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vascular complications occur in approximately a quarter of patients of pancreatitis , adding to the associated morbidity and mortality . these include splanchnic vein thrombosis ( svt ) and hemorrhage from direct arterial wall erosion or pseudoaneurysm formation . however , cerebral infarction from arterial thrombosis is a rare complication of acute pancreatitis ( ap ) . here , we report a case of cerebral infarction resulting probably from left middle cerebral artery ( mca ) thrombosis in a 48-year - old male patient of alcohol related ap . a 48-year - old male , heavy alcohol consumer for the prior 6 years , presented with complaints of severe abdominal pain , vomiting and constipation for 3 days . there was no history of diabetes mellitus , hypertension , smoking , and previous abdominal pain . on admission to our hospital ( on day 4 of illness ) , he was hemodynamically stable , had abdominal distention with diffuse tenderness and absent bowel sounds . laboratory work up on day 4 revealed serum amylase : 898 u / l , lipase : 968 u / l , glucose : 116 mg / dl , na : 132 meq / l , k : 3.6 meq / l , creatinine : 1.9 mg% , calcium : 8.6 mg / dl , bilirubin : 1.4 mg / dl , aspartate transaminase / alanine transaminase : 74/28 iu / l , alkaline phosphatase : 181 iu / l , serum proteins / albumin : 7.1/2.9 g / dl , serum cholesterol : 124 mg / dl , triglycerides : 130 mg / dl , hb : 8.4 g / dl , leucocytes : 15,400/l , platelets : 98,000/l , prothrombin time : 18 s , activated partial thromboplastin time : 40 s. computed tomography ( ct ) of abdomen [ figure 1 ] carried out with intravenous contrast on day 4 revealed enlarged , diffusely enhancing pancreas , multiple peripancreatic fluid collections and bilateral pleural effusions , confirming grade e ap ( ct severity index = 4 ) . he was kept nil per orally . continuous nasogastric aspiration , intravenous fluids , stress ulcer prophylaxis and subcutaneous unfractionated heparin 5000 units twice / day for venous thromboprophylaxis were started . on day 5 ct of brain revealed large left mca territory infarct [ figures 2 and 3 ] . electrocardiogram ( ecg ) and echocardiography of the heart were normal . work up for hyperhomocysteinemia , protein c and s deficiency , factor v leiden , antithrombin iii deficiency and antiphospholipid antibody syndrome was negative . he was intubated on day 8 for progressive respiratory distress and hypoxia and was shifted to intensive care unit for mechanical ventilation . on day 9 , he developed shock and was discharged against medical advice upon insistence of his relatives . computed tomography scan of the abdomen taken after intravenous contrast showing bulky , diffusely enhancing pancreas ( indicated by white arrows ) and a fluid collection ( black arrow ) plain computed tomography of the brain showing an area of hypodensity with poor gray - white differentiation in the left parieto - occipital regions , suggesting a large left middle cerebral artery territory infarct plain computed tomography of the brain showing an area of hypodensity with poor gray - white differentiation in the left parieto - occipital regions , suggesting a large left middle cerebral artery territory infarct splanchnic veins are most often the involved sites with a reported incidence of 1 - 2% , the consequences being portal hypertension , gastrointestinal bleeding , bowel ischemia and ascites . splenic vein is the most common site , followed by portal and superior mesenteric veins . thrombosis of inferior vena cava , renal veins and pulmonary thromboembolism have been reported rarely . arterial thromboses are less common than venous thromboses , involve arteries in peripancreatic distribution namely celiac trunk , perigastric , splenic and colonic arteries . vascular complications are more commonly reported with alcohol related than with gall stone induced pancreatitis and correlate with severity of ap . the index patient had severe alcohol related ap as suggested by imaging [ figure 1 ] and the development of multi - organ dysfunction , but there was no evidence of svt . neurological complications of ap include encephalopathy resulting from hypoxia or metabolic causes , uncommonly visual loss due to retinopathy or cerebral infarcts and polyneuropathy from nutritional deficiency ( vitamin e ) or prolonged critical illness . hemiplegia due to cerebral infarction resulting from vascular occlusion is rare , as is spinal cord infarction leading to paraplegia . earlier reports of cerebral infarction in ap have suggested fat embolism as the cause but left mca thrombosis seems to be the most probable cause in our patient as he had a large infarct in the same territory [ figures 2 and 3 ] . cardiac source for cerebral embolism is less likely in the index patient , considering that he had sinus rhythm throughout the course and ecg and echocardiography were normal . other risk factors for ischemic stroke ( hypertension , diabetes mellitus , obesity , smoking and advanced age ) were absent in the index case and there was no hypotension before development of cerebral infarction . arterial thrombosis may lead to infarction of spleen , stomach and colon as well , sometimes necessitating emergency surgeries . acute limb ischemia of both lower limbs due to arterial thrombosis has also been reported in ap . the thrombotic tendency in ap may be related to systemic hypercoagulability resulting from inflammatory cytokines , endothelial dysfunction due to release of pancreatic enzymes into circulation , compression of vessels and direct vasculitis from surrounding inflammatory process . the pathogenesis of fat embolism involves the release of chylomicrons and vldl into the systemic circulation from omental fat necrosis in severe ap , along with elevated c - reactive protein which induce intravascular activation of the coagulation cascade and vascular occlusion . dual phase contrast enhanced ct of abdomen , conventional or digital subtraction angiography , color doppler ultrasonography and of late magnetic resonance angiography ( mra ) are the modalities employed to diagnose vascular complications in ap . ct cerebral angiography / mra could not be carried out in the index case to confirm thrombosis because of worsening renal failure , progressive organ dysfunction and rapid clinical deterioration after development of cerebral infarction . as there is increased risk of bleeding from pseudoaneurysms , frequent need for pancreatic debridement or drainage of infected collections , early anticoagulation ( heparin followed by oral vitamin k antagonists to achieve an internationally normalized ratio of around 2.0 ) for svt in patients of ap can be problematic . spontaneous recanalization was observed in about a third of patients of svt irrespective of anticoagulation in a study . hence , the role of anticoagulation for svt is unclear and the decision of anticoagulation has to be individualized , after considering the risk benefit ratio . guidelines for management of arterial thrombosis are lacking , but heparin has been used in some cases . full therapeutic dose of heparin was avoided in the index patient considering the significant risk of hemorrhage into large mca territory infarct . to conclude , cerebral infarction can be a rare complication of ap and the treating physicians should be aware of vascular thrombotic and neurological complications of ap .

peripancreatic vascular thrombosis is a known complication of acute pancreatitis ( ap ) and chronic pancreatitis . however , hemiplegia resulting from cerebral infarction due to cerebral arterial thrombosis is a rare complication of ap . here , we report a case of alcohol related severe ap with multi - organ dysfunction , which was complicated by large left sided middle cerebral artery territory infarct - leading to right sided hemiplegia in a 48-year - old male patient . the neurological and vascular thrombotic complications of pancreatitis , their pathogenesis and management are discussed in brief .

