , department of oral pathology and microbiology , subharti dental college and hospital , meerut , uttar pradesh , india . well - circumscribed epithelial sprouts present within the loose connective tissue stroma representative of juxtaoral organs of chievetz ( h and e , 100 ) . inset : cells showing paler cytoplasm and clear cell - like features ( h and e , 1000 ) juxtaoral organ of chievitz : a histopathological masquerade . indian j med paediat oncol 2015;36:193 the inner layer called stratum fibrosum internum consists of dense collagen fibers that are separated from the epithelial islands by a distinct basal laminathe middle layer , stratum nervosum , is characterized by loose connective tissue stroma , populated with myelinated and nonmyelinated fibersthe outer layer , the stratum fibrosum externum , connects to the muscle fascia of the buccotemporalis . the inner layer called stratum fibrosum internum consists of dense collagen fibers that are separated from the epithelial islands by a distinct basal lamina the middle layer , stratum nervosum , is characterized by loose connective tissue stroma , populated with myelinated and nonmyelinated fibers the outer layer , the stratum fibrosum externum , connects to the muscle fascia of the buccotemporalis . histochemically , the available ck profiles to date suggest that the epithelial nests of jooc share the immunohistochemical phenotype of nonkeratinized stratified squamous cells . alkaline phosphatase activity of the epithelial component of the jooc and a possible mechanoreceptor function due to a close approximation of jooc to structures resembling pacinian corpuscles have also been documented . jooc is an innocuous variation of normal anatomy and carries no risk for malignant transformation and no recurrence after its removal .

the juxtaoral organ of chievitz is a normal anatomical structure located within the soft tissue in the buccotemporal fascia on the medial surface of the ascending ramus . this enigmatic vestigial structure is considered to be of neuroepithelial origin with no known function . as a matter of fact , jooc is one of the most treacherous pitfalls in surgical pathology with respect to lesions in the head and neck area . hence the basic aim of this short communication is to reveal the importance about this organ and enlighten the oral pathologist about this histopathological structure , thus preventing extensive and unnecessary investigations .

a 26-year - old man presented to our outpatient clinic with complaints of lower abdominal discomfort and a palpable mass in the right lower quadrant . the abdomen examination revealed a 6 cm palpable mass without tenderness in the right lower quadrant . routine urine analysis revealed pyuria of 10 - 19 white blood cell ( wbc)/high - power field ( hpf ) and microscopic hematuria of 5 - 9 red blood cell ( rbc)/hpf . abdominal ultrasonography revealed irregular wall thickening of the bladder dome with extension to the abdominal wall . an abdominal computed tomography ( ct ) scan revealed an abdominal wall mass that extended from the bladder dome and irregular perivesical infiltration , suggesting urachal remnant - associated disease ( fig . additional fluorine-18 fluorodeoxyglucose ( fdg ) positron - emission tomography ( pet)/ct was performed to rule out a urachal tumor . the pet / ct showed hypermetabolic bladder wall thickening with mesenteric and omental infiltration , extending along the urachus ( fig . partial cystectomy with resection of the abdominal wall mass was performed because malignancy could not be ruled out completely . the mass contained necrotic lesions with yellowish foci in the deep resection margin and the final pathology was consistent with actinomyces israelii with sulfur granules ( fig . 3 ) . the patient underwent treatment with oral fluoroquinolone for 3 months and recovered without complications . actinomyces israelii invades and penetrates the intestinal mucosa and bowel wall , producing localized or extended peritoneal and retroperitoneal abscess formation . actinomyces israelii is a commensal organism within the oral cavity , alimentary tract , and vagina and spreads by direct extension . definite diagnosis can be made by demonstration of actinomyces israelii in a needle or surgical biopsy specimen . hypermetabolic changes at the bladder dome and urachus on pet / ct made the diagnosis very elusive in this case . because there is not much difference in the pet / ct findings between malignancy and actinomycosis , utilization of pet / ct to rule out malignancy does not seem to be necessary , unless the case is strongly suggestive of malignancy . we performed a partial cystectomy to clarify this elusive disease entity and confirmed actinomyces israelii colonies in the specimen . intravenous administration of penicillin should be given , followed by oral penicillin or amoxicillin . if the patient has penicillin allergy or resistance , ceftriaxone , doxycycline , clindamycin , or fluoroquinolone is recommended .

a 26-year - old man presented with lower abdominal discomfort and a palpable mass in the right lower quadrant . an abdominal computed tomography ( ct ) scan revealed an abdominal wall mass that extended from the dome of the bladder . fluorine-18 fluorodeoxyglucose ( fdg ) positron - emission tomography / ct ( pet / ct ) showed hypermetabolic wall thickening around the bladder dome area that extended to the abdominal wall and hypermetabolic mesenteric infiltration . differential diagnosis included a urachal tumor with invasion into adjacent organs and chronic inflammatory disease . partial cystectomy with abdominal wall mass excision was performed , and the final pathologic report was consistent with urachal actinomycosis .

cases that involve bleeding from the midgut present a much more significant challenge in terms of detection and treatment . methods of evaluation include small bowel endoscopy , arteriography , and gastrointestinal contrast studies . the differential diagnosis includes arteriovenous malformations , angiodysplasia , ulcers , and small bowel tumors . we will demonstrate that both the evaluation and treatment of these lesions may be accomplished using minimally invasive techniques . a case of occult gastrointestinal bleeding from a polypoid hemangioma located in the distal jejunum is presented . laparoscopic small bowel resection after angiographic localization was successful in removing the jejunal polypoid hemangioma . a laparoscopic approach is an appropriate and beneficial treatment modality in a bleeding midgut lesion provided the lesion can be localized preoperatively and an oncologic resection is maintained . gastrointestinal bleeding that originates in the small intestine is often difficult to diagnose and treat . angiography is frequently used to identify the source of bleeding and may also be used to locate the source of bleeding by injecting the surrounding tissue with methylene blue . when successful , this should allow a laparoscopic approach to small bowel resection and eliminate the need to manipulate the entire length of the small intestine in hopes of palpating the lesion . a 62-year - old female was found to have anemia during a routine screening exam by her primary care physician . her past medical history is significant for severe valvular heart disease secondary to rheumatic fever . she has prosthetic mitral and aortic valves , a history of a tricuspid annuloplasty , and takes coumadin . an esophagogastroduodenoscopy revealed only mild gastritis that did not account for her degree of blood loss . colonoscopic findings were unremarkable . a ugi / sbft demonstrated poor gastric motility but otherwise no abnormalities . over the 6-week course of her evaluation , she received a total of 10 units of packed red blood cells . angiographic evaluation of the superior mesenteric artery demonstrated a lesion with rapid venous filling in the distal jejunum ( figure 1 ) . laparoscopy was successful in identifying the location of the dye , and a mass was appreciated within the lumen of the small bowel . . these neoplasms may represent either a benign or malignant process with a wide range of symptoms that are often nonspecific . surgical series report an equal frequency of benign and malignant tumors , whereas autopsy series heavily favor benign tumors as the most common . this is usually occult and generally requires an extensive gastrointestinal evaluation before a diagnosis is obtained . modalities used include plain films , ugi / sbft , enteroclysis , computed tomography , routine and extended upper endoscopy , tagged rbc scanning , and angiography . this requires the lesion to be easily identified and amenable to passage of an intravascular catheter to within close proximity . methylene blue must then be injected into the surrounding tissue allowing the location of the lesion to be identified from an extramural vantage point . minimally invasive surgery using laparoscopy laparoscopic small bowel resection is an established technique and is performed by exteriorization of the diseased segment of bowel . this provides a resection identical to historical control while decreasing the invasive nature of the procedure . compromise of the surgeon 's ability to perform an adequate oncologic resection , however , mandates conversion to an open procedure . the incidence of malignancy is too high in this group of tumors to allow complacency . this offers a minimally invasive treatment with established techniques that is well tolerated by the patient and reduces recovery time . conservatism , however , necessitates the surgeon to consider that up to 50% of bleeding lesions of the small bowel may represent a malignant process , and an adequate oncologic technique should be preserved .

objectives : occult gastrointestinal bleeding can originate from the foregut , midgut , or hindgut . the evaluation of the foregut and hindgut are well established . cases that involve bleeding from the midgut present a much more significant challenge in terms of detection and treatment . methods of evaluation include small bowel endoscopy , arteriography , and gastrointestinal contrast studies . the differential diagnosis includes arteriovenous malformations , angiodysplasia , ulcers , and small bowel tumors . we will demonstrate that both the evaluation and treatment of these lesions may be accomplished using minimally invasive techniques.methods:a case of occult gastrointestinal bleeding from a polypoid hemangioma located in the distal jejunum is presented . diagnosis and treatment was accomplished using angiographic localization with laparoscopic resection.results:laparoscopic small bowel resection after angiographic localization was successful in removing the jejunal polypoid hemangioma . the patient experienced no further gastrointestinal bleeding.conclusions:we will discuss the technique of localization and treatment used in this unusual case . a laparoscopic approach is an appropriate and beneficial treatment modality in a bleeding midgut lesion provided the lesion can be localized preoperatively and an oncologic resection is maintained .

breast tissue develops from bilateral ectodermal ridges , also known as the milk line , extending from the axilla to the inguinal region . ectopic breast tissue ( ebt ) occurs when there is incomplete regression of the ridges , can occur anywhere along the line and less commonly outside involving areas such as the face , neck , shoulder , chest , back , perineum and thigh region ( fig . the incidence of ebt has been reported to range from 0.2 to 6% , higher in asians compared to caucasians , with the majority of cases ( 6070% ) found in the axilla , and only 5.3% of cases in men . primary ectopic breast carcinomas ( pebc ) are even rarer accounting for only 0.20.6% of all breast cancers ( bc ) . here we describe an unusual case of male axillary pebc . figure 1:possible sites of ebt . a previously fit and well 52-year - old caucasian gentleman presented to his general practitioner ( gp ) with bilateral skin lesions in his axilla that had been present for the last 2 years . he had a positive family history of bc , with two paternal aunts and a cousin affected . examination revealed an area of suspected keratosis located in the left axilla , with a probable pigmented nevus in the right axilla . the patient re - presented 6 months later complaining of discomfort from the lesion in the right axilla . on second examination , the nodule had increased in size from 0.5 to 1.5 cm in diameter , and was becoming marginally red and prominent . immunohistochemistry of the tumour cells returned strongly positive for e - cadherin , ck7 , oestrogen receptor ( er ) and progesterone receptor ( pr ) . histological examination demonstrated a 6 mm focus of invasive ductal carcinoma with narrow excisional margins ( figs 2 and 3 ) . mammogram and ultrasound scan of the breast and axilla post - surgery revealed no residual cancer . staging computed tomography examination of the thorax , abdomen and pelvis demonstrated no evidence of metastasis . figure 2:low power image demonstrating the skin surface and dermal nests of tumour completely filling the tissue . figure 3:high power image of the dermal nests of tumour showing solid islands of invasive breast carcinoma . low power image demonstrating the skin surface and dermal nests of tumour completely filling the tissue . high power image of the dermal nests of tumour showing solid islands of invasive breast carcinoma . a re - excision of the right axillary scar with a sentinel lymph node biopsy and a wide local excision of the left axillary nodule were performed . final histology of the right re - excision revealed no residual malignancy or any nodal involvement . it has been postulated that risk factors for bc may also apply for ectopic tissue . suspicious mass around the axilla can be the result of several aetiologies including benign or malignant lymphadenopathy , lymphoma or metastatic carcinoma . the two most common histological diagnoses is invasive ductal carcinoma ( 4070% ) , followed by invasive lobular carcinoma ( 12% ) , which is similar in eutopic bc . the presence of malignant cells in the excised nodule with normal surrounding breast tissue that was er and pr positive confirmed the diagnosis . to date , there are only six cases of pebc reported in males . due to its rarity and low index of suspicion especially in males , it is often not on the differential diagnoses list which leads to delayed diagnosis . it is worth noting that pebc can occur in various parts of the body and may require further investigation on the lymphatic drainage with an individualized management plan . the prognosis of pebc is contentious ; some consider it similar to bc but others argue that it has worst prognosis due to higher chance of lymph node involvement [ 6 , 7 ] . the difficulty in diagnosis contributing to the rare incidence and lack of reporting in literature precludes detail evaluation of the management and prognosis . we have reported a rare case of pebc of the axilla in a male patient . in the presence of an enlarged axillary nodule , the possibility of pebc

primary ectopic breast carcinoma in male is very rare . we report a case on a 52-year - old gentleman who presented initially with bilateral lesions in his axilla and after delayed diagnosis the right lesion was confirmed as an ectopic breast carcinoma . we reviewed the literature and discussed the significance of the case .

they included morning nausea , bloating , frequent flatulence , burping , occasional pyrosis , alternating diarrhea and constipation . the patient consulted a primary care physician who prescribed symptomatic treatment that resulted in temporary relief . the following treatment was prescribed : four tablets of 500 mg tinidazole ( 2,000 mg ) taken orally in a single dose and repeated ten days later . it is a heavily under - diagnosed and as a result under - treated disease . contamination is usually indirect via water or vegetables , but can occur from dirty hands and though oro - anal sex . the only severe complication is malabsorption - a disorder only occurring in children of endemic areas . dyspeptic symptoms are often prominent and can be mistaken as stemming from viral hepatitis or peptic ulcer . diagnosis is made by parasitological stool exams showing cysts or mobile trophozoites . because there are periods when parasites are not excreted in feces , it is necessary to repeat stool exams . the most effective treatment is provided by nitroimidazole compounds such as ornidazole , tinidazole , and secnidazole . for adults , individually , prevention rests upon : i ) body hygiene , particularly washing hands before eating ; ii ) drinking encapsulated or boiled water ; iii ) avoiding vegetables in endemic areas . collectively , prevention relies on : i ) the improvement of sanitary infrastructure and water networks like sewage ; ii ) the encouragement of breast feeding , particularly in urban areas ; iii ) the discontinuation of human feces used as fertilizer in many asian countries .

we present the case of a 32-year - old french man who presented with morning nausea , bloating , frequent flatulence , burping , occasional pyrosis , and alternating diarrhea and constipation two weeks after a trip to morocco . the diagnosis was established by a parasitological stool exam that revealed cysts of giardia lamblia . he was successfully treated with tinidazole .

in the previous issue of critical care , niklason and colleagues use computer modeling to point out that blood flowing through unventilated regions of the lung ( a shunt ) will increase arterial partial pressure of carbon dioxide ( pco2 ) if ventilation remains constant . this will increase the calculated physiological dead space accordingly ( above that normally present due to the volume of air in the conducting airways ) . they also show that the increase in pco2 can be avoided by even modest increases in total alveolar ventilation ( although the calculated dead space will remain elevated ) . while this is not an entirely novel discovery ( west performed very similar calculations in 1969 as did mecikalski and colleagues in 1984 ) , it is well worth having niklason and colleagues remind us that physiological dead space not only can be caused by the development of regions with a high ventilation / perfusion ratio ( va / q ) , but also can come from areas of low va / q and a shunt . after all , physiological dead space is simply the difference between arterial and mixed expired pco2 divided by the arterial pco2 . first , it should be remembered that , since introduced by riley and cournand more than 50 years ago , physiological dead space is a virtual concept wherein the lung is conceived as a two - compartment organ in which one compartment is normal and the other is completely unperfused . physiological dead space , then , is the percentage of the tidal volume that must be distributed to the alveolus that is completely unperfused ( and which thus delivers no co2 to the expired gas ) to account for the difference between measured arterial and mixed expired pco2 . physiological dead space in actual patients may be increased even when no alveoli are completely unperfused as is the case here in the presence of a shunt . it is useful as a general parameter quantifying gas exchange disturbances but must not be overinterpreted as necessarily implying the existence of unperfused alveoli . second , as niklason and colleagues show , the relationship between shunt and physiological dead space is nonlinear , especially when shunts are high . a shunt of 20% of the cardiac output increases dead space by just 5% , a shunt of 40% raises it to approximately 11% , but a shunt of 60% produces a dead space of about 20% . this is because basic mass balance considerations show that the increase in arterial pco2 caused by a shunt depends on the factor qs/(100 - qs ) , where qs is the percentage shunt . thus , for co2exchange , the importance of shunts of less than approximately 30% is not great , but as shunts approach and exceed 50% , the potential for hypercapnia increases rapidly . third , very modest increases in alveolar ventilation can return the arterial pco2 to normal : an increase from just 5 to 7 l / minute will restore normocapnia ( assuming no other changes have occurred or abnormalities exist as ventilation is increased ) , even when the shunt is 60% of the cardiac output . fourth , va / q inequality is generally a cause of greater physiological dead space than shunt is ( figure 1 ) ( calculations using algorithms from ) . for example , it takes a very large , 60% shunt to increase dead space by 20% but a log - normal pattern of only moderate va normal log sdq is less than 0.6 , and the highest log sdq values seen are about 2 to 2.5 . log sdq is a parameter defined for quantifying va / q inequality in the multiple inert gas elimination technique and is the second moment ( dispersion ) of the va / q distribution on a log scale . comparison of effects of shunt ( top ) and ventilation / perfusion ratio ( va / q ) inequality ( bottom ) on calculated physiological dead space . in general log sdq , second moment ( dispersion ) of the ventilation / perfusion distribution on a log scale . fifth , niklason and colleagues show that , for any given value of shunt , additional perturbations commonly seen in the intensive care unit influence arterial pco2 and therefore will increase calculated dead space . this also means that a high cardiac output will reduce the dead space effect of shunt , as will alkalosis . the clinical message is that observed changes in dead space may reflect changes in cardiac output or acid / base state rather than changes in the shunt itself . in summary , the calculations of niklason and colleagues serve to point out the complexity of gas exchange in critical illness and the challenges we face in trying to interpret apparently simple measurements as indicators of the lung 's ability to carry out its primary responsibility gas exchange . co2 = carbon dioxide ; log sdq = second moment ( dispersion ) of the ventilation / perfusion distribution on a log scale ; pco2 = partial pressure of carbon dioxide ; va / q = ventilation / perfusion ratio .

since around 1950 , physiological dead space the difference between arterial and mixed expired pco2 ( partial pressure of carbon dioxide ) divided by the arterial pco2 has been a useful clinical parameter of pulmonary gas exchange . in the previous issue of critical care , niklason and colleagues remind us that physiological dead space , while easily measured , consolidates potentially very complex physiological derangements into a single number . the authors show how shunts raise arterial pco2 , thereby increasing dead space , and how changes in other variables such as cardiac output and acid / base state further modify it . a solid understanding of respiratory physiology is required to properly interpret physiological dead space in the critically ill .

overactivation of mineralocorticoid receptor pathways in choroidal vessels have been noted in experimental models of central serous chorioretinopathy ( cscr ) . mineralocorticoid antagonism through oral agents such as eplerenone has subsequently demonstrated success in the treatment of persistent cscr . significant subretinal fluid can also be encountered in select cases of neovascular age - related macular degeneration ( amd ) and polypoidal choroidal vasculopathy that can present challenges to successful treatment . in this report , successful reduction in subretinal fluid in a case of polypoidal choroidal vasculopathy is demonstrated . a 72-year - old woman presented with a gradual , painless decrease in vision in the left eye . on examination , visual acuity was 20/40 in the right eye and 20/150 in the left eye . biomicroscopic examination of the left eye revealed significant macular subretinal fluid with the absence of any evident hemorrhage , drusen , retinal pigment epithelial changes , or exudate in either macula . optical coherence tomography confirmed the presence of subretinal fluid with shaggy photoreceptor outer segments , absence of intraretinal fluid , and some outer segment / inner segment junction changes ( fig . intravenous fluorescein angiography ( ivfa ) was deferred due to a history of significant allergic reaction to ivfa in the past . further history assessment revealed a recent use of oral steroids ( 2 months previously ) . b.i.d . based on a presumed diagnosis of cscr and was followed up for 2 weeks initially to ensure improvement , given other etiologies could not be conclusively ruled out in the absence of ivfa . at the 2-week follow - up , visual acuity the follow - up was extended to 4 weeks . up to week 6 , visual acuity remained 20/100 , and the subretinal fluid had further decreased , but some exudate was evident on examination and oct ( fig . 1c ) that suggested an alternative diagnosis may be possible . after review with the patient , the decision was made to premedicate the patient with steroids and benadryl and to proceed with fa / indocyanine green , which revealed a network of peripapillary polypoidal choroidal vasculopathy with active leakage ( fig . 2 ) . intravitreal avastin was added to the treatment regimen , and the patient was maintained on oral eplerenone at 25 mg p.o . four weeks later , nearly all subretinal fluid had resolved and the exudate had regressed ( fig . 1d ) , and vision had improved to 20/50 . up to the 1-year follow - up , the patient has remained stable with absence of intraretinal or subretinal fluid or exudate on eplerenone at 25 mg p.o . polypoidal choroidal vasculopathy is a variant of neovascular amd that is characterized by branching subretinal aneurysmal polyp - like vessels . polypoidal choroidal vasculopathy is frequently characterized by subretinal hemorrhage , pigment epithelial detachment , or exudate , in addition to subretinal fluid . the everest study pointed toward the efficacy of photodynamic therapy as being superior to anti - vegf monotherapy in these lesions , which is further suggestive of its distinction from neovascular amd . the pathogenesis of polypoidal choroidal vasculopathy remains elusive , but the choroidal vasculature has been implicated , with indocyanine green angiography elucidating these polyp - like vessels best . while the natural history and disease course of polypoidal choroidal vasculopathy and cscr differ significantly , they share an implication of abnormal dilation of the choroidal vasculature in their presumed pathophysiology . this anatomic overlay begs the question of whether a deeper overlap of polypoidal choroidal vasculopathy and cscr exists in some patients than has previously been realized . the lack of a diffusely leaky choroid argues against a classic presentation of cscr in this case , and the identification of polyps in the setting of exudates is more consistent with a typical case of polypoidal choroidal vasculopathy . it is possible that some patients with polypoidal choroidal vasculopathy develop a secondary focal reactive retinal pigment epithelium dysfunction that leads to a cscr type of response . this secondary accumulation of subretinal fluid with associated shoddy photoreceptor outer segments may independently lend itself to a response with eplerenone treatment . alternatively , it is plausible that mineralocorticoid receptor antagonism may add an adjunctive efficacy in the setting of subretinal fluid from both etiologies , particularly given a potentially shared choroidal pathologic origin . in this case , oral eplerenone demonstrated efficacy as an adjunct to intravitreal anti - vegf in a case of polypoidal choroidal vasculopathy . to the authors knowledge , this is the first report of eplerenone use in the setting of polypoidal choroidal vasculopathy . further research is needed to better elucidate the precise role of mineralocorticoid antagonists in polypoidal choroidal vasculopathy . this study complied with the guidelines for human studies , subjects were given informed consent , and the study protocol was approved by the committee for human research .

overactivation of mineralocorticoid receptor pathways has been implicated in the pathophysiology of central serous chorioretinopathy ( cscr ) . recently , mineralocorticoid receptor antagonists such as eplerenone have demonstrated success in treating subretinal fluid in cscr . this case demonstrates a patient who was initially presumed to have subretinal fluid secondary to cscr and was started on a trial of oral eplerenone . it quickly became evident that her subretinal fluid was secondary to a peripapillary polypoidal choroidal vasculopathy network , but she demonstrated a significant improvement with oral eplerenone . to the authors ' knowledge , this is the first case of eplerenone use to treat polypoidal choroidal vasculopathy .

periodontal injury with localized destruction often occurs due to inadvertent force applied to the periodontium . such injury could be related to some psychosocial condition ( i.e. , stress related ) , habitual , or related to the patient 's profession . notching of the associated tooth with resultant extrusion and proclination and periodontal destruction with or without periodontal abscess that is often seen in carpenters , cobblers , tailors , and musicians is due to the common habit of keeping nails , sewing needles , or a musical instrument ( as the case may be ) between their teeth . in this case report we describe an electrician who habitually used his teeth to strip the rubber coating off electrical wires . the habit resulted in extrusion and proclination of the incisor and exacerbation of periodontal destruction , leading to recurrent periodontal abscess formation . a 31-year - old male presented to the department of periodontics , manipal college of dental sciences , manipal , india , with recurrent swelling and pain in the maxillary anterior teeth over the previous 6 months . the pain was dull and slightly increased whenever he used that particular tooth for biting . the maxillary right central incisor was found to have a 5 mm pocket mesiolabially and a 6 mm pocket mesiopalatally . the incisal edge in the center of the tooth had a notch ( abraded ) . the notching of the incisal surface at the center can also be seen radiographic evaluation revealed the presence of a vertical defect [ figure 2 ] mesial to the right central incisor . when the clinical findings were correlated to the radiographic findings , it was evident that the cause of such localized destruction was either trauma or an endodontic - periodontic lesion . since the tooth was not discolored and not tender on percussion , we sought for history of possible trauma . iopa shows a vertical defect mesial to the maxillary right central incisor enquiries related to his work as an electrician revealed that he often used his incisors to strip the outer rubber coating off electrical wires . he would hold the wire between his maxillary anterior and mandibular anterior teeth and pull the wire , thus removing the outer tubing and exposing the tungsten core . in view of the localized destruction and the recurrent attacks of periodontal abscess , it was evident that the lesion was related to his occupation . based on the history and the clinical and radiographic findings , we made a diagnosis of chronic periodontal abscess . the relationship between the recurrent attacks of periodontal abscess and periodontal destruction and his professional habit was explained to him and he was advised to stop the habit . oral prophylaxis was given and the patient was advised to return after 15 days for surgical treatment . open flap debridement in the form of a papilla preservation flap , combined with a regenerative periodontal surgical procedure , was done . the combined regenerative procedure consists of citric acid root conditioning , bone graft ( bio - oss , geistlich biomaterials ) , and guided tissue regeneration ( gtr ) ( bio - gide g ) [ figures 3 and 4 ] . the patient was recalled ater 15 days for suture removal and then advised to come for follow - up at 6 months . after debridement mesial to the maxillary right central incisor , the twowalled defect on the mesial surface and dehiscence in the facial aspect can be seen papilla preservation flap sutured after combined regenerative procedures there are several etiologies for periodontal abscess formation . chronic continuous trauma , pernicious bruxism is one of them . a subgingival calculus acts as a continuous source of infection . continuing trauma to the periodontium results in the destruction of the periodontal ligament fibers and abscess formation . this was clearly explained to the patient and he was advised to stop the habit .

we report an unusual case of recurrent periodontal abscess in a 31-year - old male electrician due to his habit of using his teeth as a tool for stripping electrical wires . the patient was not aware of the consequences of this habit . clinically , there was presence of moderate depth of periodontal pocket around the tooth and , radiographically , there was a vertical defect mesial to the involved teeth . the patient was educated about the consequences of his habit and surgical treatment was undertaken . a papilla preservation flap with regenerative periodontal surgical procedure was done , orthodontic and restorative treatment was planned at the follow - up . this case highlights the importance of eliciting a proper and complete personal history , including occupational details . in our patient these details helped us correlate the destruction of the periodontium to the unusual etiology .

co - culture of macrophages with calcifying vascular cells or human vascular smooth muscle cells enhanced alkaline phosphatase activity and mineralization potential . tumor necrosis factor and oncostatin m have been suggested as molecular mediators of macrophage - derived vascular calcification . in addition , depletion of macrophages reduced osteophyte formation in osteoarthritic models [ 8 - 10 ] , and macrophages have been implicated in the sites of pathologic bone loss in inflammatory bone disorders . depletion of macrophages in primary calvarial osteoblast cultures in vitro has been shown to delay osteogenic differentiation and mineralization . in the macrophage fas - induced apoptosis ( mafia ) transgenic mouse model , short - term depletion of macrophages with treatment of a synthetic ligand in vivo showed a quantitative reduction of bone formation sites in endocortical bones . in a recent study , in vivo long - term depletion of macrophages in young ( 321 days ) and adult ( 1622 months ) mafia mice demonstrated an osteopenic phenotypes with suppressed serum bone turnover markers . this study reinforced the hypothesis that osteal macrophages play a pivotal role in bone anabolism . another independent study with lysozyme m - deficient mice also showed that pre - natal macrophage depletion led to early skeletal growth retardation and progressive osteoporosis . the latter two studies clearly showed that functional osteoclasts were not significantly affected in these macrophage - deficient models . taken together , these results suggest that osteal macrophages play an essential role in normal bone development and remodeling , especially through anabolic actions . one of the critical concerns with osteal macrophages is how to distinguish bone marrow resident macrophages from osteoclasts , since they share the same precursors . studies of mafia mice or lysozyme m - deficient mice showed functionally active osteoclast activities , while macrophages were remarkably depleted , but still there were possible impacts of subtle changes in osteoclasts on overall bone metabolism . a recent study showed more clear evidence supporting the independent presence of functioning osteal macrophages apart from osteoclasts . ccl5- deficient mice showed decreased f4/80-positive macrophages at the endocortical bone surface , following reduced bone formation compared to the wild - type mice . previous studies have demonstrated that macrophages are present during multiple stages of fracture healing , and produce mesenchymal growth factors . macrophages are also associated with more stable callus formation and healthy union . keeping pace with the studies of osteal macrophages in bone metabolism , several groups have extensively studied how osteal macrophages participate in fracture healing of bone . both systemic and local depletions of macrophages delayed fracture healing and impaired woven bone formation , while treatment of colony stimulating factor 1 increased macrophage recruitment into the injury sites and supported woven bone formation . this study showed that macrophages were essential for collagen type i - positive matrix formation and bone mineralization . similarly , an independent study also showed that depletion of macrophages during fracture repair , even after several days later to fracture , led to impaired bone union with incomplete callus formation accompanied with more fibrotic changes . they observed that macrophages were also involved in promoting the osteogenic differentiation of marrow mesenchymal progenitor cells . moreover , a recent study clarified that inflammatory m1-macrophages ( f4/80 mac-2 ) played a crucial role in the initiation of early inflammation , and both inflammatory ( f4/80 mac-2 ) and resident ( f4/80 mac-2 ) macrophages derived anabolic signals for endochondral callus formations in murine fracture models . taken together , accumulating evidence suggests that macrophages and their specific molecular mediators contribute to fracture healing in a phase - specific polarization - dependent manner . to date , osteal macrophages have been considered a third cellular component , in addition to osteoblasts and osteoclasts . macrophages construct a cellular canopy structure over bone remodeling sites , coordinate osteoclast - to - osteoblast coupling , and drive anabolic cytokines for bone formation . in addition , macrophages might play a role in bone and marrow interactions especially at the osteoblastic stem cell niche . targeting osteal macrophages or their molecular mediators could be potent therapeutic challenges for developing anabolic therapies for bone disease . further studies are needed to develop specific targets that could be distinguished from osteoclast or inflammatory macrophages .

macrophages have been shown to have pleiotropic functions in various pathophysiologies , especially in terms of anti - inflammatory and regenerative activity . recently , the novel functions of bone marrow resident macrophages ( called osteal macrophages ) were intensively studied in bone development , remodeling and tissue repair processes . this review discusses the current evidence for a role of osteal macrophages in bone modeling , remodeling , and fracture healing processes .

brain metastases are the most common type of intracranial neoplasm , and lung cancer is the most frequent neoplasm of brain metastases . non - small cell lung carcinoma ( nsclc ) has a 2040% chance of developing brain metastases in the disease course . whole - brain radiotherapy or platinum - based chemotherapy have been the standard therapy choices for patients with brain metastases , but the prognosis of patients with brain metastases is still disappointing . penetration of chemotherapeutic drugs into the central nervous system ( cns ) is limited primarily by the blood - brain barrier ( bbb ) . gefitinib is an oral agent and epidermal growth factor receptor ( egfr ) tyrosine kinase inhibitor ( tki ) , which has been reported to be effective in the treatment of brain metastases from nsclc by overcoming the bbb . an egfr mutation is a predictive biomarker for a good response to egfr - tki , even in brain metastases . here , we report the case of a woman with diffuse brain metastases from lung cancer who experienced total regression of the metastases under gefitinib treatment . the patient , a 58-year - old married taiwanese woman , was referred to our hospital with a complaint of severe headache and unsteady gait for 2 months . the patient had had a 10-year history of hypertension and a 4-year history of hyperthyroidism with regular follow - up . physical examinations revealed tenderness over her posterior neck and drowsy consciousness , with a glasgow coma scale score of e2 , v4 , m4 , and an ecog performance status of grade 4 . on admission , the patient underwent a brain mri which revealed diffuse metastatic lesions of variable sizes in the cerebra and cerebellum ( fig . a chest x - ray revealed a focal mass in the left infrahilar region , and a chest ct scan showed a lobulated mass , measuring 3.5 2.1 cm , in the superior segment of the left lower lobe ( lll ) of the lung with pleural effusion ( fig . therefore , adenocarcinoma of the lll portion of the lung , with brain and bone metastases , ct2n3m1 , stage iv was diagnosed . an analysis of the egfr mutation elucidated a glu746_ala750 deletion in exon 19 ( fig . 3 ) . the patient received egfr - tki therapy with gefitinib 250 mg per day . her subjective symptoms improved gradually within 1 month of gefitinib therapy . after 6 months of treatment , a chest ct scan revealed partial remission of the primary pulmonary tumor , measuring 3.0 1.5 cm ( fig . a brain mri showed the dramatic total regression of the diffuse brain metastatic lesions ( fig . currently , the patient continues to receive egfr - tki therapy , and her survival time has exceeded 18 months since the initial diagnosis . so far , the patient has had a good ecog performance status of grade 1 and no obvious recurrence elsewhere . nsclc with brain metastases is usually associated with a poor outcome , and treatment is palliative in most cases . multiple brain metastases are associated with an even worse prognosis , and median overall survival is only a few months . standard treatment options include symptomatic therapy with whole - brain radiotherapy and corticosteroids , which lead to a median survival of 36 months . the use of conventional chemotherapy for brain metastases has been limited because of a presumed lack of effectiveness due to poor penetration beyond the bbb . the bbb is a highly specialized structure of astrocytes , pericytes , and vascular endothelium that maintains cns homeostasis . in a mouse model , the bbb has already been found to be permeable to brain metastases of tumors < 0.25 mm in diameter . ct scans and mri have detected edema , and contrast enhancement in brain metastases has confirmed the disruption of the bbb , which is no longer intact when brain metastases become clinically detectable . further studies show that egfr - tki has a low molecular weight and could penetrate beyond the bbb . therefore , it might be efficacious in the treatment of brain metastasis [ 5 , 6 ] . many studies have proposed several factors which could make it possible to predict the response to gefitinib in patients with advanced nsclc , for example , asian female , non - smoker , with adenocarcinoma , and the presence of an egfr mutation . to our knowledge , the most common types of egfr mutation are an exon 19 deletion and an exon 21 l858r mutation . in our case , an asian female had adenocarcinoma of the lung with diffuse brain metastases and was treated with gefitinib therapy because of an egfr exon 19 deletion . after 6 months of follow - up , the dramatic response of total regression of the brain metastases was proved by brain mri . as of now , our patient has survived more than 18 months since the initial diagnosis . in conclusion , therefore , due to its ability to reverse poor performance status and achieve the unbelievable response of total regression of brain metastases , egfr - tki therapy could be considered as a first - line treatment for advanced adenocarcinoma of the lung , positive for an egfr mutation , with brain metastases .

we report the case of a woman with diffuse brain metastases from lung cancer who experienced total regression of the metastases under gefitinib treatment . the 58-year - old woman was referred to our hospital with a complaint of severe headache . a brain mri revealed diffuse metastatic lesions in the cerebra and cerebellum . adenocarcinoma of the lung with multiple brain metastases was diagnosed . the tumor was positive for an epidermal growth factor receptor ( egfr ) exon 19 deletion mutation . she was treated with gefitinib 250 mg per day . one year later , the diffuse brain metastases had totally resolved . egfr - tyrosine kinase inhibitor therapy could be a first - line treatment for patients with advanced adenocarcinoma of the lung with egfr mutation , especially in those with brain metastases .

we conducted an investigation to verify and validate the utility of a triage cc - based edss in southeastern ontario as a tool for monitoring respiratory disease by comparing it retrospectively with data from nacrs and telehealth ontario . this study was part of a broader research project approved by the queen s research ethics board and adheres to the principles and policies for the protection of personal health information charter . daily counts of discharges of persons with respiratory disease based on icd-10-ca codes were obtained from the nacrs database , and counts of respiratory ccs were likewise collected from edss . patient location was determined by forward sortation address ( i.e. , first 3 digits of postal code ) and health unit code in the nacrs database and by specific reporting hospital in the edss data set . we categorized telehealth ontario calls into episodes of upper or lower respiratory disease on the basis of a priori classification schemes verified by other research ( 6,1113 ) . all data were compiled into weekly totals ( sunday saturday ) from each of the 3 nonidentifiable data sets . during july 2004march 2006 , edss contained 29,668 reports of respiratory diseases in persons seeking care at 1 of the 7 area hospitals . during the same period , telehealth ontario received 4,247 calls about upper and lower respiratory disease , and nacrs recorded 19,315 cases of respiratory disease from southeastern ontario . analysis comparing the edss respiratory ccs with the telehealth ontario calls about respiratory disease ( figure ) resulted in a spearman correlation coefficient of 0.91 , indicating good correlation . analysis comparing the edss respiratory cc to all nacrs respiratory disease diagnoses resulted in a spearman correlation coefficient of 0.98 , indicating very good correlation . correlations were highest and most significant when no time lags were included in the models . weekly totals of emergency department surveillance system ( edss ) respiratory chief complaints , national ambulatory care reporting system ( nacrs ) respiratory visits , and calls to telehealth ontario ( th ) about respiratory illness , ontario , canada , july 2004june 2006 . this study verified that ed cc data can be used as a timely source of surveillance for respiratory diseases . ed ccs in southeastern ontario strongly correlated in time with nacrs respiratory discharge diagnoses and calls to telehealth ontario about respiratory disease . nacrs data are unavailable to public health stakeholders in a timely enough fashion to be useful for day - to - day monitoring of respiratory disease trends in the community , whereas ed ccs are available electronically and in real time . as expected , edss ccs about respiratory disease peaked during the influenza seasons ( early november 2004mid - april 2005 and early december 2005early may 2006 ) ( figure ) ; however , edss ccs continued to fluctuate during the influenza off season , probably because of other respiratory pathogens . the nature of the edss data did not allow us to separate respiratory complaints related to influenza from those related to other pathogens . one consideration for interpreting edss data is that the hospitals in this surveillance system include large referral hospitals that have high volumes of patients visiting from outside our health unit boundaries . although this large referral area may result in higher counts of visits than reflected in the nacrs database , we believe it does not affect our interpretation of the data . even though each hospital is required to submit data , it is still possible that not all records from each hospital are sent on time to nacrs . although the public health system has accepted syndromic surveillance as a useful tool , doubts remain about its anticipated early warning benefits ( 14 ) . these potential benefits can not be tested because no large - scale outbreaks have occurred since the inception of our real - time syndromic surveillance system . when a pandemic occurs , syndromic surveillance may be able to help healthcare workers recognize a potential outbreak , which theoretically could help them mitigate effects on society earlier . our study demonstrates that in southeastern ontario , ed ccs accurately reflect respiratory conditions of patients in the area . the correlations found strongly suggest that edss accurately monitors respiratory disease in the community and contributes to early detection of respiratory disease outbreaks . we continue to monitor the system from day to day and future studies will use laboratory data to assess the value of advanced warning on a number of syndromes captured in our system .

to validate the utility of a chief complaint based emergency department surveillance system , we compared it with respiratory diagnostic data and calls to telehealth ontario about respiratory disease . this local syndromic surveillance system accurately monitored status of respiratory diseases in the community and contributed to early detection of respiratory disease outbreaks .

hereditary hypotrichosis simplex of the scalp ( hss ) is a rare autosomal dominant genotrichosis characterized by a hair defect confined to the scalp in the absence of other ectodermal or systemic abnormalities . hereditary hypotrichosis simplex of the scalp ( hss ) is a rare autosomal dominant genotrichosis characterized by a hair defect confined to the scalp in the absence of other ectodermal or systemic abnormalities . a 26-year - old girl referred to our dermatology clinic because of sparse and short hair . she had normal hair at birth , but hair loss began when she was four months old . she had short hairs of varying length , its length , never exceeds 7 cm . on physical examination , she had normal physical and mental development with no neurological impairment . in addition , her scalp hair was sparse and fragile with no signs of cicatricial alopecia [ figure 1 ] . sparse and fragile hair with no sign of cicatricial alopecia eyebrows and eyelashes , nails , dental , eyes and sweat glands were normal . the following investigation : blood count , erythrocyte sedimentation rate , liver , thyroid and renal function tests , serum electrolytes , urinalysis , blood glucose , the glucose tolerance test , hb a1c , copper , zinc , and ferritin . trichogram of the patient 's hair show multiple abnormalities : distorted hair bulbs , ruffling and fraying of hair cortex with fracturing of hair shaft , resembling trichorrhexis nodosa [ figure 2 ] . distorted hair bulbs , ruffling and fraying of hair cortex with fracturing of hair shaft a scalp biopsy show marked decrease number of hair follicles ; most of them are in anagen phase , accompanied by mild chronic predominantly lymphocytic perifollicular infiltration , consistent with hypotrichosis simplex . . marked decrease number of hair follicles , most of them are in anagen phase , accompanied by mild chronic predominantly lymphocytic perifollicular infiltration , consistent with hypotrichosis simplex hereditary hypotrichosis simplex of the scalp ( hss ) is a rare autosomal dominant genotrichosis characterized by a hair defect confined to the scalp in the absence of other ectodermal or systemic abnormalities . usually , patients with the ( hss ) present with normal hair at birth and in the first years of life . they experience a progressive , gradual loss of hair that is limited to the scalp , beginning at the middle of the first decade and leading to almost complete loss of scalp hair by the third decade . a few sparse , fine the body hair , beard , eyebrows , axillary hair , teeth , and nails are normally developed . scalp skin biopsy revealed a decreased number of follicles , especially in the telogen phase , with no specific pattern and no structural changes . before , structural hair defects may be presented with a genetic disorder affecting hair growth or part of a congenital syndrome or may indicate underlying metabolic disorders , or may be associated with other diseases . abnormalities of the hair shaft are varied and often confusing and can be congenital or acquired . they do require accurate recognition , which can be helpful in the diagnosis and management of a hair disorder , or in the detection of underlying disease . trichorrhexis nodosa is a common shaft defect affecting scalp hair , in which there is a distinctive response to injury . the hair is fragile and on examination regularly , spaced pale node - like swellings may be observed . it may affect normal hair following excessive or repeated trauma , or may occur after minimal trauma if there is an inherent defect in keratin synthesis causing abnormally brittle hair . blume - peytavi u , et al . suggested the triad of hypotrichosis , structural hair - shaft defects ( dysplastic and broken hair shafts as seen in pili torti , trichorrhexis nodosa and pseudomonilethrix ) , and abnormal amino - acid composition ( hypercysteine hair ) , associated with glucosuria without diabetes , may represent a new genetic syndrome due to an enzyme defect or deficiency . in 2004 , a novel hidrotic ectodermal dysplasia ( hypotrichosis , trichorrhexis nodosa and nail dystrophy ) in a 3-year - old girl was reported . we reported a 26-year - old iranian girl affected by hss associated with trichorrhexis nodosa with history of the same disease in six members of her family . investigation suggested mutations in lipase h ( liph ) were responsible for autosomal recessive hypotrichosis simplex with woolly hair in three families . human hair as a key phenotypic marker can lead us to the underlying metabolic or genetic syndromes . the finding of hypotrichosis simplex of the scalp , associated with structural hair - shaft defects in seven adults of one family who were otherwise healthy , in the latest generation may represent a new genetic syndrome . the finding of hypotrichosis simplex of the scalp , associated with structural hair - shaft defects in seven adults of one family who were otherwise healthy , in the latest generation may represent a new genetic syndrome .

hereditary hypotrichosis simplex of the scalp is a genetic disorder , characterized by sparse or absent scalp hair without structural defects , in the absence of other ectodermal or systemic abnormalities . structural hair defects may be presented with a genetic disorder affecting hair growth or part of a congenital syndrome or may indicate underlying metabolic disorders , or may be associated with other diseases . we describe a 26-years - old persian girl suffering from hypotrichosis simplex of the scalp with trichorrhexis nodosa who had no ectodermal defects and systemic disease .

paraumbilical hernia occurs as a result of congenital incomplete closure of the fetal umbilical defect . they present as a lump and/or swelling commonly associated with abdominal discomfort and the majority are reducible ; however , strangulation is not uncommon . the most common content of the sac is omentum , bowel loop and surgical repair remains the only definitive treatment [ 1 , 2 ] . appendicitis within the hernia sac has been reported in the inguinal ( amyand hernia ) and femoral region ( de garengeot hernia ) ; however , their presence in the paraumbilical hernia is extremely rare and a search of the literature demonstrated three previous perorated cases . herein , we would like to report a case of a successfully treated acute appendicitis presenting in a paraumbilical hernia in an 84-year - old lady with 6-month follow - up . an 84-year - old lady with a past medical history of hypertension , ischemic heart disease , congestive heart failure and hypercholesterolemia presented with 2-day history of abdominal pain and nausea . on examination she was found to have a raised c - reactive protein of 97.5 mg / dl and a white cell count of 8.9 10 with otherwise normal hematologic markers . computed tomography ( ct ) of the abdomen demonstrated cecum and appendix in the hernia sac . this was associated with mild degrees of edema , stranding and presence of mesentery ( figs 1 and 2 ) . figure 1:sagittal slice of the ct demonstrating the paraumbilical sac containing cecum and appendix along with fat stranding and air loculation and narrow neck ( red arrow ) . figure 2:coronal and axial slice of the ct showing the paraumbilical hernia ( within marked areas ) . sagittal slice of the ct demonstrating the paraumbilical sac containing cecum and appendix along with fat stranding and air loculation and narrow neck ( red arrow ) . coronal and axial slice of the ct showing the paraumbilical hernia ( within marked areas ) . the decision was made to operate and the patient was taken to the operating room for the repair of the paraumbilical hernia under general anesthesia . a midline incision ( mini laparotomy ) therefore , a mayo repair with full reduction of the viable cecum back into the abdominal cavity following sac excision and appendectomy was performed . the patient made an uneventful recovery and was discharged 5 days later with no postoperative complication on 6-month follow - up . acute appendicitis remains the most common surgical emergency to date and their presentation can vary , however , the majority present with the classical symptoms of central to right iliac fossa abdominal pain , nausea , anorexia and vomiting . this is related to the anatomical position of the appendix from developmental phase of intestinal rotation . review of n = 8692 cases of acute appendicitis , demonstrated that 0.13% of all appendicitis could present within the incisional , inguinal , femoral and obturator hernia . the incidence of appendicitis in a paraumbilical hernia remains unknown and an extensive search of literature in the english language highlighted only three prior cases that presented with peroration and pus collection . it remains unclear how the cecum and appendix can freely mobilize to the midline and present themselves within the sac of a paraumbilical hernia . it has been suggested that in 10% of the population , there might be an anatomical variation and abnormal cecum mobility otherwise referred to as mobile cecum syndrome . in such individuals , the lateral peritoneal attachment of cecum is either absent or so mobile that terminal ileum and cecum can be found in any quadrant of the abdomen depending on the position and activity of the patient . in addition , acute inflammatory response ( appendicitis ) and subsequent intraabdominal events ( localization , adhesion and abscess ) and the presence of a prior defect ( paraumbilical ) could explain such presentation . another explanation in such circumstances is appendicitis as a result of extrinsic pressure , strangulation and necrosis within the hernia defect . however , it is difficult to establish which pathophysiological process ( or perhaps both ) could have attributed to this rare presentation . clinical examination remains vital in such cases ( irreducible hernia ) and arguably ct remains the best investigative modality of the choice in doubtful and complicated circumstances specially when there is a suspicion of malignancy due to old age . however , the only definitive treatment is surgery for both appendicitis and strangulated hernia , and detailed examination of the sac contents remains crucial before their reduction into the abdominal cavity . following an appendectomy , primary repair over mesh repair due to later incidences of mesh infection is highly recommended .

paraumbilical hernia sac usually contains omentum , bowel loop and rarely appendicular epiploicae , metastatic deposits and vermiform appendix . presentation of acute appendicitis in a paraumbilical hernia is rare and limited to few case reports in the literature . herein , we would like to report a case of a successfully treated acute appendicitis presenting in a paraumbilical hernia in an 84-year - old lady with 6-month follow - up .

a 46-year - old man was referred for ophthalmologic examination due to gradually decreasing visual acuity . he had suffered from disturbances of ocular movements , ptosis and weakness of the extremities for two years . through polymerase chain reaction ( pcr ) , the patient was found to have amplification of ctg repeats on chromosome 9 , which is compatible with myotonic dystrophy type 1 . on ophthalmologic examination , intraocular pressure was 13 mmhg in the right eye and 15 mmhg in the left eye . the levator function was 0 mm in the right eye and 1 mm in the left eye . fundus examination showed geographic depigmentation of the retinal pigment epithelium along the vascular arcade and pigment clumps in the peripheral area ( fig . fourteen months later , the patient 's best - corrected visual acuity had decreased to 0.3 in both eyes . phacoemulsification and intraocular lens implantation were sequentially performed in both eyes and his best - corrected visual acuity improved to 0.7 . myotonic dystrophy type i is caused by a genetic defect composed of an expansion of cytosine - thymidine - guanine ( ctg ) repeats , resultingin a defect of the dystrophia myotonica protein kinase ( dmpk ) gene and a reduction of dmpk messenger rna expression . this genetic defect affects zinc finger protein 9 expression.6 the most common ocular complications associated with myotonic dystrophy are cataracts that may be induced by a defect of the lens epithelium.7 as in the present case , they generally have the appearance of iridescent dust and fine points with colored crystals.3 various retinal degenerations associated with myotonic dystrophy include a butterfly pattern in the macular area , peripheral reticular pigmentary changes , and polymorphic atrophy.8 peripheral reticular pigmentary change is the most common form of retinal degeneration and was observed in the present case . this pigmentary change causes decreased b - wave amplitude on electroretinography which we also observed.3 kimizuka et al.9 report on atrophy of the inner retinal layers with preservation of the photoreceptors in the peripheral retina and increased pigmentation with granular , striate or satellite patternin the macula . the reduced saccadic peak velocity and impaired smooth pursuit gain in the present case were almost identical with those observed and described in a previous report.10 lessell s et al.10 reported that limitation of ocular movement and ptosis may be due to one or all of three possible mechanisms : supranuclear control , peripheral motor apparatus and extraocular muscle atrophy . previously reported histological findings showed pathological changes with a shredded appearance and an abundance of lipofuscin in muscle fibers.11 in conclusion , the visual disturbances associated with myotonic dystrophy may be caused not only by cataracts but also by retinal degeneration . therefore , fundus examination is essential and should be performed carefully in patients with myotonic dystrophy .

a 46-year - old man presented with visual disturbances in both eyes . his best corrected visual acuity was 0.7 ( both eyes ) . ptosis and limitation of ocular movement in every direction were observed . slit lamp examination showed a bilateral iridescent cataract . fundus examination showed peripheral depigmentation of the retinal pigment epithelium and pigmentary clumping in both eyes that agreed with blocked fluorescence and widow defects on fluorescein angiography . the amplitude of b - wave was decreased on electroretinography . fourteen months later , the patient 's best corrected visual acuity decreased to 0.3 due to increased lens opacity . phacoemulsification and intraocular lens implantation were performed on both eyes . at the patient 's final visit , retinal findings were stable with a best corrected visual acuity of 0.7 in both eyes . in conclusion , the visual disturbance could have been caused by both cataracts and retinal degeneration , meaning the fundus should be examined carefully in patients with myotonic dystrophy .

iridoschisis is an uncommon condition characterized by separation of the anterior iris stroma from the posterior stroma.1 iridoschisis is a rare disease , of which a only few cases have been reported.2 most patients are aged over 65 years and the condition is usually bilateral,2,3 associated with angle - closure glaucoma,35 trauma,4 and syphilitic interstitial keratitis.6 iridoschisis presents with two or more layers of iris tissue that usually is characterized by iris fibers flowing in the anterior chamber.7 in 2001 , agrawal et al reported the rare association of unilateral iridoschisis and ipsilateral lens subluxation.5 in 2004 , adler et al reported unilateral iridoschisis and bilateral lens subluxation.8 to the best of our knowledge , the current report is the first about unilateral iridoschisis and ipsilateral lens displacement into the vitreous cavity . a 67-year - old woman presented with visual loss in the right eye of two months duration . her spherical equivalent refractive error was + 11.75 diopters ( d ) in the right eye and 0.75 d in the left eye . the intraocular pressure was 15 mmhg in the right eye and 19 mmhg in the left eye . slit - lamp examination showed sectoral schisis of the right iris stroma inferonasally from the 4 to 6 oclock position ( figure 1 ) . a normal peripheral anterior chamber was seen in the right eye , but no lens was present ( figure 1 ) . postmydriatic examination showed lens displacement into the vitreous cavity in the right eye ( figure 2 ) , and no abnormalities in the left eye . the endothelial cell densities in the center were 1,263 cells / mm in the right eye and 2,849 cells / mm in the left eye ( figure 3a , b ) . a 25-gauge pars plana vitrectomy and lens removal were performed immediately in the right eye . iris tissue flowing into the anterior chamber was cut with a vitreous cutter during surgery . one month postoperatively , the va was 1.0 , and the spherical equivalent refractive error was + 11.25 d. the endothelial cell density inferotemporally was 763 cells / mm , 2,525 cells / mm superotemporally , and 1,623 cells / mm in the center ( figure 4a c ) . the postoperative progress has been satisfactory and we are planning scleral fixation of an intraocular lens . we considered that lens subluxation had worsened to lens displacement into the vitreous cavity in this patient . based on previous reports , it is plausible that iridoschisis is related to lens subluxation or lens displacement into the vitreous cavity.5,8 however , adler et al reported unilateral iridoschisis in the right eye and bilateral lens subluxation;8 that the patient presented with lens subluxation without iridoschisis in the left eye and had a longstanding history of periocular eczema.8 our current patient had no such general complications . future studies will clarify the connection between iridoschisis and lens subluxation or lens displacement into the vitreous cavity . the corneal endothelial cell density decreased to 1,263 cells / mm preoperatively in our patient . it is interesting to confirm the presence of iridocorneal contact overlying the area of iridoschisis using ultrasound biomicroscopy.1 although there was no clinical evidence of iridocorneal contact in the current case , we speculated that intermittent iridocorneal touch might have a normal distribution in the left eye . have caused this change , as srinivasan et al reported,1 as the free end of the iris fibers sometimes seemed to be in contact with the corneal endothelium before surgery . in addition , there was a report that the iris fibers touched the corneal endothelium , and caused decreasing corneal endothelial cell density.9 finally , the inferonasal endothelial cell density , which corresponds to iridoschisis , decreased extremely after surgery . we cut iris tissue flowing into the anterior chamber during surgery , with care not to injure the corneal endothelial cells . patients with iridoschisis should undergo specular microscopy to determine the status of the corneal endothelial cells . we report a case of iridoschisis with lens displacement into the vitreous cavity of the right eye . the postoperative progress has been good but the corneal endothelial cell density decreased from preoperatively

we report the case of a 67-year - old woman with a lens that was displaced into the vitreous cavity in one eye and ipsilateral iridoschisis . she was free from a history of ocular trauma or of heritable ocular disease . her best - corrected visual acuity was 1.2 bilaterally and right eye showed signs of iridoschisis . the corneal endothelial cell density decreased to 1,263 cells / mm2 in the right eye preoperatively . we speculated that iris tissue flowing in the anterior chamber might have intermittently touched the corneal endothelium . 25-gauge pars plana vitrectomy and lens removal were performed immediately . free - floating iris tissue was cut during surgery with care not to injure the corneal endothelial cells . the postoperative progress was satisfactory and scleral fixation of an intraocular lens is planned . iridoschisis is an uncommon cause of lens displacement into the vitreous cavity .

there have been a few case reports on selective serotonin reuptake inhibitor ( ssri)-induced hyperprolactinemia,123 ) which may lead to secondary amenorrhea ; however , to our knowledge , this is the first case in which a false - positive urine pregnancy test was observed following initiation of escitalopram treatment . this case report suggests that women of child - bearing age taking antidepressants should be closely monitored . miss l is a 34-year - old caucasian female with a history of premenstrual dysphoric disorder and panic disorder . she then returned to the clinic in 2013 for worsening signs of depression and anxiety following the murder of her brother . she was started on alprazolam 0.5 mg four times a day when necessary ( prn ) and zolpidem 5 mg every hour of sleep ( qhs ) prn for anxiety and sleep disorders , respectively . maximum citalopram dosage was reached at 40 mg in the morning ; hence , mirtazapine was added to the treatment regimen for worsening affective symptoms . citalopram treatment was discontinued because mirtazapine was effective , and her wellbeing was maintained for over 12 months on mirtazapine monotherapy . in 2014 , subsequently , she was started on escitalopram 10 mg daily ( qd ) as an augmenting agent for her worsening depressive symptoms ; after 3 months , the escitalopram dosage was increased to 20 mg qd . she presented for follow - up at 1 month after starting on 20 mg qd escitalopram and reported that she had missed her period after initiating escitalopram and had subsequently completed a home pregnancy test , which was positive . upon evaluation by her primary care physician , it was determined that her body mass index had not changed and there was no change in her mood . she was advised by her physician to discontinue escitalopram because it was the only new medication that she had recently started . there have been a few reported cases of ssri - induced hyperprolactinemia and development of galactorrhea while on escitalopram.123 ) serotonin may stimulate prolactin release either directly through postsynaptic 5-hydroxytrypamine ( 5-ht ) receptors in the hypothalamus or indirectly via 5-ht mediated - inhibition of tuberoinfundibular dopaminergic neurons.4 ) one study comparing citalopram and escitalopram showed that after a single dose , escitalopram acted centrally ( and not peripherally ) and increased prolactin and cortisol levels while also exhibiting successful blockade of cortisol following administration of dexamethasone.5 ) miss l , who reports a history of regular menses , is thought to have developed amenorrhea as a result of escitalopram treatment . the mechanism behind the development of amenorrhea may be a result of serotonin 's effect of increasing prolactin levels . unfortunately , the patient 's prolactin levels were not ascertained at her follow - up appointment with her mental health provider ( after having initiated escitalopram ) because two months had already passed since discontinuation of escitalopram . elevated prolactin levels could cause amenorrhea by suppressing hypothalamic gonadotropin - releasing hormone , thereby decreasing production of gonadotropins such as luteinizing hormone ( lh ) and follicle - stimulating hormone . lh may play a role in false - positive urine pregnancy tests in patients receiving chlorpromazine.6 ) one study showed secretion of the posterior pituitary ( neurohypophysial ) hormones vasopressin and oxytocin through stimulation of serotonergic receptors in rats ; in particular , the 5-ht1a receptor was involved in serotonergic stimulation of oxytocin secretion.7 ) most studies investigating the role of oxytocin in lh regulation have been conducted in rats and show that oxytocin elicits concentration - dependent secretion of lh.8 ) in a small study , an oxytocin antagonist affected the ovulatory cycle of non - pregnant women , pointing to a role for oxytocin in the physiological processes of lh regulation in women.9 ) in the case of miss l , the serotonergic effects of escitalopram ( which may be unique in its central - acting nature ) may have been involved in an increase in oxytocin and subsequently an increase in lh . lh apparently cross - reacts with the antichorionic gonadotropin antibody used in immunologic urine pregnancy tests and can cause a false - positive result.6 ) potential causes of false - positive urine pregnancy tests include medical conditions such as malignancy and proteinuria . this case report suggests that women of child - bearing age should be carefully monitored while they are on an antidepressants .

escitalopram is a selective serotonin reuptake inhibitor antidepressant approved by the food and drug administration for the treatment of major depressive disorder and generalized anxiety disorder . a 34-year - old female patient with major depressive disorder developed amenorrhea and had a false - positive urine pregnancy test after initiation of escitalopram treatment . to our knowledge , no published case report of amenorrhea and false - positive urine pregnancy tests in women taking escitalopram exists . this case report suggests that women of child - bearing age should be carefully monitored for amenorrhea while they are on an antidepressant treatment regimen .

witkop defined taurodontism as teeth with large pulp chambers in which the bifurcation or trifurcation are displaced apically , so that the chamber has greater apico - occlusal height than in normal teeth and lacks the constriction at the level of cemento - enamel junction ( cej ) . the distance from the trifurcation or bifurcation of the root to the cej is greater than the occluso - cervical distance . this localized diorder was labeled as taurodontism because of its appreance of or a similarity to a bull 's head with horns on x - ray , hence named after taurus the bull . it also has been found to mimic the molar of cud - chewing animals . in diverse populations , the objective of this study was to assess the frequency of taurodontism in the posterior teeth of the turkish population by radiographic analysis and to compare the results with published data in different population groups . panoramic radiographs from 6912 patients ( 3,860 women and 3052 man , mean age : 29.04 years range 15 to 50 years ) attending krkkale university dental faculty hospital during the period from july 2009 to august 2011 were reviewed for the presence of taurodontism . exclusion criteria included patients who were less than 15 years of age at the time of radiographic examination , records with poor quality radiographs and records with radiographs of only primary teeth . a tooth with an apically displaced pulp chamber which did not show the usual constriction of the pulp at the cemento - enamel junction ( cej ) and had an apically displaced furcation area was considered as a taurodont . statistical analysis of the data was done using the statistical package for the social sciences ( spss 15.0 ) . chi - square test was also used to compare the prevalence of taurodontism between male and female subjects and upper and lower jaws . six thousand nine hundred and twelve patients , 3860 women and 3052 men between the ages of 15 and 50 years ( average , 29.04 8.68 years ) were considered in this study ; 97362 posterior teeth ( including third molars ) were evaluated . eightteen patients were found to have a taurodont teeth ( 10 women and 8 men [ p = 0.98 ] ) . taurodontism was detected in only four premolars ( two mandibular first premolars and two mandibular second premolars ) . the overall incidence of patients with taurodontism was 0.26% ( 0.26% for women and 0.26% for men ) . the distribution of taurodontism among different teeth in the upper and lower arches is shown in table 1 . taurodonts were significantly more common in the mandibula compared with the maxilla ( 71.0% cf 29.0% respectively , p < 0.05 ) . the prevalence of taurodont molars among all teeth examined was 0.047% ( 0.043% for molars , 0.004% for premolars ) . the mandibular second molar was the most common tooth involved followed by the mandibular first molars . radiographically , all these teeth showed no signs of a previous root canal treatment or apical periodontitis . distribution of taurodont teeth among 6912 patients , in the maxilla and mandible by tooth type taurodontism is a morphologic change generally occurring in multirooted teeth characterized by wide elongated pulp chambers and apical oor displacement . the prevalence of taurodontism was reported to be 8% in a jordanian , 46.4% in a young adult chinese , 5.6% in an israeli people , 9.9% in a dutch and 33 - 41% of certain african populations in our study , the prevalence of taurodont teeth was found to be 0.26% . this nding is in agreement with a previous study conducted in seven - year - old swedish children . the prevalence in the turkish population was reported to be from 4.5% to 7.4% in some studies which were markedly higher than from our findings . discrepancies in the same population may be explained by regional differences and number of study samples . in other studies assessing the prevalence of taurodontic teeth in different ethnic groups , much higher incidences were reported [ table 2 ] . the wide variation in reported prevalence may be explained by the different cohorts studied , geographical differences and diffreerences in criteria used for interpretation of taurodontism and also the specifc teeth examined . survey of available studies on the prevalence of taurodont molars the present study should be considered with caution as it may not be representative for the overall turkish population .

the aim of this retrospective study was to evaluate the frequency of the occurrence of taurodontism in a turkish population with using panoromic radiographs . a retrospective study was performed using full - mouth periapical and panoramic radiographs of 6912 patients ( 3860 females and 3052 males ) ranging in age from 15 to 50 . a total of 97362 posterior ( including third molars ) were evaluated . a chi - square test was used to determine the difference in the prevalence of tauorodntism between genders . eighteen patients were found to have a taurodont molar ( 10 women and 8 men [ p = 0.98 ] ) . the overall incidence of patients with taurodont molars was 0.26 % and the prevalence of taurodont molars from all teeth examined was 0.024% , and the prevalence taurodonts were significantly more common in the mandibula compared with the maxilla ( 71.0% cf 29.0% respectively , p < 0.05 ) . it was almost equally distributed between males and females . taurodontism is not uncommon in turkish population but further larger scale studies are required to assess its prevalence in the general population to compare it with other ethnic groups .

although approximately 90% of them pass spontaneously , they can result in perforation or obstruction in the gastrointestinal ( gi ) tract . toddlers aged 2 - 3 years are most commonly affected ; as children in this age group are ambulatory and more orally explorative . it normally affects the ileocaecal and rectosigmoid regions . according to goh et al . , the most common site of intra - abdominal perforation as the terminal ileum ( approximately 39% ) . we present a case of young female with ingestion of foreign body which was impacted in a small intestine . a 23-year - old female presented to the emergency of the max super speciality hospital , saket , new delhi , india with a history of ingestion of teaspoon , while she was eating ice cream 1 day before . physical examination revealed soft abdomen with mild tenderness around umbilicus and no signs of peritonitis . a plain x - ray abdomen revealed presence of a radio - opaque foreign body ( metallic teaspoon ) in the stomach . initially , we decided to observe and closely monitor the patient after admitting her and starting conservative expectant treatment . the next day she was not relived , and the abdominal pain continued . in view of that repeat x - ray abdomen was performed in erect and supine position to locate the position of the teaspoon [ figure 1 ] . abdominal x - ray showing spoon in jejunum diagnostic laparoscopy was performed with one 10 mm and two 5 mm midline ports . on initial evaluation there were no bowel adhesions . on the exploration and careful examination of upper gi tract jejunum on tracing the loop of jejunum , the spoon was located at the mid jejunal level . enterotomy was performed on the antimesenteric border , and tablespoon identified and was retrieved [ figures 2 and 3 ] . the foreign body ( spoon ) patient had an uneventful post - operative recovery and was ultimately discharged on post - operative day 4 . the management of foreign bodies in gi tract is based on collective anecdotal experience of surgeons . the highest incidence of swallowed foreign bodies occurs in children between 6 months and 3 years , and coins are the most commonly ingested foreign bodies . there is a definite predilection for swallowed foreign bodies to become impacted at the level of cricopharyngeus and just below it or at the oesophagogastric junction . in our patient , a large number of foreign bodies will pass through the entire gi tract once past the gastroesophageal junction ; nevertheless it is preferable to observe them in the hospital for a possible need for immediate abdominal exploration should bleeding , or features of perforation occurs . during the observation period , a daily radiograph should be obtained , and patient should be checked for signs of peritonitis or gi bleeding . all sharp foreign bodies should be removed before they pass from the stomach because 15 - 35% of these will cause intestinal perforation , usually in the area of the ileocecal valve . if a sharp foreign body does not progress for three consecutive days surgical intervention should be considered , and if the patient becomes symptomatic , surgical intervention will be necessary . intraluminal endoscopic techniques are limited by the length of the instrument and the curved path it takes . laparoscopic removal of foreign bodies from the peritoneal cavity ( translocated intrauterine contraceptive devices ) and a needle from the pelvis have been reported previously . laparoscopically removed a toothpick causing small bowel perforation followed by lavage of the abdominal cavity and laparoscopic closure of the perforation including omentoplasty . accurate localisation of foreign body in the small bowel is the main challenge . in our case for irregular objects such as a safety pin , the site requires localisation and then a small enterotomy . depending on the availability of skill and expertise , laparoscopic removal of the gi foreign bodies should be considered an option . the most optional method of retrieval in the form of endoscopy or surgery should be contemplated at the earliest indication . laparoscopic retrieval may be a better option in comparison with laparotomy where facility and proper expertise are available .

ingestion of foreign body is a serious problem commonly encountered in our clinical practice . most of them pass spontaneously , whereas in others endoscopic or surgical intervention is required because of complications or non - passage from the gastrointestinal tract . we present here a case of teaspoon ingestion , which did not pass spontaneously . laparoscopic retrieval of teaspoon was done from mid jejunum after enterotomy and the patient recovered uneventfully . right intervention at the right time is of paramount importance .

compared with the more common inguinal and femoral hernias , obturator hernias are rare with an incidence of 0.051.4% of all abdominal wall hernias . probably due to a wider pelvis and a more triangular obturator canal with a greater transverse diameter as well as previous history of pregnancy , obturator hernias are more common in elderly , emancipated women . since obturator hernias often become only clinically apparent when incarcerated , signs of acute small bowel obstruction can be found in 90% of patients with newly diagnosed obturator hernia . owing to unspecific clinical signs and therefore often delayed diagnosis , advanced age of the patient , comorbidities and associated chronic disease mortality has been described as high as 47% [ 24 ] . a 97-year - old woman presented to the emergency department ( ed ) with a sudden onset of pain in the right lower abdomen with radiation to the right thigh . in her past medical history , the patient had bilateral open inguinal hernia repair and an open appendectomy . no inguinal or femoral hernia was palpable , but coughing and internal rotation of her right hip caused increasing pain ( howship romberg sign ) . computed tomography ( ct ) scan revealed an obturator hernia on the right side with a herniated small bowel loop with early signs of incarceration ( fig . 1 ) . we performed an emergency laparoscopic transabdominal preperitoneal plasty ( tapp ) to repair the hernia . during laparoscopy no herniated small bowel was present , but an erythema of a small bowel loop was seen not justifying a resection . figure 2:intra - operative view after opening the peritoneum , showing the corona mortis ( a ) just above the obturator hernia orifice ( b ) , the obturator vein with underneath the obturator artery ( c ) and the obturator nerve ( d ) . intra - operative view after opening the peritoneum , showing the corona mortis ( a ) just above the obturator hernia orifice ( b ) , the obturator vein with underneath the obturator artery ( c ) and the obturator nerve ( d ) . apart from the obturator nerve and vessels , we detected a vessel crossing the pubic bone : the corona mortis ( fig . this vessel was spared from extra manipulation and the hernia closed with a monocryl - prolene mesh that was fixed with titanium tacks . obturator hernia is a rare form of abdominal wall hernia published the first time by de ronsil in 1724 . a compression of the obturator nerve by the hernia can cause pain or cramps from the groin to the knee . the symptoms can be even enforced by adduction and internal rotation of the thigh , which is called the howship in addition , compression of the obturator nerve can lead to an absent adductor reflex in the presence of a positive patellar reflex ( hannington kiff sign ) . pain from the groin to the knee might get mistaken for neuromuscular pain , as joint pain is common in elderly patients . quite often diagnosis is missed and patient undergoes surgery for bowl obstruction and obturator hernia is diagnosed during the operation . if suspected preoperatively , the diagnostic modality of choice is nowadays the ct scan of the abdomen . for the treatment of an obturator hernia , the advantages of laparoscopic versus open abdominal surgery , namely less post - operative pain , earlier oral intake , shorter hospitalization , fewer risk of an incisional hernia and smaller wounds are well known . furthermore , with the technical progress in laparoscopic surgery , transabdominal and extraperitoneal approaches are possible and have been described to be successful in obturator hernia repair [ 7 , 8 ] . in our case , the transabdominal ( tapp ) approach was chosen because of clinical and radiographic signs of incarceration . by the transabdominal approach a good visualization and assessment of the concerning bowel loop is possible . as demonstrated by the positive clinical course , our patient with 97 years of age has been benefiting from the minimal invasive procedure . this so - called crown of death has an incidence of up to 40% . as an increasing number of abdominal hernias are repaired by a laparoscopic approach , surgeons should be aware of its existence and spare the vessel as severe bleedings can occur . in summary , obturator hernias are rare and often present to the ed when incarcerated . especially in elderly , thin women presenting with bowel obstruction and hip pain this exclusive type of hernia

obturator hernias are a rare form of abdominal wall hernias . we present a case of a patient with an obturator hernia diagnosed by the classical signs of lower abdominal pain , a positive howship romberg sign ( painful internal rotation of the hip ) and a computed tomography scan showing a herniated loop of small bowel . during the emergency laparoscopic hernia repair ( transabdominal preperitoneal approach ) a variant vessel , the corona mortis , was detected .