the relation between orthodontic force application and dental pulp tissue has been the subject of studies in the recent years . however , there is no conclusive evidence on the effect of orthodontic forces on pulpal tissue , and therefore , the issue has been studied for many years in human . reported that light continuous forces have little or no effect on dental pulp . on the other hand , the reaction of dental pulp to orthodontic forces has been reported to vary from mild hyperemia to complete necrosis in the literature . type of the force application , duration and dimension of the force , age of the patients , and size of the apical foramen are among the contributory factors . furthermore , higher incidence of irreversible pulpal reactions is usually expected in teeth with complete root formation . the aim of the present study was to evaluate histologic changes of dental pulp of human premolars in response to intrusive forces and to compare pulpal changes in patients of two different age ranges ( adults vs. adolescents ) . furthermore , early ( after 7 days ) and delayed ( after 30 days ) response of the pulp is assessed . this study was approved by the regional ethics committee on research of mashhad university university of medical sciences . a written informed consent form was signed by all participants before start of the study . patients with a history of systemic disease , probing depth of more than 3 mm in upper premolars , marginal bone resorption , and anti - inflammatory drug application during the last month was excluded from the study . furthermore , premolars with incomplete apical root formation , caries , restorations , and endodontic treatment were left out . the patients were classified into two groups according to their age : adolescent of 1318-year - old ( n = 11 ) and adults of 2532-year - old ( n = 11 ) . for each subject , one randomly selected maxillary premolar was loaded with intrusive force . the contralateral premolar was not subjected to mechanical loading and served as control tooth . orthodontic bands with triple buccal tubes were cemented onto the maxillary first molars . to avoid tipping and extrusion of molars , first molars were connected with a 1 mm stainless steel palatal bar into a rigid unit . orthodontic brackets ( 0.018 0.022 standard edgewise ; dentaurum , germany ) were bonded in the center of the buccal surface of the first and second upper premolar of the test side . a stainless steel wire ( 0.016 0.22 , dentaurum , germany ) was inserted into the molar tube and second premolar bracket to improve the anchorage . a cantilever spring ( 0.16 0.22 stainless steel , dent aurum , germany ) was fabricated for each patient to generate intrusive force . the spring was positioned 3 mm above the slot of the bracket of the first premolar in the passive state and was ligated to the bracket of the test tooth , with the use of wire ligature [ figure 1 ] . intraoral view of the cantilever spring for application of intrusive force to upper first premolar . ( a ) passive , ( b ) active position , ( c ) transpalatal arch cemented to avoid extrusion and tipping of the first molar . the magnitude of the intrusive force for every experimental tooth was approximately 15 g. in both groups of adults and adolescents , 6 pairs of teeth were extracted after 7 days , whereas the other 5 pairs were extracted after 30 days . after extraction , the tip of each root was cut with a bur to facilitate fixation . the teeth were fixed in 10% formalin for one week and were then immersed in decalcifying solution including 5 ml pure nitric acid , 5 ml pure formalin , and 90 ml 95% alcohol for 710 days immediately after removal . serial sections ( 45 m thick ) were cut longitudinally and stained with hematoxylin and eosin dye . the specimens were examined by an expert pathologist under a light microscope ( leica , exwave had , model number : ssc - dc58ap ) . the studied histological changes were as follows : degree of inflammation was determined by counting inflammatory cells by high magnification field ( 400 ) . each high magnification field corresponds to 0.1 mm none = 01 cell per field , mild = 25 cells per field , moderate = 615 cells per field , severe = more than 15 cells per fieldtype of inflammation : acute - chronic - nonefibrous tissue formation ( mild to severe)necrosis ( none , partial , complete)disruption of odontoblastic layerodontoblastic aspiration into dentinal tubulesvascular dilationresorption of cementum or dentin . degree of inflammation was determined by counting inflammatory cells by high magnification field ( 400 ) . each high magnification field corresponds to 0.1 mm none = 01 cell per field , mild = 25 cells per field , moderate = 615 cells per field , severe = more than 15 cells per field type of inflammation : acute - chronic - none fibrous tissue formation ( mild to severe ) necrosis ( none , partial , complete ) disruption of odontoblastic layer odontoblastic aspiration into dentinal tubules resorption of cementum or dentin . statistical analysis was performed using statistical package for the social sciences ( version 16.0 , spss inc , chicago , ill , usa ) . frequency distribution of the histologic parameters in the studied groups is shown in tables 13 and figures 1 , 2 . there was not a significant difference between the test and control teeth during the 7 days and 1 month test period in adolescents and adults . furthermore , there was not a significant difference between the test teeth after 7 days compared to 1 month in the adolescents and adults . whitney u - test revealed that there was a significant difference between adolescents and adults after 1 month regarding degree of inflammation ( p = 0.032 ) , and type of inflammation ( p = 0.032 ) in the test teeth . frequency distribution according to degree of inflammation , fibrous tissue formation , vascular dilation , and odontoblastic layer disruption in the studied groups in adolescents frequency distribution according to degree of inflammation , fibrous tissue formation , vascular dilation , and odontoblastic layer disruption in the studied groups in adult patients frequency distribution of aspiration of odontoblasts into dentinal tubules , as well as resorption of dentin or cement in adolescents and adult patients ( a ) fibrous tissue formation in the dental pulp . however , 2 teeth ( 33.3% ) in the test group and also 1 tooth ( 16.6% ) in the control group showed chronic inflammation after 7 days in the adolescents . in the adult group , chronic inflammation was observed in 4 teeth ( 66.6% ) in the intrusive group and 2 teeth ( 40% ) in the control group after 7 days . similarly , after 1 month , 4 teeth ( 80% ) and 2 teeth ( 40% ) showed signs of chronic inflammation in the intrusive and control group , respectively . some studies have reported significant pulpal reactions to orthodontic tooth movement , yet there is not conclusive evidence on the relation between orthodontic forces and pulpal alterations . some studies have demonstrated that most of the pulpal changes are associated with intrusive forces compared to other orthodontic movements . in the present study , pulpal reactions to orthodontic forces were investigated 7 days and 1 month after force application to study both the immediate and the late pulpal responses . some pulpal reactions to intrusive forces have been reported to occur as early as 3 days after force application in ramzanzadeh 's study . in present study , mild inflammation was observed in adolescents only after 1 month of force application . in contrast , cases with moderate and severe inflammation were found among the adult patients after 7 days . this result is in line with our findings . on the other hand , we found a significant difference in the amount of chronic inflammation between the adolescents and adults this emphasizes the importance of applying lighter forces with suitable intervals in the adult patients . some studies have demonstrated that hemodynamic changes are the first observable signs after orthodontic movements . some studies have reported a considerable decrease of pulpal blood flow after intrusion , whereas kvinnsland et al . have demonstrated an increase or no change . in the present study , we did not find a significant difference in vascular dilation between adolescents and adults after 7 days and 1 month of intrusion . we found no fibrous tissue formation after 7 days and 1 month of intrusion in adolescents . however , there were some cases with mild ( 33.2% ) and moderate ( 16.6% ) fibrous tissue after 1 week . nevertheless , the difference between the adolescents and adults and also between the control and intrusive groups was not significant . distribution of collagen fiber changes according to the age , fibers gradually change into fibrotic bundles . these changes usually occur in response to external stimuli such as caries or enamel attrition . since the studied teeth in the present study was completely intact , it seems that the observed difference between the adolescents and adults is related to the age of patients , albeit not statistically significant . similarly , ramazanzadeh et al . reported no significant difference between their intrusive and control group regarding fibrous tissue formation . aspiration of odontoblasts into dentinal tubules has been demonstrated as pulpal reactions to external stimuli in several studies . found odontoblasts aspiration in 1 case ( 10% ) after 3 days and also 3 weeks of intrusion . probable trauma to the teeth during extraction or before the study in the adult group can be mentioned as possible causes of this finding . in the current study , we did not find a significant difference in disruption of odontoblastic layer between the studied groups . in contrast , ramazanzadeh et al . reported more cases with odontoblastic layer disruption in the intrusive group compared to controls . similar to the results of ramazanzadeh 's study , we did not find a significant difference in resorption of dentin or cement between the studied groups . it seems that some reactions of pulpal tissue including disruption of odontoblasts , aspiration of odontoblasts into dentinal tubules , and resorption of dentin or cement occur with a considerable delay in adults compared to the adolescent group . according to graber et al . , lag phase before tooth movement takes usually longer time in adults compared to younger patients . the delayed reactions of pulp in the adult group in comparison to adults might be associated with longer lag phase in these patients . the 1-month period used in this experiment corresponds to the usual interval between consultations of orthodontic treatment and is sufficient for a tooth to move and complete its cycle of bone formation and resorption provided that the orthodontic forces are optimal . on the other hand , immediate response to orthodontic forced has been shown to occur as early as 3 days . furthermore , some studies have found some pulpal changes 7 days after orthodontic force application . thus , we decided to investigate immediate pulpal reactions to force application after 7 days . the results of the present study should be interpreted with caution due to the limited number of cases in each group . mild orthodontic intrusive force application in closed apex teeth causes no significant histological changes in adolescents and adults . however , it seems that inflammatory - related histological pulpal changes are more severe in adults after one month of intrusion . this emphasizes the importance of applying mild orthodontic forces with adequate rest intervals in older individuals . the authors of this manuscript declare that they have no conflicts of interest , real or perceived , financial or nonfinancial in this article . the authors of this manuscript declare that they have no conflicts of interest , real or perceived , financial or nonfinancial in this article .

background : there is no conclusive evidence on the effect of orthodontic force application on dental pulp tissue . the aim of this study was to compare early and delayed histological effects of intrusive forces on dental pulp of adolescents and adults.materials and methods : patients referred to the department of orthodontics of mashhad university of medical sciences participated in this study . they were assigned to adult ( 2532-year - old ) and adolescent ( 1318-year - old ) groups . a cantilever spring made of 16 22 steel wire was used to apply intrusive force to upper first premolars ( 11 teeth in adolescents and 11 teeth in adults ) and the opposing teeth were considered as control group . in each group , 6 pairs of teeth were extracted after one week , and the remaining 5 pairs were extracted after one month of intrusion . histologic changes were compared between the control and intrusive groups and also between the adults and adolescents after 7 days and 1 month . statistical analysis was performed using statistical package for the social sciences and wilcoxon and mann whitney u - tests . p 0.05 was set as statistically significant.results:significant difference was not found in any histological parameters between intrusive and control groups 1 week and 1 month after intrusion in adolescents and adults ( p > 0.05 ) . one month after intrusion , inflammatory cell response intensity ( p = 0.032 ) and frequency of chronic inflammation ( p = 0.032 ) were significantly higher in adults compared to adolescents.conclusion:mild intrusive force in closed apex teeth causes no significant histologic changes in adolescents and adults . however , it seems that inflammatory - related histologic pulpal changes are more severe in adults after one month of intrusion .

diverticular diseases of the gallbladder are unusual congenital or acquired diseases occurring only in 0.1% to 0.2% of cases in previous studies of resected gallbladder specimens.1 - 3 these diseases are divided into congenital ( true ) diverticula and acquired pseudodiverticula according to different developmental , clinical , and pathological features.4,5 we describe a unique imaging case of pseudodiverticulosis of the gallbladder mimicking multiseptate gallbladder accompanied with multiple stones , as confirmed by surgical operation . a 70-year - old woman presented with right upper quadrant abdominal pain radiating to the right lower abdomen ; the pain had begun to aggravate the subject 8 to 9 hours earlier . laboratory tests revealed the followings : white blood cell count , 8.90010/l ; hemoglobin , 13.4 g / dl ; amylase , 36 iu / l ; aspartate aminotransferase , 42 u / l ; alanine aminotransferase , 50 u / l ; and alkaline phosphatase , 162 iu / l . abdominal ultrasonography revealed multiple hyperechoic lesions in the gallbladder and linear septum - like structures in the fundus of the gallbladder . subsequently , endoscopic retrograde cholangiography ( erc ) was performed to evaluate the lesion ; it showed multiple linear septated radiolucent defects and a diffusely scattered bunch of grape - like saccular filling defects in the elongated gallbladder ( fig . 1 ) . operative findings showed a normal outer surface of the elongated gallbladder without any protruding lesions fixed on the gallbladder fossa of the liver ( fig . 2 ) . grossly , multiple black stones and a round saccular lesion with an intervening septum - like structure were noted on the dissected gallbladder specimen ( fig . microscopic findings showed mucosal gland structures downsloping into a thin muscle layer ( characteristically , the muscle layer is not thickened ) , which was different from adenomyomatosis ( fig . gallbladder anomalies are diversely classified according to the shape and position of the phrygian cap , multiseptation , and diverticula . erc can be helpful in making a diagnosis and in the differentiation of these anomalous diseases . one septum or fold of the gallbladder between the fundus and the body is called the " phrygian cap ; " whereas , multiseptate gallbladders are characterized by multiple internal septa of various sizes , and a faintly bosselated external surface.6 - 8 gallbladder diverticulum is an unusual congenital disease , which has the appearance of a hernia - like protrusion of the normal gallbladder wall . this disorder may not be diagnosed until surgically resected because it has no clinical significance unless there are associated diseases.1 - 3 gallbladder pseudodiverticulum is a different type of adenomyomatosis pathologically , and can be differentiated from other similar anomalies based on some important factors . pseudodiverticula have an acquired cause , multiple fundal lesions , an association with gallstones , internal saccular lesions without external hernia - like protrusions , and little to no smooth muscle in the gallbladder wall ( table 1).7,8 in our case , erc revealed a unique shape similar to a bunch of grapes and a septation infilling pattern , contrasting with the fundus of a lengthened gallbladder . we found a multiseptate gallbladder ; it was characterized by a " honeycomb " multicystic pattern and further characterized by multiple fixed lucent defects within an opacified gallbladder . however , operative findings showed a grossly normal gallbladder without any outpouches of the wall or inflammatory changes , and we could see multiple saccular outpouches internally with multiple gallstones when the gallbladder was opened . histopathologic examination revealed multiple pseudodiverticula , which were characterized by multiple downslopings of the mucosal gland to a thin muscle layer of fundus . this lesion was different from the fundal type of lesion that is typical of adenomyomatosis or true diverticula , in terms of the definitive muscle thinness . in summary , we diagnosed a unique , acquired anomaly of multiple pseudodiverticula presenting with calculous cholecystitis , which was pathologically different from true diverticula , adenomyomatosis , or multiseptate gallbladders .

gallbladder diverticula have the appearance of hernia - like protrusions of the gallbladder wall . this disorder may not be diagnosed until surgically resected because it has no clinical significance unless there are associated diseases . gallbladder pseudodiverticula have an acquired cause , multiple fundal lesions , an association with gallstones , internal saccular lesions without external hernia - like protrusions , and little to no smooth muscle in the gallbladder wall . we report a unique anomaly of multiple pseudodiverticula presenting with calculous cholecystitis , which was pathologically different from true diverticula and had a unique shape similar to a bunch of grapes and a septation infilling pattern on endoscopic retrograde cholangiography .