the intrapulmonary bronchogenic cyst appears a sharply circumscribed , round or oval nodule or mass , usually in the medial third of the lungs . the lesion do not communicate with the tracheobronchial tree until they become infected , a complication that occurs in about 75% of cases recognized clinically ( 1 , 2 ) . bronchial polyps are rare findings and classified as multiple papillomas , solitary papillomas , and inflammatory polyps ( 3 ) . bronchial polyp occurs spontaneously or after airway injury such as chronic infection , foreign bodies , asthma , and inhalation injury . we report a case of polypoid intrapulmonary lung cyst , which was the first case among koreans , has been removed by bronchoscopy . a 68-yr - old woman came to our hospital with a month history of discomfort and pain in the right upper chest . she denied a history of fever , upper respiratory infection , or allergies . she had never smoked . on admission her blood pressure was 120/80 mmhg , pulse rate 84/min , respiratory rate 24/min , and body temperature 36.6. cardiac examination showed normal findings . the lungs on auscultation showed a decrease in vesicular sounds in the right upper lung field . laboratory tests revealed normal findings . on spirometry , her forced vital capacity and forced expiratory volume in 1 sec were 2,480 ml ( 120% of the predicted value ) and 2,000 ml ( 139% of the predicted value ) , respectively . flexible bronchoscopy revealed a peduncular polyp about 2 cm in length originating from the anterior segment of the right upper lung ( fig . after bronchoscopic removal with biopsy forceps of the polyp , cystic lesion of the right upper lung disappeared ( fig . 1b ) and the discomfort and pain in the right upper chest of patient improved . gross appearance showed polyp with stalk and light - microscopical examination showed a lymphocyte infiltration with epithelial lining cells that was consistent with the diagnosis of a bronchial inflammatory polyp ( fig . this is a rare case of polypoid intrapulmonary bronchogenic cyst , which was disappeared after bronchoscopic removal . there were possible diagnoses for the initial radiographic chest findings of the cystic lesion in the right upper lung , including infected cyst , infected large bullae , pulmonary sequestration . bronchogenic cysts are usually solitary , thin walled , unilocular , and roughly spherical in shape . they are filled with either mucoid or serous fluid and do not communicate with the tracheobronchial tree unless they become infected , in which case the cyst fluid may be pus or by pus and air ( 4 ) . in this case however they may communicate with the tracheobronchial tree and become infected and some enlarge to cause airway obstruction . bronchial polyps are classified as multiple papillomas , solitary papillomas , and inflammatory polyps ( 3 ) . inflammatory polyps of the airways are now regarded as histopathologically distinct nonneoplastic endobronchial lesions , which in adults are associated with a variety of chronic inflammatory insults such as chronic infection , foreign bodies , asthma , or inhalation injury ( 5 - 7 ) . generally , benign bronchogenic cysts need not be resected unless they cause symptoms . in treatment of bronchial polyp the developments in bronchoscopic techniques have made it possible to remove superficial tumors by bronchoscopy . removal of the foreign body or inhalation of corticosteroid may resolve bronchial polyp ( 5 ) . in the present case , bronchial polyp was removed by bronchoscopy and then lung cyst disappeared suggesting that intrapulmonary cyst communicate with bronchus . histologically the bronchogenic cyst wall is lined by a pseudostratified , ciliated epithelium and contains cartilage and strands of smooth muscle important for diagnosis . in the present case , polyp composed of epithelial lining cells without cartilage in their wall may represent intrapulmonary cyst as a result of ingrowth from communicating airway epithelium .

pulmonary bronchogenic cyst in adults is rare and the typical appearance is a sharply circumscribed , round or oval nodule or mass , usually in the medial third of the lungs . bronchial polyps are rare histopathologically distinct nonneoplastic endobronchial lesions and are classified as multiple papillomas , solitary papillomas , and inflammatory polyps . we herein report a patient with polypoid endobronchial lung cyst . a 68-yr - old woman presented with a discomfort and pain in the right upper chest of four weeks??duration . chest radiography revealed a cystic lesion in the right upper lung . computed tomography revealed a 45 cm sized large cyst . neither enlarged mediastinal lymph nodes nor extrabronchial involvements were observed . flexible bronchoscopy revealed a peduncular polyp about 2 cm in length originating from the anterior segment of right upper lung . after bronchoscopic removal of polyp , cystic lesion of the right upper lung disappeared .

the mullerian duct regresses in male due to a glycoprotein secreted by the developing testes called mullerian inhibiting factor ( mif ) . failure to regress may be due to lack of mif or defective mif receptor , resulting in various disorders of regression , and one such disorder is persistent mullerian duct syndrome ( pmds ) . pmds is a rare form of male pseudohermaphroditism characterized by the presence of uterus and fallopian tubes in phenotypically and genotypically normal male ( 46 , xy ) , with testosterone production and responsiveness . the association between pmds and transverse testicular ectopia ( tte ) is even more uncommon . a 25-year - old male presented with absent left testis since birth and right sided inguinal swelling for 5 years , and pain in swelling for 2 days . on physical examination , the left scrotum was empty , and right side revealed indirect inguinal hernia with right testis at the root of the scrotum . ultrasonography showed right inguinal hernia with undescended testis in the right inguinal canal and an absent testis on the left side . surgical exploration revealed indirect sac with the right testis . while retrieving the testis , we noticed a complex mass resembling uterus - like structure , and gonad ( left ) with the fimbria - like structure [ figure 1 ] . gonad with fimbria - like structure ( above ) , uterus like structure ( middle ) , and testis ( below ) both the gonads had vas deferens and vascular supply . the uterus like structure was removed along with left gonad as it was atrophic and sent for histopathology . histopathological study proved it to be uterus [ figure 2 ] and left gonad like structure proved to be testis which was atrophic without spermatogenesis [ figure 3 ] . testis with absent spermatogenesis chromosomal analysis revealed normal male genotype 46 xy [ figure 4 ] . embryologically , between 7 and 8 week of gestation , masculinization occurs in a male fetus . testosterone secreted by the leydig cells in the testis helps in the development of wolffian duct in to vas deferens , epidydimis and seminal vesicle . mif secreted by sertoli cells in the testis , acts locally to suppress the mullerian ducts and causes their regression by 8 and 10 weeks of gestation . pmds results from failure of synthesis of mif , or failure of end organs to respond to mif . the mechanical effect of persistent mullerian duct structures might produce cryptorchidism by preventing normal testicular descent . pmds represents a small fraction of this broad spectrum of male pseudohermaphroditism , characterized by the presence of well - developed or rudimentary uterus , cervix , vagina and fallopian tube in normal 46 xy male . patients with pmds have normal androgen production , male external genitalia and normal penile development . failure of the testis to descend in to the scrotum at birth results in undescended testis . ectopic testis have been reported at various sites including superficial inguinal pouch , suprapubic , femoral , perineal region and the base of penis . migration of the testis to the opposite side where both testis pass through the same inguinal canal is known as tte . partially descended testicles ( 80 90% of cases ) with unilateral cryptorchidism and contralateral inguinal hernia . the term hernia uteri inguinalis is used when uterus is found in the hernia sacsometimes the contralateral testis is found in the hernia sac due to abnormal mobility of the mullerian derivatives , known as ttebilateral cryptorchidism with uterus fixed in pelvis and both testes embedded in round ligaments . partially descended testicles ( 80 90% of cases ) with unilateral cryptorchidism and contralateral inguinal hernia . the term hernia uteri inguinalis is used when uterus is found in the hernia sac sometimes the contralateral testis is found in the hernia sac due to abnormal mobility of the mullerian derivatives , known as tte bilateral cryptorchidism with uterus fixed in pelvis and both testes embedded in round ligaments . a rare form of clear cell adenocarcinoma of the mullerian duct in pmds has been reported . diagnosis is usually made incidentally during surgery for an inguinal hernia or exploration for cryptorchidism . laparoscopy , ultrasonography , and mif detection using bioassay techniques is helpful in diagnosing the syndrome . orchidectomy is indicated when testes can not be mobilized to a palpable location . otherwise orchiopexy is done and patient kept on long - term follow - up .

persistent mullerian duct syndrome ( pmds ) is a rare form of male pseudohermaphroditism characterized by the presence of mullerian duct structures in a normal male with 46 , xy karyotype . transverse testicular ectopia ( tte ) is rare form of testicular ectopia in which two testes are located on one inguinal side . the opposite scrotum is empty . pmds with tte is rare . we report a case of pmds with tte discovered during surgery for a right inguinal hernia in a 25-year - old male .

bilateral pedicle fractures in the spine are uncommon because they have a higher mechanical strength than the pars interarticularis , even in elderly patients.359 ) furthermore , the pedicle has great intrinsic strength and a short moment arm , and can therefore resist greater cyclic shear forces.1 ) spondylolysis , or fracture of the pars interarticularis , is the most common injury of the neural arch , and osteoporotic compression fracture is common in adjacent segments after instrumented fusion due to loss of motion at fused segments by altered biomechanics.79 ) however , bilateral pedicle stress fractures at adjacent cephalad levels after instrumented lumbar fusion are extremely rare because stress concentration on the proximal junction area is associated with severe junctional changes including adjacent compression fractures or stenosis . here , we report a rare case of bilateral pedicle stress fractures , which were not detected before surgery at an adjacent upper level after instrumented lumbar fusion and not associated major trauma . a 77-year - old woman was admitted to our institute with severe back and buttock pain . four years previously , she underwent anterior lumbar interbody fusion ( alif ) with bone cement augmented screw fixation at the l5-s1 level under a diagnosis of foraminal stenosis . at that time , there were no pedicle fractures at the l4 level ( figure 1 ) , and the lowest t - score by dual - energy x - ray absorptiometry ( dxa ) bone mineral densitometry was -3.8 . the patient presented with only mild back discomfort after alif with screw fixation , but the back pain progressively worsened without any history of trauma for 2 months before re - admission . ambulation was limited and the patient was re - admitted to our institute . a physical examination revealed neurologically intact status , but prominent tenderness was present in the low back area and back motion was reduced , especially in backward extension . plain radiographs showed marked irregularity of the l4 pedicle suggesting l4 pedicle fractures at both sides ( figure 2a ) , and magnetic resonance images and computed tomography scans revealed bilateral pedicle fractures through l4 accompanying foraminal stenosis at l4 - 5 level ( figure 2b - e ) . she was treated by posterior lumbar interbody fusion of l4-s1 with rigid screw ( figure 3 ) . at her 8-month follow - up assessment , osteoporosis contributes to cephalad compression fractures due to altered biomechanics in adjacent segments caused by junctional failures associated with loss of motion at fused segments.6 ) fused lumbar segments may increase stress and motion at adjacent unfused segments and accelerate degeneration . however , adjacent fracture of bilateral pedicles after instrumented lumbar fusion is extremely rare and to our knowledge , no such case has been previously reported . furthermore , bilateral pedicle fractures are rare and have only been reported on a few occasions.2458910 ) in these reported cases , most bilateral pedicle fractures were generally related to previous spine surgery or stress - related activities , and pedicle stress fractures after lumbar fusion surgery occurred at the most proximal or distal level of fusion.6 ) to our knowledge , three cases of bilateral pedicle stress fracture after lumbar fusion without screw removal have been reported,8910 ) and two of these cases occurred at the uppermost level of fusion.89 ) tribus and bradford10 ) described the case of a patient treated by posterior spinal fusion using segmental instrumentation from t3 to l4 who developed fractures of the lowest l4 pedicle . however , in this case , the adjacent upper level of the l4 pedicle was involved after instrumented l5-s1 fusion . repetitive mechanical stress fractures in the posterior elements are usually located in the pars interarticularis or to a substantially lesser extent , in the pedicle . the pedicle has great intrinsic strength and a short moment arm from the vertebral body , and can therefore resist greater cyclic shear forces.4 ) as a result , the pedicle is an uncommon location of fracture at the posterior neural arch . rather , fractures are more frequently observed in the isthmus , which corresponds to the weakest zone . nevertheless , bilateral pedicle fractures at adjacent levels can occur due to adjacent pedicles associated with spinal fusion masses may experience abnormal repetitive shear forces and cantilever because of continued motion through intervertebral discs and the pars interarticularis.10 ) in our patient , the fractures appeared to be fresh , because no sclerotic change was evident at fracture margins in spite of the absence of a trauma history.6 ) we had performed bone cement augmented screw fixation at l5-s1 level . the overstiffness and enhanced strength may increase the risk of bilateral pedicle fractures of adjacent , non - augmented vertebrae , because of increased biomechanical stress . we fused the l4 - 5 segment to stabilize the pedicle fractures , and the solid stabilization may result in pain relief , and allowed our patient to return to normal activities . we report an uncommon case of bilateral pedicle fractures at the adjacent upper level of previous instrumented fusion without a history of evident trauma . although it is rare , this report gives useful information to spine surgeons regarding the treatment and diagnosis of similar cases .

bilateral pedicle stress fractures are rare even in the elderly . bilateral pedicle fractures are due to post - surgical complications at the level of fusion or stress related activities in most cases . the authors describe a unique case of adjacent l4 bilateral pedicle fractures , which developed 4 years after anterior lumbar interbody fusion with bone cement augmented screw fixation at the l5-s1 level . as far as the authors ' knowledge , no similar case has been previously reported in the literature . the pathophysiological mechanism of this rare entity is discussed with review of relevant literature .

temporary inferior vena cava ( ivc ) filters are being used for short - term protection in patients who are at a high risk for pulmonary thromboembolism . the tempofilter ii ( b. braun , boulogne , france ) is one of the temporary ivc filters , and this is a second - generation long - duration temporary device that is safe , effective and useful in patients who are in a critical thromboembolic situation ( 1 ) . several episodes of atrial migration or upward displacement have been reported for both the tempofilter i ( first - generation device ) and the tempofilter ii , but no cases of filter fracture have been reported ( 1 - 3 ) . here we report on the first case of fracture of one leg of the filter and this leg was embedded in the ivc wall in a patient with deep vein thrombosis . a 62-year - old man presented with a 2-day history of right leg pain and swelling . there was a previous history of stenting for left common iliac vein stenosis five years ago . the axial ct venogram showed a duplicated superficial femoral vein ( sfv ) and deep venous thrombosis in the right femoral vein , the right popliteal vein and the right calf veins . there was no thrombosis in the infrarenal vena cava and the diameter of the infrarenal vena cava was around 21 mm . catheter - directed thrombolysis and aspiration thrombectomy were planned as treatment for the patient 's dvt . a tempofilter ii was inserted into the inferior vena cava at the infrarenal level under digital subtraction angiography ( fig . the following afternoon , catheter - directed thrombolysis using 120,000 iu of urokinase was first performed via the catheter inserted from the right popliteal vein and then aspiration thrombectomy was performed without complication . one week after the procedure , an axial ct venogram demonstrated some residual thrombus in the right sfv and no radiologically evident complications of the filter were noted . three weeks after the procedure , removal of the filter was performed , but the fluoroscopic image of the ivc demonstrated upward displacement of the tempofilter ( displacement distance : 3 cm ) and fracture of one filter leg ( fig . at the time of explantation , we observed that thrombus was present in the filter and the filter was fractured with one missing leg ( fig . the patient was asymptomatic and he was discharged without surgical removal of the embedded filter leg . given the long - term complications of permanent filters , the development of a safe and effective temporary filter would be of great benefit for young patients or for patients with a temporary thromboembolic risk that requires short - term protection against pulmonary thromboembolism . however , some temporary , retrievable filters can not be removed and so they must be left as permanent , and this maintains the risk of dvt and caval thrombosis ( 4 ) . the tempofilter ii is a second generation temporary ivc filter that is introduced and withdrawn by using a tethered catheter with a subcutaneous anchoring device . unlike other temporary filters , the manufacturer validated that retrieval is easy after up to three months without the need for additional equipment ( 1 ) . other temporary filters often become irretrievable after only two or three weeks as a result of thrombus formation and endothelialization . while the initial experience with the first - generation device ( tempofilter i ) has been positive ( 5 ) , several episodes of filter migration to the right atrium due to catheter buckling , one of which was fatal , have suspended further development of this filter ( 2 , 3 ) . the problems related to structural stability were resolved by significant modifications of the filter cone and the tethering catheter . ( 1 ) reported a prospective 104-case multicenter study with the tempofilter ii and that study confirms the safety and effectiveness of the tempofilter ii . the filters were successfully removed with no complications in all but one case . while there have been no reported cases of tempofilter fracture in the english medical literature , we found that one leg of the filter had fractured and was embedded in the ivc wall . fortunately , the one fractured filter leg was embedded in the ivc wall without migration and no pulmonary thromboembolism was observed . the patient was asymptomatic and he is currently being examined as an outpatient without surgical removal of the embedded filter leg . filter fracture is very rare and it has been reported in less than 1% of cases ( 6 - 8 ) . a few cases of a fractured ivc filter migrating to the heart and even causing cardiac tamponade have been reported , suggesting that strenuous physical activity and increased intra - abdominal pressure can lead to the fracture and migration of ivc filters ( 9 , 10 ) . we can postulate that the embedment of one filter leg with constant movement of the tethered catheter can cause fatigue fracture of the embedded filter leg .

tempofilter ii is a device that is used for pulmonary embolism prophylaxis . since the appearance of the tempofilter ii following withdrawal of the tempofilter i , it has been reported that the tempofilter ii is safe , effective and useful . here we report on the first case of a fracture of one leg of the filter and this leg was embedded in the inferior vena cava wall in a 62-year - old man with deep vein thrombosis .

sarcomas of penis are very uncommon , representing less than 5% of malignant tumors in this area . ks is the most common sarcoma of the penis and the second one is leiomyosarcoma . primary presentation of ks on penis is not common , but more often observed in aids patients , whose lesions are " aggressive form " , and only approximately 2 - 3% cases have shown penile ks lesions as first manifestation of disease . the patient was 47 years old male , suffered from itchy penile papules which the first one had started to grow 5 years ago . the first manifestation of his disease had appeared by a violet sub - coronal papule ( about 5 mm in diameter ) . during the last three months the lesion had extended rapidly and appeared multiple lesions similar to the first lesion , around the coronal region . he did n't have any history of fever , weight loss , or mucosal involvement . he had unprotected extra marital sex with a female partner but 2 years after initiation of lesions . the patient did n't have a history of chemotherapy , radiotherapy , hiv infection , dermatologic disorders and disease and medications with immune suppression . in his past medical history , there was no report of any kind of disease or surgery , but only he underwent surgical remove of right urethral stone , 7 years ago . on examination , there were popular indurate glandular and sub - coronal lesions which some of them were crusted . no inguinal or iliac nodes were palpable and other sites of skin and mucosal surface had not involved by tumor ( figure 1 , 2 ) . laboratory tests include : cell blood count ( cbc ) , haemoglobin , urine analysis and urine culture were normal . serology of hiv , hbv , hcv tests were negative in two times but the hhv8 was detected in tissue by pcr method in biopsy sample . wedge biopsy of the lesions had shown a tumor which was composed of spindle cells , around the blood spaces and ectatic capillaries . fibrotic connective tissue with hemosiderin deposition and mild infiltration of lymphoplasmacytic inflammatory cells had enveloped spindle cells and blood spaces . the abdominopelvic ultrasonography had shown renal stone in the middle calix of left kidney with mild fullness and other findings were normal . computed topographic scan ( ct scan ) of thorax , abdomen and pelvic were normal too . classic forms have often occurred in elderly patients , black equatorial africans , patients with lymphoma or immune deficiencies . primary kaposi sarcoma of penis often has seen in hiv infected patients and in patients with competent immune system , it has occurred in elderly patients . according to some studies , primary presentation of ks on penis is reddish - purple to bluish nodules . other types of lesions such as papules , plaques and wart like lesions are less common [ 4 - 9 ] . ks is a proliferative disease , has characterized by angiogenesis , endothelial spindle cell growth ( ks cells ) , inflammatory cell infiltration , and edema . these lesions have reflected immune dysregulation characterized by cd8 + t - cell activation , production of th1 cytokines , and angiogenic factors . treatment needs to be individualized , based on the patient 's clinical and immunologic status . highly active anti - retroviral treatment ( haart ) results in clinical improvement of ks lesions and prolongation of time to treatment failure anti - ks activity of haart appears to reflect immune system reconstitution and , to a lesser extent , suppression of hiv replication . hiv protease inhibitors are also potent anti - angiogenic molecules that could affect ks pathogenesis . localized , cutaneous ks lesions could be treated using radiation , laser , cryotherapy , or intralesional injections of antineoplastic medicines . cytotoxic chemotherapy has indicated for patients who have not responded to haart and patients with life - threatening or visceral disease . in some studies , palliative excision of lesions of ks on penis without chemotherapy after oncologic consult and evaluation of the patient 's condition , we planed radiotherapy for our patient .

primary kaposi sarcoma of penis is very rare . we will introduce a 47 years old male patient referred to our clinic from dermatology service , in this report . the patient suffered from itchy penile papules around coronal region . the lab tests had revealed a negative serology of hiv but tissue pcr was positive for human herpesvirus-8 ( hhv8 ) . histological findings were compatible with kaposi sarcoma . primary kaposi sarcoma of penis is rare but could occur in hiv negative patients .

he had undergone a caldwell - luc operation 30 years ago , and had no history of medical disease . the right nasal cavity was not visible because of bulging from the inferior meatus , which almost reached the septum . images of the paranasal sinus revealed a 6 5-cm - sized well - demarcated cystic mass filling the right maxillary sinus and nasal cavity ( fig . 1 a and c ) . the bulging mass led to erosion of the posterior wall of the maxillary sinus and pterygoid plate causing anatomical deformity and sphenoid sinusitis ( fig . endoscopic decompression and sphenoid sinusotomy were performed , considering it to be a patient of postoperative maxillary cyst with sphenoid sinusitis . the sphenoid sinus ostium was located using an image - guided system ( fiagon gmbh , berlin , germany ) , and massive bleeding was noted during the widening of the ostium . the estimated blood loss was about 1500 cc and the bleeding was temporarily controlled by nasal packing using rapid rhino ( smith & nephew , austin , tx ) and merocel ( medtronic , mystic , ct ) . since right facial swelling was gradually progressive , we performed immediate angiography , which revealed a thrombosed large pseudoaneurysm feeding from the right i m a ( fig . materials used for embolization were n - butylcyanoacrylate ( 33% ) and 3 8 mm platinum detachable coils ( covidien , axium , plymouth , mn ) . ( a ) axial and ( b ) coronal images of paranasal sinus computed tomography . the bulging mass shows a homogenous density occupying right maxillary sinus with erosion of the posterior wall of maxillary sinus and sphenoid sinusitis ( arrow ) . a 6 5-cm - sized , gadolinium - enhanced mass with internal cystic change ( arrow ) can be seen and the lesion is well demarcated with smooth margins . blood circulation of right internal carotid artery and external carotid artery was checked before embolization . embolization of right i m a ( arrow ) was done using n - butylcyanoacrylate and platinum coils . in this patient , since the postoperative maxillary cyst was huge and bulging onto adjacent structures , normal anatomic structure was altered , and the course of the i m a was also displaced . the diagnosis of pseudoaneurysm can be confirmed by duplex ultrasonography , computed tomography angiography , or conventional angiography . in this patient , even though the bleeding was temporarily controlled by nasal packing , immediate computed tomography angiography was performed because of progressive facial swelling . several studies showed that the success and complication rates are quite comparable between surgical ligation and embolization . although embolization is a minimally invasive technique , there are many possible complications including skin ischemia , temporary hemiparesis , temporary monocular visual field loss , monocular blindness , peripheral facial nerve paralysis , and cerebral infarction . therefore , the application of embolization should depend on the anatomical factors , patient preference , and availability of experienced interventional staff . in this patient , immediate embolization was successfully performed , and there were no complications after 6 months . in review of the literature , the pseudoaneurysms occurred following a postoperative delay of 2 days to 4 months ( table 1 ) . it is clinically significant that we did not require a transfusion despite encountering uncontrolled massive bleeding after the compact nasal packing , since we immediately performed an intervention procedure . another point of clinical significance is that this is the first patient of pseudoaneurysm occurring in i m a after ess . therefore , this patient highlights the importance of the application of immediate embolization in the management of pseudoaneurysm occurring due to intractable bleeding after ess . previously reported patients of pseudoaneurysm after endoscopic sinus surgery ica , internal carotid artery ; pva , polyvinyl alcohol ; rbc , red blood count ; spa , sphenopalatine artery ; u , unit .

abstractpseudoaneurysm is defined as blood leaking out of a vessel that does not have true 3 arterial walls like a true aneurysm , and is susceptible to rupture . only 4 patients of pseudoaneurysm after endoscopic sinus surgery have been reported so far in english literature . recently , the authors encountered a pseudoaneurysm in the internal maxillary artery after endoscopic sinus surgery , which was immediately and successfully managed with endovascular embolization . there was no bleeding or complications 6 months after the embolization .

when you publish , you get to claim scientific priority for a discovery . in return , you share what you know in sufficient detail so that others can reproduce and build on that discovery . what is surprising is that many papers fail to report experimental procedures in sufficient detail for this to happen . i do not think it is intentional in most cases ; rather , i think that we tend to use other published papers as examples of what to report and , facing word limits at many journals , often the methods are the first place we cut corners . we do this even with the knowledge that compromising detail in this section of the paper might be detrimental to readers . when papers do nt provide experimental procedures in sufficient detail another group may have to start from scratch , wasting valuable time and resources . this is unfortunate in any case , but especially so some might even say unethical when the procedures involve experimental animals during my phd in peter walter s lab , part of my first major project was to figure out how to separate and purify the proteins in signal recognition particle ( srp ) . it took about a year of testing different kinds of columns and loading and elution conditions , but i finally got it right , and i published the experimental procedure in my first research paper in 1985 ( siegel and walter , 1985 ) . a couple of years after i started my postdoc , a technician in peter s lab called to tell me she was going to purify some srp proteins , and asked me whether my published experimental procedure was complete and reproducible . i told her i thought it was , but i was terrified that i had left out some crucial step , and that the purification in her hands would fail which would mean that the paper i had published was flawed because , without the purification , the experiments using the purified proteins would be impossible to reproduce . when she called a few days later to announce her success , i was relieved . in a research paper that you write , the methods usually comprise some experimental procedures that you have personally fine - tuned or even designed , and others that were established by others or that you might consider standard . those that are new and yours alone to describe in detail are probably the ones reported most precisely in your research articles . then there are scores of other experimental procedures that have been handed down from colleagues or in lab notebooks and which you consider standard . rather than describing these in detail in your article , you might reference a previous paper that you know used the method , even if you re not sure the method is actually detailed in that paper and if it is nt , you expect it will reference the paper in which it was first described . and then there are the experiments performed at a core facility at your institute , which you trust have been done according to some standard procedure and you may or may not obtain and report those precise details in your paper . you look to other papers to see what details they have reported , and you include what they include , leave out what they leave out . on the flip side , almost all of us have tried to repeat the experimental procedures described in a published research paper , only to find ourselves frustrated by the lack of detail and the need to look up references to other papers that also do nt provide the procedure we re after . so , we start on a wild goose chase , reading the methods sections of several generations of referenced papers eventually to find the goose , or , alternatively , contacting the author to find out what they really did and hope that they know . when papers do nt provide experimental procedures in sufficient detail to know precisely how the experiments were performed at a level of detail sufficient to reproduce them , another group may have to start from scratch , wasting valuable time and resources . this is unfortunate in any case , but especially so some might even say unethical when the procedures involve experimental animals . how , then , can we improve the situation ? when i teach manuscript writing , i urge my students to provide methods like a that s great advice , but as a procedure for manuscript preparation it too is faulty , because it lacks the detail to really guide our students . what we really need are detailed guidelines checklists for describing every type of experiment . perhaps the most well known of these are the consort guidelines for clinical trial reporting ( http://www.consort-statement.org/consort-statement/ ) , which enable both clear reporting of the clinical trial itself and also systematic reviews of related trials that may be informative in a way the individual trials were not . more recently , in 2010 , a study group comprising animal researchers , journal editors , statisticians and research funders convened to develop guidelines for the reporting of research involving experimental animals [ see accompanying editorial in this issue ( percie du sert , 2011 ) and http://www.nc3rs.org.uk/arrive ] . dmm is pleased to endorse these guidelines and to recommend them to our authors and reviewers . their recommendations for writing the main text of the paper , from title through discussion , are for the most part very sensible , but i especially value the guidelines for describing methods . i urge our authors to use them as a checklist when preparing manuscripts for submission , and to read the accompanying editorial from the programme director of the center that provides these guidelines ( percie du sert , 2011 ) . we welcome the development of guidelines for research reporting , and will continue to endorse and to publish guidelines that we find relevant to our authors . as one example , in 2010 , we published a special article called standard operating procedures for describing and performing metabolic tests of glucose homeostasis in mice by ayala et al . for the mouse metabolic phenotyping center consortium ( ayala et al . , 2010 ) . we encourage you to participate in guideline development in your research area and to publish those guidelines in dmm , where they will be immediately freely available upon publication for everyone to read and to use .

summaryprogress in biomedical research depends in part on being able to build on the findings of other researchers and thereby on being able to apply others methods to your own research . however , most of us have struggled to understand how to repeat or adapt another researcher s study because of minimal or missing details in the methods section of a published paper . in expensive and complex experiments involving animal models , clear descriptions of the methods are particularly important . in this and the accompanying editorial in this issue , we discuss how crucial the methods section is to the integrity and utility of a biomedical research paper , and encourage researchers working with animal models to follow the recently released arrive guidelines when preparing their studies for publication .

a healthy 25-year - old caucasian female presented 2 months postpartum complaining of a mass above her right eye . she first noticed it when she was 6 months pregnant and it had progressively enlarged . examination revealed a freely mobile 1 1 cm firm , solitary nodule above the superomedial aspect of the right orbital rim . a computed tomography ( ct ) scan examination of the orbits showed a rounded , soft - tissue mass in the subcutaneous soft tissue at the right supraorbital notch [ fig . 1 ] . there was no associated osseous defect and no intraorbital , sinus or other extension identified . a rounded subcutaneous soft - tissue mass at the right supraorbital notch . there is no associated osseous defect or extension identified the nodule was completely excised and the surgical site closed primarily . they were arranged in interlacing fascicles with occasional storiform pattern in a myxoid stroma [ fig . 2 ] . there were numerous fine capillaries with scattered collections of extravasated lymphocytes and red blood cells present . bland plump spindled cells in a loose myxoid background with extravasated red blood cells and scattered chronic inflammation , ( h and e , 200 ) the etiology remains unknown although trauma and inflammatory reactions have been blamed even though limited evidence substantiates this . periorbital nf can be very concerning since its rapid onset and growth may simulate a malignant process . although periorbital lesions have similar histological features when compared to nf identified at other anatomic sites , the lesions tend to be smaller presumably due to the lack of abundant subcutaneous fat and earlier patient presentation . recurrence of the excised lesion has been documented , but it is so uncommon that it has been suggested that recurrence of a lesion initially diagnosed as nf should lead to a careful reevaluation of the original diagnosis . ophthalmologists are unlikely to consider nf in their differential of lesions in the periorbital region . clinically , the differential diagnosis may include fibroma , solitary fibrous tumor , dermatofibroma , fibrosarcoma , neuroma , neurofibroma , lipoma , granuloma , dermoid , and epidermal inclusion cyst . the clinical and imaging features of nf are not pathognomonic and this can lead to potential diagnostic confusion . histopathologic examination and immunohistochemistry are usually required for the precise diagnosis . despite the absence of cellular atypia , nf can be confused with a spindle cell sarcoma because of its infiltrative quality , rich cellularity , and variable mitotic figures . these include fibrosarcoma , neurofibrosarcoma , myofibroblastic sarcoma , and osteosarcoma . as a spindle cell tumor , nf stains positive for vimentin and variably for sma . similar to our case , nf in the head and neck region more commonly stains diffusely for sma than lesions of the trunk and extremities , suggesting stronger expression by myofibroblasts . a weak presence of estrogen receptors was reported in a series with three out of four cases of back and upper extremity nf , demonstrating focal cytoplasmic positivity for estrogen receptors . a case of intravascular fasciitis , a nf variant , was discovered during pregnancy and the authors hypothesized that the hormone - related changes during pregnancy may have contributed to the development of the lesion . they reasoned that estrogen is known to stimulate fibroblasts and smooth muscle cell types and has been implicated in other fibroproliferative disorders such as carpal tunnel syndrome . since our patient developed nf during pregnancy without a history of trauma , we also reasoned that hormone - related changes may have contributed to the development of the lesion by inducing smooth muscle and fibroblast proliferation . the lesion stained negative for estrogen and progesterone receptors , but this can sometimes be due to poor fixation and embedding procedures . although rare , nf should be considered in the differential diagnosis of periorbital soft - tissue masses arising during pregnancy .

nodular fasciitis ( nf ) is a benign proliferation of fibroblasts and myofibroblasts that rarely occurs in the periorbital region . we report what we believe to be the first case of periorbital nf associated with pregnancy . a case of intravascular fasciitis , a nf variant , has been reported during pregnancy , but it was not located in the periorbital region . a weak presence of estrogen receptors has been reported in nf . this may make it more susceptible to the hormone - related changes during pregnancy and contribute to the development of the lesion by stimulating fibroblasts and smooth muscle cell types . although rare , nf should be considered in the differential diagnosis of periorbital soft - tissue masses arising during pregnancy .

anandamide and the other " endocannabinoids " are endogenous ligands for " brain - type " ( cb1 ) and " spleen - type " ( cb2 ) cannabinoid receptors . also " non - classical " cannabinoid receptors and vanilloid receptors are activated by aea , which plays a number of roles with potential clinical relevance , both in the central nervous system and in the periphery . in view of the broad implications of aea as central and peripheral modulator , its quantification is of utmost importance , also for the consideration that inhibition of aea degradation via uptake and hydrolysis might open new therapeutic perspectives . aea content has been measured in pig , sheep and cow brain , in rat brain and rat peripheral tissues [ 5 - 7 ] , in human brain and human cells in culture , and in mouse brain . most quantitative analyses of aea content have been made by gas chromatography / mass spectrometry ( gc / ms ) after prepurification of the lipid extracts , and normalized to the fresh weight of the samples . this quantification has yielded concentration values in the range 0.2 30 pmol / g fresh weight [ 4 - 7 ] . recently , we have developed a gc / ms procedure for the direct analysis of lipid extracts without prepurification steps . moreover , we normalized the amounts of aea to the protein content of the samples , in order to better compare different tissues and cells , and also in consideration of the fact that determination of proteins is much more reliable than that of fresh weight . using this direct gc / ms analysis we found concentrations of aea in the 340 400 pmol / mg protein range . here , we show that , besides the procedure adopted , the normalization of aea content is a critical factor , which might induce significant differences in the same sample . most notably , we show how applying the same normalization procedure very similar or even identical amounts of aea are found in tissues and in cells independently of their origin , suggesting that this compound is evenly distributed in animals . aea was determined in rat brain , mouse brain , human neuroblastoma chp100 cells and human lymphoma u937 cells , and its content was then normalized to 1 mg of protein , dna or lipid phosphorus , to fresh weight , or to the cell number . while it is obvious that a different normalization method may yield very different values of aea in the same sample ( ~12 to 50-fold lower when aea was normalized to fresh weight or cell number , as compared to protein or dna content ) , it is noteworthy that normalization to a common parameter yielded similar or even identical levels of aea in all samples tested ( table 1 ) . in particular , normalization to dna content yielded the same amounts of aea in rat and mouse brain , but approximately half that value in both tumor cells ( table 1 ) . this finding seems in agreement with the fact that these cells are rapidly growing , and hence they have more dna . values of ~40% , in line with previous reports [ 4 - 7 ] , whereas normalization to the other parameters showed s.d . impact of different normalizations on the quantification of anandamide in brain , and in human cells values are reported as the mean s.d . pi , lipid phosphorus ; fw , fresh weight ; n.d . , not determined . taken together , the present observation might represent a caveat to researchers when they report on the content of a metabolite , also by using newly developed liquid chromatography / mass spectrometry techniques . on the other hand , the present results suggest that the most reliable reference to quantify aea and congeners from different sources is the protein content . in fact , it is a parameter common to cells and tissues , which is easy and rapid to measure with accuracy and reproducibility , even in tiny samples . the authors wish to thank drs natalia battista and valeria gasperi for their skilful assistance .

anandamide ( n - arachidonoylethanolamine , aea ) is an endogenous lipid that binds to cannabinoid receptors in the central nervous system and in peripheral cells . quantitative analysis of aea is generally based on the normalization to the fresh weight of the samples . here , we show that the normalization procedure of aea content is such a critical factor , that it might introduce per se significant discrepancies in the quantification of aea even in the same sample . we suggest that a rapid , accurate and most reliable reference to quantify aea and congeners from different sources is the protein content , a common parameter to cells and tissues .

inverted papilloma is a true epithelial neoplasm characterized by hyperplastic epithelium inverting into the underlying connective tissue . the first description of this entity was made by ward in1854 . this lesion originates from the lateral nasal cavity wall or a paranasal sinus , usually the antrum and appears as a soft , pink or brown , polypoid or nodular growth . possible causes include allergy , chronic sinusitis , occupational exposure to dusts and aerosols , tobacco , and viral infections . the characteristic features of inverted papilloma are the presence of associated nasal polyps , its tendency to recur , destructive potential , and malignant transformation . recurrences after conservative surgical excision have occurred in 75% of cases and transformation to malignancy , usually scc , in 324% of cases . as a result , close postoperative follow - up is necessary for early detection of recurrences and malignant transformations . a 41-year - old woman presented to the department of oral and maxillofacial surgery , faculty of dentistry , tabriz university of medical sciences , tabriz , iran , with a chief complaint of a nodule on the hard palate . the patient had a history of diabetes mellitus and clinical intraoral examination revealed a nodule measuring 0.5 0.7 cm with soft consistency . on radiographic studies no changes were seen . excisional biopsy was performed and histological findings showed multiple islands of epithelium extending into the underlying connective tissue , suggestive of inverted papilloma with mild dysplasia . the patient returned 5 months later with a rapidly growing lobulated mass on the hard palate and maxillary alveolar ridge [ figure 1 ] . a lobulated mass on the hard palate and maxillary alveolar ridge surface ulceration was evident in some parts . computed tomography ( ct ) scan of this massive lesion did not show sinus involvement and bone lysis [ figure 2 ] . palatal biopsy showed epithelial proliferation with multiple inverting islands of epithelium extending into the underlying connective tissue . varying degrees of cellular and nuclear pleomorphism and individual cell keratinization were seen [ figure 3 ] . the patient was sent for chemotherapy before surgery and the treatment has not come to an end yet . scan did not show sinus involvement and bone lysis varying degrees of cellular and nuclear pleomorphism and individual cell keratinization were demonstrated inverted papilloma ( schneiderian papilloma ) is considered the most common benign sinonasal tumor and it is characterized by aggressive local invasion , high recurrence rate , and transformation into malignancy . the name inverted is justified by the endophilic growth pattern of the superficial epithelium . inverted papilloma originates from the nasal cavity lateral wall , and it secondarily affects the maxillary , ethmoidal , frontal , and sphenoidal sinuses . the incidence ranges from 0.5 to 4% of all primary nasal tumors and it is prevalent in the fifth and sixth decades of life . the symptoms include nasal obstruction , hyposmia , frontal headache , epistaxis , and rhinorrhea ( buchwald et al . , 1989 ; 1995b ) . ct scan is considered the investigation of choice ( lund and lloyd , 1984 ) but the size of an inverted papilloma may be exaggerated by ct ( lund , 2000 ) . with mri the tendency to overestimate the size of ip is less than that with ct ( oikawa et al . , 2003 ) . treatment is complete surgical excision , but in cases associated with scc the lesion is treated as a malignancy by performing more radical surgery with or without radiotherapy and chemotherapy . recurrences are usually noted within 2 years of surgery and smoking is associated with increased risk of recurrence . patients with carcinoma in ip are older than those ip patients without carcinoma and they are predominantly males . ( 2003 ) reported two cases of nasal inverted papillomas in 60- and 73-year - old males with malignant transformation . in the case we presented inverted papilloma had originated from the hard palate without sinonasal involvment , which is quite different from what we know about the origin of inverted papilloma in the literature . in this case , the tumor was limited to the palate ; therefore , complete resection was achieved by an intraoral surgery .

the inverted papilloma is a unilateral sinonasal benign tumor which is characterized by aggressive local invasion , high recurrence rate , and transformation into malignancy . the etiology of inverted papilloma is still unknown . possible causes include allergy , chronic sinusitis , occupational exposure to dusts and aerosols , tobacco , and viral infections . treatment is complete surgical excision and close postoperative follow - up is necessary . here we report a case of inverted papilloma arising from the hard palate with malignant transformation in a 41-year - old female . clinical and histological features and treatment are discussed with the review of literature .

eccrine angiomatous hamartoma , a very rare benign hamartoma , usually presents at birth or during early infancy as solitary nodule or plaque generally over extremities . eccrine angiomatous hamartoma ( eah ) is characterized by benign proliferation of eccrine glands associated with capillary in close approximation with surrounding dilated capillaries . in most of the cases they are solitary and they may present as angiomatous nodules to erythematous - purpuric plaques with hypertrichosis , localized hyperhidrosis or occasional pain . eighty percent of the cases are reported over the extremities , with a predilection for palms and soles . we report a rare case of an eah on the face below the right lower eyelid . a 20-year - old female patient presented to us with complaints of solitary small red swelling on the face below the right lower eyelid , gradually increasing in size over the past 8 years . occasionally , she noticed throbbing pain and sweating over the lesion , which aggravated during physical exertion or emotional stress . she did not give any history of birth injury or trauma or any other symptoms suggestive of systemic involvement . cutaneous examination revealed solitary , irregular , erythematous , soft , slightly elevated plaque of about 3 2 cm in size having a smooth , moist surface just below the right lower eyelid [ figures 1 and 2 ] . on palpation , beaded drops of sweat were observed on the surface of the lesion on mild stroking and physical exertion . no pulsation or bruit was felt over the lesion . based on the history and clinical features , a possibility of eah was considered . this was confirmed histopathologically by the presence of circumscribed foci of thin walled capillary channels surrounding large coils of increased eccrine structures in the dermis [ figures 3 and 4 ] . color doppler study of the lesion , in addition , revealed a mild to moderate intensity vascularization in the deep dermis . above clinicopathological features supported our diagnosis of eah . solitary , irregular , erythematous plaque with beaded drops of sweat below the right lower eyelid distant view of the same increased number of eccrine coils with surrounding dilated thin walled capillaries in the dermis ( h and e , 100 ) dilated thin walled capillaries in close approximation with eccrine coils ( h and e , 400 ) eah usually appears at birth or during childhood , although in our case it appeared during adolescence . eah presenting with a blue - colored , ill - defined swelling over the dorsum of left hand in a 26-year - old female has recently been reported . generally , they enlarge very slowly ; more rapid growth has been described during pregnancy and adolescence . the bluish - red or frankly angiomatous smooth nodules or plaques are usually solitary , although multiple lesions have also been described . an unusual presentation of a verrucous lesion over the gluteal region in an elderly person has been reported . lesions mostly favor sites of increased number of eccrine glands like extremities , but there are case reports of occurrence over face and trunk . the lesions are mostly asymptomatic although pain spontaneous or on pressure , may be encountered and might be due to involvement of nerve fibers . they often have overlying hyperhidrosis , as in our case , probably due to stimulation of eccrine glands by the local temperature generated within the angioma . lesional hypertrichosis and the association of eah with cowden 's syndrome , neurofibromatosis , etc . histopathologically , the large secretory eccrine coils are surrounded by thin walled blood vessels and lymphatic channels in the deep dermis with occasional invasion of adipose tissue . the presence of less number of capillary channels in our case helped us to differentiate it from sudoriparous angioma where numerous such vessels are seen . when there are nonspecific clinical findings , common differentials like nevus flammeus , glomus tumor , smooth muscle hamartoma , blue rubber bleb nevus syndrome , angiokeratoma , and macular telangiectatic mastocytosis can readily be differentiated by histopathology . color doppler study , as was done in our case , is not diagnostic but along with magnetic resonance imaging ( mri ) can delineate the extent of the lesion . immunohistochemical studies to demonstrate s-100 protein , carcinoembryonic antigen ( cea ) and antifactor viii - related antigens can be helpful , but were not done for institutional nonavailability . although botulinum toxin , lasers , and sclerosants are now being used as treatment options , we referred the patient to plastic surgery outpatient department ( opd ) for excision and repair . the unusual location of eah in our case and the paucity of its mention in the literature prompted us to report this case .

eccrine angiomatous hamartoma ( eah ) is a very rare benign neoplastic condition characterized by hamartomatous proliferation of eccrine glands and accompanying blood vessels and lymphatics . these lesions are more often present at birth or appear during early infancy and childhood and present as solitary nodule or plaque with occasional pain and sweating . they are generally present on the extremities , mostly the palms and soles . we report here a case of eah in a 20-year - old female who presented with a solitary angiomatous plaque close to the lower eyelid of the right eye with occasional pain and sweating for its rarity .

treatment protocols for such complication are debatable , however , surgical intervene have been advocated . 14 years old male presented with pain and redness around the knee with no history of injury . among all skeletal tumors , osteochondroma constitutes about 10 - 15 % non - traumatic fracture of osteochondroma through the stalk is a known , but rare complication . a 14 years old male patient presented to our outpatient department with pain , redness , and swelling over distal and posterolateral aspect of left thigh with 4 days . on history , taking patient stated that he had a gradual progressive painless mild swelling over that area for 6 month . for 4 days patient increased pain , redness , along with increments in size of previous . he did not reveal episode of recent significant trauma . on physical examination , there was tender , palpable mild swelling over posteromedial aspect of distal thigh . on radiographic examination , it showed fracture through base of pedunculated osteochondroma , which was situated in distal left thigh posteromedially ( fig-1 ) . on meticulous questioning patient gave the history of mild intermittent pain over osteochondroma site after moderate to severe exertion . showing fracture from base of pedunculated osteochondroma for excision posterolatearl approach was used , vastus lateralis was reflected anteriorly and plane was developed between it and lateral intermuscular septum covering hastring muscles ( internervous plane of femoral and sciatic nerve ) to reach the base of growth . with the help of chisel , extra - periosteal excision was done ( with cartilaginous cap ) and raw surface filed ( fig-2 ) and confirmation was done after histopathological examination . recuperating period was uneventful and patient resumed pre - disease activity status after two week . fracture , bursa formation , malignant transition and neurovascular compromise are mentioned complications of osteochondroma which entail it for being symptomatic [ 5 , 6 ] . malignant transition in solitary lesion of osteochondroma is very less ( 1% ) in comparison to autosomal dominant hereditary multiple exostoses , in which it may be up to 5% [ 1 , 8 , 9 , 10 ] . usually pathognonomonic radiological features are sufficient for delineating it , and ct scan is further needed for diagnostic confirmation and pre - op management . it also measures the cartilaginous cap , which ( 1.5 cm ) may be the herald of malignant changes [ 1 , 2 , 11 ] . biopsy usually not used , until other diagnostic tools fail , due to chance of spreading . commonest site of fracture of osteochondroma is around knee [ 1 , 2 , 12 , 13 ] . only few cases of non - traumatic fracture of pedunculated osteochondroma has been reported [ 4 , 7 , 13 , 16 , 17 ] . growth of stalked osteochondroma leads to weakness at its stalk , so the violent muscle contraction or relative friction of muscles may cause the fracture and pain in the absence of history of trauma [ 14 , 15 ] . our patient did not give the history of significant trauma so indirect muscle contraction was the probable cause of fracture . observation and conservative management has also been suggested for such a rare complication , but surgery gives quicker recovery and return to normalcy [ 2 , 7 ] . in our case report , it was also true in which patient got full recovery in two week . in conclusion , it was an uncommon type of presentation of non - traumatic fracture of pedunculated osteochondroma . strong muscle contractions are postulated to cause this complication and surgical excision provides prompt relief .

introduction : non - traumatic fracture of pedunculated osteochondroma is a known , but rare complication . treatment protocols for such complication are debatable , however , surgical intervene have been advocated.case report:14 years old male presented with pain and redness around the knee with no history of injury . radiograph showed fracture of solitary osteochondroma of femur . excision was done through posterolateral approach and confirmed with histopathology . patient returned to activities at 2 weeks post surgeryconclusion : atraumatic fractures may occur due to strong muscular contractions in cases of pedunculated osteochondroma . surgical excision gives prompt relief from symtoms

modern liver techniques allowed the development of segment - based anatomical liver resections [ 13 ] . nevertheless , there is still a place for nonanatomical liver resections . enucleation of small lesions located near the hepatic surface is achieved with low morbidity and mortality and is a current practice among surgeons . however , in some cases , there is a need for enucleation of deep located liver tumors . another option is to use radioablation of these tumors , but this option is not always available and may result in high recurrence in inexperienced hands . the main problem with enucleation of a liver tumor deeply located in the middle of the liver is the control of bleeding resulting from the rupture of small or medium vessels . the authors describe a simple way to control the bleeding without the use of any special instrument or material . this technique can also be used to control bleeding from stellate liver lesions after blunt or penetrating liver injury . after identification of the lesion by inspection and intraoperative ultrasonography , glisson 's capsule is marked with eletrocautery 2 cm away from the tumor margin . the marked area is checked by ultrasonography to ascertain surgical margin right before liver transection . hemihepatic ischemia or pringle maneuver can be applied , according to location of the tumor . after removal of the tumor , a large and deep defect is produced , often with minor or major bleeding . the technique consists of filling the defect with any absorbable hemostatic tissue available , such as surgicel ( ethicon , cincinnati , oh , usa ) , and wait until this hemostatic tissue is imbibed with blood . the cautery is put at maximum power in coagulate mode and the blood is cooked until a crust is formed ( fig . 1 ) . figure 1:technique of bleeding control . ( c ) hemostatic tissue is imbibed with blood and liver borders are brought together with manual compression . ( d ) the cautery is put at maximum power in coagulate mode and the blood is cooked until a crust is formed . ( e ) the lateral compression is released and some residual bleeding is controlled with cautery . ( f ) final view after the use of the technique ( larger arrow ) . note that another enucleated area was controlled with the same technique ( smaller arrow ) . ( c ) hemostatic tissue is imbibed with blood and liver borders are brought together with manual compression . ( d ) the cautery is put at maximum power in coagulate mode and the blood is cooked until a crust is formed . ( e ) the lateral compression is released and some residual bleeding is controlled with cautery . ( f ) final view after the use of the technique ( larger arrow ) . note that another enucleated area was controlled with the same technique ( smaller arrow ) . although anatomical resection , which allows a better clearance between tumor deposits and the cut section of the liver , is recommended as a standard procedure for liver tumors , nonanatomical resection is quite feasible for small tumors with little risk of microscopic local invasion [ 57 ] . indeed , liver resection of peripheric small lesions is feasible and can be done with minimum morbidity and mortality rates . enucleation is also used to remove small liver tumors from the future liver remnant after major liver resections . enucleation of deep located liver tumors may result in rupture of small venous or portal branches that are not always easy to control . another common situation that may be a good indication for the present technique is penetrating abdominal trauma with liver injury . usually , multiple stellate liver injuries are not easy to control and liver packing may be necessary for damage control . this technique may help dealing with these injuries without the use of any special equipment . it did not require any fancy device or instrument , and it is an important adjunct for the treatment of multiple liver tumors . we have been used this technique for hemostasis control after nonanatomical liver resections since 2012 , with excellent results . this technique is useful in combination with anatomical liver resections , such as right and left hemihepatectomies , or two - stage liver resections . it is also useful to control the bleeding from penetrating liver injury and therefore can be an important tool for the general surgeon .

modern liver techniques allowed the development of segment - based anatomical liver resections . nevertheless , there is still a place for nonanatomical liver resections . however , in some cases , there is a need for enucleation of deep located liver tumors . the main problem with enucleation of a liver tumor deeply located in the middle of the liver is the control of bleeding resulting from the rupture of small or medium vessels . the authors describe a simple way to control the bleeding without the use of any special instrument or material . this technique can also be used to control bleeding from penetrating liver injury .

much attention is being paid these days to the importance of engaging patients and their caregivers in identifying and prioritizing research topics and throughout the conduct of the research itself.2 however , this trend toward user engagement is far broader than the individual patient or clinician . for over 30 years , the field of community - based participatory research has been refining methods for engaging community representatives in research design and execution.3,4,5 researchers focused on policy relevant questions have long recognized the importance of connecting with policymakers early on at the federal , state and local levels.6,7,8 increasingly , delivery system leaders are building embedded research units to apply rigorous hsr methods to the study of the operational questions system leaders have . what these user groups have in common is a desire to play a substantive role in setting the agenda for the research community as well as sometimes being involved in the research itself . however , doing this effectively will require significant changes in how many investigators approach their work which will entail changes in how research is funded and knowledge of which user engagement approach is effective for which research . academyhealth convenes the consumer patient researcher ( cpr ) roundtable as a collaborative forum to explore these issues and has recently published a report on the many phases of consumer / patient engagement in research.9 egems extends our work in this area and is an opportunity to share what the field is learning about truly engaging patients and other users in our research . recent investments in health information technology and comparative effectiveness research ( cer ) have provided substantial capital to make meaningful progress toward building an infrastructure ( governance , data , methods , and training ) capable of addressing many of the challenges of traditional study designs and data sources used in outcomes research and quality improvement ( qi ) . of the $ 1.1 billion provided for cer in the american recovery and reinvestment act , approximately 38 percent10 supported infrastructure development ( including data , methods , governance , and training ) . the prospect , drn , enhanced registry studies ( representing a $ 100 million investment to build ecd infrastructure for multiple uses ) , as well as the edm forum are all funded through this mechanism and offer key lessons that are important for others to learn from if we are to accelerate cer and qi and use the knowledge to improve clinical care and patient outcomes . the proliferating numbers of research and qi networks are each confronting fundamental issues and challenges in all aspects of using ecd including access , governance , management , and linkages . while the lessons they are learning are not the stuff of traditional peer - reviewed journals , they do have tremendous scientific import . we need to exchange these lessons as rapidly as possible to benefit the growing community of researchers grappling with problems that , more often than not , are similar . our hsr community needs a platform like egems to make this happen . without this type of dissemination and sharing , researchers are doomed to keep re - learning the same lessons in study after study , network after network.11,12,13,14 the challenges of translating and disseminating hsr , cer , pcor , and qi are anything but new.15,16,17,18 what is new is the urgency of the need to change business as usual in health care . policymakers , employers , health system leaders , and patients have made it clear that costs can not continue to increase and that better quality and outcomes must be achieved . the research community can not stand apart from this demand : we need to deliver answers more quickly and effectively . to do so we need to learn together how to respond to the imperative to improve health and health care . to that end academyhealth is launching a new translation and dissemination institute to extend our capacity to have an impact . as a research community we have much to learn in the coming years for us to effectively seize our moment . egems is another new tool to help all of us accelerate this learning together . to borrow from ralph waldo emerson , learning is also a journey , not a destination , and egems can help us share our journeys .

the field of health services research faces significant challenges as it aims to address pressing issues of quality and cost in the us healthcare system . major advances in the availability of electronic clinical data ( ecd ) provide the opportunity to address questions that are important to the recipients , providers , and purchasers of health care . this is where egems has a role to play , meeting an expressed need in the scientific community by disseminating approaches and methods for using ecd . egems can help researchers address these important questions and consider strategies to further improve the us healthcare system .

trichotillomania consists of the recurrent compulsive habit of pulling out of one 's own hair , resulting in a perceptible hair loss pattern that frequently is associated with other psychiatric processes , and social or functional impairment . it can be a self - limiting symptom but in most cases is a chronic disorder with frequent remissions and relapses . therapeutical management is difficult and behavioral therapy , psychotherapy , hypnosis , or pharmacological treatment has been used without satisfactory results . recently , n - acetylcysteine has been proposed as an effective alternative in the treatment of this disorder . the first patient was a 23-year - old woman that attended at our outpatient dermatology department with partial alopecia of her eyebrows , eyelashes , and frontal hairline of the scalp . the disorder was related with the death of her mother during childhood . on physical examination , patchy alopecia in eyebrows , eyelashes and in the frontal area was noted , with somewhat artificial appearance and presence of hairs with different length [ figure 1a ] . in the past n - acetylcysteine 1,200 mg / day was started and complete regrowth occurred in the frontal area within the first two months of treatment , which maintained until the 6-month follow - up period [ figure 1b ] . the second patient was a 19-year - old woman with an irresistible urge to pull out of her hair since the age of 9 . she presented diffuse hair loss affecting the entire scalp with broken hairs and hairs with different lengths on dermatoscopic examination [ figure 2a ] . complete regrowth was observed after introducing n - acetylcisteine 1,200 mg / day during 3 months [ figure 2b ] . no adverse events with the medication ( a ) patchy alopecia in frontal area with presence of hairs with different length ; ( b ) complete regrowth in the frontal area after two month treatment with n - acetylcysteine dermoscopic examination before ( a ) and after ( b ) three month treatment with n - acetylcysteine 1,200 mg / day trichotillomania is a traumatic alopecia caused by the patient himself by pulling out of the hair with the aim of tearing it off . the incidence it 's not known with exactitude , but it is estimated that affects between 0.6 - 1% of the population . it can appear in any hair - bearing area , but the most frequent locations are the scalp and eyebrows , while the eyelashes are exceptionally affected . the alopecia presents with an artificial pattern , with circular or lineal forms , and fractured hairs at different lengths . the disorder can be associated with trichofagia , onichofagia and other self - inflicted cutaneous mutilations , as well as trichobezoar . it depends on the beginning - age of the disorder and of the possible associated co - morbidities . in any case is important to establish a good doctor - patient relationship , to inform and advice about the nature of the disorder and recommend a psychiatric evaluation . between the available pharmacological treatments for trichotillomania , tricyclic antidepressant clomipramine has shown to be effective , but often the patient adherence is poor and the results are modest . also , selective serotoninergic receptor reuptake inhibitors ( ssris ) have been considered as a first line treatment for this disorder but there is no evidence that supports its benefits . furthermore , some agents , such as naltrexone or neuroleptics , like pimozide , have been used in combination with other alternatives . habit reversal training is the most effective behavioral therapy , and should be associated with pharmacological treatment . recently several reports have indicated that n - acetylcysteine , a glutamate modulator , could be effective in reducing symptoms of trichotillomania . it acts by restoring the extracellular glutamate concentration in the nucleus accumbens , decreasing its levels , which seem responsible for the pathogenesis of compulsive behaviors , and therefore , trichotillomania . conducted an aleatorized double - blind clinical trial , comparing n - acetylcysteine with placebo , with doses ranging between 1200 and 2400 mg per day and have observed that it was more effective and safe than placebo , and that also produced better results than other pharmacological alternatives , with no reported adverse events . nevertheless , the promising results n - acetylcysteine is showing further studies need to be conducted to establish the appropriate treatment regimen and to evaluate it long - term efficacy in improving this chronic condition .

trichotillomania is as medical condition caused by the patient himself by pulling out of is own hair , resulting in a perceptible hair loss pattern that frequently is associated with other psychiatric processes . generally has a chronic course in most patients , and a challenging therapeutical management . there are several available options for is treatment , but the clinical response is not satisfactory in many patients . recently , n - acetylcisteine , a glutamate modulator , has shown efficacy in the treatment of trichotillomania and other compulsive behaviors , and is considered a new alternative in the management of this condition . we describe two patients with trichotillomania successfully treated with n - acetylcysteine . nevertheless , further studies need to be conducted to establish the appropriate treatment regimen and to evaluate it long - term efficacy in improving this chronic condition .

a 55-year - old man in good general health had pain and intermittent locking of the left knee of two months duration . magnetic resonance imaging ( mri ) showed a displaced bucket - handle tear of the lateral meniscus and so arthroscopic lateral meniscectomy was performed . increasing pain and swelling in the left popliteal fossa developed postoperatively over the following five days . a 65-ml hematoma was aspired and repeat arthroscopy of the knee detected only remnants of blood . the same symptomatology was displayed four days later and so the patient was referred for endovascular management . selective arteriography was performed via the right femoral artery , and a 4-fr catheter was placed into the left proximal popliteal artery . after contrast injection ( 30 ml at 8 ml / sec ; iopromida , shering , madrid , spain ) , a pseudoaneurysm measuring 2.51.60.9 mm and arising from the lateral inferior genicular artery was detected ; there was early venous drainage via the hypertrophied genicular veins , forming an arteriovenous ( av ) fistula ( fig . 1 ) . a hydrophilic 3-fr catheter ( terumo , leuven , belgium ) was selectively advanced over a guide wire into the injured genicular artery . the pseudoaneurysm was embolized with two small ( 2 mm in diameter , 20 mm in length ) fibered platinum coils ( cook europe , bjaeverskov , denmark ) . follow - up angiography demonstrated complete occlusion of the av fistula , with no filling of the pseudoaneurysm ( fig . clinically , the patient became free of symptoms a few days after the embolization and further clinical follow - up at six months was uneventful . vascular injuries arising from artroscopy of the knee are very rare , and several large series have reported an incidence of less than 1% ( 1 , 2 ) . most vascular injuries involve the popliteal artery or vein , or both ( 2 ) . pseudoaneurysms of the popliteal and lateral genicular arteries after knee surgery are rare and only a few , isolated case reports have been published ( 3 - 6 ) . pseudoaneurysms are more likely to form when a vessel is incompletely divided and blood dissects into the surrounding soft tissues . the susceptibility of the popliteal artery and its branches to injury during arthroscopic meniscectomy is due to several factors , including the employed surgical technique , and the operator 's experience and knowledge of their anatomic location ( 3 , 4 ) . the popliteal artery is close to the posterior capsule of the joint and it is moved forward during knee flexion . however , visualization of this region during knee arthroscopy is limited and any injury is often not immediately recognized ( 4 ) . nevertheless , the formation of combined pseudoaneurysm and av fistula after knee arthorscopy is extremely rare . only two such cases have been previously reported on , and both of these occurred in the popliteal artery ( 5 , 6 ) . reported a case of av fistula of the lateral superior and inferior geniculate arteries , and the etiology of this was unclear ( 7 ) . in our case , the mechanism to injury was probably direct trauma by cutting all three layers of both the artery and vein with scissors , which resulted in an av fistula . alternatively , hematoma formation around the artery and vein with degradation of the enclosed vessels may have also resulted in a combined pseudoaneurysm with av fistula . when a patient has popliteal swelling , mass , bruit , thrill , recurrent hemarthosis , pain , calf edema , and/or a neurologic deficit after a knee arthroscopy , the possibility of a vascular injury should be considered early on in the diagnostic process ( 2 , 4 ) . the diagnosis can be confirmed by conventional arteriography , as in our case , by color doppler sonography , or with using three - dimensional ct or mri arteriography techniques ( 4 - 8 ) . surgical exploration with vessel ligation is the " gold standard " of treatment because it preserves distal flow if collateral circulation has formed ( 3 , 5 - 8 ) . other treatment options include correction of the vascular tear by vascular patch or direct suture ( 8) . sonographically guided compression to occlude the postcatherterization pseudoaneurysm of the femoral and brachial arteries has been reported on ( 9 ) . however , with the advances in selective endovascular techniques , percutaneous embolization has been successfully performed for the management of popliteal pseudoaneurysms and also for the delayed combined pseudoaneurysm and av fistula of the anterior tibial artery after an open tibial fracture ( 10 ) . in our case , we embolized the lesion with using microcoils to definitely occlude the pseudoaneurysm and av fistula . this case demonstrates that superselective percutaneous angiographic embolization with coils offers the advantages of a minimally invasive approach ( no surgical incision , a reduced risk of infection and a shortened hospital stay ) ; therefore , this technique may represent an effective and safe therapeutic alternative for this uncommon complication of knee arthroscopy . in summary , we report here on a unique case of a lateral inferior genicular artery pseudoaneurysm with concomitant arteriovenous fistula as a complication of knee arthroscopy .

arthroscopic meniscectomy of the knee is generally a safe and effective procedure with a low rate of vascular complications . we report here on a unique case of a 55-year - old man with a lateral inferior genicular artery pseudoaneurysm and a concomitant arteriovenous fistula that developed after arthroscopic meniscectomy ; this was successfully treated with selective angiographic embolization . this case illustrates the effectiveness of an endovascular approach as a minimally invasive treatment for this uncommon complication that occurs after an arthroscopic procedure .

charcot arthropathy was first described in 1868 by jean martin charcot as a progressive and destructive joint disease , . although in the years described neurosyphilis was the most frequent cause , at the present diabetes mellitus is the most common etiology for this disease . incidence among the patients with diabetes is 7.5% and the disease most commonly involves the feet and ankles . it is known that the 6% of the charcot arthropathy in diabetes affects knee joint , . its pathophysiology is explained with sensorineural , autonomic and motor dysfunction leading to instability , osteopenia , and micro trauma . polyneuropathy , syphilis , syrengomyelia and chronic alcoholism are the main causes of the disease in the literature . however , charcot arthropathy can be seen after some spinal cord pathologies , there is no literature known as charcot knee arthropathy as a complication of spinal stenosis surgery . in this study a 62 years old women had a spinal stenosis surgery at 2010 with a posterior instrumentation ( figs . 1 , 2 ) . at the 1 year follow up an mri of the patient s left knee showed inflammatory changes compatible with a charcot knee . patient had been out of follow up for 4 years and did not receive any treatment . when patient first presented there were an increased varus and valgus instability with hyperextension laxity in her left knee joint . x - rays also showed excessive bone loss at the medial plateau of the tibia ( figs . 3 , 4 ) . there were no sings of oedema , swelling and erythema on inspection . according to the patient s medical history it was obvious in hindsight that the patient had been charcot arthropathy and the disease was already beyond the fragmentation and coalescence stages at that moment . an immediate emg study showed us the l3-s1 roots had a severe chronic polyneuropathy with total sensorineural loss.fig . 4lateral x - ray of the knee joint at the end stage of the disease.fig . lateral x - ray of the knee joint at the end stage of the disease . patient also had an ulcerative wound at the left heel which diagnosed as charcot foot because of the polyneuropathy and that wound was treated at 2006 with surgery . based on the medical history , orthopaedic and neurologic examination and the radiologic sings we believe that this patient developed a neuropathic arthropathy at her left knee after a spinal stenosis surgery . we preferred conservative treatment for the patient and suggested a custom made hinged knee brace for a daily use , , ( fig . follow up we have seen that the patient was walking comfortably with crutches while using the brace . patient was consulted with the physical therapy and rehabilitation department for the use of bisphosphonates and medical treatment as well .fig . 5clinic and functional pictures of the patient , at present.fig it is usually seen at patients with diabetes mellitus as a long - term complication with or without polyneuropathy . furthermore the literature shows us that after spinal canal pathology or even after spinal anaesthesia procedure charcot arthropathy can be seen . incidence of the involvement of the knee is less than the distal joints such as foot and ankle . for that reason , spinal procedures should be applied with extra caution on the patients with polyneuropathy or any neuropathic arthropathy . it should be remembered that it is possible to encounter unexpected complications such as proximally migration of the level of sensorineural loss and progression of the actual disease after spinal procedures of these patients . written informed consent was obtained from the patient for publication of this case report and accompanying images .

highlightswe report here a case of a 62 years old patient with charcot arthropathy at her left knee developed one year after spinal stenosis surgery.the patient s knee joint was already beyond the fragmentation and coalescence stages at the moment of physical examination.unsuccessful spinal surgery affected polyneuropathy and migrated the level of the sensorineural loss proximally.elevated level of sensorineural loss resulted in charcot knee joint in a short period of time .

in switzerland , the so - called clinical electives year is integrated into the three - year masters study programme as part of the altogether six - year medical studies course in the faculties of medicine of bern , basel , geneva and zrich , as well as the faculty of biology and medicine in lausanne . during this year , the emphasis is on the clinical instruction of students . in principle , courses of study in medicine , dentistry , veterinary medicine , pharmacy and chiropractic are regulated by law at the federal level under the swiss federal law on medical professions . here , the statutory text defines general learning objectives valid for all courses of study , as well as specific learning objectives for the study of medicine . in addition to this , the swiss catalogue of learning objectives for undergraduate medical training ( sclo ) describes the profile required to enter postgraduate training in terms of competences , learning objectives and learning content . the second edition is mentioned in the swiss federal examination regulations for swiss federal licensing examination for human medicine , and is thus applied to the faculties in significantly more binding form . furthermore , in the second half of 2014 a federal working group from the federal office of public health ( bag ) and the faculties mandated via the swiss medical inter faculty commission ( smifk ) was set up to develop the third edition of the learning objectives catalogue by early 2017 . depending on the different faculties , there are differences , and sometimes considerable ones , between the content and structural framework of the clinical electives year . regarding content , all faculties largely reference the competences and learning objectives outlined in the sclo . nevertheless , there are differences between faculties , for example with respect to guidelines on the choice of clinical disciplines , or the proportion of clinical rotations completed in medical practices , research groups or health care institutions . with regard to the structural aspects , for example , the location of the clinical electives year within the study programme varies depending on the faculty ( 2 , 2 - 3 or 3 year of the masters programme ) , as does the duration ( a total of 7 - 10 months ) . regarding the perspective of the quality development of instruction during the clinical electives year , in addition to the difference in content and structural aspects , two main categories can also be highlighted : firstly , the guidelines available to individual students on how to construct their clinical electives year , and secondly , the basic criteria for hospitals , clinics , medical practices and other institutions in which medical students complete their different clinical rotations . especially in view of the second category , the work of raes et . al . proposes a substantial and comprehensive catalogue of criteria , which includes criteria for process and structure as well as results . from the swiss perspective , a similar approach seems reasonable and feasible in principle , particularly due to the high mobility of swiss national students during their clinical electives year . this high mobility amongst other things - results in the application of different basic criteria from different faculties to students on the same course of instruction . in addition , the guidelines for individual students should basically have a uniform structure , although adapted to the variable duration of clinical rotations in the same clinical discipline which is possible in all faculties . with regard to the structuring of content , and based above all on the competences which must be taught , all faculties have introduced a portfolio or logbook for the clinical electives year . as a rule , these are based on the sclo in terms of competences and roles , learning objectives in the field of clinical skills , and the chapter problems as starting points for training . with regard to the future quality development of the clinical electives year in switzerland , above all it would appear to be essential that all faculties work together to further develop structural and content guidelines for students and institutions . in addition , the objective should be , where possible , to implement and use the same tools to structure content ( logbook , portfolio ) and for formative and summative assessment ( for example , workplace - based assessment ) . not least , emphasis must also be placed on the crucial importance of student participation in the context of systematic feedback on the clinical electives year and its further development .

with their publication on quality management of clinical - practical instruction for practical year medical students in germany and the preparation of a catalogue of criteria , raes et al . tackle questions , both in terms of content and structural framework , in a current and relevant subject area [ 1].the following commentary provides an additional outline of the current situation of clinical - practical instruction during the so - called clinical electives year in switzerland , which broadly corresponds to the practical year in germany .