the goal of vision 2020 the right to sight , is the worldwide reduction of childhood blindness from the current level of 0.75/1000 to 0.4/1000 children.12 blindness in children remains the second leading cause of blind person years worldwide.2 the prevalence of childhood blindness in africa is approximately 10 times higher than in industrialized nations.3 of the 1.4 million children suffering from blindness worldwide,4 congenital cataract remains a major cause especially in middle and low income countries.25 the purpose of this 2-year retrospective study is to review the visual outcomes , postoperative complications and other challenges of pediatric cataract surgery at a tertiary eye hospital in northwestern nigeria . a retrospective chart review was performed for all patients who underwent surgery for congenital or developmental cataract . we defined congenital cataract as cataract that developed within the first year of life or the signs of poor fixation signifying early onset . developmental cataract was defined as a cataract that develops after the first year of life.12 data were collected on patient demographics , preoperative characteristics , intraoperative complications , and postoperative outcomes . patients below 5 years of age underwent primary capsulotomy with or without anterior vitrectomy ( vitron 2020-bf geuder , germany ) . msics was performed in the following manner ; first a 3 - 7 mm scleral tunnel [ depending on the need for an intraocular lens ( iol ) ] was lifted ; cortical matter was washed out / or nuclear material was extracted ( older children ) and at least one alternate stitch using 10.0 non - absorbable nylon suture was applied for all patients below 18-years - old . the sutures were only removed in some cases , mainly in older children due to irritation . the iol power was calculated using the srkii or hofferq formulas and 20% and 10% of the calculated power was deducted in patients 2 - 4-years - old and 5 - 7-years - old , respectively . polymethylmethacylate ( pmma ) iols were implanted in children 2 years and older and in some patients below 2 years . postoperatively , all patients were placed on topical steroid and chloramphenicol for at least 2 months , and 5 days course of 5 - 10 mg of oral prednisone . uncorrected visual acuity ( ucva ) was assessed with age appropriate acuity testing techniques , such as ability to fix and follow lights / objects hundred and thousand sweet test , kay picture , and the snellen chart . children who did not receive an iol were provided aphakic glasses and occlusion therapy for amblyopia was initiated where indicated . in cases of monocluar surgery , aphakic glasses was also provided with an eye patch on the seeing eye for variable duration ( depending on the age of the patient ) during waking hours . posterior capsular opacity was managed by yag laser capsulotomy for patients older than 4 years and manual posterior capsulectomy for patients below 4-years - old . , new york , ny , usa ) . a p value less than 0.05 was considered statistically significant . a total of 181 eyes of 102 patients underwent surgery , 95 surgeries were performed on the right eye . there were 64 ( 62.7% ) males in the study sample . the mean age of all the patients was 6.88 7.97 years ( range , 0 - 13 years ) . the differences in the gender proportions of the was independent age - group ( p > 0.05 ) . seventy - two percent of the patients were from northwestern nigeria , where the hospital is located . age and sex distribution seventy - eight percent of the eyes were blind at presentation [ ucva of light perception ( lp ) to < 3/60 , figure 1 ] . thirty - seven percent of the congenital cataracts were identified after the first birthday , and 66% of the developmental cataracts were noticed between the first and the eighth birthdays [ table 2 ] . pre - operataive va of operated patients age at which cataract was noticed by pateints / care givers amblyopia , nystagmus and strabismus were the most frequent ocular comorbidities accounting for 50.3% , 36.5% , and 35.4% of patients , respectively [ figure 2 ] . these were signs of severe vision deprivation early in life . the associated systemic abnormalities included , hearing loss ( 1 child ) ; mental retardation ( 1 child ) and delayed developmental milestones ( 5 children ) . showing ocular co - morbidities in eyes simultaneous bilateral intraocular surgery ( sbis ; bilateral surgery in one session ) was performed in 77.5% of patients . iol implantation in operated eyes intraoperative complications recorded include : miosis in five eyes , posterior capsule rupture with vitreous loss in two eyes and hyphema in one eye [ table 3 ] . intra operative complications approximately 87.3% of the eyes presented for postoperative evaluation at one week , 71.2% at 4 weeks postoperatively and 27.1% at 12 weeks postoperatively . patients were more likely to present at 1 week postoperatively ( p = 0.000 ) . the follow - up rate was low which limited the ablity to refract patients and to treat patients with amblyopia or low vision . one hundred and forty three eyes ( 78.8% ) were blind preoperatively . at 1 week postoperatively 9/73 ( 12.3% ) eyes remained blind and 6/65 ( 9.2% ) remained blind at 4 weeks . and 71.2% of the eyes had moderate vision i.e. between < 6/18 and 6/60 , one week , 4 weeks and 12 weeks postoperatively , respectively the proportion of eyes with this vision preoperatively was 11.8% . [ table 4 ] . post- operative ( available ) visual acuity corneal edema was the most common complication on the first postoperative day ( 34 eyes ) . other complications included posterior capsule opacification ( 20 eyes ) , fibrinoid reaction in the anterior chamber ( 7 eyes ) and shallow anterior chamber ( 2 eyes ) [ table 5 ] . post- op complications complications at 1 week postoperatively included , posterior capsular opacification ( 49 eyes ) , conjunctivitis ( 4 eyes ) , and uveitis ( 2 eyes ) . four and 12 weeks postoperatively , posterior capsular opacification accounted for the majority complications [ table 5 ] . opacification at the visual axis was more common in younger patients and in patients who underwent sbis [ tables 6 and 7 ] . opacification at the visual axis occured in 65 eyes of 43 patients at various follow - up visits . age distribution of patients with pco after sbis age distribution of patients with pco after unilateral cataract surgery pediatric cataract is the most common cause of childhood blindness worldwide.26 a review by tablin et al . , reported that up to 75% of childhood blindness is due to cataracts in developing countries.7 in children with cataract , sight can only be restored by surgery . a good childhood cataract surgery service we performed a retrospective review of cataract surgery in children in our hospital over a 2 year period . this may due to the fact that male children are valued more than the female children across african communities.6 the average age of our patients at the time of surgery was 7 years . at this age , amblyopia is a significant complication depending on the laterality and morphology of the cataract . late presentation is an important factor in the management of pediatric cataract in developing countries . yortson et al 's study from east africa , reported a mean age at surgery of 3.5 years.3 in nepal the average age at the time of surgery was approximately 6-years - old which is similar to our study.8 in tanzania health treatment seeking behavior , poverty , gender , local health beliefs , and the ability of the health care team to provide the needed care determined when children are brought to hospital.69 due to late presentation , the majority of the eyes ( 79% ) were blind at presentation ( > 3/60 to lp ) . in east africa and india , a similar proportion of the eyes were blind at presentation.310 children with developmental cataract are brought to a hospital relatively late in time frame for the development of the visual system.10 this explains the high number of eyes with amblyopia , nystagmus and strabismus . only seven of our patients had associated systemic abnormalities such as deafness , mental retardation , and delayed developmental milestones . the children with other severe systemic associations might have died or not been brought to the hospital for cultural reasons . the main reason for bilateral surgery was to reduce cost , reduce the risk of anesthesia and to increase the uptake of surgery for the second eye . previous studies have reported that bilateral simultaneous cataract surgery in children is safe.1112131415161718 long - term assessment of visual outcome is limited by very poor follow - up . however , follow out 1 week postoperatively was good . in tanzania , 67% and 43% of children who underwent cataract surgery were seen at two and ten weeks postoperatively respectively.19 comprehensive long term postoperative care of these children is precluded with this early and high rate of attrition . this care includes refraction , spectacle prescription , treatment of amblyopia and monitoring for long term complications such as glaucoma and corneal decompensation . sex ( being a male ) , close proximity to hospital and short delay in presentation were significantly associated with presenting for the two weeks follow up in a study from tanzania.20 the 10 weeks postoperative visit was related to the distance from hospital and good preoperative vision in the operated eye.20 high quality counseling to parents and good tracking of patients / parents improved the follow - up after surgery at the kilimanjaro christian medical centre in tanzania.19 visual outcome was generally fair , with about three quarters of the eyes regaining useful vision in the operated eye . yortson et al . , reported a visual acuity of better than 6/60 in about 91% of their patients.321 in kuwait , a mean best corrected visual acuity of 6/60 and 6/12 was achieved after surgery for unilateral and bilateral cataracts in children respectively.22 postoperative refraction needs to be enforced in our centre in order to achieve the best vision for these children . cornea edema and fibrinoid reaction were the most common immediate postoperative complications in our study . the loss of the clarity of visual axis needs to be urgently treated in order achieve the aim of cataract surgery in children . numerous surgical techniques have been described to either prevent or manage visual axis opacification , none of which are ideal.23 techinues for treating visual axis opacification includes removing the posterior capsule ( intraoperative or postoperative ) , removing the anterior vitreous body and membranectomy . very few patients underwent these procedures and low follow up was low likely due to financial constraint . the refraction is easier to perform once the wound is stable as about 10 - 12 weeks postoperatively . refraction outcome is useful in determining need for amblyopia treatment and referral to the low vision service . decentralization of follow up as suggested by cataract experts at the kilimanjaro centre for community ophthalmology ( kcco)7 may significantly enhance postoperative checkups . follow up can be improved by telephone follow up and home visits as appropriate . the current standard of care is inclusive care that is good preoperative counseling , varying surgical techniques , good postoperative visual rehabilitation including treatment of amblyopia , low vision services and inclusive education for the children .

purpose : to assess the outcomes of congenital / developmental cataract from a tertiary eye care hospital in northwest nigeria.materials and methods : a retrospective chart review was performed of all patients diagnosed with congenital or developmental cataract who underwent surgery from january 2008 to december 2009 . data were collected on patient demographics , preoperative characteristics , intraoperative complications , and postoperative outcomes as well as complications.results:a total of 181 eyes of 102 patients underwent surgery . there were 95 ( 52.5% ) right eyes . there were 64 ( 62.7% ) males . the mean age of the patients was 6.88 7.97 years . fifty - four ( 51.3% ) patients were below 3 years old . most ( 62% ) patients had congenital cataract with a history of onset within the first year of life [ 39 ( 62.9% ) patients ] . amblyopia , nystagmus , and strabismus were the most frequent ocular comorbidities accounting for 50.3% , 36.5% , and 35.4% of eyes respectively . the majority ( 84.3% ) of the patients had surgery within 6 months of presentation . all patients underwent manual small incision cataract surgery ( msics ) . seventy - nine ( 77.5% ) patients underwent simultaneous bilateral surgery . intraocular lens implantation was performed in 83.4% eyes . the most common early and late postoperative complication was , posterior capsular opacity which occurred in 65 eyes of 43 children . in these cases , moderate visual acuity was predominant visual outcome.conclusion:treatment of pediatric cataract in our setting is complicated by demographic factors which results in late presentation and consequently , late treatment of children . short - term visual outcome is fair . data on long term postoperative outcomes could not be acquired due to poor follow - up .

intrahepatic arterial aneurysms are rare and typically related to trauma , transplantation , iatrogenic injury , or infection we present the case of a 49-year - old man with an intraparenchymal hepatic artery aneurysm that presented as massive hemobilia following a laparoscopic cholecystectomy . the aneurysm could not be managed by interventional embolization and required a left hepatic lobectomy , which was performed laparoscopically . . the diagnosis of hepatic artery aneurysm can be most readily made by mri or ct scan . interventional embolization of the aneurysm may be effective treatment but is not always possible due to anatomic considerations . where indicated , surgical resection in a manner that preserves a maximal amount of normal hepatic parenchyma is the treatment of choice . this is the first report of laparoscopic liver resection performed for bleeding from a hepatic artery aneurysm and adds an effective treatment modality to the surgical armamentarium . hemobilia , the phenomenon of bleeding into the biliary tree , from an intrahepatic aneurysm is an extremely rare occurrence . hepatic artery aneurysms account for approximately 10% of hemobilia cases , and most are related to trauma , transplantation , surgical injury , or infection . hemobilia caused by an intrahepatic arterial aneurysm is rare and presents a challenging medical diagnosis . currently , several potential therapeutic options are available , including embolization , stenting , and resection . the choice of treatment must consider the acuity of the bleeding and the anatomic location of the aneurysm as well as the underlying cause . the role of laparoscopic liver resection in the treatment of a bleeding hepatic artery aneurysm has not been evaluated previously . we report on a 49-year - old male with massive hemobilia , a recent laparoscopic cholecystectomy , a past medical history of hypertension , and a newly diagnosed aortic dissection . we present the diagnostic approach , a review of the literature , and treatments for hemobilia caused by an intrahepatic aneurysm . in this case a 49-year - old african - american male with abdominal pain and dark tarry stools was seen at a community hospital . he had developed right upper quadrant pain and had passed several dark melanotic stools over 2 days . hospital admission laboratory tests showed his hemoglobin and hematocrit were 5.3 and 16.8 , respectively . he required transfusion of several units of packed red blood cells but remained hemodynamically stable . an ultrasound demonstrated gallbladder sludge , stones , and thickening consistent with cholecystitis . within 72 hours of admission , the patient 's hematocrit became stable , and he did not require further transfusion . postoperatively , the patient had further gastrointestinal bleeding with significant drops in hemoglobin and hematocrit requiring repeated transfusions . he received 7 units of blood within 48 hours after cholecystectomy and was transferred to our hepatobiliary service for further treatment . the ct scan revealed a previously undiagnosed aortic dissection beginning just distal to the left subclavian artery and terminating at the level of the left renal artery . the scan also showed intrahepatic biliary dilatation and an accompanying left hepatic artery aneurysm with associated outpouching of the right portal vein that likely represented a venous varix ( figure 1a ) . the mra showed a lobulated area in the left lobe of the liver , which measured 3 cm by 3 cm , highly suggestive of a portal venous varix ( figure 1b ) . the options for treatment of the hepatic vascular / biliary abnormality included embolization by interventional techniques or hepatic resection . the arteriogram and subsequent catheter placement were technically challenging , secondary to the aortic dissection with prominent false and true lumens . the catheter was guided to the common hepatic artery and further to the left hepatic artery ; however , secondary to high - grade stenosis at the origin of the left hepatic artery aneurysm , the catheter could not be advanced , preventing embolization . intraoperative ultrasound duplex was used to identify the location of the aneurysm with the left lobe of the liver . the left portal vein and left hepatic artery were divided intrahepatically by using a 45-mm laparoscopic linear stapler , with 2.5-mm staples . ultimately , the left hepatic vein was isolated and similarly divided . the specimen contained a large aneurysm with connection to the biliary system ( figure 2 ) . the final pathology was consistent with an aneurysm that communicated with the biliary system and also demonstrated thrombi in adjacent portal vein tributaries . a hepatic artery aneurysm is very rare but potentially life - threatening . of the visceral arteries most prone to true aneurysmal formation , the splenic and hepatic arteries are most common . splenic and hepatic aneurysms account for 60% and 20% of all visceral artery aneurysms , respectively . hepatic artery aneurysms may occur anywhere along the hepatic arterial system , both external to the liver and within the liver parenchyma . seventy - seven percent of hepatic aneurysms are confined to the segment proximal to the liver , 20% have combined intra- and extraparenchymal involvement , and 3% are exclusively within the liver . excluding traumatic aneurysms , there is a male predominance ( approximately 3:2 ) . historically , most hepatic artery aneurysms have been mycotic in origin . today , nearly 50% of hepatic aneurysms traumatic hepatic aneurysms typically result from either trauma ( car accidents ) or are iatrogenic , resulting from a diagnostic procedure . the remainder is associated with medial degeneration and secondary atherosclerosis , with hypertension as the predominant comorbid condition . interestingly , the populations most at risk for developing hepatic aneurysms are patients with fibromuscular dysplasia or polyarteritis nodosa . decompression into the biliary tree with resulting hemobilia is more common than free rupture is into the abdominal cavity . , hemobilia has increased in incidence , presumably secondary to increasing numbers of surgical and interventional radiologic procedures involving the liver . the most common symptoms associated with hemobilia are jaundice ( 30% ) , biliary colic ( 52% ) , and gastrointestinal hemorrhage ( 73% ) . the complete triad occurs in approximately 20% of symptomatic patients . once an upper gastrointestinal ( ugi ) bleed is suspected , endoscopy is the first - line diagnostic modality . if blood or clot is seen at the ampulla of vater , hemobilia is highly likely . however , only 12% of the upper endoscopies done to evaluate acute ugi bleeding are diagnostic . radiologic studies , such as computed tomography , abdominal sonography , magnetic resonance , and angiography , are all potentially useful in identifying hepatic arterial abnormalities . angiography can detect the source of significant hemobilia in over 90% of patients , allowing for localization of the vascular abnormality and possible therapeutic stenting or embolization . the ultimate goal is to prevent or stop active hemorrhage and relieve any associated biliary obstruction . for extrahepatic aneurysm excision , arterial reconstruction or intraarterial stenting to affect aneurysm exclusion embolization has a success rate of between 80% and 100% in some reports and a lower morbidity and mortality rate compared with that in open surgery . if embolization fails or is contraindicated , surgical intervention , such as ligation of the artery or aneurysm excision , should be considered . laparoscopic surgery for hemobilia caused by a hepatic artery aneurysm has not been described previously in the literature . in centers experienced in laparoscopic liver resection , this approach adds an additional treatment modality . in our patient , laparoscopic resection allowed for complete removal of the aneurysm , preventing further bleeding or other potential complications that could result from a vascular - biliary fistula . hemobilia secondary to intrahepatic aneurysm in a patient with newly diagnosed aortic dissection is a rare finding . embolization is a first - line therapy for intrahepatic aneurysms but could not be accomplished in this case secondary to stenosis and anatomic limitations imposed by aortic dissection . in this case , laparoscopic left lobe resection provided definitive treatment without complications . increasing familiarity with laparoscopic liver resection in centers familiar with the techniques involved

background : intrahepatic arterial aneurysms are rare and typically related to trauma , transplantation , iatrogenic injury , or infection . they account for approximately 10% of clinically significant hemobilia.case report : we present the case of a 49-year - old man with an intraparenchymal hepatic artery aneurysm that presented as massive hemobilia following a laparoscopic cholecystectomy . the aneurysm could not be managed by interventional embolization and required a left hepatic lobectomy , which was performed laparoscopically.discussion:evaluation of hemobilia requires a multidisciplinary team approach . the diagnosis of hepatic artery aneurysm can be most readily made by mri or ct scan . interventional embolization of the aneurysm may be effective treatment but is not always possible due to anatomic considerations . where indicated , surgical resection in a manner that preserves a maximal amount of normal hepatic parenchyma is the treatment of choice.conclusion:this is the first report of laparoscopic liver resection performed for bleeding from a hepatic artery aneurysm and adds an effective treatment modality to the surgical armamentarium .