a fifty - year - old man was referred to our hospital for pain and instability in the left knee , which had developed after removal of the illizarov external fixator . twenty months ago , he suffered a midshaft open fracture ( type iiia ) of the left tibia in a traffic accident . so , he underwent an open reduction and external fixation with illizarov , which was removed after completion of bone union . physical examination revealed no direct tenderness , swelling , and neurovascular deficit . range of motion of the knee joint was normal ( range , 0 to 135 ) . on the knee stress test , the patient showed posterior drawer grade iii instability , and there was no posterolateral rotary instability . the femoral tunnel was created under arthroscopic guidance with the patient lying in supine position . we passed a guide wire through the tunnel for the passage of the graft tendon . then , the operating table was tilted to the left side and the knee was externally rotated to partially expose the popliteal fossa . a hockey stick skin incision was made on the posteromedial aspect of the knee joint . the plane between the medial head of the gastrocnemius and the semimembranous tendons was identified . the medial head of the gastrocnemius tendon was retracted laterally to protect the neurovascular structures . then , a vertical incision was made through the oblique popliteal ligament and posterior capsule to expose the tibial attachment site of the pcl . we used an achilles tendon allograft : the tendinous portion of the graft was 1.1 cm in thickness ; and tibial bony trough of the graft was 3 cm in length , 1.3 cm in width , and 1.3 cm in thickness . after passage of the graft , pretension of the graft was done in the femoral tunnel , and the achilles tendon bone block was inlaid within the tibial window and fixed with a 4.5-mm cannulated screw and a washer ( depuy synthes , amersfoort , netherlands ) ( fig . immediate postoperative physical examination revealed grade i muscle power in great toe dorsiflexion , grade iii muscle power in great toe plantarflexion , and numbness in the dermatome of the deep peroneal nerve . the pulse of popliteal artery was checked , but that of the posterior tibial artery and dorsalis pedis artery was not checked . it was suspected that the decreased muscle power and numbness were due to popliteal artery compression , and emergency femoral angiography was done . , we found that the tibial bone block , not the cannulated screw and washer , compressed the popliteal artery posterolaterally ( fig . , we made an incision along the previous operation scar and removed the screw and bone block . we moved the bony trough more distally from the anatomic pcl footprint to secure appropriate graft tension and refixed it with a 7.0-mm cannulated screw and a washer ( depuy synthes ) ( fig . we used the tibial inlay technique in single - bundle pcl reconstruction using achilles tendon allograft because it has been reported as a favorable method providing good results6 ) . it has been especially advocated for patients with osteopenia from disuse , fractures , and in revision surgery4 ) . miller et al.7 ) fixed the grafted bone block with a screw on the back of the tibia after injection of barium into the femoral arteries in eight fresh - frozen knees . then , they measured the distance from the center of the screw to the edge of the popliteal artery , the average distance of which was 21.1 mm ( range , 18.1 to 31.7 mm ) . they reported that the tibial inlay technique is safe with regard to the popliteal artery . berg8 ) attempted anterior and posterior approaches with the injured leg in an elevated lateral position . burks and schaffer9 ) fixed graft to the tibia using the posterior approach after passing the graft tendon through the femoral tunnel in supine position . originally , tibial inlay bone graft is supposed to be fixed in a prone or lateral position in the tibial inlay technique . however , we could not obtain a sufficient view of the popliteal fossa in the surgical field because the injured leg was maintained in external rotation and abduction with the patient placed in supine position . moreover , it appeared that screw insertion for fixation of the bone block could result in lateral displacement of the bone block due to the risk of wrong placement of the screw from posteromedial to anterolateral in the supine position . in our opinion , direct posterior approach is safer than supine position . we think that the patient should be placed in lateral or prone position when the tibial inlay technique is utilized . in our case , we used a bone block thicker than the cortical window of the tibia , and the popliteal artery compression was attributed to the short distance between the graft bone block and the posterior neurovascular structures . therefore , it is our understanding that the bone block thickness also plays a role in the development of popliteal artery compression . in the second operation , mismatch of the tension of the graft tendon occurred . for prevention of abrasion of the graft tendon , we took care to relieve tension of the graft tendon and induce anterior displacement of the graft tendon , and the tibial bone block was re - fixed at a more distal site than the normal pcl footprint . in general , the tibial inlay technique is a preferred method in pcl reconstruction that rarely results in neurovasulcar complication . however , graft bone block size , screw positon and direction , and patient 's position during surgery may be risk factors for this complication . therefore , the surgeon should take consideration into such factors during pcl reconstruction using the tibial inlay technique .

popliteal artery compression rarely occurs after posterior cruciate ligament ( pcl ) reconstruction using the tibial inlay technique that allows for direct visualization of the surgical field . however , we experienced a popliteal artery compression after pcl reconstruction performed using the technique , which eventually required re - operation . here , we report this rare case and discuss reasons of popliteal artery compression .

an ethical committee consent was taken to use oral paracetamol for patent ductus closure in preterm neonates with significant pda who had contraindication for brufen / indomethacin use . there were total of 18 preterm neonates who had significant pda , out of these oral brufen was given to eight preterm neonates and 10 were given oral paracetamol as brufen was contraindicated . we report 10 preterm neonates born at gestational age 27 - 33 weeks with birth weight range 800 grams to 1,400 grams admitted to our nicu . all these preterm neonates were diagnosed to have hemodynamically significant ( features of congestive cardiac failure ) pda at 4 - 7 days of life . each of these neonates were given oral paracetamol in the dosage of 15 mg / kg 8 hourly for 48 h. these neonates were monitored for temperature changes before and 30 min after giving oral paracetamol and no significant temperature difference was noted . the ductal closure was confirmed with repeat echocardiography after 72 h of administration of oral paracetamol . require pharmacologic and/or surgical intervention to close a hemodynamically significant patent ductus arteriosus ( pda ) . indomethacin has been the pharmacologic treatment of choice and has also been used prophylactically in very premature neonates to prevent pda . the drug , however , is associated with renal and gastrointestinal adverse effects . in july 2006 , the mechanism of action for both indomethacin and ibuprofen is through inhibition of prostaglandin synthesis , resulting in ductal constriction . ibuprofen has demonstrated significantly less effects on cerebral , renal , and mesenteric blood flow in premature neonates when compared with indomethacin . a transient but significant increase in serum creatinine concentration , decrease in urine output , and increase in frequency of oliguria however , the rate of reopening of the ductus after pharmacologic closure and the need for rescue therapy were not different between the two drugs . in addition , no differences were noted in other outcomes such as frequency of intraventricular hemorrhage , necrotizing enterocolitis , or chronic lung disease , as well as in duration of mechanical ventilation and length of hospital stay . although its precise mechanism of action remains controversial , paracetamol seems to act at the peroxidase segment of the enzyme . therefore , paracetamol - mediated inhibition is facilitated at reduced local peroxide concentrations ( e.g. , hypoxia ) . theoretically , these differences would permit peroxidase inhibition to be optimally effective under conditions in which cyclooxygenase inhibition is less active or hypothetically , render it ideally suited for treatment in the pda environment . the exact mechanism use of oral paracetamol in ductal closure has not been studied on large scale ; however with this study it is evident that oral paracetamol is equally effective in ductal closure with no side effects which was there with brufen / indomethacin . however

patent ductus arteriosus ( pda ) , in which there is a persistent communication between the descending thoracic aorta and the pulmonary artery that results from failure of normal physiologic closure of the fetal ductus , is one of the more common congenital heart defects in preterm neonates . the closure of pda can be done with either indomethacin or brufen which are cyclooxygenase 1 , 2 inhibitor ; however these drugs are associated with side effects . we report an interesting findings of ductal closure in 10 preterm neonates ( gestational age 27 - 33 wks ) presenting with significant large pda who had failed or had absolute contraindication with brufen . these preterm neonates were treated with oral paracetamol in the dose of 15 mg / kg 8 hourly . the pda closure was achieved within 48 h and there was no complication .

raised creatinine is known to occur in hypothyroidism , and there are different mechanisms for this . cases of hypothyroidism with severe myopathy , rhabdomyolysis , and acute kidney injury are rare and are limited to case reports.[13 ] we present one such patient who was directly referred to a nephrologist by the general practitioner suspecting renal pathology , and discuss the mechanisms of such a presentation and the importance of looking for alternative causes in a patient presenting with isolated elevation of creatinine . a 30-year - old male presented with a history of generalized edema and significant weight gain of 20 kg in 6 months . the creatinine was elevated at 2.12 mg / dl , which was the reason for referral to the nephrologist . routine investigations revealed a completely normal hemogram and urine analysis , elevated creatinine at 2.17 mg / dl but normal blood urea at 15 mg / dl . hypothyroidism was suspected , which was confirmed with a t3 of 0.19 ng / ml , t4 of 0.4 g / ml , and a thyroid stimulating hormone ( tsh ) of 780 iu / ml . a diagnosis of severe hypothyroidism with myopathy was made and given the normal blood urea , normal urine analysis , and renal ultrasound , the raised creatinine was thought to be secondary to excessive production rather than impaired renal function . he was commenced on thyroxine replacement therapy and a review in 2 weeks revealed a ck of 2,228 u / l and a creatinine of 1.5 mg / dl , both of which had normalized during the subsequent visit . serum ck levels are often modestly elevated in hypothyroidism , but elevations in the levels usually seen in inflammatory myopathies or dystrophies are rare . there are case reports of extremely high elevations of serum ck with or without rhabdomyolysis associated with hypothyroidism.[13 ] if such a patient has significantly elevated creatinine , it may either be due to excessive production or acute kidney injury ( aki ) caused by the toxicity of the non - protein heme pigment that is released from myoglobin . a urine analysis that shows microhematuria in the absence of visible red cells by urine microscopy in the appropriate clinical setting is sufficient to diagnose aki due to rhabdomyolysis . our patient was non - oliguric and had completely normal urine analysis , which ruled out rhabdomyolysis as the cause of his elevated serum creatinine . an elevation in the serum creatinine concentration usually means a reduction in the glomerular filtration rate ( gfr ) , and is associated with a concomitant rise in the blood urea . however , there are a variety of settings in which the creatinine can increase in isolation , independent of the gfr , and therefore there is no true change in the overall kidney function . this may be due to one of the three factors : decreased creatinine secretion , interference with the serum assay , or enhanced creatinine production . our case is one such example of a mechanism where there is likely to be a release of pre - formed creatinine from injured muscle and/or release of creatine that is then converted into creatinine in the extracellular fluid . it is important to look for such unusual causes in someone with unexplained isolated elevation in serum creatinine , especially in the absence of other markers of renal disease like abnormal urine analysis or ultrasonological abnormality of the kidneys . consistent and reversible elevation of serum creatinine in the hypothyroid state has been described in a study of 24 consecutive patients of iatrogenic hypothyroidism . in this study , the rise in creatinine levels did not relate to abnormalities in ck levels or abnormal urine analysis , suggesting that neither hypothyroid myopathy nor intrinsic renal disease contributed to the changes seen . another study has shown significantly elevated serum urea and creatinine in patients with overt and sub - clinical hypothyroidism , which correlated positively with tsh levels . in our patient , both the ck and the serum creatinine levels were significantly elevated and blood urea was consistently normal with unremarkable urine analysis and renal ultrasound . both creatinine and ck levels improved together , suggesting that the elevated creatinine was a reflection of enhanced creatinine production in the muscle rather than decrease in the gfr . proving this theory will involve measuring the gfr with radionuclide study or inulin clearance , which has not been carried out in this case . serum cystatin c level has also not been measured in our patient ; however , the cystatin level showed no superiority when compared with serum creatinine estimation in the assessment of renal function in the setting of hypothyroidism . to conclude , our patient had an unusually high level of ck , which resulted in elevation in his serum creatinine level , both of which normalized with the treatment of hypothyroidism . elevation in serum creatinine levels can occur even in the absence of decline in the gfr , and one should look hard for unusual causes , especially in a patient with absence of concomitant elevation of blood urea .

myopathy is common in hypothyroidism , but a very high creatinine kinase ( ck ) level in the range commonly seen with inflammatory myopathy is rare . reversible elevation of creatinine is known to occur in hypothyroidism due to a decrease in the glomerular filtration rate , but it can also occur rarely due to enhanced creatinine production . we present a case of severe hypothyroidism with massively elevated ck levels and high creatinine levels , both of which reversed on treatment of hypothyroidism .

a small number of cases of congenital prepubic sinus ( cps ) have been reported.1 2 cps is a rare congenital anomaly of the urinary tract . it is associated with discharge from an opening overlying the symphysis pubis , and affects both males and females.3 cps may either be a complete or incomplete channel that runs parallel to the normal urethra from the prepubic glans or clitoral area and extends to the bladder , which may either join the urethra or end blindly.4 dorsal urethral duplication and cloacal anomalies are assumed to be the causes of this condition.5 in most cases of cps , a tiny hole is seen in the prepubic area . we herein report a case of cps in which the tissue extending from the overlying skin mimicked the corpus spongiosum of the penis . a 3-year - old boy with weight of 12 kg was admitted for yellowish discharge from a tiny opening along the midline of the pubic physical examination revealed a tiny sinus in the prepubic area and 3 cm of tissue , similar to the corpus spongiosum , attached to the sinus . fistulography showed a noncommunicating fistulous tract coursing from the prepubic skin toward the bladder ( fig . the overlying tissue located 3 cm from the base of the penis was excised and found to be continuous with the sinus tract . the sinus opening was probed and simple excision of the sinus tract was performed , revealing a tract approximately 4 cm long that extended to the retropubic space and ended in a fibrous tract . the postoperative course was uncomplicated , and the boy remains asymptomatic 1 year after the intervention . histomorphological findings showed that the tissue was lined with squamous epithelium , and the accompanying urothelial residue was compatible with urothelial cysts and surrounded by focal smooth muscle layers . the sinus usually passes from the base of the penis near the abdominal wall toward the anterior bladder without communicating with the urinary tract.6 the diagnosis is generally established by confirming the presence of the sinus tract using fistulography or the us . the diagnosis in our case was confirmed with us , and fistulography revealed the precise anatomy of the sinus . variants of cps have been reported , and because the anatomic features often differ , a consensus concerning the embryology and classification has not yet been established . rozanski et al7 reported a case of cps that represented a mild form of a midline closure defect . a second theory is that the defect does not allow for complete replacement of the ventral cloacal membrane by the lateral mesodermic folds , creating a fistulous tract.8 van der putte9 considered the basis for this condition to be congenital malformations of cloaca - derived orifices , such as hypospadias , epispadias , vesical and cloacal exstrophy , double urethra , and prepubic sinuses . most reported cases of cps have been characterized by a tiny opening in the prepubic area that was primarily surrounded by squamous epithelium . campbell et al10 reported three cases of cps in which the sinus tract was surrounded by stratified squamous epithelium or transitional epithelium with concentric bundles of collagen and smooth muscle fibers . the authors concluded that these sinuses may represent a variant of epispadiac duplication of the urethra . huang et al1 performed an immunohistochemical study , and found that the epithelium lining was transitional proximally and squamous distally in five patients . they reinforced the theory that cps is a variant form of dorsal urethral duplication . in our case , the squamous epithelium was surrounded by muscle and glands within the tissue , and urothelial epithelium was found within the sinus tract . the difference between the locations of the squamous epithelium and transitional epithelium may have been because of the fact that cps reacts with ductal and glandular epithelia , including the urothelium . this finding might support the theory that dorsal urethral duplication is the etiology of this condition . stephens11 stated that cps might be caused by an inturned epithelial tube or remnant along the line of fusion of the infraumbilical abdominal walls , and classified this into three parts based on where the sinus begins . we believe that this case involved type 2 dorsal urethral duplication according to stephens ' classification , which describes a sinus that simulates an accessory urethra and tract from the dorsum of the penis behind the symphysis pubis to the bladder wall . however , we found no previous studies indicating that the sinus continues with the urinary tract tissue mimicking the corpus spongiosum . it is possible that the sinus tract was hypertrophic because of the accumulation of discharge from the cps . in conclusion , we postulate that all the previously reported cases may be manifestations of a wide spectrum of the same condition . however , according to most investigators , cps may represent a variant of dorsal duplication of the urethra . to the best of our knowledge , this is the first case in which the cps continued outward from the skin within the urinary tract .

a congenital prepubic sinus is a tract that originates in the skin and overlays the base of the penis ; however , its embryologic basis is still debated . we herein present a case involving a 3-year - old boy who was admitted for examination of overlying tissue located a few centimeters distal to the dorsal base of the penis . examination revealed a tiny sinus in the prepubic area , and 3 cm of tissue was attached to the sinus . pathologic examination showed that the tissue was lined with squamous epithelium and continued along the sinus tract , which was lined with urothelial epithelium . according to stephens ' classification , the sinus appeared to be a variant of type 2 dorsal urethral duplication , and the remnant tissue mimicked the corpus spongiosum of the penis .

today 's fast pace of life is extremely demanding and people stretch beyond their limits to meet the challenges . nonsteroidal anti - inflammatory drugs ( nsaids ) are the most widely prescribed medication as well as sold over the counter . nsaids are said to function as inhibitors of isoforms of 1 and 2 of cyclo - oxygenase enzyme ( cox-1 and cox-2 ) . nsaids thus produce gastric and renal side effects through their indirect inhibition of pge-2 and pgi2 synthesis . coxibs are a class of nsaids designed to inhibit cox-2 selectively . their development was based on the hypothesis that cox-2 was the source of pge-2 and pgi2 , which mediate inflammation and that cox-1 was the source of the same pg in gastric epithelium where they afford cytoprotection . this prompted the development of selective cox-2 inhibitors ( coxibs ) such as rofecoxib and celecoxib , second - generation coxibs valdecoxib , parecoxib and etoricoxib . a 37-year - old woman was referred from the emergency department for complaint of redness on her legs since 2 days . she had experienced pain in her right shoulder for which she had been taking etoricoxib 60 mg orally once daily for 5 days . on cutaneous examination , diffuse erythema [ figures 1 and 2 ] was observed below the knees to just above the ankles on both lower limbs . redness was more evident on the anterior aspect of the leg , similar to that observed in pretibial myxedema except that it was pitting in nature . her temperature , blood pressure , and routine investigations and thyroid function tests were all within normal limits . naranjo 's score in this patient was 5 denoting thereby that this was probably a drug - induced reaction . high usage of etoricoxib by prescription as well as self - administered routes has led to increase in reports of side effects and adverse reactions including dermatologic reactions in 0.1%0.3% of cases . various studies have been done wherein cases with a history of adverse cutaneous reactions to nsaids were challenged with etoricoxib . sporadic cases of etoricoxib - induced acute generalized exanthematous pustulosis and erythema multiforme - like eruption have also been documented as are case reports of erythema and fixed drug eruption induced by etoricoxib . drug - induced erythema is a type iv hypersensitivity reaction of the gell and coombs classification . no specific treatment is required ; however , topical corticosteroids and/or oral antihistaminics may give symptomatic relief from itching . however in doubtful circumstances , the possibility of any kind of adverse reaction to a drug must be kept in mind . in our case , to the best of our knowledge , pretibial erythema associated with edema has not been reported so far in any patient receiving etoricoxib .

cyclooxygenase inhibitors were developed in the quest of enhanced analgesic efficacy devoid of gastric side effects . etoricoxib is a second - generation cox-2 inhibitor and as its use increases so do the reports of side effects . we report a case of extoricoxib - induced pretibial erythema and edema ; and review the literature .

rhinoplasty is a plastic surgery procedure that is employed to reshape the nose , often through the use of implants . alloplastic materials are composed of silicone and other synthetic materials . since alloplastic materials are cheaper and easier to acquire and process , they are used more frequently . however , alloplastic materials , especially silicone , lead to a higher risk of extrusion and infection . in addition , calcification on the surface of silicone implants after rhinoplasty with transformation into a semiliquid form has been reported to be quite rare . herein , we report a case of gruel - like calcification about 50 years after silicone implant rhinoplasty . a 72-year - old female presented at our hospital with complaints of progressive swelling of the nose . she had noticed mild pruritic sensations of the nose 1 year earlier , and the dorsal area of the nose had then swollen gradually without any other symptoms . she had a history of rhinoplasty with silicone implant approximately 50 years earlier . upon physical examination , we found a subcutaneous mass , 15 5 mm in size , at the dorsal nasal area ( fig . a superficial ultrasound test showed a well - circumscribed subcutaneous mass with post - acoustic shadow , which indicated calcification therein ( fig . x - ray and ultrasound tests showed a high - intensity plate over the dorsal nasal area ( fig . 1c ) , indicating the silicone plate placed in her nose . based on the clinical manifestation , the differential diagnosis included calcinosis cutis , calcifying epithelioma , foreign body granuloma and subcutaneous tumors . to confirm a diagnosis a white , gruel - like , semiliquid material seeped out and solidified shortly thereafter . histological analysis of this white gruel - like semiliquid material confirmed calcified deposits and fibrosis ( fig . there were no foreign body giant cells or malignant cells . from the above findings , we considered the calcified deposits to be a possible result of rhinoplasty using silicone . in this case , we observed gruel - like , semiliquid calcified deposits , probably related to the long - term use of a silicone implant . silicone is a widely used rhinoplasty material that is chemically stable and has low biological reactivity , but in this case , calcification at the surface of the implant appears to have occurred after approximately 50 years . it has been reported that the severity of calcification is correlated with the duration of use , and that a denatured type of large calcification can be observed in silicone implants older than 15 years . calcification on the surface of the implant after rhinoplasty often occurs , but to the best of our knowledge , this is the first report of it transforming into a semiliquid state . although the precise mechanism of calcification on the surface of implants is unclear , silicone - rich surfaces are more likely to be calcified compared to non - silicone implants . in addition , long - term mechanical stress and inflammatory reactions might be responsible for calcification , namely the deposition of calcium phosphate . it is difficult for calcium phosphate to dissolve under normal conditions , but it dissolves easily in a low - ph environment . in inflammatory lesions , tissue ph decreases locally due to the increased production of lactic acid , which is related to tissue damage and bacterial metabolism . in our case , calcification at the surface of the silicone implant was observed after approximately 50 years of use . the patient had pruritus before the formation of a subcutaneous mass at the dorsal nasal area , which is indicative of inflammation occurring at the site . although the underlying mechanism remains unclear , a ph change in the tissue might have occurred during the process of inflammation that resulted in the dissolution of calcified deposits .

rhinoplasty is a plastic surgery procedure to reconstruct the nose . silicone alloplastic materials are most widely used as implants for rhinoplasty , but calcification on the surface occurs with long - term usage . herein , we report a case of gruel - like calcification approximately 50 years after silicone implant rhinoplasty . in this case , calcification on the silicone surface might have transformed into gruel - like deposits , which presented as a subcutaneous mass at the dorsal area of the nose . the precise mechanism is unclear ; a ph change in the tissue might have occurred during the process of inflammation , leading to the dissolution of calcified deposits .

first , long arm of this osteotomy line started from the forefront of the superior border of the zygomatic arch , where the arch met the lateral orbital rim , and extended toward the medial and anterior areas of masseter muscle attachment . second , short arm of the osteotomy line was made perpendicular to the long arm at the maxillary buttress of zygoma . finally , an incision was made ( 1 cm long ) in the sideburns , and the posterior portion of the zygomatic arch was fractured . all of the osteotomy line was made with a reciprocating saw ( fig . frontal view of osteotomy line ( a ) and inferior view of osteotomy line ( b ) . freed zygomaticomaxillary complex was repositioned by medially rotating the inferior border of the zygomatic arch . the most important step is medially rotating the most prominent point ( red point in fig . 2 ) . because ostectomy and bone removal were not carried out , freed zygomatic arch would prematurely contact with the posterior wall of the maxillary sinus . therefore , contour of the posterior wall of the maxillary sinus was gradually adjusted to eliminate a gap in the l - shaped osteotomy line . when intimate bony contact is verified in the osteotomy line by eliminating the gap , rigid fixation is conducted with plates and screws ( fig . 2 ) . the most prominent point of zygoma ( red dot ) and mesial clockwise rotation of the zygomaticomaxillary complex . therefore , reduction malarplasty can result in nonunion after reduction malarplasty if intimate bone contact is not obtained . mesial clockwise rotation of the zygomaticomaxillary complex can produce intimate bone contact and facilitates reduction malarplasty .

abstractthe 2 most common complications of reduction malarplasty are nonunion or malunion and cheek drooping . because masseter muscle is attached from zygomatic process of the maxilla to inferior two thirds of the zygomatic arch , rigid fixation and intimate bone contact without creating a gap are crucial for reduction malarplasty.mesial-clockwise rotation of the zygomaticomaxillary complex can produce intimate bone contact and facilitates reduction malarplasty .

schwannoma , also known as neurilemoma , is the most common benign tumour of peripheral nerves originating from the schwann cells of the nerve sheath [ 1 , 2 ] . schwannomas are usually solitary , encapsulated and homogenous masses and present with slowly growing masses , sometimes associated with pain and paresthesia [ 13 ] . schwannomas are usually isolated masses < 2.5 cm in diameter , but the size of these tumours may differ according to localization . these tumours may be located anywhere in the longitudinal axis of the extremity originating from nerve sheath of a peripheral nerve . because of their similar consistency , they may be misdiagnosed as ganglion . preoperative evaluation is based on ultrasonography and magnetic resonance imaging ( mri ) , but final diagnosis requires histopathology . the characteristic histological features include the presence of alternating antoni a and antoni b areas . . there may be nuclear palisading . in - between two compact rows of well - aligned nuclei , the mass usually appears at trunk , head and neck , or at upper extremity . localization in the lower extremity originating from tibial nerve sheath is very uncommon and rarely reported in the literature . diagnosis of tibial nerve neurilemmoma is usually delayed because only 48% of these masses can be detected and can also be misdiagnosed as baker cyst . in this article , we present a case of popliteal schwannoma that can be misdiagnosed as baker cyst . fifty - eight - year - old man presented to the outpatient clinic of orthopaedics department with the complaints of slowly growing mass on his right popliteal region and mild pain and intermittent paresthesia of right leg and right foot . the patient emphasized that the mass existed for 2 years but has grown in the last 6 months . on physical examination , 4 2 cm mobile , solid mass was palpable at the posterior of the knee . ultrasound imaging showed that the mass was solid and separate from the adjacent muscles and tendons . mri showed well - defined solid , heterogenous , dense mass originating from the tibial nerve ( fig . 1 ) . sheath of the nerve was incised longitudinally to minimize damage to the nerve fascicles and the mass was resected in en - bloc form by sharp dissection using the microscope with no complication . the patient was discharged at the post - op third day . at the third week of the operation , histopathological examination of the mass revealed hypocellular antoni b and spindle - shaped schwann cells containing antoni a areas with nuclear palisading . schwannoma is the most common benign neoplasm of the peripheral nerves and may originate from any of peripheral nerves . it is usually solitary , painless , encapsulated and well - defined , slowly growing mass [ 13 ] . in our case , both patients experienced non - specific symptoms , such as painful numbness and burning dysaesthesia , involving the lower extremity and tinel s sign was positive over the popliteal fossa in one of these cases . in our case , tinel 's sign was positive . in the literature , tarsal tunnel syndrome secondary to tibial nerve schwannoma was reported and mr imaging was advised . sometimes it is impossible to differentiate the schwannoma from neurofibroma or malignant peripheral nerve sheath tumours and biopsy can be a necessity to confirm the diagnosis . . in our case , we also preferred to excise the tumour and confirmed the diagnosis by histopathological examination . histopathological examination of the schwannoma reveals hypocellular antoni b and spindle - shaped schwann cells containing antoni a areas with nuclear palisading . also immunohistochemical staining ( s100 + ) confirms the tumoural cells originating from schwann cells and the diagnosis of schwannoma . in our case , necrosis , increased mytotic activity or atypical cells were not observed in histopathological examination and also positivity of s100 staining confirmed the diagnosis of schwannoma ( fig . 2 and 3 ) . after surgical excision , sometimes paresthesia may be seen but usually it resolves without any neurological problem and also recurrence of the tumour is very uncommon [ 13 ] . in this case , we did not meet any neurological complication . at the last control the patient was free of symptoms and baker cysts are very common pathologies of popliteal region , but other benign and malignant tumours should also be kept in mind . we suggest mr investigation for differential diagnosis and excisional biopsy for confirmation of diagnosis and we also suggest excision of the schwannoma with careful dissection by using a microscope to minimize the complications and not to damage the nerve fascicules .

schwannoma , also known as neurilemoma , is the most common tumour of peripheral nerves . although it is the most common tumour of peripheral nerves , it is seldom seen in adult population . we present a very rare case of schwannoma in an unusual localization . the presented case concerns a 58-year - old patient with a slowly growing popliteal mass and neuralgia for 6 months . a mass originating from a nerve or compressing a nerve was thought in the differential diagnosis . ultrasonographic and magnetic resonance imaging revealed a heterogenous , well - defined solid mass that seems to originate from tibial nerve . surgical excision and histopathological examination confirmed the diagnosis of schwannoma . diagnosis of the neurilemmoma originating from lower extremity peripheral nerves may be delayed because the mass can be misdiagnosed as baker cyst or the symptoms of the patient can be thought as a result of lumber disc herniation .

patients with ophthalmic manifestation of chronic myeloid leukemia ( cml ) have been reported to have lower 5-year survival than those without.1 however , ocular manifestations as the only presenting sign of cml are rare . we present a case of a previously healthy male who presented with only visual symptoms and was subsequently diagnosed with cml . this case report highlights the importance of recognizing early fundus changes , which should allow earlier diagnosis and treatment . typically , the ophthalmic manifestations of cml are florid , with vascular changes such as retinal vein tortuosity or obstruction , flame - shaped hemorrhages , dot - and - blot hemorrhages , roth spots , and even optic nerve edema . a case of macular lesion and optic nerve involvement has previously been reported as being an early ocular presentation of cml . our case presented with preretinal and white - centered hemorrhages only . a 30-year - old myanmarese male with no medical history presented with a history of seeing a black dot in his left visual field for the past 1 week . visual acuity was 20/100 and 20/20 in his left and right eyes , respectively . fundus examination revealed preretinal hemorrhage and white - centered hemorrhage in his left eye [ figure 1a ] . ( a ) picture of the left eye fundus shows the preretinal hemorrhage over the macular area , with a white - centered hemorrhage ( arrow ) seen infero - nasally.(b ) peripheral blood smear shows basophil , three segmented neutrophil ( n ) , and two band forms ( bf ) . ( c ) histological sections of bone marrow aspirate show hypercellular segment and cell trail ( arrow ) . ( e ) resolved preretinal hemorrhages and white - centered hemorrhage in the left fundus there was no history suggestive of cardiac or autoimmune disease or family history of blood dyscrasias . a full blood count revealed a raised white blood cell count of 173 10/l ( normal range : 3.269.28 10/l ) . peripheral blood film [ figure 1b ] and bone marrow aspirate [ figure 1c ] showed marked myeloid hyperplasia in 89.6% of the cells , consisting of mature neutrophils and myelocytes without any blasts . fluorescent in situ hybridization ( fish ) showed karyotype 46 , xy , t(9;22 ) [ figure 1d ] . he was started on cytoreductive therapy consisting of 2 g hydroxyurea twice a day along with 300 mg allopurinol every morning . the fundus changes resolved and visual acuity improved to 20/30 in his left eye . following this , he opted to switch to a long - term trial drug bosutinib started by his hematologist . there was no ocular or systemic recurrence after 12 months of follow - up [ figure 1e ] . studies have shown that only 5%10% of cml patients present with eye symptoms at initial diagnosis.23 a case with a macular lesion and optic nerve involvement has previously been reported.4 optic nerve involvement typically leads to relatively rapid and potentially irreversible vision loss.5 this case was a rare exception as the usual ocular manifestation in cml is retinal involvement [ table 1 ] . the macular lesion in our patient could be a precursor of further fundus changes , such as optic nerve involvement . signs of ophthalmic leukemic manifestation in the fundus leukemic retinopathy can be mistaken for other hematological disorders that have similar presenting signs in the fundus [ table 2 ] . even though the other differentials of roth spot , including retinal vein occlusion , diabetes , anemia , and infective causes such as syphilis and hiv [ table 3 ] were also considered , hematologist referral was a priority in view of his abnormal blood results . comparison of fundus signs in different hematological disorders differential diagnosis for roth spots with prompt investigation and diagnosis our patient was able to receive treatment early into his disease before other signs manifested . recovery was extremely good , with no recurrence thus far , i.e. , after 12 months of follow - up . it was reported that 5-year survival of patients with ophthalmic manifestation of cml was 21.4% compared to 45.7% of those without.1 prompt diagnosis and treatment of such patients is of paramount importance . in summary , it is important to recognize early fundus changes in patients who do not present with the usual signs and symptoms of cml . a suspicious ocular finding should be followed up with appropriate systemic evaluation and workup , including a full blood count .

chronic myeloid leukemia ( cml ) is a well - studied entity and advances made in diagnosis and treatment have improved the disease outcome . patients with ophthalmic manifestation of cml have been reported to have lower 5-year survival rates . hence , recognizing the early fundus changes may improve outcome by allowing earlier diagnosis and treatment . we report a case of a previously healthy 30-year - old myanmarese male , who presented with a minor visual disturbance , complaining of seeing a black dot in his left visual field for the past 1 week . fundoscopic examination revealed bilateral retinal blot hemorrhages , white - centered hemorrhage , and preretinal hemorrhage over the left fovea . the full blood count and peripheral blood film were abnormal , and bone marrow biopsy confirmed the diagnosis of cml . cytoreduction therapy was promptly commenced and his symptoms resolved , with improvement in visual acuity . no complications were recorded at 1-year follow - up .

infection is a major source of morbidity and the leading cause of death in immunocompromised patients . the increased susceptibility to infection results from the intertwined effects of the immunocompromising condition , treatments , and co - morbidities . human infection with the novel h1n1 influenza virus was first recognized in early april 2009 and declared a worldwide pandemic by the world health organization in june 2009 . recent case series provide information on the clinical course , risk factors , and outcome of h1n1(v ) infection [ 2 - 4 ] . both new zealand and canada have experienced h1n1(v ) outbreaks with severe illness requiring intensive care unit ( icu ) admission , ventilatory support , and rescue therapies . however , no case series have specifically described the features of h1ni(v ) infection in immunocompromised patients . here , we report the clinical and epidemiologic features in 10 critically ill immunocompromised patients with h1n1(v ) infection . the case definition was icu admission for acute respiratory failure and a positive specific polymerase chain reaction test for the pandemic influenza a ( h1n1 ) 2009 virus . all patients meeting this case definition were included . in late 2009 , 15 patients with h1n1-related acute respiratory failure , including 10 immunocompromised patients , required icu admission . as reported in table 1 , median time from respiratory symptom onset to icu admission the chest radiographs consistently showed extensive pulmonary infiltrates ( median murray score 3 ; iqr 2 to 4 ) , and 80% of cases showed an alveolar pattern . all patients were treated with oseltamivir , which was prescribed 1 day ( range 0 to 6 days ) after icu admission . superinfection ( mostly bacterial pneumonia ) occurred in all patients in keeping with previous data on seasonal influenza . the clinical course was characterized by prolonged oxygen dependency in the survivors ( 10 days ; iqr 6 to 15 days ) . clinical characteristics and outcomes of h1n1(v ) critically ill immunocompromised patients all patients were receiving oseltamivir . bmt , bone marrow transplantation ; c3 g , third - generation cephalosporin ; ci , calcineurin inhibitor ; fq , fluoroquinolone ; gvhd , graft - versus - host disease ; icu , intensive care unit ; mmf , mycophenolate mofetil ; mv , mechanical ventilation ; niv , non - invasive mechanical ventilation . h1n1(v ) infection can result in a wide spectrum of clinical patterns , ranging from no symptoms to fulminant viral pneumonia . this new pandemic virus is characterized by a high prevalence of severe viral pneumonitis , which often requires mechanical ventilation . influenza viruses are known to cause severe infections in immunocompromised patients , of whom variable proportions were reported in epidemiologic descriptions [ 2 - 4 ] . our case series is the first to describe the course of h1n1(v ) infection in immunocompromised hosts . first , the risk factors for h1n1(v ) described in the overall population [ 2 - 4 ] were not found in our cohort . in contrast , none of our patients had obesity ( median body mass index 26.9 ; iqr 21 to 26 ) or chronic lung disease . of our 10 patients , 7 were on long - term steroid treatment , as described in the immunocompromised subgroup of the canadian icu patients . cellular immunodeficiency is the main risk factor for lower respiratory tract infection with influenza viruses as the main defense mechanism is cd8 t - lymphocyte - mediated cytotoxicity . the clinical presentation in our patients was similar to that described in immunocompetent individuals , with symptom onset 4 days before icu admission . mortality was high ( 40% ) compared with the overall population with h1n1 2009 infection [ 2 - 4 ] . the icu stay was shorter than in the overall icu population but the hospital stay was longer , perhaps because of prolonged viral shedding in lymphopenic patients . ea is a member of the french and european boards of pfizer inc ( new york , ny , usa ) and gilead ( foster city , ca , usa ) , respectively .

seasonal influenza virus has been described as an emerging and severe pathogen in immunocompromised hosts . since the beginning of the 2009 influenza a novel h1n1 pandemic , several series have described the clinical course of the disease in various populations . we report the clinical course of h1n1 2009 infection in 10 immunocompromised patients . half of the patients received long - term steroid therapy . disease was characterized by a clinical picture similar to that of non - immunocompromised patients but with prolonged course and higher mortality .