the one of the principal reforms of health system in federation of bosnia and herzegovina ( fbih ) is focused on strengthening of primary health care and rationalization of hospital care ( 1 ) . in spite of numerous criteria on how to differ rural or urban areas , studies worldwide refer to differences in health , as well as health care resources in rural areas in comparison to urban ones ( 2 ) . rural uninsured rates are higher than urban ( 3 ) and the uninsured often have difficulty obtaining needed care ( 4 ) . the factors with the clearest relationship to satisfaction with health care system include the accessibility of medical care , the organizational structure of clinics , treatment length , perceived competence of physicians , clarity and retention of physicians ' communication to patients , physicians affiliative behavior , physicians control and patients expectations ( 5 ) . counties has higher likelihood to yield poor health outcomes in accordance to measurements being encompassed within the county health rankings ' indexed domains of health quality . there is strong evidence that rural population has a higher percentage of acute and chronic conditions treated within hospital facilities , but could have been prevented within primary health care ( 2 ) . there are no reliable data dealing with the rural urban differences within health care system in fbih , and we aimed our study to determine the rural - urban differences in primary care practice , hospital inpatient care and total services in one canton in fbih . a cross - sectional study was conducted and included all 12 municipalities of zenica - doboj canton . out of total number ( n=1 995 ) , 47.9% was urban population and median of age was 42 years for both populations . the study included patients with recent experience in general practice , aged 18 years or older . individual interviews were conducted in one randomly selected day of the week , except monday and friday . the questionnaire was made on the basis of europep standardized questionnaire , related to the patient satisfaction with a health care ( 6 , 7 , 8) . a patient satisfaction was rated on a 5 point scale , response categories being poor , fair , good , very good , and excellent . statistical analysis was performed using the ibm spss version 21.0 for windows system ( spss inc . , data are presented as mean standard deviation or as median with interquartile range ( iqr , 25 to75 percentiles ) dependent on normality of variables distribution . smirnov statistic test with a lilliefors significance level was used for testing normality of distribution . in the case of categorical variables , the most of urban residents ( 81.4% ) had finished high school or higher education compared to rural residents ( 58.5% ) ( p < 0.001 ) . there are significant differences in employment status between rural and urban population ( p < 0.001 ) ( table 1 ) . socio - demographic characteristics rural and urban population as figure 1 demonstrates , rural residents are more likely to travel more than 15 minutes to see their health facilities compared to urban residents ( 61.7% vs. 24.4% , respectively ) . median of distance ( kilometers ) from residence location to the nearest hospital was statistically significantly higher in rural ( me = 8.0 ; iqr= 5.0 do 14.5 ) km compared to urban population ( me = 1.5 ; iqr = 1.0 to 3.0 ) km ( p < 0.001 ) ( figure 1 ) . urban differences in time ( minutes ) needed to reach health facilities ( p < 0.001 ) rural residents are more likely to use public transport ( 26.0% vs. 3.0% ) , taxi service ( 9.2% vs. 4.0% ) but not walking ( 23.4% vs. 51.1% ) to reach health facilities , compared to urban residents , respectively ( p < 0.001 ) . our results indicate that every fourth patient in rural ( 25.1% ) and urban population ( 23.2% ) waits for admission in doctor s office less than 15 minutes , for 30.1% of rural and 26.0% of urban population the waiting time is more than an hour . there was not statistically significant differences in waiting time for admission in doctor s office in primary health care between rural and urban population ( p = 0.487 ) . there was not a statistically significant association between residence in overall satisfaction proceedings of hospital staff in dealing with the patient ( p = 0.144 ) , professional conduct of hospital staff at admission ( p = 0.790 ) and professional conduct during the hospital stay ( p= 0 . urban differences in patients satisfaction with : q1- proceedings of hospital staff in dealing with the patient ; q2professional conduct of hospital staff at admission ; q3professional conduct during the hospital stay ( ns p > 0.05 ) . rural residents are more likely to buy drugs for medical treatment ( 93.4% vs. 87.2% ; =21,940 ; df=1 ; p<0,001 ) and parenteral injections in primary care practice compared to urban residents ( 54.8% vs. 46.6% , respectively ; =12,976 ; df=1 ; p<0,001 ) ( figure 3 ) . urban differences in health care system : q1- they visited phyisican in the last month ; q2 they have health problems in the past 12 months but they did not request medical treatment ; q3 they be ordered for physical examination ; q4 they bought drugs for medical treatment ; q5 they bought parenteral injections in primary care practice ; q6 they paid unoffically to someone from medical staff ( ns p > 0.05 ; * * * p < 0.001 ) . there was not a statistically significant association between residence and : visiting a physician in the last month ( =0.674 ; df=1 ; p=0.412 ) ; if they have health problems in the past 12 months but they did not request medical treatment ( =0.401 ; df=1 ; p=0.527 ) ; ordering for a physical examination ( =0.031 ; df=1 ; p=0.860 ) , unofficial payments to someone from medical staff ( =0.002 ; df=1 ; p=0.968 ) . urban residents are more satisfied with primary health care center ( p = 0.001 ) , ambulatory health care ( p < 0.001 ) and specialist services ( p = 0.022 ) compared to rural residents ( figure 4 ) . urban differences in patients satisfaction with : q1- primary health care center ; q2 the general hospital in tesanj ; q3 the cantonal hospital in zenica ; q4 ambulatory health care ; q5 specialist services ( ns p > 0.05 ; * p < 0.05 ; * * p < 0.01 ; * * * p < 0.001 ) . this study compared urban and rural populations in zenica - doboj canton in fbih about health care quality assessment . rural residents in zenica - doboj canton usually travel long distance from the village to ambulatory health care or higher level hospitals to deal with complicated situations and to receive better services . counties have statistically significantly ( p 0.05 ) lower scores in such areas as health behavior , morbidity factors , clinical care , and the physical environment ( 2 ) . in our study , rural residents are more likely to use public transport and cab service to reach health facilities , and more likely to buy drugs for medical treatment and parenteral injections in primary care practice which suggests that rural populations spent more on travelling and medication . in the study of farmer j et al . , satisfaction with local doctors and hospital services was higher in rural locations ( 9 ) . in the study of zhihua yan et al , rural patients were generally more satisfied with healthcare service compared to urban and suburban residents , also ( 10 ) . in our study , urban residents are more satisfied with primary health care center , ambulatory health care and specialist services compared to rural residents . these findings could be explained by that urban population have a grater possibility of health care professionals choice . our results indicate that there are significant differences in the overall health care assessment of rural populations compared to urban populations . we would like to point out that health care policy decision makers in the federation of bosnia and herzegovina have to take into account all these differences in order to address the health inequalities between urban and rural areas of the country . our results can not be representative for the planning of public health policy but can certainly point out to weaknesses of health system and contribute its reform in fbih .

aim : to determine the rural urban differences in primary care practice , hospital inpatient care and total services.methods:this cross - sectional study used data from zenica - doboj canton in federation of bosnia and herzegovina ( fbih ) . the overall sample size for the study was 1,995 . individual interviews were conducted in one randomly selected day of the week , except monday and friday , on the basis of europep ( european task force on patient evaluations of general practice care ) standardized questionnaire.results:out of total number ( n=1 995 ) , 47.9% was urban population and median of age was 42 years for both populations . the most of urban residents ( 81.4% ) had finished high school or higher education compared with rural residents ( 58.5% ) ( p < 0.001 ) . there are significant differences in employment status between rural and urban population ( p < 0.001 ) . rural residents are more likely to travel more than 15 minutes to see their health facilities compared with urban residents ( 61.7% vs. 24.4% , respectively ) . median of distance ( kilometers ) from residence location to the nearest hospital was statistically significantly higher in rural me = 8.0 ( 5.0 do 14.5 ) km compared to urban population me = 1.5 ( 1.0 to 3.0 ) km ( p < 0.001 ) . the rural population was more likely to buy drugs for medical treatment ( p < 0.001 ) and parenteral injections in primary care practice ( p < 0.001).conclusion : there are significant differences in the overall health care assessment of rural populations as compared to urban populations .

in fact , it is reported to be one of the three most frequent disabling symptoms in ms with as many as 90% of patients reporting fatigue . clinically , patients with ms report fatigue as exhaustion , lack of energy , increased somnolence or worsening of symptoms and weakness exacerbated by activity and heat ( uthoff phenomenon ) . certain factors such as neurological impairment , spasticity , motor weakness , nocturia , pain , depression , sleep disturbances , and heat sensitivity correlate consistently with fatigue and considered secondary causes of fatigue in ms . quality - of - life ( qol ) is defined as individual perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals expectations , standards and concerns . several studies have reported that qol is worse in patients with ms as compared to healthy controls with a higher prevalence of depression and fatigue . although there is a plethora of literature regarding the effect of ms related fatigue on the qol in the western countries , but no case series has been published with indian population of patients with ms as per our knowledge . the objective of this prospective study was to observe the prevalence of fatigue in indian patients with ms and also to see its effect on various domains of qol . this prospective observational study was performed with 31 patients with ms ( 25 females ) , who visited the out - patient facility or admitted in the department of neurology of the university tertiary research hospital between february 2010 and december 2011 . patients with definite ms according to the mcdonald 's ( 2005 ) , criteria were included in the study irrespective of age and gender . patients were excluded from the study if they had an acute relapse in the preceding 2 months , having systemic infection , received pulse methylprednisolone during the past 4 weeks and already receiving medication to reduce fatigue . all patients who agreed to participate in the study were evaluated with a questionnaire , which included personal data , kurtzke 's expanded disability status scale ( edss ) , and krupp 's fatigue severity scale ( fss ) . history of medication use such as antidepressants , sedatives and anti - hypertensives , which may have contributed to fatigue , was recorded . the qol was assessed using world health organization ( who ) qol - bref questionnaire . patient related information such as filling of proformas , history , and clinical examination of patients was carried out by a neurologist . patients underwent a complete hemogram and peripheral smear , random blood sugar , renal and liver function tests , thyroid function tests apart from imaging when necessary . the scale provides a score between 0 ( very little disability with a normal neurological examination ) to a maximum of 10 ( death due to ms ) . the first levels 1 - 4.5 refer to people with a high degree of ambulatory ability and the subsequent levels 5 - 9.5 refer to the loss of ambulatory ability . in addition , it also provides eight subscale measurements called functional system ( fs ) scores . these systems include pyramidal , cerebellar , brainstem , sensory , bowel and bladder , visual , cerebral , and others . the fs are scored on a scale of 0 ( low level of problems ) to 5 ( high level of problems ) to reflect the level of disability observed clinically . fatigue severity was assessed using krupp fss , which consists of nine items each rated on a seven point scale , which has five equidistant anchor points : strongly disagree ( 1 ) , rare ( 2,3 ) , sometimes ( 4 ) , frequently ( 5,6 ) , and strongly agree ( 7 ) . the score is obtained by computing the average of the nine items with higher scores indicating increasing fatigue severity . patients having a total fss score of 36 and above were categorized as having fatigue and those who have a score < 36 were categorized as not having fatigue . this contains a total of 26 questions , which measure the qol in four domains : physical health , psychological , environmental , and social relationships . the mean score of items within each domain is used to calculate the domain score . these raw scores are then converted to the final transformed scores on a 0 - 100 scale . descriptive statistics included frequency , means , and standard deviation for quantitative variables such as age , age at first symptoms , number of episodes , edss and fss scores and duration of illness . all quantitative measures were treated with parametric statistical analysis such as student 's t - test like ; fss , who qol domain scores in patients with ms with and without fatigue . qualitative measures such as correlation between fss scores and various domains of who qol were analyzed using chi - square test . patients underwent a complete hemogram and peripheral smear , random blood sugar , renal and liver function tests , thyroid function tests apart from imaging when necessary . the scale provides a score between 0 ( very little disability with a normal neurological examination ) to a maximum of 10 ( death due to ms ) . the first levels 1 - 4.5 refer to people with a high degree of ambulatory ability and the subsequent levels 5 - 9.5 refer to the loss of ambulatory ability . in addition , it also provides eight subscale measurements called functional system ( fs ) scores . these systems include pyramidal , cerebellar , brainstem , sensory , bowel and bladder , visual , cerebral , and others . the fs are scored on a scale of 0 ( low level of problems ) to 5 ( high level of problems ) to reflect the level of disability observed clinically . fatigue severity was assessed using krupp fss , which consists of nine items each rated on a seven point scale , which has five equidistant anchor points : strongly disagree ( 1 ) , rare ( 2,3 ) , sometimes ( 4 ) , frequently ( 5,6 ) , and strongly agree ( 7 ) . the score is obtained by computing the average of the nine items with higher scores indicating increasing fatigue severity . patients having a total fss score of 36 and above were categorized as having fatigue and those who have a score < 36 were categorized as not having fatigue . this contains a total of 26 questions , which measure the qol in four domains : physical health , psychological , environmental , and social relationships . the mean score of items within each domain is used to calculate the domain score . these raw scores are then converted to the final transformed scores on a 0 - 100 scale . descriptive statistics included frequency , means , and standard deviation for quantitative variables such as age , age at first symptoms , number of episodes , edss and fss scores and duration of illness . all quantitative measures were treated with parametric statistical analysis such as student 's t - test like ; fss , who qol domain scores in patients with ms with and without fatigue . qualitative measures such as correlation between fss scores and various domains of who qol were analyzed using chi - square test . clinical and demographic data of the patients their clinical presentation has been given in the table 2 . clinical symptoms in multiple sclerosis the mean fatigue score was 38.7 18.5 , which is above the cut off value of 36 in the fss . the mean age and age at 1 symptom was significantly greater in the group of ms patients with fatigue as compared to those without fatigue ( p = 0.01 and 0.001 respectively ) [ table 3 ] . comparison of parameters between patients of ms with and without fatigue all four domains of qol ; physical health , psychological , environmental , and social relationships were significantly more impaired in the group of patients with fatigue than in those without fatigue as mentioned in table 4 . the mean fatigue score was 38.7 18.5 , which is above the cut off value of 36 in the fss . the mean age and age at 1 symptom was significantly greater in the group of ms patients with fatigue as compared to those without fatigue ( p = 0.01 and 0.001 respectively ) [ table 3 ] . all four domains of qol ; physical health , psychological , environmental , and social relationships were significantly more impaired in the group of patients with fatigue than in those without fatigue as mentioned in table 4 . very few studies in india have been conducted in patients with ms and these aspects have not been addressed by most of the authors . the aim of this study was to estimate the prevalence of fatigue in patients with ms and its effect on qol of these patients . in our study , patients of ms with and without fatigue were compared and it was found that the severity of fatigue correlated with poorer qol in all domains . the observation highlights the importance of initiating management of fatigue in these patients as it will help not only in improving the symptom , but also will provide a global higher qol . even higher prevalence has been reported in the previous studies with much greater sample size like north american research committee on multiple sclerosis survey . this survey observed that ms patients with fatigue tended to be older and had more disability according to patient determined disease scale ( pdds ) as compare ms patients without fatigue . respondents with severe fatigue also had significantly higher mobility impairment as measured by pdds scores compared with respondents with mild / moderate fatigue . similar significant correlation between fatigue and mobility impairment was reported in another study by schwartz et al . however , krupp et al . corpus callosal atrophy , cortical atrophy of the parietal lobe with dysfunctions in higher - order aspects of motor control , regional atrophy of supratentorial brain parenchyma involving the cerebral cortex , nearby white matter and the caudate head areas , significant white matter atrophy in the posterior part of the corpus callosum and significant grey matter atrophy of the left superior frontal sulcus , left pre - central gyrus , posterior cingulate cortex , right thalamus , and left middle frontal gyrus have been some of the structural derangement in the brain found to be correlating with fatigue in ms . the causes of primary fatigue in ms include down regulation of gamma - aminobutyric acid activity as a compensatory mechanism due to conduction failure in demyelinated pyramidal tract fibers . conduction block , and activity dependent conduction block are also considered to be the mechanisms responsible for fatigue in ms patients . cytokine mechanism with increased level of tumor necrosis factor- levels and interferon- levels are found in fatigued ms patients compared to non - fatigued patients and considered to be responsible for fatigue . these tests were not done or reported in the present study . in a previous longitudinal study with ms patients , authors examined the symptom cluster of fatigue , pain , and depression as a correlate of reduced qol . cluster analysis revealed the presence of three subgroups differing in experiences of the three symptoms . the sub - group with the lowest scores on all three symptoms had the highest qol , whereas the sub - group with the highest scores on the symptoms had the worst qol . this observation supports the concept of fatigue , pain and depression as a symptom cluster , which correlates with reduced qol in patients with ms . another case - control study in women with relapsing - remitting multiple sclerosis ( rrms ) found that pain and pain intensity were significantly more in the rrms group as compared to controls . it was observed that increased fatigue intensity was a predictor for decreased physical qol in all women , regardless of group . ghaem and borhani haghighi ( 2008 ) in their study found 87.2% of patients with ms had poor sleep . significant high positive correlation was observed between the quality of mental and physical health composite scores . there was a significant negative correlation between the quality of physical score and age , fatigue score , edss score and pittsburgh sleep quality index ( psqi ) . linear regression analysis showed that psqi score , edss , and fatigue score were predictors in the model between the quality of physical score and covariates . linear regression model showed that fatigue score and psqi were predictors in the model between the quality of mental score and covariates . the explanation could be that the three symptoms are often co - occurring and possibly synergistic in persons with ms and are etiologically linked through cytokine induced manifestations of sickness behavior with diffuse axonal damage across different regions of the central nervous system . researchers have identified fatigue , depression , and pain as a symptom cluster , which is associated with reduced physical activity and qol in persons with ms . another study reported decreased qol in all domains with physical functioning being the most affected in patients with ms . the results of this study corroborate the notion that fatigue , increased lower limb tone , poor gait , and greater disability are independent factors that negatively affect the qol especially physical functioning domain in patients with ms . fatigue negatively affects both the physical and the mental components of the qol irrespective of the duration of the disease or the degree of disability . the prevalence of fatigue was found to be high in patients with ms in the present study . all four domains of qol ; physical health , psychological , environmental , and social relationships were significantly more impaired in the group of patients with fatigue than in those without fatigue . the treatment of fatigue therefore will not only help alleviating fatigue , but also improve qol of these patients . a follow - up study could have not only thrown light on the impact of fatigue on other co - morbidities , but also effectiveness of treatment in improving qol and functional abilities of these patients . fatigue is a symptom with multiple contributory factors such as poor sleep , depression , disability , and autonomic dysfunction . larger studies will be necessary to find out , which of these abnormalities are the major contributors to fatigue in ms . this may have potential therapeutic implications in the form of early recognition and treatment of these comorbidities . correlation of fatigue with radiological / imaging abnormalities in these patients can also be attempted . a follow - up study could have not only thrown light on the impact of fatigue on other co - morbidities , but also effectiveness of treatment in improving qol and functional abilities of these patients . fatigue is a symptom with multiple contributory factors such as poor sleep , depression , disability , and autonomic dysfunction . larger studies will be necessary to find out , which of these abnormalities are the major contributors to fatigue in ms . this may have potential therapeutic implications in the form of early recognition and treatment of these comorbidities . correlation of fatigue with radiological / imaging abnormalities in these patients can also be attempted .

objective : this prospective study was carried out to observe the prevalence of fatigue in patients with multiple sclerosis ( ms ) and its effect on quality - of - life ( qol).study design and setting : prospective observational study in a university tertiary research hospital in india.patients and methods : a total of 31 patients ( 25 females ) with definite ms according to mcdonald 's criteria presented in out - patient / admitted in the department of neurology ( between february 2010 and december 2011 ) were included in the study . disease severity was evaluated using the kurtzke 's expanded disability status scale ( edss ) . fatigue was assessed using krupp 's fatigue severity scale ( fss ) . qol was assessed by the world health organization qol - bref questionnaire.results:the mean age of patients was 30.1 9.1 years . the mean age at first symptom was 25.23 6.4 years . the mean number of relapses was 4.7 3.6 in the patients . the mean duration of illness was 4.9 4.4 years . the mean edss score was 3.5 2.2 . mean fatigue score was 38.7 18.5 ( cut - off value 36 in fss ) . the prevalence of fatigue in patients with ms was 58.1% ( 18/31 ) . ms patients with fatigue were significantly more impaired ( p < 0.05 ) on all qol domains ( i.e. , physical , psychosocial , social , and environment ) than ms patients without fatigue.conclusion:prevalence of fatigue was found to be high in the ms patients in the study . all four domains of qol were significantly more impaired in the group with fatigue than in those without fatigue .

essential thrombocythemia ( et ) is a philadelphia chromosome ( ph)-negative myeloproliferative neoplasm ( mpn ) . it is characterized by thrombocytosis and megakaryocytic hyperplasia of the bone marrow with jak2v617f mutation in 50 - 60% of patients . et transforms into myelofibrosis in a minority of cases , while evolution to acute leukemia is uncommon and increases with the use of certain therapies . it is mainly characterized by iron deficiency anemia that is not responding to oral iron intake , but partially responding to parenteral iron therapy . recently , it is shown that irida has stemmed from mutations in the gene tmprss6 , which encodes a transmembrane serine protease ( matriptase-2 ) expressed by the liver . irida patients indicate inappropriately increased levels of hepcidin which is a hormone delivered by the liver inhibiting iron absorption from the intestine and iron release from macrophage stores . according to recent studies , tmprss6 down - regulates hepcidin expression by cleaving hemojuvelin , a membrane - bound protein which triggers hepcidin signaling in hepatocytes . rcc , as the most common solid lesion in the kidney , represents approximately 90% of all kidney malignancies . many renal masses are asymptomatic and non - palpable till the late phases of the disease . currently , more than half of the rccs are identified incidentally through imaging while investigating some non - specific symptom complexes . the classic triad of flank pain , gross hematuria and palpable abdominal mass is uncommon ( 6 - 10% ) . a few symptomatic patients present with symptoms due to metastatic disease , such as bone pain or persistent cough . ten to forty percent of patients with rcc experience paraneoplastic phenomena over the span of the disease . the symptom that may result in erythrocytosis is the most well - known paraneoplastic hematological event . modest granulocytosis and thrombocytosis appears in approximately 20% of the patients and is seen as part of a systemic inflammatory reaction as it is typically interrelated with anemia , fever , weight loss , and increased serum levels of crp and interleukin-6 . here , we report a patient who presents with coexistence of rcc and thrombocytosis , which hasnt been caused by hormonal factors that are produced in tumor cells . we could not find similar cases previously reported and this may be the first documentation of such a case in literature . his blood counts were : white blood cells : 950010/l ; hemoglobin : 6.9 g / dl ; mean corpuscular volume 58 fl . ; platelets count : 1.423.000/mm ; c - reactive protein : 0.9 mg / l ; serum iron : 5 mol / l ( normal range : 15 - 30 mol / l ) ; total iron - binding capacity : 505 g / dl ( normal range : 110 - 350 g / dl ) ; transferrin saturation : 1% ( normal range : 20 - 45% ) ; ferritin : 3.1 ng / ml ( normal range : 20 - 330 ng / ml ) ; sedimentation rate 23 ( normal range : 0 - 20 ) . the peripheral blood smear showed hypochromic and microcytic cells , anisopoikilocytosis and thrombocytosis while his liver and kidney tests were normal . endoscopy and colonoscopy was applied to the patient in order to determine the etiology of iron deficiency anemia and no pathological signs were found . according to the etiology of thrombocytosis , jak2v617f mutation was found as positive and ph chromosome was negative in our patient . bone marrow biopsy showed megakaryocytic hyperproliferation , in which megakaryocytes are increased in size with mature hyperlobulated with abundant cytoplasm and grouped . standard cytogenetic studies showed a normal male karyotype ( 46 xy ) and fish ( fluorescence in situ hybridization ) analysis for deletion 5q [ del ( 5q ) ] was negative . abdominal computed tomography was applied to the patient to investigate the presence of other malignancies and a 3532 mm . the biopsy of this mass showed clear cell rcc ( crcc ) . during the examination of patient , the hemoglobin concentration , serum iron level and ferritin level did nt increase enough after four weeks . this failure is usually due to poor compliance , misdiagnosis , continued blood loss , or malabsorption but none of these reasons were present in our patient . starch block electrophoresis of the hemoglobin was applied to him to investigate the underlying thalassemia , and the hemoglobin electrophoretic pattern was found normal . we suspected that the patient may have irida , because all of its typical features as microcytic anemia with low serum iron , no response to oral iron , and only a partial response to intravenous iron therapy were present in our patient ; however , we could nt identify mutations of the tmprss6 gene and high plasma levels of hepcidin due to technical difficulties . as a result of all these investigations , the patient was found to have coexistence of rcc , et and irida . radical nephrectomy operation was planned for the patient by urologists . before the operation cytoreductive therapy with hydroxyurea was administered to the patient until his platelet count is reduced below 400 000/mm and parenteral ( intravenously ) iron treatment was applied to the patient until the hemoglobin level increased at least above 10 g / dl . platelet count can increase in a variety of conditions , such as anemia , reduced iron stores , inflammation , the absence of a spleen , and primary proliferative disorders . of all these conditions , malignant neoplasms are one of the most frequent causes of thrombocytosis . here we report a patient who presented with coexistence of rcc and thrombocytosis , but it hasnt been caused by hormonal factors that are produced in tumor cells . we aimed to show that coexistence of malignant neoplasms and thrombocytosis may not only arise from the production of humoral factors produced by the tumor , but concomitant mpn must be also considered .