a 35-year - old female patient presented with a complaint of a painless swelling on the right buccal mucosa [ figure 1 ] . the lesion was visible on extraoral examination as a 2.5 cm1 cm mass , which was well circumscribed and firm on palpation , midway in the ala - tragal line . a diagnosis of a benign buccal mass with a differential diagnosis of lipoma and schwannoma was made . clinical presentation of lesion as a swelling routine haematological examination was noncontributory . under local anesthesia , a soft tissue mass measuring 1 cm1.5 cm , firm in consistency and grayish brown in color , was cut into two pieces and processed . the histological examination showed a thin fibrous capsule with a surrounding membrane enclosing the larval stage of t. solium . the surrounding connective tissue showed a mild inflammatory response and an eosinophilic infiltrate [ figure 2 ] . a diagnosis of cysticercosis was made and the patient was referred for further evaluation by the physician to rule out further disseminated lesions at other sites . protean manifestations of the human pork tape worm have perplexed medical science for almost 4000 years . these platyhelminths have an egg stage and a larval stage , and then they become adult worms . by consuming inadequately cooked infected pork and raw vegetables , the cyst wall is destroyed by gastric secretion , releasing one scolex that passes into the small intestine , where it becomes fixed . embryonated eggs and gravid proglottids are released in the feces , deposited on the soil , and later ingested by the intermediate host , the pig . the animal 's gastric secretions destroy the egg wall , and after passage into the duodenum , the larve hatch from the eggs , penetrate the intestinal wall , and are carried by blood or lymph to various tissues . the cystic structure contains a small , invaginated scolex and neck resembling the adult form . t. solium does not show tropism for any tissue , but has marked tendency to localize in the subcutaneous tissue and muscles , causing palpable and visible nodules . a large series study of 450 cases by dixon and lipscome showed 1.8% of oral cysticercosis . in our case reported here , the buccal mucosa was involved and the lesion presented itself as an asymptomatic nodule . depending on the anatomical location and the number of invasive oncospheres , cysticercosis can be asymptomatic or produce a plethora of signs and symptoms . surgical excision and an effective method to control cysticercosis may be the use of a good vaccine to prevent the infection in pigs . as with other zoonotic diseases , collaborative effort of the local and national authorities is needed to control human cysticercosis . we present a case of oral cysticercosis which presented itself as an asymptomatic submucosal nodule in the buccal mucosa . we stress on the need to include the possibility of cysticercosis in diagnosis of benign nodular masses in the oral cavity , particularly in areas endemic to the presence of t. solium .

cysticercosis caused by taenia solium is endemic in many parts of the world . we present a case of one such lesion which presented itself as an asymptomatic buccal swelling . we present the life cycle of t. solium , the endemic nature of this infection , and the relevance of histological examination to arrive at a diagnosis .

we conducted a retrospective cohort study of staff members at the health post who participated in the meeting on september 15 . a case - patient was any person who participated in the meeting and had a positive direct parasitologic examination result for t. cruzi or positive serologic results and clinical evidence of acute chagas disease . a non - case was any person who participated in the meeting and had negative test results for t. cruzi . we also conducted a 1:3 case control study ( 11 case - patients and 34 controls matched by sex and age ) that included patients with laboratory - confirmed cases from barcarena . a case - patient was any person in whom during september 1october 15 t. cruzi was found by direct parasitologic examination , irrespective of signs or symptoms of disease , or who had positive serologic results and clinical evidence of disease . this interval was based on date of symptom onset of the first and last case - patient and a reported incubation period of 322 days for orally transmitted disease . controls were age- and sex - matched residents of case - patient neighborhoods who had negative serologic results for t. cruzi . parasitologic examinations were conducted for case - patients by using quantitative buffy coat test , thick blood smear , or buffy coat test ( the latter 2 tests included giemsa staining ) . serologic tests were conducted by using indirect hemagglutination test , elisa , or indirect immunofluorescent test . we ruled out leishmaniasis in all persons with positive serologic results for t. cruzi by using an immunofluorescent test for igm to leishmania spp . we conducted an entomologic investigation during december 1116 , 2006 , at the homes of 5 case - patients and in forested areas near the homes of 2 case - patients ; at the commercial establishment where aa consumed by the case - patients linked to the health post was prepared and served ; at an aa juice production and sale establishment reported to be frequented by other case - patients ; and at the river dock market where aa delivered to barcarena is unloaded . at this market , we searched baskets used to transport aa in river boats . we applied an insect - displacing compound ( piridine ; pirisa , taquara , brazil ) to the interior and exterior of buildings at investigation sites and placed traps ( 13 ) to obtain triatomines . data were analyzed by using epi info version 6.04d ( centers for disease control and prevention , atlanta , ga , usa ) . we measured relative risk in the cohort study and matched odds ratios in the matched case fisher exact , mcnemar , mantel - haenszel , and kruskall - wallis tests were used as needed . study power ( 1 ) was 5% . all case - patients had positive results for t. cruzi by direct examination of blood ( figure 2 ) . nine ( 82% ) patients were female ; median age was 39 years ( range 770 years ) . eight ( 73% ) patients resided in urban areas , 7 ( 64% ) in brick dwellings , and 3 ( 27% ) in mixed brick and wooden dwellings . all patients denied having had blood transfusions or organ transplants , having slept in rural or sylvatic areas , and having been bitten by triatomines . trypanosoma cruzi ( arrow ) in a peripheral blood smear of a patient at a local health facility in a rural area of par state , brazil ( giemsa stain , magnification 100 ) . image provided by adriana a. oliveira , brazilian field epidemiology training program , brasilia , brazil . the epidemic curve for the 11 patients is shown in figure 1 , panel c. main signs and symptoms were fever , weakness , facial edema , myalgia , arthralgia , and peripheral edema ( table 1 ) . no deaths occurred , and median time from symptom onset to treatment initiation was 22 days . the cohort consisted of 12 persons who attended the staff meeting . of these persons , 6 shared a meal , 5 ( 83% ) of whom were case - patients . exposures associated with infection were consumption of thick aa paste and drinking aa juice at the health post ; consumption of chilled aa was protective ( table 2 ) . no other foods consumed at the meal were associated with illness ( table 2 ) . among exposures tested , drinking aa juice on september 15 and at the health post were significantly associated with illness ( p<0.02 and p<0.001 , respectively ; matched odds ratio not determined ) . oral transmission of this disease in the amazon region has been reported since the 1960s . aa has long been the principal suspected food vehicle , but characteristics of outbreaks , small groups with universal exposure and high attack rates , have precluded epidemiologic implication of this food . there are no reports of timely collection of aa for laboratory testing in an outbreak . in this outbreak , a shared meal was the only event linking case - patients , and cohort and case control studies demonstrated an association between aa consumption at this meal and infection . . limitations of this study are possible recall bias caused by delay between illness and investigation and failure to collect food samples for testing . studies are needed to determine viability of t. cruzi in aa , along with the tree - to - bowl continuum of aa , to identify sources of contamination . because aa is a major dietary component in the amazon region and a component of the local economy , identifying practical prevention measures is essential .

in 2006 , a total of 178 cases of acute chagas disease were reported from the amazonian state of par , brazil . eleven occurred in barcarena and were confirmed by visualization of parasites on blood smears . using cohort and case control studies , we implicated oral transmission by consumption of aa palm fruit .

congenital rch , also called longitudinal radial deficiency or radial dysplasia , is an uncommon congenital anomaly characterized by various degrees of deficiency along the preaxial or radial side of the extremity ( 1 ) . the incidence of rch is estimated to be 1 in 30,000 to 1 in 100,000 live births ( 2 ) . bayne and klug classified radial deficiency into four types ( 3 ) : type i : mildest form with defective distal radial epiphysis . minor radial deviation of the hand is apparent , although considerable thumb hypoplasia may be evident . type ii : involves limited growth of the radius on both its distal and proximal sides and characterized by a miniature radius and moderate radial deviation of the wrist . type iii : absence of two - thirds of the radius , most commonly the distal side and severe radial deviation of the wrist . type iv : this type of rch is the most common and most severe and involves complete absence of the radius . minor radial deviation of the hand is apparent , although considerable thumb hypoplasia may be evident . type ii : involves limited growth of the radius on both its distal and proximal sides and characterized by a miniature radius and moderate radial deviation of the wrist . type iii : absence of two - thirds of the radius , most commonly the distal side and severe radial deviation of the wrist . type iv : this type of rch is the most common and most severe and involves complete absence of the radius . about 40% of patients with unilateral club hand and 27% with bilateral club hand have associated congenital anomalies involving cardiac , genitourinary , skeletal , and hematopoietic system ( 4 ) . the prominent syndromes associated with rch include : holt - oram syndrome ; thrombocytopenia - absent radius ( tar ) syndrome ; vertebral , anal , cardiac , tracheal , esophageal , renal , and limb ( vacterl ) syndrome ; and fanconi anemia . the latter is a serious associated condition which usually manifests as aplastic anemia between 3 and 12 years of age . correction of rch requires a combination of non - operative and operative management that should start immediately after diagnosis . the basic goals of correction include correction of radial deviation of wrist , balancing the wrist on forearm , maintenance of wrist and finger flexion , promotion of growth of the forearm , and improving the cosmetic appearance of the limb ( 5 ) . the non - operative management comprises of stretching of the taut radial structures by physiotherapy and splintage ( 6 ) . some centers utilize the appliances based on principles of distraction osteogenesis ( ilazarov technique ) to decrease the magnitude of contracture before definitive surgery ( 7 ) . the cases of rch need to be kept under follow - up upto adulthood to prevent the recurrence of the deformity ( 5 ) , and monitor the function of the affected limb and undertake corrective operative and non - operative interventions as warranted . the authors have not received any funding or benefits from industry to conduct this study .

congenital radial club hand ( rch ) is an uncommon congenital anomaly characterized by various degrees of deficiency along the preaxial or radial side of the extremity . we present one such case of type 4 congenital isolated rch who presented to a tertiary care center in the middle east .

a 87-year - old bedridden woman for 6 months who followed due to severe dementia and monitored in neurology clinic with the diagnosis of alzheimer s disease , was consulted to our clinic because of pruritus and bleeding of her left ear . she was suffering from itching in her left ear for nearly a month and bleeding for 2 days . on her physical examination , then the patient was brought into the operating room for otomicroscopic examination external ear canal was irrigated with 10% lidocaine spray , and 70% ethanol to restrict the movements of larvae . under microscopic guidance , 7 white - colored , thick , and segmented larvae with a mean length of 10 - 15 mm were extracted from inside the external ear canal with the aid of an aspirator , and alligator clamps ( figure 2 ) . an area of perforation on the posterior quadrant of the tympanic membrane was observed . external ear canal , and middle ear were irrigated with physiologic saline . topical antibiotherapy was initiated with a mixture of hydrogen peroxide and boric acid solution one week later larvae were not encountered within her external ear canal . because of her advanced age , and mental health state tympanoplasty operation was not conceived . myiasis can be seen in various regions , skin , body cavities , and organs . aural myiasis can manifest itself in various forms including ophthalmomyiasis , nasal myiasis , urogtenital myiasis , intestinal myiasis , and cutaneous myiasis [ 3 - 6 ] . only one species of dipterous larva can involve more than one anatomical region or different species can be seen in the same region . literature reviews have detected its presence generally in children , people with poor hygiene or those having predisposing factors . among these predisposing factors mental retardation , immobilization , immunosuppression , and diabetes mellitus can be enumerated . besides chronic otorrhea is considered as a risk factor in healthy , and ambulatory patients . our case was a bedridden patient for nearly 6 months with a limited interaction with her environment . these patients can present with complaints of sensation of foreign substance in the ear , aural itching , pain , bleeding , tinnitus , hearing loss , and vertigo [ 8 , 9 ] . in our case , however aural pruritus was not considered as an important symptom by her relatives , and the patient was not consulted to an ent specialist till her left ear bled . this otorrhagic symptom was thought to be related to frequent scratchings , and the patient was fastened to her bed . since in cases with otomyiasis early diagnosis is thought to be very important , especially in patients with predisposing factors , persistent ear itching should lead the physician to be suspicious of otomyiasis , and the patients should be evaluated with meticulous otoscopic examination . in literature reviews , the most frequently encountered species of parasites in cases with aural myiasis are cochliomyia hominivorax , wohlfahrtia magnifica , chrysomya bezziana , chrysomya megacephala , and parasarcophaga crassipalpis . in our case segmented larvae measuring approximately 10 - 15 mm covered with bands of irregularly , and however during this period because of both mechanical effects of larvae , and collagenases they secrete , they induce many complications in the patient . these complications can include perforation of the tympanic membrane , destruction of the middle ear , and mastoid cavity , and fatal central nervous system invasion . the most important point in the prevention of complications is early diagnosis , and eradication of the larvae as soon as possible . this procedure should be performed under microscope is especially important in the evaluation of the middle ear in cases with tympanic membrane perforation . following mechanical cleaning irrigation of the ear canal with 70% ethanol , 10% chloroform or physiologic saline , urea , dextrose , creatinine , and topical ivermectin is recommended so as to get rid of the remaining larvae . in addition , in cases with suspect furuncle or secondary infection , topical antibiotherapy can be prescribed [ 8 - 10 ] . in conclusion , persistent ear itching , and pain , and irritability especially in patients with predisposing factors as mental retardation , dementia , and immunosuppression , oto myiasis should be kept in mind .

myiasis is the infestation of live vertebrates with dipterous larvae . aural myiasis involves infestation of the external ear and/or middle ear . it is a rare clinical state that usually occurs in patients who have mental or physical disabilities . although myiasis is a self - limiting disease , it can be associated with fatal complications like penetration within the central nervous system . we present a 87-year - old patient suffering from alzheimer s disease with aural myiasis and also discuss the clinical presentation and efective therapies with a review of the literature .

the fungal genus ceratocystis ( microascales , sordariomycetes , ascomycota ) includes numerous important plant pathogens , some of considerable economic importance . species in the c. fimbriata complex include c. platani that causes a serious wilt of platanus trees in europe ( ocasio - morales et al . 2007 ) , c. manginecans , causal agent of mango wilt disease ( van wyk et al . 2007 ) , and c. fimbriata sensu stricto , a pathogen of sweet potato ( baker et al . 2003 ) . the genus also encompasses several other species complexes that include economically important species ( e.g. the thielaviopsis morph , punja & sun 1999 ) , agents of blue stain in timber ( e.g. c. polonica , christiansen 1985 ) and saprophytes . these fungi all have intriguing and little - understood associations with insects ( seifert et al . recent studies on ceratocystis species have focused on species delimitation ( van wyk et al . 2010 ) , reproductive strategies ( harrington & mcnew 1997 , witthuhn et al . 2000 ) and links between pathogenicity and host range ( ferreira et al . 2011 ) . although genome sequence information represents an invaluable resource for such studies , whole genome sequences have not yet been determined for ceratocystis species or other members of the microascales . in this study , we report the availability of the nuclear genome sequence for an isolate of c. fimbriata . this ceratocystis species was chosen for sequencing because it is the type species of the genus ( seifert et al . ex ipomoea batatas ( sweet potato ) , december 1998 , d. mcnew ( cbs 114723 , cmw 14799 ) . the whole genome shotgun project of the ceratocystis fimbriata genome has been deposited in ddbj / embl / genbank under the accession apwk00000000 . dna was extracted and subjected to 454 pyrosequencing ( roche diagnostics , mannheim , germany ) at inqaba biotechnology ( pretoria , south africa ) . the resulting reads were assembled into a draft genome consisting of 3 668 contigs by using the newbler v. 2.3 genome assembler . the create detailed mapping report command of the clc genomics workbench package v. 5.0.1 ( clc bio , aarhus , denmark ) was used to produce statistics for the draft sequence . the draft genome had an estimated size of 29 410 862 bp ( as calculated by summation of all the contig sizes ) , 20 average coverage , n50 contig size of 42 879 bases and an estimated gc content of 48.06 % . all contigs with a length of > 199 bp were submitted to ncbi s genome database . to assess the completeness of the genome , contigs of size 500 bp ( 2641 contigs ) were analysed with the cegma pipeline ( parra et al . although we did not produce a complete annotation for the c. fimbriata genome , analysis with augustus ( stanke et al . 2006 ) identified 7 266 putative orfs at a gene density of 246 orfs / mb . of the putative protein coding genes , the majority ( 97 % ) had 100 or more amino acids . the c. fimbriata genome is relatively small ( 29.4 mb ) and harbours fewer genes than other fungal species such as fusarium graminearum ( 36.1 mb , 11 640 genes ) ( cuomo et al . 2007 ) and neurospora crassa ( 39.9 mb , 10 082 genes ) ( galagan et al . 2003 ) . whether this difference is linked to the different lifestyles of these fungi requires further research . the availability of this ceratocystis genome sequence will contribute to our understanding of the molecular and cellular mechanisms underlying the biology of these and other fungi .

the draft nuclear genome of ceratocystis fimbriata , the type species of ceratocystis , is comprised of 29 410 862 bp . de novo gene prediction produced 7 266 genes , which is low for an ascomycete fungus . the availability of the genome provides opportunities to study aspects of the biology of this and other ceratocystis species .

. it can be re - canalized by surgical thrombectomy , thrombolysis , balloon angioplasty , aspiration thrombectomy as well as by a mechanical thrombectomy with dedicated devices or a combination of these methods ( 1 - 5 ) . among them , the mechanical thrombectomy is a method where a variety of tools is utilized with the intention to fragment or cleave and thereafter to remove or aspirate the thrombus . the arrow - trerotola percutaneous thrombolytic device ( ptd ; arrow , reading , pa , usa ) is known to be a useful tool to remove a thrombus ( 3 - 5 ) . although the ptd procedure is simple and effective in the most cases , we have experienced the disconnection of the soft rubber tip from the basket of the ptd . between january 2006 and december 2012 , 1964 sessions of endovascular intervention were performed in 908 patients because of malfunctioning hemodialysis accesses in our institution . a mechanical thrombectomy using ptd was primarily performed in patients with a thrombosed hemodialysis access in our institution . in 453 out of 1964 sessions , a mechanical thrombectomy using ptd was performed for thrombosed hemodialysis grafts ( n = 407 ) and thrombosed native fistulas ( n = 46 ) . in five ( 1.1% ) of 453 sessions , the soft rubber tip was disconnected from the ptd catheter . the described patients group consisted of two men and three women and ranged in age from 49 to 75 years ( mean age 65 years ) . the soft rubber tip was disconnected in all cases when the basket of ptd was rotating to break the thrombus . disconnection of the soft rubber tip occurred at the arteriovenous anastomosis in 4 patients with native fistulas , with an acute angulation in 2 patients ( fig . 1 ) , in 1 patient at the acute angulated transitional zone between the aneurysm like dilated segment and the normal segment and in 1 patient at the junction of the subclavian and innominate veins with an indwelled stent in the innominate vein . in 1 patient with a graft , the disconnection of the soft rubber tip developed at the mid portion of the graft . in all cases the soft rubber tip was removed in three patients using the 5 - 10 mm snare catheter and was swept away into the pulmonary artery in two patients . after that , the ptd thrombectomy was resumed with the use of another ptd device and an angioplasty for the underlying stenosis was performed . no additional medical management such as antibiotics treatment was administered in the patients with the soft rubber tip migration to the pulmonary artery . the duration of follow - up ranged from 9 to 21 months ( median 16 months ) . there were no subjective or objective symptoms associated with the soft rubber tip lodged in the pulmonary artery . arterial embolization has been reported as a possible complication of the ptd before ( 5 ) , but the disconnection of the soft rubber tip has not been previously reported . possible causes may be a knotting of the catheter due to twisting at the level of tortuous vascular structure ( 6 ) or a disconnection because of pinch - off syndrome ( 7 ) and others . the device tip is made of soft and flexible rubber which can be easily maneuvered through vessels . our speculation is the soft rubber tip can be disconnected from the ptd when it is located at an acute angle within thrombosed veins or grafts because the basket is rotating at a high speed ( 3000 rpm ) . in the present study , the disconnection of the soft rubber tip occurred in 4 out of 46 patients with thrombosed native fistula . the authors presume the acute angulation as the cause of this complication in three patients . therefore , the use of ptd for the removal of a thrombus at an acute angulation is not recommended . in this situation a balloon angioplasty or an aspiration thrombectomy could be a better alternative . in one patient with an indwelling stent in the innominate vein , the tip of the ptd was caught at the end of the stent strut so that a disconnection developed . so , the ptd device should not be activated within the stent . in the present study , a disconnection of the soft rubber tip occurred in one out of 407 patients with hemodialysis graft only . in this patient , the ptd device was reused . in this case we speculate the reuse of the ptd device as cause for the disconnection of the soft rubber tip because there is no acute angulation throughout the graft and anastomosis in hemodialysis graft in general . in our institution , the reuse of ptd device after sterilization is uncommon , because the reused ptd device may be weakened and fragile . in the literature a snare - loop wire or its modification , the wire - balloon technique , a nitinol goose - neck snare , grasping forceps and fogarty balloon catheters are methods to remove intravascular foreign bodies ( 8 - 10 ) . we also used a snare catheter to remove the rubber tip if the soft rubber tip was disconnected from the basket of the ptd . although we failed to remove the rubber tip in two patients , no symptoms were developed during the follow - up period . in conclusion , the rubber tip of the ptd can be disconnected during the procedure when the ptd is working in an acute angulated vessel particularly .

a rubber tip disconnection of arrow - trerotola percutaneous thrombolytic device ( ptd ) may occur occasionally . we experienced 5 cases of a rubber tip disconnection among 453 mechanical thrombectomy sessions with the use of ptd . we present a report about these five cases and suggest possible causes for the occurrences .

hypertrophic pulmonary osteoarthropathy ( hpoa ) is often associated with lung carcinoma , but other intrathoracic tumors or nonmalignant diseases including hepatopulmonary syndrome of advanced liver or cirrhosis , cyanotic heart diseases may also associated with this clinical condition . radiologically , periostitis presents as new bone formation and appearance of a smooth layer to the bones . bone scintigraphy is a highly sensitive method for the diagnosis of hpoa and the typical scintigraphic presentation is a diffuse , symmetrically increased uptake in the diaphysis and metaphysis of tubular bones , with a distinctive double stripe or parallel track sign . in addition , diffuse moderately increased fluorodeoxyglucose ( fdg ) uptake in the periostea of long bones had been reported . here , we present a lung cancer patient who demonstrated findings consistent with hpoa on bone scintigraphy and fdg positron emission tomography / computed tomography ( pet / ct ) imaging . a 54-year - old male patient complaining of cough , generalized bone pain and weakness was referred to our hospital . ct of the thorax demonstrated 5 cm 6 cm mass lesion with speculated margins in the upper lobe of the right lung . the patient was referred nuclear medicine department for bone scintigraphy and 18f - fdg pet / ct . bone scintigraphy was performed 3 h after intravenous injection of 20 mci ( 740 mbq ) methylene diphosphonate ( mdp ) . it demonstrated no osseous metastases but revealed increased periosteal activity in the long bones of the legs corresponding to hypertrophic osteoarthropathy [ figure 1 ] . pet / ct images were acquired 60 min after intravenous injection of 7 mci ( 259 mbq ) fdg an integrated pet / ct camera . maximum intensity projection and transaxial images showed increased fdg accumulation in the primary tumor ( suvmax : 17 ) , mediastinal lymph nodes ( suvmax : 3.3 ) and mild , symmetrical periosteal fdg uptake along both femuri and tibias ( suvmax : 2.43.0 ) [ figure 2 ] . three - hour whole body tc-99 m methylene diphosphonate images shows intense periosteal uptake in the long bones of the legs maximal intensity projection ( a ) transaxial positron emission tomography ( pet ) ( b ) transaxial fusion of lower extremities ( c ) and transaxial fusion of thorax ( d ) pet / computed tomography imaging show increased fluorodeoxyglucose accumulation in the primary tumor and mediastinal lymph nodes as well as along periosteum of long bones of legs in a symmetrical fashion with an suvmax 2.43.0 hypertrophic pulmonary osteoarthropathy is a commonly seen paraneoplastic manifestation of lung cancer or some nonmalignant diseases . incidences of hpoa of 0.217% in lung cancer patients have been reported . in a study , analyzed lung cancer patients with hpoa and were found to have more often hpoa in males , adenocarcinoma subtype , heavy smokers and stage iiib and v diseases . our patient 's diagnosis was adenocarcinoma , and he was the current smoker . in published reports , involvement of vascular endothelial growth factor ( vegf ) , platelet - derived growth factor ( pdgf ) , and platelets in the pathogenesis of hpoa has been indicated in some publications . they found that plasma vegf and pdgf levels were significantly higher in patients with hpoa compared with healthy controls . hypertrophic pulmonary osteoarthropathy is diagnosed based on clinical symptoms such as continuous pain and edema in the extremities and imaging findings . periostitis is the hallmark of hpoa and bone radiography reveals periosteal membrane thickening and periosteal new bone formation . magnetic resonance imaging findings in patients with hpoa were described in a number of cases and observed soft - tissue changes and periostitis . the findings consisted of the muscular and septal edema associated with extensive soft - tissue swelling that surrounded the femur and the attached cortex . the typical scintigraphic presentation is a diffuse symmetrically increased uptake in the diaphysis and metaphysis of tubular bones with a distinctive double stripe or parallel track sign . . also showed mild hyperemia surrounding the long bones of the legs at blood pool images and intense tc-99 m mdp uptake in the periostea at delayed bone scan imaging . recently , increased fdg uptake along the periosteum of long bones at pet / ct imaging was shown in some reports . in this case , increased fdg uptake was observed concordant with the inflammatory reaction in the periostea of the lower extremities . bone scintigraphy and fdg pet show increased metabolic activity in the long bones of patients with hpoa . physicians interpreting pet / ct images should be aware of these findings especially in patients with lung cancer . correct interpretation of bone scan as well as pet / ct findings is important to make proper treatment decisions . hence , nuclear medicine physicians should be aware and familiar with these findings and avoid reporting them as bone metastases .

hypertrophic pulmonary osteoarthropathy ( hpoa ) is not an uncommon paraneoplastic syndrome that is frequently associated with lung cancer . a 54-year - old male patient with lung adenocarcinoma underwent bone scintigraphy and fluorodeoxyglucose ( fdg ) positron emission tomography / computed tomography ( pet / ct ) scanning for initial staging . bone scintigraphy revealed increased periosteal activity in lower extremities . fdg pet / ct revealed hypermetabolic right lung mass , mediastinal lymph nodes , and mildly increased periosteal fdg uptake in both femurs and tibias . the findings in lower extremities on bone scan and fdg pet / ct were interpreted as hpoa .

a 66-year - old man presented to the out patient department with a painless swelling on the medial half of the right lower lid . it was of insidious onset , gradually increasing in size over the past eight years . fine needle aspiration cytological examination of the lesion yielded only blood and diagnosis could not be established . he was a known diabetic and hypertensive , on treatment for the past eight years . examination of the lids and adnexa of the right eye revealed a single , soft , non - tender swelling measuring 21.91 cm [ fig . 1 ] with a lobulated surface , arising from the medial half of the lower lid . the mass was causing a cosmetic deformity and so microsurgical excision with reconstruction of the lower lid was planned under local anesthesia . a pentagon full - thickness resection of the tumor mass with microscopically clear margins on all sides was done and the tissue sent for histopathology examination . the defect created by this resection was a little less than half of the eyelid . since the lower lid tissues were already stretched by the presence of the tumor , lid repair was possible with lateral cantholysis alone . the lid defect was closed in layers using 6 - 0 polyglactin sutures and the lids were apposed using a frost suture . routine postoperative care was given to the patient and the frost sutures were removed after 48 h. the patient on serial follow - up was normal at six months with no evidence of recurrence . 3b ] arranged in small fascicles in an alcian blue positive myxoid stroma . in each nodule , fine wavy bundles and swirling whorls of collagen ( highlighted by reticulin silver stain ) enclosing the elongated schwann cells and mast cells were observed . immunostatin for neurofilament revealed occasional clusters of axons while the cells in the lesion were not immunolabeled for antibodies to desmin and cytokeratin . the features were characteristic of neurothekeoma - myxoid variant . the presence of axons and absence of entrapment of adnexal structures with s-100 positivity of the cells differentiated this lesion from superficial angiomyxoma which was a very close histological differential diagnosis . myxoid neurothekeoma or nerve sheath myxoma is a rare benign neoplasm of putative peripheral nerve sheath origin first described in 1969 by harkin and reed6 and subsequently termed neurothekeoma by gallager and helwig in 1980.1 it often affects the skin with predilection for the face and extremities of young adults . they are often solitary and may be either asymptomatic or may present as a painful , raised , skin - colored , well - circumscribed dome - shaped nodule less than 3 cm in diameter . the tumor occurs in a myxoid or classic variant , cellular variant and an intermediate ( mixed ) variant,7 the myxoid variant being relatively common . this lesion forms an important differential diagnosis for myxoid soft tissue tumors , especially the benign ones . although excision is the mode of treatment for these benign myxoid tumors , proper histopathological typing is needed as some of these tumors like superficial angiomyxoma show tendencies towards local recurrence and may be associated with syndrome complex like association of superficial angiomyxoma with carney complex,8 an autosomal dominant syndrome complex comprising myxomas of heart and skin , hyperpigmentation of the skin ( lentiginosis ) and endocrine overactivity.9 the myxoid neurothekeoma lesions are consistently positive for s-100 proteins . they are also known to be positive for vimentin but negative for cytokeratin , desmin , cd34 , sma ( smooth muscle actin ) . these lesions can also sometimes show multinucleate cells , focal nuclear atypia , foci of ossification and cartilaginous metaplasia . this case was unique in that the patient was a male in the elderly age group . although neurothekeoma is rare , the clinician should consider this entity in the differential diagnosis of solitary nodule of the eyelid , as it is imperative to distinguish it from malignant lesions so that aggressive therapy can be avoided . the treatment of choice is excision with clear margins and no recurrences have been reported .

the purpose of this article is to describe a rare benign tumor of nerve sheath origin arising from the eyelid in an elderly male . local excision was done and histopathological examination revealed a neurothekeoma . six months later the patient was doing well with no recurrence . the case was unique in that the patient was an elderly male while neurothekeoma is commonly seen on the face of young adults , especially females .

during october 27november 5 , 2014 , ridoh s center for acute infectious disease epidemiology was notified of 3 l. monocytogenes infected persons residing in the same city . the 3 case - patients were all non - hispanic white persons > 60 years of age ; 2 had an immunocompromising condition . interviews conducted by the center for acute infectious disease epidemiology identified a single common restaurant visited by the 3 patients . center for food protection performed inspections and collected food and environmental samples at the establishment . pfge analysis showed that clinical l. monocytogenes isolates from the 3 case - patients shared an identical , common pfge pattern ( figure ) . to determine the relationship between the isolates , ridoh collaborated with federal partners to conduct wgs . results of wgmlst showed that the isolates were closely related ( 05 allelic differences ) ( figure ) and a close genetic match ( median allelic differences 4 ) to a clinical isolate from a 2013 patient , who was reinterviewed and reported eating at the same restaurant . a sliced prosciutto sample from the restaurant tested positive for l. monocytogenes , and pfge patterns for this isolate matched those for isolates from the 2013 and 2014 case - patients . results of wgmlst showed that the isolate from the prosciutto differed by 05 alleles ( median 3 ) from the 2014 clinical samples and by 011 alleles ( median 4 ) from the 2013 clinical sample ( figure ) . sequences for the isolates were uploaded to genbank ( 7 ) ( clinical isolates : accession nos . samn03218571 ) . median ( minimum maximum ) allele differences and pulsed - field gel electrophoresis ( pfge ) patterns for listeria monocytogenes isolates from clinical and food samples associated with a 2014 cluster of listeriosis cases and a 2013 listeriosis case , rhode island , usa . allele differences were determined by whole - genome multilocus sequence typing ( wgmlst ) . adapted from data provided by the enteric diseases laboratory branch , national center for emerging and zoonotic infectious diseases , centers for disease control and prevention ( atlanta , ga , usa ) . a total of 10 food and environmental food samples were initially collected from the restaurant . swab samples were obtained from the food slicer , preparation tables , and walk - in cooler . environmental investigation of the restaurant identified issues related to control of l. monocytogenes : the temperature of the refrigerated unit that held sliced meat and other food items was elevated ( 52f [ 11c ] ) , and cleanliness issues were observed with the preparation tables and slicer . an additional 19 environmental samples were later collected from the establishment ; however , the refrigerated unit and preparation tables had been replaced , so additional swab samples could not be collected from those surfaces . the sample of sliced prosciutto was the only l. monocytogenes positive sample identified at the restaurant ; however , just 1 of the 2014 case - patients reported eating prosciutto ( in an antipasto salad ) at the restaurant . ridoh tested a sample of prosciutto from an unopened package from the establishment and collaborated with the food safety and inspection service to see if the processing plant had recently tested positive for l. monocytogenes . the sample tested negative , and no positive tests had been reported at the plant in at least 1 year . epidemiologic , environmental , and laboratory investigation results implicated a restaurant with sanitation issues and improper sliced meat storage as the likely source of a multiyear listeriosis outbreak . a long incubation period makes wgs an effective technology to use during listeriosis outbreak investigations and to identify outbreak - associated cases originally believed to be sporadic cases . this technology can help overcome difficulties associated with investigating listeriosis cases and can be useful for the investigation of other pathogens . in this investigation , wgs ( wgmlst ) helped link the 2013 listeriosis case , which was originally believed to be a sporadic case , to the 2014 outbreak . furthermore , given that the 4 isolates had a common pfge pattern , this technology increased confidence that the restaurant , which was the only common restaurant among the 4 patients , was the source of the outbreak . the allelic differences observed are consistent with slow , spontaneous mutation occurring over a long period due to persistent contamination . there is no set number of allelic differences used to determine whether clusters of cases are part of actual outbreaks ( 8) . thus , wgs is not sufficient by itself to identify outbreaks and must be performed in conjunction with epidemiologic , laboratory , and environmental investigations ( 8,9 ) . in the investigation the close relationship that wgs showed between the clinical isolates and the isolate from meat provides additional evidence that the restaurant was the likely source of contamination for the cases in 2013 and 2014 . our findings support the need to control l. monocytogenes at retail food establishments . storing meat at < 41f ( 5c ) can prevent 9% of listeriosis cases ( 2 ) . in addition , retail delicatessens and food establishments can prevent l. monocytogenes associated illnesses among customers by controlling cross - contamination , cleaning and sanitizing food contact surfaces , and eliminating environmental niches .

in november 2014 , the rhode island department of health investigated a cluster of 3 listeriosis cases . using whole - genome sequencing to support epidemiologic , laboratory , and environmental investigations , the department identified 1 restaurant as the likely source of the outbreak and also linked the establishment to a listeriosis case that occurred in 2013 .

ectopic thyroid is a developmental defect of thyroid gland that leads to presence of thyroid tissue at sites other than its normal cervical location . it is very rare to have two ectopic foci of thyroid tissue , and only a very few cases of dual ectopia have been reported in the world literature . in 70% of cases of ectopic thyroid , it is extremely rare to have dual ectopic thyroid with a normally located thyroid gland . a 13-year - old boy presented with stunted growth and poor school performance . a thorough clinical history revealed that initial motor and social developments as a child were within limits . an ultrasonogram ( usg ) of the neck was performed which showed atrophic orthotopic thyroid gland . technetium thyroid scan [ figure 1 ] was performed to evaluate the functional status of the orthotopic thyroid gland . planar image anterior view ( a ) and face turned to the right ( b ) shows 2 foci of tracer uptake in the upper part of the neck . spect ct showed atrophic thyroid gland without any technetium uptake ( c ) and localized the ectopic thyroid tissues ( ett ) to the sub - hyoid location ( d ) and suprahyoid locations ( e ) . planar image anterior view ( a ) and face turned to the right ( b ) show 2 foci of tracer uptake in the upper part of the neck . spect ct showed atrophic thyroid gland without any technetium uptake ( c ) and localized the ectopic thyroid tissues to the sub - hyoid location ( d ) and suprahyoid locations ( e ) thyroid gland is a derivative of forgeut and its original position is marked by the foramen cecum at the junction of anterior two - thirds and posterior one - third of the tongue . an evagination appears between the first and second pharyngeal pouches at about 4 weeks of gestational age . this evagination forms a tube , descends inferiorly and anteriorly to pass anterior to the hyoid bone descends and forms the lateral lobes of thyroid . the thyroglossal duct marks the pathway from the pharynx to the anterior neck . simultaneous presence of multiple ett is highly unusual . ectopic thyroid tissue may be present in variety of locations : sublingual region , high cervical , mediastinal , or intracardiac locations . hybrid spect / ct is useful in cases of multiple ectopia of thyroid gland for accurate localization . chronic inflammation due to auto - antibodies gradually destroys the thyroid follicles and lead to hypothyroidism .

ectopic thyroid tissue ( ett ) refers to all cases in which the thyroid gland is present at a location other than its usual site . the prevalence of ett is approximately one per 100,000 to 300,000 persons and is reported to occur in one in 4,000 to 8,000 patients with thyroid disease . multiple ectopia of thyroid is extremely rare . multiple ectopia in the presence of orthotopic thyroid gland is extremely rare . we report a 13-year - old boy with stunted growth and developmental delay caused due to acquired hypothyroidism . technetium scan performed as per management protocol identified dual ectopia of thyroid . the role of hybrid single - photon emission computed tomography / computed tomography ( spect / ct ) in the localization of the sites of ett is also highlighted .