essential thrombocythemia ( et ) is a philadelphia chromosome ( ph)-negative myeloproliferative neoplasm . it is characterized by thrombocytosis and megakaryocytic hyperplasia of the bone marrow with jak2v617f mutation . iron - refractory iron deficiency anemia ( irida ) is an autosomal recessive disorder , which is mainly characterized by iron deficiency anemia not responding to oral iron intake , but partially responding to parenteral iron therapy . recently , it has been shown that irida has stemmed from mutations in the gene tmprss6 , which encodes a transmembrane serine protease ( matriptase-2 ) expressed by the liver . renal cell carcinoma ( rcc ) accounts for 2 - 3% of all cancers . as the most common solid lesion in the kidneys , it represents approximately 90% of all renal malignancies . approximately 30% of patients with symptomatic rccs seem to display paraneoplastic syndromes . the symptom that may result from erythrocytosis is the most well - known paraneoplastic hematological event . here , we report a patient who presents with coexistence of rcc and thrombocytosis , which hasnt been caused by hormonal factors that are produced in tumor cells . this patient has been therefore diagnosed with et . the patient who was expected to display rcc with polycythemia , conversely present with irida .

epidermoid cysts are benign sequestration cysts in body that may be either congenital or acquired . the congenital variety is related to aberrant embryogenic ectodermal implantation during at the time of closure of neural groove or when epithelial surfaces fuse . acquired cysts are due to traumatic iatrogenic implantation of epidermal fragments during trauma or surgery . epidermoid cysts are seen throughout the body with only 7% cases seen in oro - facial region and 1.6% within oral cavity . we herewith report a case of exceptional existence of intraoral multiple epidermoid cysts in both sides of the buccal mucosa in a 35-year - old male in the buccal cheek region . to the best of our knowledge a 35-year - old male reported to surgical department with the chief complaint of swelling in the both sides of buccal mucosa for 3 months , which was incidentally noticed . intraoral examination revealed a bilateral 1.5 cm 1.5 cm nontender swelling in lateral buccal mucosa with normal covering mucosa . extraorally , the skin overlying the swelling did not show any indurations . there was no associated regional lymphadenopathy . a detailed case history of the patient provided no association of cheek biting with the lesion . excision of the lesion lying immediately underlying the buccal mucosa was done under local anesthesia by giving an elliptical incision in the bilateral buccal mucosa . specimen on gross examination showed gray - white to gray - brown soft - tissue pieces , altogether measuring 0.5 cm 0.5 cm in size . microscopically , swelling from both the sides showed three subepidermal cysts arranged in linear fashion , lined by stratified squamous epithelium and lumen partially filled with keratin [ figure 1a d ] . surrounding stroma showed fibrocollagenous tissue with mild diffuse chronic inflammatory infiltrate comprising lymphocytes , plasma cells , and macrophages . neither dysplasia nor malignancy was noted . a histopathological diagnosis of bilateral multiple epidermoid cysts was made . ( a and b ) both right and left side linearly arranged multiple linearly arranged epidermoid cysts with overlying stratified squamous epithelial clusters ( h and e , 40 ) ; ( c ) section shows cyst lined by stratified squamous epithelium with granular cell layer . no appendages are noted within the wall of cyst ( h and e , 100 ) ; ( d ) cyst wall lined by orthokeratotic stratified squamous epithelium with keratin flakes in the lumen ( h and e , 400 ) most of the cases are reported in between 15 and 35 years of age group . the incidence of epidermoid cysts in head and neck has been reported from 1.6% to 6.9% . most of the intraoral cases are reported in the midline and floor of the mouth . rare cases are reported involving tongue , lips , uvula , temporomandibular joint , intracranial , maxilla and mandible , and buccal mucosa . intraoral epidermoid cyst often remains asymptomatic for years until they reach a size that interferes with mastication , speech , and very rarely breathing . epidermoid cysts may be classified as congenital or acquired even if there is no difference between the two on presentation or histologically . congenital cysts are dysembryogenetic lesions that arise from ectodermic elements entrapped during the midline fusion of the first and second branchial arches between the 3 and 4 weeks of intrauterine life . alternatively , they may arise from the tuberculum impar of his which , with each mandibular arch , forms the floor of the mouth and the body of the tongue . acquired cysts derive from traumatic or iatrogenic inclusion of epithelial cells or from the occlusion of a sebaceous gland duct . however , for formation of acquired cysts , a proper combination of events that is a history of trauma along with implanted epithelium that is capable of proliferation and coexistent minimal inflammation are needed to occur simultaneously . these events occurring bilaterally along with the linear arrangement of the cyst probably explain the rarity of this case . epidermoid , dermoid , and teratoid cysts are nonodontogenic cystic lesions of the oral cavity . they are rare lesions derived from germinal epithelium . while a dermoid cyst has an epidermal lining with skin adnexa such as hair follicles and sebaceous glands , the epidermoid cyst contains no such adnexa . teratoid cysts in addition to skin appendages have tissue from other embryonal sources such as respiratory , gastrointestinal , and connective tissues such as bundles of striated muscle and distinct areas of fat . however , to the best of our knowledge , till now , no case has been reported as multiple epidermoid cysts in bilateral buccal mucosa . however , numerous epidermoid cysts , especially in head and neck , are associated with gardner 's syndrome . differential diagnosis should include a variety of conditions which can be developmental , neoplastic , and infectious . infectious conditions such as odontogenic infections are mostly symptomatic and can be ruled out in the present case as it was not associated with any clinical symptoms . swelling due to lipid , salivary , and vascular benign tumors should be considered . among developmental category , an oral lymphoepithelial cyst which is seen adjacent to waldeyers 's ring should also be kept in mind . the bilaterality of the lesion and confirmation on histopathology help to rule out the above pathologies . cases which are symptomatic and others that have undergone malignant transformation have been reported in the literature . cortezzi and de albuquerque in 1994 reported an epidermoid cyst of the floor of the mouth that reached a huge proportion and caused a life threatening situation because of secondary infection . basal cell carcinoma and squamous cell carcinoma arising in the wall of an otherwise conventional epidermoid cyst has been seen . however , no carcinomatous transformation was noted in our case . epidermoid cysts are found to exist in rare site which emphasize the need for further research into the etiopathogenesis of the cysts . the present case shows no variation from the normal histopathology , but they prove to be significant because of its variation in their anatomical presentation that is buccal mucosa , multiplicity , and bilaterality . more importantly , if ever malignancy is confirmed in such cases , appropriate evaluation is need to be carried out followed by definitive management .

intraoral epidermoid cyst of buccal mucosa is generally an uncommon entity . epidermal inclusion cyst refers sequestration of epidermal elements into the dermal and deeper tissue during the fetal period in line of fusion of embryonic process or acquired due to implantation of the epithelium due to trauma or surgery . it usually presents as slow growing asymptomatic cysts but may be symptomatic due to large size , interfering with mastication and speech or secondary infection . surgical excision is done for removal of these cysts . we report an interesting case of multiple epidermal cysts in both sides of buccal mucosa in a 35-year - old male patient .