chronic burn scar developing into a malignant neoplasm is a well known complication.most of these tumors are squamous cell carcinomas followed by basal cell carcinoma , melanoma and sarcoma . we report the first occurrence of the combination of squamous cell carcinoma and epithelioid sarcoma arising in a burn scar . metastatic spread to the inguinal lymphnodes , lungs and breast was also seen in this case . a 29-year - old female presented with an exophytic tumor mass at left ankle since 3 months . she gave history of burns at the same site 9 years back , for which skin grafting had been done . bilateral axillary and right inguinal lymphnodes were palpable apart from a right thigh soft tissue mass . computed tomography ( ct ) scan examination of thorax and abdomen showed metastatic nodules in bilateral lungs , both breasts and right adrenal gland . gross examination revealed an exophytic mass at ankle measuring 11 9 9 cm , which was whitish and friable with areas of hemorrhage and necrosis on cut surface . exophytic mass at the ankle histopathologic examination of this thick plaque showed features of well - differentiated squamous cell carcinoma ( scc ) [ figure 2 ] . however , the exophytic growth showed large round to polygonal tumor cells arranged in islands and nests with large areas of necrosis and nuclear debris in the center [ figure 3 ] . individual cells had moderate eosinophilic cytoplasm , and round to oval enlarged vesicular nuclei with prominent nucleoli [ figure 4 ] . tumor cells were positive for vimentin [ inset of figure 4 ] and pancytokeratin on immunohistochemistry . the cells were negative for s-100 protein , hmb 45 , desmin , ema , cd 34 , lca and myo d1 , thereby favoring epithelioid sarcoma . fine needle aspiration cytology performed on breast mass , pulmonary nodule ( under ct guidance ) and axillary lymphnodes revealed metastasis of a sarcoma with a cell morphology resembling that of exophytic mass . epithelioid sarcoma is known to have a high rate of recurrence and metastasis predominantly to the lymphnodes , lungs and scalp . the patient self - discharged against medical advice and was lost to follow - up . well - differentiated scc ( h and e , 100 ) large round to polygonal tumor cells arranged in islands and nests with large areas of necrosis and nuclear debris in the centre ( 100 h and e ) individual cells had moderate eosinophilic cytoplasm , round to oval enlarged vesicular nuclei with prominent nucleoli . tumor cells were positive for vimentin on immunohistochemistry ( inset ) ( h and e , 200 ) in a large review of burn scar neoplasms , kowal vern reported scc as commonest neoplasms in up to 7% , followed by basal cell carcinoma ( bcc ; 12% ) , melanoma ( 6% ) and sarcoma ( 5% ) . double tumors comprising scc and bcc ( 2% ) and scc with melanoma ( 1% ) have also been reported . literature reports only two cases of epithelioid sarcoma in a burn scar and the present case is the first case report of epithelioid sarcoma along with scc in a burn scar . the overall histopathologic and immunohistochemical features were consistent with a diagnosis of epithelioid sarcoma in addition to the metastatic spread to the inguinal lymphnodes , lungs and breast . prognosis is primarily related to the local extent of the disease , its anatomical location and the presence or absence of lymphnode metastasis .

development of a malignant tumor is a well known complication of a chronic burn scar . most of these tumors are squamous cell carcinomas and only 28 cases of burn scar sarcomas have been reported in literature . we report the first occurrence of the combination of squamous cell carcinoma and epithelioid sarcoma arising in a burn scar .

a nonsmoker 51 year - old man used sildenafil citrate ( viagra ) for erectile dysfunction . the patient did not clarify the quantity of the drug that he used the previous day , but he mentioned during history recording that he had been using this specific agent for the last 6 months at least once a week . the following morning , he noted painless blurred vision in his right eye and he was referred to the university eye clinic of ioannina . ophthalmologic examination revealed a corrected visual acuity of 1/10 for the right eye and 10/10 for the left eye . the color vision score for the affected eye was 10 out of 15 ishihara plates while the unaffected eye had a score of 15 out of 15 . dilated fundus examination revealed swelling of the right optic disk while the vessels , macula , and the peripheral retina were normal . fluoroangiography revealed hyperfluorescence of the right optic disk and leakage from it , indicating edema . the patient was not hyperopic and the cup - to - disk ratio in the fellow eye was 0.3 . syphilis screening tests , antinuclear antibodies , antinuclear cytoplasmic antibodies , and anticardiolipin antibody tests were all negative . in addition , laboratory screening revealed that erythrocyte sedimentation rate , c - reactive protein , and blood count were in the normal range . a magnetic resonance image scan of the brain and orbits with gadolinium demonstrated normal optic nerves and no white matter lesions . the above mentioned results led to the conclusion that the patient had experienced a naion attack on his right eye . the patient was subjected to three subtenon injections of beta - methoxazone with a 20-day interval in between . visual acuity at the last follow - up evaluation , 1 year after the initial attack , improved to 8/10 for the right eye with ensued optic disk atrophy yet without any significant improvement concerning the impaired visual field . naion is the most common acute optic neuropathy in older age groups with an estimated annual incidence of 2.3 per 100,000.1,2 it is presumed to result from circulatory insufficiency within the optic nerve head , but the specific mechanism of the vasculopathy remains unproven . therefore , the most important considerations in understanding the development of naion are the factors that influence blood flow in the optic nerve head . hypovolemia , mainly due to severe surgical procedures,3,4 atherosclerotic risk factors,5 hypercoagulable states,68 and crowded optic disk,9 in possible combination with regional vascular endothelial disorders has been implicated in the pathophysiology of naion . over the last few years there has been an increasing number of case reports concerning patients who have developed naion soon after the use of sildenafil and other phosphodiesterase type 5 inhibitors.1013 it has been hypothesized that these agents might exaggerate the physiologic nocturnal hypotension resulting in ischemia to the optic nerve head or that they might interfere with the autoregulation of blood flow thereby decreasing perfusion to the optic nerve head.14 in most of the reported cases of naion after the use of sildenafil , patients detected visual loss upon awakening in the morning . it is usually described 636 hours after use of the agent , as it was in this case . the majority of affected users of phosphodiesterase type 5 inhibitors suffer already from other possible risk factors for naion . in a retrospective matched case - control study , 38 patients with naion and age - matched controls without previous history of naion were questioned for the use of erectile dysfunction agents . the study showed that men with a history of myocardial infarction or hypertension are at increased risk for naion when using sildenafil or taldenafil.15 in this case , the patient had mild hypercholesterolemia without any other systemic or vascular predisposing risk factors based on clinical examination and the rest of the screening as described above . however , the family history of his father having suffered from bilateral attacks of naion indicates the possible presence of anatomical or other unidentified risk factors for the development of naion . the role of hereditary factors in familial naion remains unknown and the only clinical difference between classical and familial naion is that the familial type seems to have an earlier onset and a higher frequency of bilateral disease.16 this case might support all previous indications of the association between naion and the use of erectile dysfunction drugs . since it seems that sildenaf il can provoke naion in some individuals who have a risk profile , the physician might need to investigate the presence of a family history of naion among other risk factors before prescribing erectile dysfunction drugs .

a 51-year - old male was referred to the university eye clinic of ioannina with nonarteritic anterior ischemic optic neuropathy ( naion ) 12 hours after receiving sildenafil citrate ( viagra ) . examination for possible risk factors revealed mild hypercholesterolemia . family history showed that his father had suffered from bilateral naion . although a cause - and - effect relationship is difficult to prove , there are reports indicating an association between the use of erectile dysfunction agents and the development of naion . physicians might need to investigate the presence of family history of naion among systemic or vascular predisposing risk factors before prescribing erectile dysfunction drugs .

gastrojejunocolic fistula ( gjf ) is a rare and late complication of gastrojejunostomy applied for recurrent peptic ulcer disease . it was thought to be induced by a stomal ulcer , due to inadequate gastrectomy or incomplete vagotomy . the symptoms in these situations include upper abdominal pain , weight loss , diarrhea , gastrointestinal bleeding , and fecal vomiting . these patients are cachectic and dehydrated , with labs showing malnutrition . barium upper gastrointestinal series ( ugis ) , gastroscopy , and colonoscopy are used for diagnosis . although the occurrence of gjf has decreased remarkably as a result of better treatment , the modern management of this condition and the generally accepted surgical treatment strategies must be discussed . a 55-year - old man was admitted to the medical center at dankook university hospital in december 2011 . the patient had complaints of chronic watery diarrhea that occurred immediately after meals for 6 months , general weakness , and a weight loss of 15 kg during a 3-month period . past medical history revealed primary repair for duodenal ulcer perforation in 1982 and truncal vagotomy and gastrojejunostomy in 1996 due to gastric outlet obstruction . laboratory parameters revealed malnutrition with albumin level of 2.6 g / dl ( range , 3.4 to 4.8 ) , protein level of 4.3 g / dl ( range , 6.4 to 8.3 ) , and cholesterol of 72 mg / dl ( range , 120 to 239 ) . the infusion of contrast into the colon was identified near the gastrojejunostomy , according to a thin barium ugis double study ( fig . copious fecal fluid was evident in the stomach through a gastroscopy , and a canal was identified in the previous gastrojejunostomy site and low body posterior wall connected directly to the colon ( fig . 2 ) . a colonscopy revealed an anastomosis site was seen in the transverse colon stricture and t - colon connected to the stomach . after improving the patient 's state of malnutrition and his weight through total parenteral nutrition ( tpn ) , the patient was taken into the operation room and an exploratory laparotomy was undertaken . in surgery , the gastrojejunostomy site and distal gastrectomy , roux - en - y anastomosis , t - colon segmental resection and anastomosis were performed . three month after discharge , there was no ulcer , inflammation or passage disturbance at anastomosis site on endoscopic examination and the patient improved his symptoms . along with the development of medical treatment , such as h2 receptor blocker , proton pump inhibitors , and eradication of helicobacter pylori , the need for an operative treatment for peptic ulcer disease decreased , dramatically . for such a reason , the incidence rate of these fistulas has been remarkably decreased . the symptoms of gjf are diarrhea with food containing stools , upper abdominal pain or discomfort , gastrointestinal bleeding , fecal vomiting , weight loss , and general weakness . computed tomography is used to determine this complex fistula and to exclude extra - abdominal diseases that may define underlying etiology . gastroscopy and colonoscopy is a diagnostic tool that can identify the orifice of the fistula , find intraluminal diseases , and rule out malignancy thorough an endoscopic biopsy . the conventional treatment for gjf includes improving the nutritional status and two - to - three - phased operations with colostomy to minimize mortality . today , however , due to improved parenteral and enteral support treatment , single - stage procedures can be applied and these have been favored to minimize mortality . in our case , truncal vagotomy was performed in previous operation on medical record , therefore we did n't perform truncal vagotomy . if truncal vagotomy has not previously been completed , it is advisable to perform it nonetheless . in conclusion , the development of the peptic ulcer agents including those capable of eradicating h. pylori , gjf incidence has decreased dramatically . but , since the fistula formation needs a 20 to 30 years latent period after surgery , this complication can occur . today , one - stage resection is preferred over the staged operation if the general status of the patient is suitable . tpn is a crucial factor for recovering the patient 's malnutrition status and so should precede surgery .

gastrojejunocolic fistula is a rare condition after gastrojejunostomy . it is severe complications of gastrojejunostomy , which results an inadequate resection or incomplete vagotomy during peptic ulcer surgery . the symptoms are diarrhea , upper abdominal pain , bleeding , vomiting and weight loss . a 55-year - old man with chronic diarrhea and weight loss for 6 months visited dankook university hospital . the patient had received a truncal vagotomy and gastrojejunostomy for duodenal ulcer obstruction 15 years previously . the patient underwent gastroscopy and upper gastrointestinal series evaluations , which detected the gastrojejunocolic fistula . after improving of malnutrition , an exploratory laparotomy was undertaken , which revealed that the gastrojejunostomy site and the t - colon formed adhesion and fistula . en block resection of the distal stomach and t - colon included the gastrojejunocolic fistula , and roux - en - y gastrojejunostomy was performed . recovery was uneventful and the patient remained well at the follow - up . we report a gastrojejunocolic fistula , which is a rare case after gastrojejunostomy .

mycobacterium tuberculosis was isolated from the cerebrospinal fluid ( csf ) of a patient diagnosed with tuberculosis at a local hospital . the sample was cultured in bbl mgit mycobacterial growth indicator tube supplemented with bbl mgit oadc enrichment and bbl mgit panta antibiotic mixture ( becton - dickinson , oxford , united kingdom ) . since the isolate was found to be resistant to rifampicin and isoniazid , it was labeled as multidrug resistant m. tuberculosis strain pr10 ( mdr - tb pr10 ) . genomic dna was extracted and sequenced using miseq ( illumina , ca , usa ) , generating a total of 10,595,456 reads in a 300-cycle run . raw reads were trimmed and assembled de novo using clcbio ( clc genomics workbench version 7.0.3 ) ( clcbio , aarhus , denmark ) , producing 163 contigs with an average coverage of 334 . annotation was performed using the bacterial annotation system ( basys ) and rapid annotation using subsystem technology ( rast ) online services , and the pathogenicity and virulence genes were determined . the genes identified were validated using the following external gene annotation databases : tuberculist ( http://tuberculist.epfl.ch ) , uniprotkb ( http://www.ebi.ac.uk/uniprot ) , virulence factor database ( vfdb ) ( http://www.mgc.ac.cn ) , and tbdatabase ( tbdb ) ( http://www.tbdb.org ) . the size of the draft genome mdr - tb pr10 is 4,347,484 bp with a g + c content of 65.6% . basys annotation software predicted 4637 genes and 50 rna - encoding elements . using rast , a total of 400 subsystems and 4286 protein - coding genes were annotated in the mdr - tb pr10 genome ( fig . a gene that encodes dna - directed rna polymerase beta ' subunit ( rpob ) ( ec 2.7.7.6 ) was annotated in mdr - tb pr10 . the gene was reported to be involved in the invasion and intracellular resistance subsystem that may play a role in resistance towards certain drugs such as rifampicin . the rpob gene is responsible for the transcription of dna into rna using the four ribonucleoside triphosphates as substrates catalyzed by dna - dependent rna polymerase . mutations that occur in the rpob gene may cause the changes in the protein translation of mycobacterium that may confer resistance to rifampin , . comparison of genome sequences using rast showed that the strains closest to pr10 are m. tuberculosis ncgm2209 ( score of 521 ) , followed by m. tuberculosis na - a0008 ( score of 459 ) and m. tuberculosis um 1072388579 ( score of 400 ) . the whole genome shotgun project has been deposited at ddbj / embl / genbank under the accession number cp010968 . the authors declare that there is no conflict of interests with respect to the work published in this paper .

here , we report the draft genome sequence and annotation of a multidrug resistant mycobacterium tuberculosis strain pr10 ( mdr - tb pr10 ) isolated from a patient diagnosed with tuberculosis . the size of the draft genome mdr - tb pr10 is 4.34 mbp with 65.6% of g + c content and consists of 4637 predicted genes . the determinants were categorized by rast into 400 subsystems with 4286 coding sequences and 50 rnas . the whole genome shotgun project has been deposited at ddbj / embl / genbank under the accession number cp010968 .

photorhabdus ( family : enterobacteriaceae ) with their natural vectors , the entomopathogenic nematodes ( epn ) ( phylum : nematoda ; order : rhabditida ; family : heterorhabditidae ) , have emerged as important biological control agents of insect pests , and are capable of production and delivery of diverse compounds to influence host biology , , . raw sequencing reads , and whole - genome shotgun assemblies for three p. luminescens strains have been deposited at ddbj / embl / genbank under the accession numbers provided in table 1 . total raw reads , sequenced base - pairs , n50 value of wgs assembly and snps identified from p. luminescens nbaii h75hrpl105 , p. luminescens nbaii hipl101 , and p. luminescens nbaii hbpl105 have been summarized in table 2 . are symbiotic bacteria associated with soil - born heterorhabditis and steinernema species of entomopathogenic nematodes . bacterial cultures were established from isolation in these natural hosts , then cultured in lab hosts galleria mellonella . finally , pure monoxenic cultures were then grown in lb media . purity of these isolations was checked with 16s rrna gene sequences , before they were used for whole genome sequencing . isolated genomic dna was then used for sequencing and library preparation using the illumina miseq platform ( at chromous biotech ltd . , bengaluru , 560692 , karnataka , india ) with paired - end libraries generated for each of the three bacterial genomes . reads were processed , analyzed and trimmed according to fastqc to remove illumina adapter sequences . trimmed reads were assembled into contigs to capture whole - genome shotgun sequences ( wgs ) using de novo and reference - guided methods using clcbio genomics workbench v. 7.5 . luminescens strains were mapped to the reference genome of p. luminescens laumondii strain tt01 ( ncbi accession nc_005126.1 , for reference - guided genome assemblies ) using global alignment , and trimmed where base - call confidence was less than 95% . sequence variants ( snps , multiple nucleotide polymorphisms and indels ) were identified against the reference genome of p. luminescens subsp . laumondii tt01 reference genome ( ncbi accession nc_005126.1 ) in clcbio genomics workbench using the following parameters : minimum variant coverage50 , minimum variant count9 , minimum variant frequency50% , minimum quality score neighborhood radius13 , minimum variant quality score30 , and minimum neighborhood quality score25 , p. luminescens strain nbaii h75hrpl105 , p. luminescens strain nbaii hipl101 , and , p. luminescens strain nbaii plhb105 isolated from the entomopathogenic nematodes , heterorhabditis species strain nbaii h75hr , heterorhabditis indica strain nbaiihi101 and heterorhabditis bacteriophora strain nbaii hb105 , respectively .

we report here draft whole genome sequences of three novel strains of photorhabdus luminescens of 5.25.3 mbps in size , and with a g + c content of 42.5% ( each ) . symbiotic -proteobacteria belonging to the genera , photorhabdus ( family : enterobacteriaceae ) with their natural vectors , the entomopathogenic nematodes ( epn ) ( phylum : nematoda ; order : rhabditida ; family : heterorhabditidae ) , have emerged as important biological control agents of insect pests , and are capable of production and delivery of diverse compounds to influence host biology [ 1 ] , [ 2 ] , [ 3 ] . analysis of these genomes is expected to provide enhanced insight into mechanisms of virulence , insecticidal toxin genetic diversity , antibiotic resistance and monoxenicity . the nucleotide sequence information for the three strains nbaii plhb105 , nbaii hipl101 and nbaii h75hrpl105 has been deposited in ncbi nucleotide database and is accessible via azab00000000 , jthj00000000 and jxur00000000 accession numbers respectively .

lipoma of the abdominal cavity , a benign neoplasm of mature fat cells usually presents as an asymptomatic abdominal mass or progressive abdominal distention . lipomas are sometimes detected incidentally as an intraperitoneal radiolucent fat density mass on a ct scan . extrahepatic , fat - containing masses of the abdomen and pelvis represent a broad spectrum of congenital , metabolic , inflammatory , traumatic , degenerative , and neoplastic processes . we present a rare case of giant retroperitoneal lipoma in an infant , mimicking hirschprung 's disease , and presenting as an emergency . at laparotomy , a six - month - old baby girl presented to our accident and emergency department with progressive abdominal distention and recurrent constipation , with episodes lasting four to nine days , for all of the four - month duration , and significant wasting . there was no history of delayed passage of the meconeum , no vomiting , and no fever . the child was in respiratory distress , the abdomen was grossly distended , tensed , and nontender , but with uniform dullness to percussion [ figure 1 ] . a plain x - ray of the abdomen revealed a soft tissue mass displacing and compressing the bowel loops , with the dome of the diaphragm at the level of the fourth rib anteriorly . an ultrasound ( us ) examination of the abdomen showed a huge heterogeneously hyperechoic mass occupying the whole abdomen , with the bowel loops displaced toward the periphery . thin fibrous septations were also noted within the lesion . on doppler scanning of the abdomen the vessels the patient was optimized and the nasogastric tube ( ngt ) drained , with scanty , clear effluent and no reduction of the abdominal girth . an emergency laparotomy was performed , which revealed a huge yellowish tumor arising from the retroperitoneal space occupying the whole abdomen [ figure 2 ] . by careful dissection the tumor was removed , it measured 26 19 13 cm and weighed 1.7 kg [ figure 3 ] . gross abdominal distention due to retroperitoneal lipoma retroperitoneal lipoma being delivered at the laparotomy the lipoma weighing 1.7 kg retroperitoneal lipoma is an unusual entity that is most often found in adults between 40 and 60 years of age and rarely occurs in the first decade of life . retroperitoneal benign lipomas are extremely rare and represent about 2.9% of all primary retroperitoneal tumors and about 80% of them are malignant neoplasms . in a series of 190 retroperitoneal tumors in infants and children till 1979 , only 12 cases of retroperitoneal lipoma in children , diagnosed in the first decade of life , were reported in the literature . clinically , these lipomas produce few symptoms and therefore tend to become large before being discovered . the only report of malignant degeneration was by kretschmer , who removed a large lipofibrosarcoma from a two - yearr - old girl . lipoma of the abdominal cavity usually presents as an asymptomatic abdominal mass or progressive abdominal distention . lipomas are sometimes detected incidentally as an intraperitoneal radiolucent fat density mass , on a ct scan . two cases of histologically proven giant retroperitoneal lipomas , evaluated by ct and sonography , appear to be similar on ct , but they exhibit different echographic patterns sonographically . weather the lipoma is congenital in infants is uncertain , as abdominal masses are not seen at birth in most cases , but the presence of a huge abdominal mass in early infancy , in this patient , indicates that this retroperitoneal lipoma is most probably congenital the long - term behavior of retroperitoneal lipoma in children is not well - defined as compared to adults , due to the inadequate number of cases , therefore , a long - term follow - up is essential in children . retroperitoneal lipoma is rare in children , more especially in infancy ; the emergency presentation was due to pressure symptoms . the characteristic behavior in children is yet to be defined ; therefore a long - term follow - up is recommended .

retroperitoneal lipomas have remained the essentially rare tumors seen in clinical practice . the tumors are rarer in children , with very few reported cases in surgical literature worldwide . we are reporting the case of a six - month - old child who presented with a giant retroperitoneal lipoma that was successfully managed by complete excision . there has been no recurrence noticed during follow - up .

minimally invasive approaches have been the actual goal for neurosurgery . in line with this philosophy besides the esthetic benefit of the minimally invasive approach , there is the possibility to minimalize the operative time and length of hospital stay . at an emergency setting , a 47-year - old patient was admitted with a glasgow coma scale ( gcs ) of 13 points and remained neurologically stable until surgery , which he was submitted after 72 h of trauma . although he was neurologically stable , the location of the hematoma implicated in the risk of brain stem compression with normal intracranial pressure . it would be necessary to observe for a long period to be sure that there were no more risks for the hematoma expansion . brain computed tomography ( ct ) scan showed a temporal hematoma with 30 ml of volume , extending from the temporal posterior region to the anterior compartment of the right media fossa . the volume and the location of the hematoma implicate in a high risk of brain stein compression . the brain ct scan was reconstructed using the program osirix , as shown in fig . 1 , so that it was possible to establish accurate cranial landmarks to guide the burr hole position . figure 1:osirix ct reconstruction . was put in the proper position , guided by the 3d imaging , we were able to perform a single small incision and a single burr hole at the posterior aspect of the hematoma . the neuroendoscope ( storz hopkinsforward oblique telescope 30 ) was positioned in a 45 direction , headed from the posterior limit of the hematoma to the media fossa floor , in a way that the whole hematoma could be visualized . with the neuroendoscope in place then , both the suctor and the neuroendoscope are progressively inserted through the burr hole , following the natural corridor provided by the hematoma evacuation . if some level of hemorrhage emerges , irrigation with 0.9% saline is enough to stop bleeding . if bleeding persists , pieces of surgicel can be left in place . a small piece of gelfoam is placed over the burr hole , and the wound is closed in layers . the comparison between the pre- and postoperative ct scans is shown in fig . 2 . in the actual scenario of minimally invasive techniques , the endoscopic method has been at high spot , especially for intracerebral hematomas . in contrast , for hemorrhagic strokes several authors , with or without complementary methods , have described the technique . in 2010 the author used a 3d reconstructed ct scan to guide the entry point , depth of penetrating path and surgical trajectory . the average hematoma evacuation rate was 82% . using stereotactic guidance described a hematoma evacuation inserting the endoscopy through a metal tube positioned by stereotaxic . the holder assured that the guide tube did not move , providing safety to the procedure . other papers [ 35 ] confirm that the method is safe with lower mortality compared with the conventional method to treat spontaneous hematomas , and those do not extend the operative time . in traumatic brain injuries , these features may decrease the operative time , which is crucial for a safer procedure . when considering posterior fossa , it is marked the time gained with the endoscopic technique ( 64.5 versus 230.6 min ) , as described by yamamoto t. . considering these advantages , two groups applied the endoscopic technique for acute subdural hematomas drainage [ 7 , 8 ] describing one case of non - traumatic and other traumatic large acute subdural hematomas . the technical note presented in this report expresses the tendency of minimally invasive surgeries , focused on lower operative time and lower blood loss , besides the esthetic aspect considered as another advantage . endoscopic surgery , usually described for spontaneous hematomas , may expend its perspectives considering the reduced time of surgery , blood loss and safety , and may also be considered for traumatic brain injuries . this case report is the first to describe the endoscopic technique applied to traumatic intracranial hematoma . also , comparing it to the other tools described before to guide the procedure , the surgical planning reported here has the great advantage that does not require any cost and is also simple to use . our group has already described the use of the open access osirix software for planning craniotomy or burr hole in the emergency setting with a detailed description on how to use the tools provided by the software , which surely does not postpone the procedure . nevertheless , its use to assist an endoscopic surgery was not described in our previous article . this first described technique could be widely spread considering its cost and all the possible morbidities that could be applied , gathering both safety and effectiveness for minimally invasive procedures .

the endoscopic technique has been described as a minimally invasive method for spontaneous hematoma evacuation , as a safe and effective treatment . nevertheless , to our knowledge , there is no description of a technical report of traumatic intracerebral hematoma removal using the neuroendoscope . a 47-year - old man was admitted sustaining 13 points in glasgow coma scale with brain computed tomography ( ct ) scan showing a temporal contusion . guided by a 3d reconstructed ct , using the program osirix , the posterior limit of the hematoma was identified . a burr hole was placed at the posterior temporal region , and we used the neuroendoscope to assist the hematoma evacuation . the postoperative tomography showed adequate hematoma removal . he was discharged from hospital 48 h after surgery . two weeks later , he was conscious and oriented temporally . this endoscopic - assisted technique can provide safe removal of traumatic hematomas of the temporal lobe .

red phosphorus is nonvolatile , insoluble , and unabsorbable , and therefore nontoxic when ingested . yellow phosphorus ( also referred to as white phosphorus ) , on the other hand , is a severe local and systemic toxin causing damage to gastrointestinal , hepatic , cardiovascular , and renal systems . we describe here a case of acute yellow phosphorus poisoning that led to fulminant hepatic failure and eventually , the patient recovered with conservative management . a 3-year - old girl was brought to the hospital with an alleged history of accidental consumption of an unknown quantity of rodenticide paste ( ratol , containing 3% yellow phosphorus ) . she was made to rinse her mouth with salt water and remained asymptomatic until 8 hours when she started vomiting . she was then brought to the hospital 14 hours after poisoning due to persistent vomiting . there was no history of jaundice , abdominal pain , breathlessness , or oliguria . on admission , the child was conscious and afebrile with a heart rate of 122/minute and respiratory rate of 32/minute . the liver was palpable 2 cm below the costal margin , soft , and with rounded margins . results of the investigations done on the day of admission and subsequently are shown in table 1 . stages of hepatic encephalopathy and investigation reports on the second hospital day , the child developed fever and was noticed to be sleeping excessively and not taking feeds . a diagnosis of stage 1 hepatic encephalopathy was made and the patient was given intravenous ( iv ) fluids with 10% dextrose , iv cefotaxime vitamin k , injection ranitidine , and oral ampicillin . intake and output was strictly monitored and blood glucose was measured six - hourly . despite initiation of antihepatic failure therapy , the child progressed to stage 3 encephalopathy on day 3 and had malena for which she was administered fresh frozen plasma . the sensorium started improving on the 8 hospital day , with a simultaneous improvement in her laboratory parameters [ table 1 ] . yellow phosphorus is an inorganic substance used in military ammunition , fire crackers , fertilizers , and as rodenticide . after absorption , it is distributed to all tissues , particularly the liver , and the peak level is reached after 2 to 3 hours of toxic oral ingestion . bile salts are important for absorption of phosphorus . because of water content and low oxygen tension , phosphorus remains stable in gut for longer period . phosphorus is a general protoplasmic poison causing cardiac , hepatic , renal , and multiorgan failure . the first stage occurs during the first 24 hours in which patient is either asymptomatic or has signs and symptoms of local gastrointestinal irritation . there may be mild elevation of liver enzymes and bilirubin in this stage . the third stage ( advanced ) patients may present with acute hepatic failure , coagulopathy , and deranged liver function , as was witnessed in our patient . central nervous system effects include changes in mental status like confusion , psychosis , hallucinations , and coma . gastric lavage with potassium permanganate is recommended to convert the phosphorus to relatively harmless oxides . fernandez and canizares in a series of 15 patients have reported a mortality of 27% , confirming that yellow phosphorus is extremely lethal when ingested . the indiscriminate use of yellow phosphorus in the manufacture of fireworks should be eliminated . since rodents are developing resistance to rodenticides containing warfarin , rat poisons containing yellow phosphorus are making a big come - back . the yellow phosphorus rodenticides pose a special problem in that the product directions suggest that the paste be applied to bread to enable ingestion by rodents , thus making it appealing to children as well .

we report a case of three year old girl , who was brought to hospital for accidental consumption of rat - poison ( 3% phosphorus ) . the patient was asymptomatic for first 48 hours . later on she developed the symptoms of hepatic failure . she was managed conservatively and was discharged after 14 days .

foot drop is the dropping of the forefoot due to weakness and it is characterized by the inability to dorsiflex the ankle . there are various aetiologies for foot drop ; it can be caused by injury to the peroneal nerve , neuromuscular disease , trauma to the l5 nerve root ( disc prolapse , direct trauma or iatrogenic ) , degenerative diseases like poliomyelitis , spinal cord tumours , stroke , intracranial tumours and genetic , such as charcot marie tooth disease and hereditary neuropathy . a 89 year old gentleman presented with sudden onset of low back pain which came on suddenly when he was standing . his mobility deteriorated gradually over the next two weeks until he developed bilateral complete foot drop . he was awaiting a right hemi colectomy for carcinoma of the caecum . in the past he also had a nodular melanoma on his nose with node metastases 7 years ago . he also had past medical history of temporal arteritis , hypertension , left hip arthroplasty and left inguinal hernia repair . mri demonstrating synovial cyst on examination he had straight leg raise of 45 degrees bilaterally . he had 1/5 power of bilateral ankle dorsiflexion and 3/5 power of dorsiflexion of big toe . mri demonstrating synovial cyst mri of the whole spine revealed that he had multiple metastatic deposits throughout his spine with complete collapse of l3 vertebral body but intact disc space . significant spinal canal stenosis at l4/5 level was seen due to a degenerative posterior disc bulge as well as a 2 x 1 x 1 cm size well capsulated , well defined lesion seeming to arise fromthe ligamentum flavum contributing to the canal narrowing.the appearances were thought to be either due to underlying haematoma from ligamentum flavum or a haemorrhagic synovial cyst . he underwent emergency l4/5 lumbar laminectomy . a juxta articular synovial cyst containing straw coloured fluid histology showed dense collagen bearing a small cyst lined by reactive synovium and containing some fibrin but no evidence of neoplasia is seen . however this turned out to be from a completely different pathology in the form of a synovial cyst , even though he did have spinal metastases . synovial cysts are relatively uncommon in the spine but occur most frequently at the l4 - 5 level . the majority of these cysts are lined with synovial cells and contain a straw - coloured fluid . there have been several previous reports of symptomatic hemorrhagic synovial cysts in the lumbar spine . most cases are associated with facet joint osteoarthritis and degenerative spondylolisthesis , but there is no correlation with age , gender , or degree of disc degeneration . as in this case , most patients present with progressive low back and lower extremity radicular symptoms resulting from compression of the thecal sac or nerve roots . patients may complain of focal tenderness over the facet joints with exacerbation of pain during extension . other common findings not present in the current case , include motor and sensory deficits and positive straight leg raising test . the recommended treatment of symptomatic synovial cysts is excision through laminectomy . in this case , a wide decompression was required to facilitate removal of the cyst . other reported treatment options include computed tomography guided fine needle aspiration and percutaneous injection of hyaluronidase ( 1 ) . symptomatic lumbar facet cysts should be included in the differential diagnosis for patients presenting with progressive back pain and radicular symptoms . patients with significant facet degeneration and instability are predisposed to the development of facet cyst ( 2 ) . haemorrhage into a lumbar synovial cyst causing an acute cauda equina syndrome has been reported ( 3 ) . normally synovial cysts cause a gradual onset of symptoms , however these two cases highlight that this can present acutely if haemorrhage occurs into it .

an 89 year old gentleman awaiting surgery for carcinoma of caecum presented with sudden back pain and developed foot drop two weeks later . mri revealed multiple spinal metastases with a cyst in the canal at l4/5 causing spinal canal stenosis . surgery revealed a juxta articular synovial cyst with haemorrhage in it . we discuss the presentation and management of juxtarticular cysts with a review of the literature .

colchicine is an alkaloid found in the plant colchicurn autumnal , first recommended for the relief of articular pain in the 6 century a.d . , and now most commonly used to treat gout , familial mediterranean fever , behet 's disease , atrial fibrillation following cardiac tissue ablation , and pericarditis . an overdose of colchicine inhibits cell division , and thus the most affected organs are those that have a high rate of cell turnover , such as the gastrointestinal tract , bone marrow , and hair follicles . colchicine poisoning typically shows three phases : initially , gastrointestinal symptoms predominate ; in the second phase , multiorgan failure may occur ; and if the patient survives , the third phase of recovery follows , during which the patient often presents with hair loss . we present a case of a 17-year - old girl with a personal history of depression , several suicide attempts , alimentary behavioural disorder , and a recently diagnosed pericarditis , for which she was taking colchicine ( 1 mg / day ) . she was admitted to the psychiatric department of our hospital after recovering from a suicide attempt , apparently taking 40 pills of colchicine ( 40 mg ) , which led to severe pancreatitis and bicytopenia . one week after poisoning , a sudden onset of hair loss was observed [ figure 1 ] . positive hair pull test ( + + + ) and trichoscopy demonstrated the presence of anagen hairs with pigmented long roots covered by the root sheaths [ figure 2a ] . dermoscopy of the scalp showed no signs of trichotillomania such as broken hairs , black dots , flame hair , v - sign , or follicular hemorrhages [ figure 2b ] . the diagnosis of anagen effluvium following acute colchicine poisoning was made . hair loss on day 7 after colchicine poisoning ( a ) trichoscopy of anagen hairs collected with hair pull test . ( b ) dermoscopy of the scalp where no signs of trichotillomania such as broken hairs , black dots , flame hair , v - sign , or follicular hemorrhages can be observed as occurs with exposure to toxic chemicals , hair loss due to colchicine poisoning presents as anagen effluvium . hair loss usually begins 714 days after the exposure and gradually recovers after 36 months , as the follicular ostia remains intact . pharmacotherapy or specific treatment is not usually required because the follicle resumes its normal activity after withdrawal of the antimitotic factors . anagen effluvium should be differentiated from telogen effluvium , androgenetic alopecia , and trichotillomania . in this case , we focused on the differential diagnosis between trichotillomania and anagen effluvium because of the personal psychiatric history of the patient . there are few reports in the literature describing hair loss following acute colchicine poisoning , and none of them are recent . to our knowledge , this is the first report describing the dermoscopic and trichoscopic findings in colchicine poisoning alopecia . physicians should bear in mind this infrequent cause of anagen effluvium and try to avoid prescribing colchicine to psychiatric patients due to its potentially dangerous side effects . the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s ) has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal . the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed . the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s ) has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal . the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed .

we present a case of a 17-year - old girl admitted to the psychiatric department recovering from a suicide attempt with colchicine . one week after poisoning , a sudden onset of hair loss was observed . positive hair pull test and trichoscopy demonstrated the presence of anagen hairs with pigmented long roots covered by the root sheaths . colchicine poisoning is an uncommon , but potentially life - threatening toxicologic emergency . an overdose of colchicine inhibits cell division , and thus the most affected organs are those which have a high rate of cell turnover . hair loss resulting from colchicine poisoning presents as anagen effluvium , as it occurs with an exposure to toxic chemicals . pharmacotherapy or specific treatment is not usually required , since the follicle resumes its normal activity after withdrawal of the antimitotic factors .

a 29-year - old japanese man presented with a reddish nodule , of approximately 15 mm in diameter , on the nose ( figure 1 ) . dermatoscopic examination of the nodule revealed a yellowish - white network , yellowish - orange globules at its center , and a pinkish structureless peripheral area ( figure 2a ) . on histopathological examination , we observed an exophytic lesion composed of dilated , follicular infundibular structures connected with multiple sebaceous lobules and surrounded by fibrous connective tissue with thick collagen bundles ( figure 3a ) . moreover , the surrounding stroma was fibrotic , with a high number of small vessels ( figure 3c ) . fsch , first described by kimura et al . in 1991 , is characterized by a relatively rare cutaneous hamartoma composed of follicular , sebaceous , and mesenchymal components . fsch clinically manifests as a solitary skin - colored sessile or pedunculated nodule that is most commonly located on the central part of face , particularly on the nose or the paranasal area . fsch shares several similar histopathological features with sebaceous trichofolliculoma ( stf ) and may be considered a variant of stf with a marked sebaceous component . however , certain histopathologic features of fsch are believed to be distinct , and thus , this condition can be differentiated from stf . described that the prominent mesenchymal component and double cleft formation between fibroepithelial units and the altered stroma are distinguishing features of fsch . in contrast , stf has rudimentary hair follicles and hair shafts connecting to the infundibular cyst wall , and lacks the distinctive mesenchymal component observed in fsch . on dermatoscopy , we detected a yellowish - white network and yellowish - orange dots / globules at its center , with a pinkish structureless peripheral area ( figure 2a ) . the whitish - yellow network observed on histopathological examination represented the elongation of the rete ridges in addition to dermal sebaceous components ( figures 2b and 3b ) . moreover , whitish - yellow clods were identified at the center of the nodule , indicating the presence of exophytic lesions consisting of sebaceous lobules connected to the dilated infundibular cystic structures via sebaceous ducts ( figure 2b ) . furthermore , at the center of the nodule , the yellowish - orange globules represented conglomerations of sebaceous glands located in the superficial dermis ( figure 2c ) . the color of the pinkish structureless peripheral area appeared similar to that of dermal dilated blood vessels . based on the clinical findings , the differential diagnoses would include melanocytic nevus , poroma , and sebaceoma . however , additional features observed via dermatoscopy could help exclude these disorders , including the lack of residual pigmentation around the hair follicles suggesting melanocytic nevus , the absence of glomerular or hairpin vessels and a whitish - pink network suggesting poroma , and the presence of a yellowish structureless area and arborizing vessels suggesting sebaceoma . to our knowledge , only one case presenting with the dermatoscopic features of fsch has been reported in japan . in that report , the dermatoscopic features of fsch included a yellowish - orange area and whitish - yellow globules . although fsch can only be diagnosed based on the microscopic features , certain characteristic dermatoscopic features observed in the present case may also be useful to distinguish among several differential diagnoses . moreover , we believe that the awareness of this entity and the use of dermatoscopy can facilitate the diagnosis of fsch . in conclusion , we described the dermatoscopic features of fsch , such as a whitish - yellow network , yellowish - orange dots / globules , and whitish - yellow clods . however , additional dermatoscopic findings are needed to elucidate whether the features described here are characteristic findings in fsch .

a 29-year - old japanese man presented to our institution with a nodule on his nose that had increased in size since childhood . physical examination indicated the presence of an elastic , firm , pedunculated red nodule measuring 15 mm in size . dermatoscopic examination of the nodule indicated a yellowish - white network , yellowish - orange dots / globules at its center , and a pinkish - white structureless peripheral area . histopathological examination of an excisional biopsy specimen showed a dilated infundibulocystic structure with sebaceous lobules proliferating radially , surrounded by fibrous stroma . moreover , mature adipocytes and small vessels were noted in the stroma . based on these histopatho - logic findings , the patient was diagnosed with folliculosebaceous cystic hamartoma .

a 40-year - old caucasian male presented to the emergency department complaining of intermittent painless frank haematuria over the preceding six weeks . past medical history was significant for hypercholesterolemia , type 2 diabetes mellitus and hereditary non - polyposis colon cancer ( hnpcc ) . he had undergone a prophylactic total colectomy six years previously . his father had resection of colorectal cancer on two occassions , and was subsequently diagnosed with hnpcc . none of the index patient 's father 's siblings underwent genetic testing , but reportedly there were cases of colorectal cancer amongst them . genetic testing of the index patient and his six siblings showed two of the five to have lynch gene positivity . a first cousin of the index patient is lynch gene positive and has undergone a prophylactic total colectomy . he was a non - smoker and consumed approximately ten units of alcohol a week . computed tomography urogram showed thickening in the posterior wall of the bladder on the right side at the level of the seminal vesicles ( figure 1 ) . specifically thickened bland urothelium , which focally had papillary architecture and elsewhere had an inverted growth pattern , with no visible muscularis propria and no evidence of invasion was seen . figure 1transverse section of computed tomography abdomen and pelvis showing thickening of the right aspect of the posterior bladder wall at the level of the seminal vesicles . transverse section of computed tomography abdomen and pelvis showing thickening of the right aspect of the posterior bladder wall at the level of the seminal vesicles . hnpcc , also known as lynch syndrome , is an autosomal dominant cancer susceptibility disorder responsible for 35% of colorectal cancers . it is caused by germline mutations in four mismatch repair ( mmr ) genes ; nearly 90% in mlh1 and msh2 , with the remaining 10% in msh6 and pms2 . carriers of the abnormal gene have a risk of up to 70% of developing colorectal cancer by the age of 70 . while most of these mutations are hereditary , sporadic cases are known to exist . these include , in addition to colorectal cancer ; endometrial , ovarian , stomach , pancreas , biliary tract , small bowel , brain , renal pelvic and ureteric tumours , sebaceous gland adenomas and keratocanthomas . while an association between hnpcc and bladder tumours is not as well established as the association with the above listed tumours , there are reports in the literature that suggest an association . one such case study from japan showed a possible association between lynch syndrome and two cases of bladder cancer . a study from the netherlands showed a correlation between lynch syndrome and urothelial bladder tumours , which was more significant when one specific mmr gene mutation in contrast analysis of the swedish family cancer database , showed that lynch syndrome patients have an increased risk of cancers in the ureter , but not in the urinary bladder . further large - scale evaluation is necessary to establish a link between hnpcc and bladder tumours . punlmp represents an indolent pathology which has a low propensity to recur , a negligible risk of progression and never results in tumour - related death . punlmp 's should be treated similarly to low grade , non - invasive urothelial carcinoma .

a 40-year - old caucasian male presented to the emergency department complaining of intermittent painless frank haematuria . past medical history was significant for hereditary non - polyposis colon cancer ( hnpcc ) and a prophylactic total colectomy . computed tomography urogram showed thickening in the posterior wall of the bladder . cystoscopy showed a small bladder mass . histology showed a papillary urothelial neoplasm of low malignant potential . hnpcc , also known as lynch syndrome , is an autosomal dominant disorder responsible for 35% of colorectal cancers . there are certain cancers known to be associated with hnpcc ; colorectal cancer , endometrial , ovarian , stomach , pancreas , biliary tract , small bowel , brain , renal pelvic and ureteric tumours , sebaceous gland adenomas and keratocanthomas . an association with bladder tumours is not well established .

the adenomatoid odontogenic tumor ( aot ) represents 3%7% of all odontogenic tumors and was once considered as a variant of ameloblastoma . microscopically , aot exhibits tubular characteristic and duct - like structures that led to the term the basal cells of oral epithelium were a potential source of origin . in the latest edition of who classification of odontogenic tumors in 2005 , aot was classified into the first group of tumors ( odontogenic epithelium without ectomesenchyme ) instead of the second group ( odontogenic epithelium with ectomesenchyme ) . because of the absence of ectomesenchyme in immunohistochemical staining , dysplastic dentin , aot is now considered the result of a metaplastic process rather than epithelial - ectomesenchyme interaction . in this paper , a rare odontogenic tumor with histopathologic features resembling aot along with hard tissue formation the armed forces institute of pathology ( afip ) in united states of america has described a similar neoplasm with recurrence potential and suggested the term adenoid ameloblastoma with dentinoid for these lesions . a 24-year - old indian female was referred by her general practitioner for evaluation of a maxillary swelling to department of oral medicine , faculty of dental sciences , institute of medical sciences , banaras hindu university . intraoral examination disclosed a nontender expansion of the left maxilla , covered by normal mucosa ( figures 1(a ) and 1(b ) ) . an orthopantomogram revealed the presence of a significant unilocular radiolucent area with well - defined sclerotic borders , involving an embedded upper left permanent canine ( figure 1(c ) ) . a denta scan ( 64 slice ct scan ) showed a well - defined tumour mass covering the complete left maxilla ( figures 1(d ) and 1(e ) ) . according to the clinical and surgical findings enucleation of the lesion was performed , to completely extirpate the cystic lesion with extraction of upper left canine ( figures 2(a ) , 2(b ) , and 2(c ) ) . the differential diagnosis was of dentigerous cyst , calcifying odontogenic cyst , calcifying epithelial tumor , odontogenic keratocyst , and unicystic ameloblastoma . using local anesthesia , the surgical sample was fixed in formalin , embedded in paraffin , and stained with hematoxylin - eosin using the standard method . the tumor displayed a cystic pattern with characteristic features of a plexiform - type ameloblastoma , containing microcysts formation . sheets and cords of epithelial cells were observed , which demonstrated a loose arrangement similar to stellate reticulum , intermixed with focal areas showing a whorled appearance . reverse polarity of peripheral cells was prominent and tubular or duct - like structures lined by cuboidal cells were observed in some areas ( figures 2(d ) and 2(e ) ) . there is a slight female over male incidence , almost 2 : 1 , and appears most often in the second decade of life [ 57 ] . the sex and the age of the patient we described in this report are consistent with the literature . the lesions are typically asymptomatic , but may cause cortical expansion and displacement of the adjacent teeth . the origin of the aot is controversial . because of its predilection for tooth - bearing bone , it is thought to arise from odontogenic epithelium . the tumor has three clinico - pathologic variants , namely , intraosseous follicular , intraosseous extrafollicular , and peripheral . the follicular type ( in 73% of all aot cases ) is associated with an unerupted tooth ; whereas extrafollicular type ( 24% ) has no relation with an impacted tooth . follicular and extrafollicular types are over two times more located in the maxilla than in the mandible and most of the tumors involve anterior aspect of the jaws . in our case , the tumor was an intrafollicular intraosseous type and also found in the anterior region of the maxilla . although larger lesions reported in the literature , the tumors are usually in the dimensions of 1.5 to 3 cm . radiographically , they usually appear unilocular , may contain fine calcifications , and irregular root resorption is rare [ 10 , 11 ] . this appearance must be differentiated from various types of disease , such as calcifying odontogenic tumor or cysts . the differential diagnosis can also be made with ameloblastoma , ameloblastic fibroma , and ameloblastic fibro odontoma . the patient in the present report presented with no root resorption , but displacement of the adjacent teeth . radiographically , it was easily differentiated from dentigerous cyst , which usually occurs as a pericoronal radiolucency . the histological findings for aot are remarkably similar in the literature [ 68 , 11 ] . the histological features of the tumor were described as a tumor of odontogenic epithelium with duct - like structures and with varying degree of inductive changes in the connective tissue . the tumor may be partly cystic and in some cases the solid lesion may be present only as masses in the wall of a large cyst . the tumor may contain pools of amyloid - like material and globular masses of calcified material . our case was consistent with the common features reported in the literature [ 10 , 11 ] .

the adenomatoid odontogenic tumour is a relatively uncommon lesion which mainly affects females in their second decade of life . it exhibits a predilection for the anterior region of the maxilla . the lesion is usually associated with the crown of an embedded tooth , most commonly the maxillary canine . in this paper , we present a case of adenomatoid odontogenic tumor affecting the left maxillary region in a 24-year - old female . the authors also discuss clinical , radiographic , histopathologic , and therapeutic features of the case .

although laryngoscopy is a safe procedure and complications rarely occur , intraoral manipulation can produce damage to soft and hard tissues of the oral cavity , patient discomfort , and postoperative pain . dental injury has been reported as the most common anesthetic - related incident . patients with pathological changes , especially if involving pathosis of the incisors , are considered to be at the greatest risk of oral tissue trauma following laryngoscopy and endotracheal intubation . most complications during anesthesia are related to unrecognized problems . recognizing and understanding ; oral and dental pathological changes ; and the presence of dental prosthesis are thus important . an 8-year - old boy reported to the department of pedodontic and preventive children dentistry complaining of a missing upper front permanent tooth since 1 month . the child 's parents gave a history of missing tooth during the tonsillectomy procedure under general anesthesia and the same was mentioned in the discharge summary . on examination , the patient was moderately built , well nourished , conscious , and cooperative . on intraoral examination an upper left central incisor and a mesially erupting upper left lateral incisor were not seen [ figure 1 ] . an orthopantomograph was taken to confirm the finding , which revealed a missing upper left central incisor and a mesially - erupting upper left lateral incisor with a developing root [ figure 2 ] . patient showing a missing 21 , mesialy erupted 22 we decided to give a removable anterior space maintainer , i.e. removable partial denture ( rpd ) to prevent the mesial drifting of 22 . both the child and the parents were pleased with the new look of the child , which gave him a normal appearance [ figure 3 ] . his mother was advised to maintain good oral hygiene for the child ; recall visits to make any necessary adjustments for the rpd , if needed ; and to go for an implant , fixed prosthetic appliance , or orthodontic correction in future . the loss of maxillary incisors in childhood is problematic , especially up to 10 - 12 years of age , and predictable treatment methods are difficult . children in the age group of 6 - 8 years are susceptible to the loss of maxillary teeth during endotracheal intubation due to the prevalence of immature roots , increased overjet , ectopic eruptions , dilacerated roots , or pathology . the principle treatment options are : ( a ) re - implantation of the avulsed tooth immediately within a certain time period , ( b ) maintaining the space by giving a space maintainer or reopening the space for auto - transplantation using a premolar ; future prosthodontic restoration of missing teeth or single tooth implant , ( c ) total orthodontic space closure , followed by prosthodontic modification of the lateral incisor to imitate the central incisor . it is advisable to re - implant the avulsed tooth into the socket within the specified time interval in order to preserve the vitality of the tooth and also to promote root completion . if dental injury occurs in children during laryngoscopy and intubation an evaluation should be done , as soon as possible , by a pediatric dentist to determine the extent of the injury , to confirm the location and ensure successful retrieval of the avulsed or broken tooth . in the case of any tooth fragment avulsion of a primary tooth does not require treatment , as replacement into the socket can damage the underlying permanent successor . when a permanent tooth is avulsed , it should be stored in normal saline or cool fresh milk until it can be splinted or re - implanted . after a traumatic intubation , the success of the treatment is primarily determined by the time elapsed since injury . if the young permanent tooth is avulsed during general anesthesia , a pediatric dentist must be informed immediately to replace the tooth in the socket and splint the tooth . dental damage in the operating room may also be caused by surgeons such as otorhinologists by inadvertent injury during laryngoscopy . traumas to a patient 's dentition have also been reported following endoscopic and bronchoscopic interventions . in the case of such a trauma , the patient this should include a clear apology and a description of the events that led to damage and the efforts made to minimize any complications . all actions and discussions should be clearly documented in patient 's records . during the preoperative assessment , the anesthesiologist should enquire about loose teeth , unstable crowns , veneers , bridgework , and any intraoral prosthesis ( dentures or orthodontic appliances ) . minimizing dental injuries begins with the anesthesiologist 's preoperative assessment of the patient 's oral health including dentition . documentation of the patient 's preoperative dental condition and informing the patient about the potential dental damage will diminish costs for any related postoperative dental treatment . upon discovery of a potentially hazardous dental condition , whilst there is no standardized method for recording this , a simple diagram and a brief written description may be satisfactory . all risk factors , both anesthetic and dental , should be identified and explained to the patient . the flange of the macintosh blade is responsible for much damage , and alternative equipment or techniques of endotracheal intubation should be considered , particularly when risk factors are present . custom mouth guards can be useful to decrease the force of a laryngoscope affecting the upper central incisors . oral tissue trauma , a common anesthetic complication , should be considered a recognized hazard of endotracheal intubation during general anesthesia . before administering anesthesia , understanding and recognizing the oral anatomical conditions and pathological changes may help the anesthesiologists prevent oral and dental complications , thus avoiding legal suits .

anesthesiologists consistently work in the mouth of patients but are not exposed to comprehensive education of teeth , the surrounding structures , and intraoral prosthesis . one of the most common adverse events related to anesthesia is perioperative dental damage . to minimize these dental injuries , a preoperative assessment of patient 's dentition and intra - oral tissues should be undertaken .

coarctation of the aorta is one of the most common diagnoses in congenital cardiac defects . it comes in an isolated form or in association with various obstructive lesions along the left side of the heart or with a perimembranous ventricular septal defect ( vsd ) . the diagnosis is mostly established in the neonatal period and hence the great majority of corrections are performed within two or three days after birth . an extended resection [ 1 , 2 ] is almost always possible at that time due to the particular elasticity of the aortic tissue allowing extensive mobilization of both segments of the thoracic aorta . the risk of paraplegia is minimal as long as the cross - clamping of the aorta does not exceed 30 minutes . later in life , the repair may require an assisted circulation ( a left heart bypass between the left atrial appendage and the thoracic aorta ) to the lower body to avoid such a complication or other visceral ischemic lesions [ 4 , 5 ] . coarctation associated with a long , hypoplastic distal aortic arch is also repaired with a left thoracotomy without circulatory assistance in our center , but is preceded by an enlargement plasty of the roof of the distal arch . the enlargement is performed first , with a patch of tanned pericardium , and with the use of ductal perfusion to avoid any visceral ischemia . the resection - anastomosis of the coarctation is performed after the plasty . since the establishment of a minimally invasive , muscle sparing and extrapleural approach to repairing coarctations , we have abandoned the single stage repair when a perimembranous vsd was associated . for us , the only consideration for a coarctation repair with a sternotomy is when enlargement of the distal aortic arch is not possible with regular cross - clamping ( in the case of common carotid truncus , in some cases of arteria lusoria and very rarely in the case of particularly unfavorable anatomy of the arch ) . banding of the pulmonary artery is not routinely performed in the regular cases , and the vsd is closed when signs of heart strain arise , usually a little before the regular time . the extrapleural approach has furthermore reduced the development of subsequent collaterals between the thoracic wall and the left upper lobe , and has proved a significant advantage in cyanotic univentricular hearts requiring subsequently a fontan circulation . recoarctations refractory to balloon dilatation [ 8 , 9 ] are handled in our center anatomically , with surgery . the choice of approach between a sternotomy and a posterior thoracotomy depends on the exact location of the residual stenosis . in a few patients , our preferred approach is through a sternotomy with enlargement of either the superior or the inferior part of the aortic arch , depending on the anatomy . in children , we have often used the anterior wall of the ( dilated ) pulmonary artery to enlarge the inferior part of the aortic arch . this autologous patch has excellent elastic characteristics and holds the systemic pressure well , with no degeneration . we have simply used a regular patch for the arch enlargement . in many patients , the anatomy is favorable for a roof plasty of the aortic arch ( a technically easier repair ) . we commonly transect the left common carotid artery to facilitate this enlargement , and reimplant it at the end of the reconstruction . it is only in multiple redo procedures , or in very complex arch anatomy that we consider an extra - anatomic bypass between the ascending and the coeliac aorta [ 11 , 12 ] .

the surgical treatment of an aortic coarctation requires a resection of the stenotic area and direct suture of the aorta . an extended mobilization allows an enlargement of a hypoplastic distal aortic arch . in ductal dependent circulation , the distal aortic arch can be enlarged with a patch before tackling the coarctation itself . postsurgical aortic arch stenoses often require a surgical intervention . our preferred method is an anatomic correction with an enlargement plasty either on the concavity or on the convexity of the arch , depending on the local anatomy . an extra - anatomic bypass is also an option .

an 18-year - old female came to our clinic reporting blurred vision of the left eye for 2 days . she also complained of decreased hearing with tinnitus of the right ear and mild headache . best - corrected visual acuity ( bcva ) was 20 / 50 in the left eye , and 20 / 20 in the right eye . fundus examination and fluorescein angiography of the left eye showed ischemic retina with signs of branch retinal artery obstruction ( fig . 1 ) . we performed brain magnetic resonance imaging ( mri ) and lumbar puncture to evaluate any brain or central nervous system lesions . the mri scan showed a t2-weighted , high - signal , discrete area around the periventricular region , in the white matter and in the corpus callosum ( fig . blood pressure , echocardiography , carotid ultrasonography , full blood count , erythrocyte sedimentation rate , fasting lipids and glucose , autoantibody screen including anti - cardiolipin antibody , protein s and c levels , and antithrombin iii level were all normal . the patient was treated with intravenous prednisolone 1 g / kg for 3 days followed by oral steroid tapering . three months after treatment , bcva recovered to 20 / 25 in the left eye . a mild residual auditory defect remained , but no remaining tinnitus or headache were observed . susac syndrome was first described by susac in 1976 and since then has been called by different names , including red - m ( retinopathy , encephalopathy , deafness associated with microangiopathy ) , sicret ( small infarction of cochlear , retina and encephalitic tissue ) , and retinocochlear vasculopathy . this syndrome is rare and usually shows female predominance with a sex ratio of 3 to 1 . approximately 80 cases of susac syndrome have been reported in the literature [ 1 - 4 ] . the syndrome is often misdiagnosed and should be differentiated from a number of other diseases , including multiple sclerosis , disseminated encephalomyelitis , lupus erythematosus , mnire disease , migraine and thromboembolic strokes . moreover , many patients do not present initially with the clinical triad and show incomplete forms of the disease in which only branch retinal artery obstruction or hearing loss in the absence of encephalopathy is observed . susac and colleagues reported that there was always involvement of the corpus callosum , and callosal lesions typically involve the central fibers with relative sparing of the periphery . yellow retinal arterial wall plaque in association with susac syndrome has been described , but plaques were not identified in our patient . the bilateral or unilateral hearing loss is due to cochlear involvement . hearing loss may be asymptomatic and found only by audimetry . the pathogenesis of this syndrome is believed to be an immunological reaction , leading to small vessel vasculitis causing micro infraction in the retina , brain and apical turn of the cochlea . in a recent autopsy study , the findings of retinas with susac syndrome suggested that the syndrome could be an endothelioapthy . the disease course is known to be monophasic and self - limited , with a duration of 1 to 4 years . different therapeutic protocols such as corticosteroids , immunosuppressive agents , anti - platelet agents , anticoagulant agents and plasmapheresis have been reported . although their efficacy remains difficult to evaluate , early recognition of the disease is important because treatment with immunosuppression seems to reduce permanent cognitive , audiologic , and visual sequelae . to the best of our knowledge , this is the first report of susac syndrome in korea . a high index of suspicion leading to early recognition of this syndrome is important because immunosuppressive treatment may decrease permanent neuropsychological or visual impairment . in cases with retinal arterial occlusion with hearing loss or neuropsychological symptom , early detection of the characteristic brain mri finding , audimetry , and funduscopic examination

the purpose of this article is to report on the first known korean case of susac syndrome . an 18-year - old female came to our clinic reporting blurred vision of the left eye for 2 days . she also complained of decreased hearing with tinnitus of the right ear and mild headache . she was previously healthy and had no remarkable medical history . best - corrected visual acuity was 20 / 50 in the left eye and 20 / 20 in the right eye . an axiomatic triad of ocular , cochlear , and neurologic involvement was observed in the patient . fluorescein angiography showed branched retinal arterial occlusions in the left eye . a sudden right sensorineural hearing loss was observed on audimetry . magnetic resonance images showed a hyperintense lesion in the white matter around the corpus callosum . the patient was treated with high doses of systemic corticosteroids , and no neuropsychological sequelae were observed . this is the first case report of susac syndrome in korea . in cases of retinal arterial occlusion with hearing loss or neuropsychological symptoms , susac syndrome should be suspected .

broadly , there are five areas which are available for a bams graduate to build a career successfully viz . clinical practice , academic ( teaching ) , management & administration , drug manufacturing and research . research is a process of searching the knowledge by systematic investigation and to establish novel facts by scientific methods . medical research has lot of importance as it is much needed for the addition of knowledge and thereby to improve health care . it can be achieved by various methods of research ranging from drug trials to community surveys and from trends in the past years to unusual cases in the hospital . even though variety of approaches are available , the scenario of medical research in india is not encouraging . there are reports available mentioning facts & figures about the modern medical undergraduate students level research and also discussing the potential reasons behind this apathy , . considering the global scenario , the medical council of india is focusing more on the improvement of medical research and emphasizing the same even at undergraduate level . in case of ayurveda , although the research culture is slowly gaining pace , the undergraduate students are not educated or motivated in this direction . the present study reports the attitude of interns in an ayurveda teaching hospital about research as a career . we carried out a cross sectional study among the interns of the kleu 's bmk ayurved mahavidyalaya , belgaum , wherein the interns ( n = 40 ) were asked to prioritize their career options from research , teaching and clinical practice . lastly , the interested candidates were asked to enroll their names for the ongoing research projects in the college . this whole exercise was done at the end of a lecture , which was arranged as a part of routine activities for the interns as an institutional norm . out of 40 interns , 36 preferred clinical practice as first career priority , whereas 4 selected teaching as option . research was chosen as second priority by 18 and third priority by 22 interns . when asked about the rationale behind this priority , they unanimously opined that ayurveda is a clinical science and they have opted for a medical degree , hence clinical practice obviously becomes their first preference . they also feel that treating the patients and thereby helping mankind is a noble job and they would be happier to take up this job . further , they have experienced that the physician who treats the patients receives high regards in the society and that is why their preference is towards clinical practice . interestingly , although they could justify their first preference towards clinical practice reasonably well ; they could not provide any justification for their preference towards research . rather , they expressed their inability to comment anything about research . regarding enrollment to the research projects the present study was carried out to know the attitudes of the interns towards research as career option in an ayurvedic teaching hospital . this may be because they are not exposed to the research methodology and importance of research during their undergraduate studies . further , the current curriculum does neither include terms like evidence base , data generation nor the introduction to findings of major nationwide research projects such as csir - nmitli , a science initiative in ayurveda . the central council for indian medicine ( ccim ) has introduced research as a subject in final year ayurvedic ( bams ) students , which is welcoming step . although this will impart theoretical knowledge , it would prove more impactful if coupled with practical training . the students during their undergraduate studies rarely get an opportunity to visit a research institute or get hands - on - training in certain techniques . the same thing is reflected in the career options prioritized by the interns participated in our study . we therefore suggest that an elective module exclusively in research can be introduced during the internship tenure , wherein the interested students can be posted at a research institute for a period of two months or so . for the students of modern medicine ( mbbs ) , various schemes and programmes are available such as icmr short term studentship ( sts ) , kvpy ( kishore vaigyanik protsahan yojana ) , conferences for medical students and so on . mbbs students are eligible to get srf through which they can work on a research project for three years and can extend the work by registering to phd . it is offered by indian council of medical research ( icmr ) , council of scientific and industrial research ( csir ) and university grants commission ( ugc ) . we further feel that if the students are exposed to the research methodology in their undergraduate days , they will be in a better position to conduct full - fledged research studies during their postgraduate tenure . this will certainly help to improve the standards of md / ms dissertations and phd theses . vaidya - scientist fellowship programme to train the candidates in the shastras , science and medicine along with exposure to appropriate research methodology is an ambitious programme , which not only needs to be continued but also to be strengthened by increasing intake capacity . our study thus highlights the ignorance ( and therefore apathy ) of interns towards research as career option . however , it must be noted here that the study has not been conducted in structured way . this makes the results less generalizable and it would be desirable to carry out such study in different colleges across the country involving a larger sample size . to sum up , the career preferences given by interns in our study indicates conventional approach towards medical education . there is need to change their attitudes through appropriate training and by introducing different programmes to foster the research culture .

although today 's ayurvedic graduates have many career options to select from , they are not given any exposure to these options during their study . this results in apathy towards selection of any career apart from clinical practice . the present study carried out amongst interns of one ayurvedic college highlights this fact and underlines the importance of introducing research as a subject in the curriculum .

growths on the penis invariably cause alarm both on the part of the part of the patient as well as the treating physician and need to be biopsied and treated accordingly . certain rare tumors initially show benign histology or later show either a low - grade or delayed malignant growth potential . those are penile horn , giant condyloma ( buschke - lowenstein tumor ) and an extremely rare penile growth pseudoepitheliomatous , keratotic , and micaceous balanitis ( pekmb ) . we report here a patient with pekmb who , having declined definitive surgery was managed with topical therapy and lifelong follow - up . a 35-year - old unmarried man presented with a thick scaly plaque on the glans penis present for the past one and half years [ figure 1 ] . the lesion initially was small and progressed very slowly and to attain the current size . the thick scaly plaque on the glans penis examination revealed a thick scaly plaque on the glans penis measuring about 1.5 cm by 1.5 cm . examination of the rest of the body , mucous membranes , hair and nails revealed no abnormality . results of blood examination including blood sugar , hepatitis b surface antigen , venereal disease research laboratory ( vdrl ) test and human immunodeficiency virus were normal . incisional biopsy was done and sent for histopathological examination . the slide [ figure 2 ] revealed pseudoepitheliomatous hyperplasia , acanthosis , and elongation of rete ridges . there was a nonspecific dermal inflammatory cell infiltrate consisting mainly of lymphocytes with few eosinophils . a non - specific dermal inflammatory cell infiltrate consisting mainly of lymphocytes with few eosinophils is seen . there is no cytological atypia or koilocytes based on the clinical features and histology , the diagnosis of pekmb of civatte was made . the patient declined definitive surgery and was started on topical 5-fluorouracil cream on a daily basis and advised life - long follow - up . ulcerations , cracking , and fissuring on the surface of the glans are frequently present . the keratotic scale is usually micaceous and resembles psoriasis or may be nail like which could be easily peeled off . most patients are over the age of 50 and frequently have been circumcised for phimosis in adult life . the differential diagnosis includes squamous cell carcinoma ( scc ) , verrucous carcinoma , keratoacanthoma , giant condyloma , penile horn , and erythroplasia of queyrat . the pathogenesis of pekmb occurs in four stages : ( a ) initial plaque stage , ( b ) late tumor stage , ( c ) verrucous carcinoma , and ( d ) transformation to scc and invasion . topical 5-fu has been effective , but the hyperkeratotic scale may make penetration suboptimal . if topical chemotherapy is utilized , post - treatment biopsies are recommended . out of the 15 cases described in the english literature , 6 progressed to verrucous carcinoma , 4 cases developed scc , out of which 2 had progressed from verrucous carcinoma to invasive scc . our patient had presented at a relatively young age , and as in other reports , had a previously existing phimosis problem . he was asymptomatic but was anxious about the cosmetic disfigurement and potential for developing cancer . , that chronic irritation and inflammation of long standing phimosis predisposes to the condition . however , larger studies are required to corroborate this observation . to the best of our knowledge , only 15 cases have been described in the literature until date throughout the world , with very few reports from the indian subcontinent . this case is being reported not only for its rarity , but also for emphasizing the need for early diagnosis and long - term follow - up .

pseudoepitheliomatous , keratotic , and micaceous balanitis is a rare condition characterized by verrucous excrescences with scaling . most patients are over the age of 50 and frequently have been circumcised for phimosis in adult life . we present here a case of 35-year - old male patient with long standing phimosis presenting with a firm whitish plaque on the glans penis . the crusts were micaceous in nature . histopathologically , there was pseudoepitheliomatous hyperplasia with acanthosis and no cellular atypia . the condition was explained to the patient and treatment options discussed . the patient was started on topical 5-fluorouracil cream on a daily basis as he did not express consent for operative intervention .

a 29-year - old cambodian lady with a history of transfusion - dependent -thalassemia from six years of age was referred for ophthalmic evaluation . she presented with recent onset of impaired color vision , constriction of visual fields and night blindness . she had been on subcutaneous desferrioxamine ( 40 mg / kg ) six times per week since her initial transfusion . ten weeks prior to her referral , she was started on intravenous desferrioxamine ( 50 mg / kg per day ) for gross hepatic iron overload ( serum ferritin level 5440 microgram / l , therapeutic index 0 .009 ) . on examination , visual acuity was 20/20 in the right eye ( re ) and 20/40 in the left eye ( le ) . she had a left relative afferent pupillary defect and markedly diminished color vision in both eyes . fundus fluorescein angiography ( ffa ) showed speckled hyper - fluorescence with well - demarcated areas of blocked fluorescence [ fig . further evaluation with full - field electro - retinogram ( erg ) showed marked bilateral reduction in amplitude for photopic , scotopic and 30-hz flicker erg . electro - oculogram ( eog ) revealed a diminished response ( arden index of 1.36 in the re and 1.11 in the le ) . the p100 latency period was more delayed in the left compared to the right on pattern visual evoked potential ( vep ) testing . color fundus photos demonstrating diffuse mottling of the retinal pigment epithelium at the posterior pole and mid - periphery in the right eye ( a ) and left eye(b ) fundus fluorescein angiogram ( late venous phase ) showing diffuse retinal hyper - fluorescence in both eyes along with blocked fluorescence in the peripapillary , macular and equatorial regions in the re ( a ) and blocked fluorescence in the peripapillary , inferior papillomacular bundle and equatorial regions in the le ( b ) desferrioxamine was stopped and replaced with deferipone ( 1 g three times per day ) . four months later , there was marked recovery in color vision in both eyes ; the visual acuities remained unchanged . desferrioxamine mesylate is a widely used chelating agent in managing patients with chronic iron overload , acute iron poisoning and aluminum toxicity . as illustrated by this report , patients on desferrioxamine can present with acute / sub - acute deterioration in visual acuity and color vision , night blindness , scotomas or constricted fields . the ocular toxicity is postulated to be due to the direct effect of desferrioxamine , chelation of ions ( iron , copper , aluminum ) on the retinal pigment epithelial with resultant dysfunction or due to defective vasoregulation . ocular side - effects include cataracts , retrobulbar optic neuritis , pigmentary retinopathy , bull 's eye maculopathy and vitelliform maculopathy.[46 ] the pigmentary retinopathy is classically macular or peripheral but can rarely present in the paramacular , papillomacular or peripapillary pattern . it is still unclear whether ocular toxicity is dose - dependent or not ; however , existing literature as well as our experience with this patient shows that those with lower iron loads and desferrioxamine dosage higher than 50 mg / kg / day are at increased risk for developing systemic toxicity . as ocular toxicity can be asymptomatic , all patients on desferrioxamine should have baseline visual acuities , color vision , visual fields , ffa , eog and erg . during the follow - up phase , diffuse outer retinal fluorescence on ffa is a useful marker for ongoing disease activity , whilst eog and erg are helpful in monitoring the retinal dysfunction . regular ophthalmic screening at three - monthly intervals along with monthly monitoring of serum ferritin levels and maintenance of the therapeutic index level of desferrioxamine ( daily dose per body weight ( mg / kg ) divided by serum ferritin ( microgram / l ) ) at levels < 0.025 can help in prevention and reversal of ocular toxicity . it is also interesting to observe that a presenting therapeutic index level of desferrioxamine below 0.04 can be indicative of better visual prognosis . in conclusion , heightened awareness amongst ophthalmologists and regular ophthalmic screening is required in patients receiving desferrioxamine to avoid delayed diagnosis and management of desferrioxamine - related optic neuropathy and retinal dysfunction .

a 29-year - old lady receiving repeated blood transfusions for thalassemia since childhood , presented with rapidly deteriorating symptoms of night blindness and peripheral visual field loss . she was recently commenced on high - dose intravenous desferrioxamine for reducing the systemic iron overload . clinical and investigative findings were consistent with desferrioxamine - related pigmentary retinopathy and optic neuropathy . recovery was partial following cessation of desferrioxamine . this report highlights the ocular side - effects of desferrioxamine mesylate and the need to be vigilant in patients on high doses of desferrioxamine .