with the increase in life expectancy , the proportion of the elderly population is constantly growing . in the uk , between 2002 and 2011 , there was a 26% increase in the number of people aged 90 years ; the number of nonagenarians was estimated to be 440290 ( just under 1% of the total population ) , and the number of centenarians was 11700 in 2011.1 ) by the year 2015 , there will be more than 2.4 million nonagenarians and 0.1 million centenarians in the u.s.2 ) cardiovascular disease is one of the leading causes of morbidity and mortality among the elderly . though not advocated by the standard practice guidelines , these very elderly patients are often treated half - heartedly , and an invasive strategy is often avoided in them . patients aged 85 years represent nearly 12% of all acute coronary syndrome ( acs ) admissions to uk hospitals , but this age group is the least likely to receive revascularization , with only 10% of patients undergoing a diagnostic coronary angiogram ( cag).3 ) here , percutaneous coronary intervention ( pci ) was performed in a symptomatic centenarian patient with complex coronary artery disease ( cad ) , with good angiographic success . a 108-year - old man was referred with ongoing chest pain on minimal or no exertion ( canadian cardiovascular society class iii - iv ) despite optimum medical therapy . he was an ex - smoker , hypertensive , but non - diabetic , and had chronic kidney disease , parkinsonism and below - knee amputation of the left leg due to a previous road - traffic accident . his pulse was 80/min , blood pressure 140/90 mm hg , and the lung bases were clear . his resting electrocardiogram ( ecg ) showed sinus rhythm , st depression and t inversion in leads v 5 , v 6 , i and avl , and st elevation in avr ( fig . 1a ) ; echocardiography revealed distal septal and basal inferior left ventricular wall hypokinesia with a left ventricular ejection fraction of 45 - 50% . serum creatinine was 1.6 mg / dl , and the glomerular filtration rate was 40.8 ml / min . cag was done because of ongoing chest pain ; there was triple vessel disease with involvement of the left main coronary artery ( lmca ) ; there was 75% stenosis in the distal lmca , 95% stenosis in the proximal segment and 75% stenosis in the mid segments of the left anterior descending ( lad ) artery , 75% osteo - proximal and 90% distal stenosis in the left circumflex ( lcx ) artery , and total occlusion of the right coronary artery from the origin ( fig . coronary artery bypass graft ( cabg ) surgery was advised , but the surgeons declined to perform it . so , percutaneous transluminal coronary angioplasty and stenting were done for the lmca and lad lesions ; lmca was hooked by a jl 3.5 , 7 fr guide catheter , and the lad lesion was navigated with a hydrophilic guidewire ( bmw guidewire , abbott vascular , santa clara , ca , usa ) , while another hydrophilic guidewire ( runthrough ns coronary guidewire , terumo medical corporation , tokyo , japan ) was kept in the distal lcx . predilatation was done with a 2.512 mm noncompliant balloon ( nc sprinter rx noncompliant balloon dilatation catheter , medtronic vascular , minneapolis , mn , usa ) at 12 - 14 atm . a 2.7536 mm biodegradable polymer drug - eluting stent ( des ) ( biomatrix flex , biosensors international , bulach , switzerland ) was deployed over the proximal to mid lad lesion at 14 atm for 20 seconds . another 3.533 mm biomatrix flex stent ( biosensors international ) was deployed over the left main to proximal lad lesion at 14 atm for 20 seconds , and overlapped with the previous stent . post - dilatation was done with a 3.512 mm quantum balloon ( quantum maverick balloon catheters , boston scientific corp . ) the lcx wire was re - crossed , and the ostial lesion was dilated with a 2.512 mm noncompliant balloon ( nc sprinter rx noncompliant balloon dilatation catheter , medtronic vascular ) at 12 atm . finally , kissing balloon dilatation was done with lad ( 3.512 mm quantum ) and lcx ( 2.512 mm sprinter ) balloons at 18 and 12 atm respectively . a temporary pacemaker and intra - aortic balloon pump , and provisions for an emergency cabg were kept ready . 1b ) , echocardiography revealed improvement in regional left ventricular wall motion , with an ejection fraction of 58% , and the troponin i was negative ( 0.118 ng / ml ) . however , on the first post - procedural day , the patient developed an acute confusional state and abdominal distension . a ct scan of the brain and an ultrasonogram of the abdomen revealed no significant abnormalities . blood biochemistry including the serum creatinine was normal . on day 2 , the confusional state and abdominal distension improved with conservative measures , and on the third post - procedure day , the patient was oriented and able to converse well . he was discharged with aspirin 75 mg and clopidogrel 75 mg daily . during the subsequent 3 months ' follow - up in contemporary practice , almost 25% of all pcis are performed in patients aged 75 years and 12% are performed in those aged 80 years.4)5 ) the elderly have more cardiovascular risk factors and a greater ischemic burden than younger patients needing pci , and therefore , derive greater benefit from revascularization ; however , they are also more likely to experience procedural complications owing to age - related physiological changes , frailty , and comorbidities.6 ) early studies and their meta - analyses demonstrated higher mortality and morbidity in elderly patients undergoing pci in comparison to younger patients , but the scenario has improved subsequently.4)5)7 ) this reduction in mortality has been attributed to a combination of improved patient selection , evolution of revascularization techniques , and evidence - based use of periprocedural medications that better balance the risks of thrombosis and bleeding.4 ) a recently published single - centre , retrospective , cohort study involving patients aged 85 years undergoing pci showed in - hospital , 30-day and 1-year mortality rates of 2.4% , 4.4% , and 17.7% , respectively ; 30-day ( 5.6% vs. 3.4% , p=0.24 ) and 1-year ( 20.0% vs. 14.0% , p=0.19 ) mortality rates were similar between the acs and elective patients , respectively . age , male sex , previous pci and the presence of shock were the independent predictors of 1-year mortality.8 ) pci is clearly effective in old age but a careful and holistic approach to patient selection is essential to get the best outcomes.9 ) the choice between pci and cabg for myocardial revascularization in the elderly depends on the complexity of the coronary lesions , and the presence of comorbidity . it is generally accepted that patients with single - vessel obstructive cad are best treated with pci ; however , the optimum revascularization strategy in patients with multivessel cad with a higher ischemia burden , greater risk of recurrent ischemic events , and higher mortality is a matter of ongoing debate.10 ) in a cohort of 10141 patients with multivessel cad aged > 85 years , pci showed early benefits of lesser morbidity and mortality , but cabg outcomes were significantly better by 3 years ( p<0.01).11 ) in meta - analyses of trials comparing pci and cabg for coronary revascularization , cabg was found to have either similar7 ) or better12 ) mortality outcomes in elderly patients . other recent meta - analyses of studies comparing pci and cabg in patients with a mean age of 70 years and unprotected lmca disease revealed no significant differences between pci and cabg for all cause - mortality , nonfatal mi , and major adverse cardiac and cerebrovascular events ( macce ) at 30 days and 12 and 22 months ; however , pci was associated with shorter hospital stay and lower rates of early stroke but higher repeat revascularization rates on the longer term follow - up.13 ) however , in comparison to pci , cabg surgery was associated with a higher risk of neurological complications , perioperative mi , renal failure , prolonged ventilation and nosocomial infections.14 ) so , despite the slight advantage of surgical over percutaneous revascularization in elderly patients with multivessel cad , surgical revascularization should remain an option only for selected highly functioning elderly patients with few comorbidities.6 ) the patient presented here was already frail , had parkinsonism , some cognitive impairment and amputation of a limb , so surgery would have been less suitable for him despite the presence of complex coronary lesions . cabg surgery is considered as the gold standard for the treatment of unprotected lmca lesions ; however , recent data comparing the efficacy and safety of pcis using des and cabg showed comparable results in terms of safety and a lower need for repeat revascularization for cabg.15)16 ) in a meta - analysis of 4 randomized controlled trials,17 ) and a recently published 5-year follow - up study of the syntax trial,18 ) pci was associated with a higher frequency of macce , and a higher risk of target vessel revascularization compared with cabg . so , it has been suggested that all patients with complex multivessel cad should be reviewed and discussed by both a cardiac surgeon and an interventional cardiologist to reach consensus on the optimum treatment.18 ) for the present case , surgeons were consulted with , and pci was done as a last resort only . the choice of stent in elderly patients may depend on the nature of the coronary artery lesions , comorbid conditions , and compliance to a dual antiplatelet regimen . dedicated rcts comparing des and bms in patients aged > 65 years are lacking , and the representation of elderly people in the existing rcts is also poor.7 ) however , observational data have indicated the superiority of des over bms in the elderly population.19)20 ) sometimes , compliance to dual antiplatelet therapy is a concern in very elderly patients undergoing des implantation . des was implanted in the case presented here , and aspirin and clopidogrel were given , and the patient tolerated this dual antiplatelet regimen well . percutaneous coronary intervention in the elderly is becoming a more common practice day by day . pci in the nonagenarian is less common , and rare in the centenarian at present , but with the increase in life expectancy , it may be a commoner practice in the future . a centenarian patient presenting with acs with an unprotected left main lesion is a real challenge . a minimum amount of contrast and a simple technique even for complex lesions should be adopted .

with the increase in life expectancy , the proportion of very elderly people is increasing . coronary artery disease ( cad ) is an important cause of mortality and morbidity in this age group , for which myocardial revascularization is often indicated . percutaneous coronary intervention ( pci ) in the very elderly bears the inherent risks of complications and mortality , but the potential benefits may outweigh these risks . a number of observational studies , registries , and few randomized controlled trials have shown the safety and feasibility of pci in octogenarians and nonagenarians . however , pci is only rarely done in centenarians ; so , the outcome of percutaneous coronary revascularization in this age group is largely unknown . pci in a centenarian with complex cad is described here ; the patient presented with unstable angina despite optimum medical therapy , and surgery was declined . good angiographic success was followed by non - cardiac complications , which were managed with a multidisciplinary approach .

mental illness is a global public health concern . according to the world health organization , one out of four ( 25% ) the prevalence of mental disorders is higher in developed countries , but the global burden of untreated mental disease is higher in developing nations . eighty percent ( 80% ) of the population suffering with mental illness lives in low - and middle - income ( lami ) countries . the presence of mental illness does not affects only the individual and his personal , social , educational and occupational life , but it also makes his entire family to suffer from negative consequences . considering the fact that india has 17.5% of the world 's population , the number of people suffering with mental illness is assumed to be huge . it is highly crucial for india to have a true estimate of the number or prevalence of mental illness in the nation . poverty , genetic and environmental factors : stress and abuse in childhood stage are common associates of mental disorders in the nation . distribution of mental disorders also varies with age , socioeconomic status , gender and rural and urban settings . compared to urban settings , people in rural poor communities have higher accessibility and affordability challenges in receiving professional help . the prevalence of mental illness appears higher in children due to behavioral and emotional disorders . those are often associated with learning difficulties , poor parenting and schooling , while age - related dementia , and other cognitive disorders increase with age . because mental disorders differ with age , the nature of psychiatric and psychological service requirements also vary . for the purpose of planning and provision of services , age - related prevalence of mental illnesses is very important . a high proportion of the indian population resides in rural settings with significantly higher poverty rates than the urban setting . because poverty is an important social determinant of mental disorders , the differences in prevalence between rural and urban settings also need to be studied for planning and development of services to the population this study examines the correlation between age and prevalence of mental illness , and compares rural and urban settings . this study examines the correlation between age and prevalence of mental illness , and compares rural and urban settings . secondary data from the indian national sample survey organization ( nsso ) 2002 are used for analysis . this report is named - nss 58 round , report no . 485 ( 58/26/1 ) , disabled person in india , 2002 , and available in the public domain . this was the first time mental illness and intellectual disability were covered by nsso in the disability survey . data on mental illness and intellectual disability are presented separately and in combination in this report , for planning purposes . this survey was performed by non - medical personnel . in designing the questionnaire , help from consultants with medical background geographically , the whole nation was covered in this survey except leh and kargil districts of jammu kashmir , interior villages of nagaland , andaman and nicobar ( which , together , constitute less than 1% of the total indian population ) due to challenges in accessibility . with the help of experts , the entire survey was conducted in 6 months , beginning from july to december 2002 . data in this report are presented by gender and rural or urban setting on several variables in many tables of the report and appendixes . , data were taken from the text of this report , and used to develop tables for statistical analysis . spearman correlation ( ) was computed for age and prevalence , z - test between rural and urban , and least square regression model were used to determine the association of prevalence rate with age in rural and urban populations . statistical package for social sciences ( spss ) version-21 , for statistical analysis was used . spearman correlation ( ) was computed for age and prevalence , z - test between rural and urban , and least square regression model were used to determine the association of prevalence rate with age in rural and urban populations . statistical package for social sciences ( spss ) version-21 , for statistical analysis was used . our analysis indicated that the prevalence of mental illness was strongly correlated with the age in rural ( =0.910 , p = 0.001 ) , and urban ( =0.940 , p = 0.001 ) population groups [ table 1 ] . however , the rural prevalence rate was significantly different from the urban population ( z = 8.10 , p = 0.001 ) [ table 2 ] . the rural population had significantly higher rate of mental illness compared to the urban [ table 2 and figure 1 ] . in the anova , f = 49.486 , p = 0.001 indicate a statistically significant strong association between age and mental illness in rural populations in india , where r = 0.81 , demonstrates that 81% of the variance in prevalence of mental illness is explained by age the rural model . however , with anova of f = 79.954 , p = 0.001 , in the urban setting , age is also strongly associate with mental illness , while an r = 0.87 , indicates 87% of the variance in the prevalence is explained by age . in further predicting prevalence of mental illness based on age , the least - square regression equation was obtained . according to this statistical predictive model , age increase of one year predicted an increase in prevalence of 2.98 persons per 100,000 rural population . however , in the urban population , the same increase in age predicts a 2.087 persons per 100,000 thousand increase in prevalence [ table 3 and figure 1 ] . correlation with age separated by rural and urban setting prevalence of mental illness in different age groups data from nsso report : case per 100,000 prevalence of mental illness in rural and urban india by age ( constructed from table 1 ) regression analysis of age with mental illness in rural and urban settings of india this study finds that age is an important predictor of mental illness in the population irrespective of where people live , rural or urban . mental illness is linearly associated with age and these findings agree with prevalence studies conducted previously . however , in another epidemiological study , the association of age with psychiatric illness among young children below the age of 3 years was found higher than for children in age range of 12 - 16 years . this study found that the cumulative prevalence rate in rural ( 17.10/1,000 ) , urban ( 12.7/1,000 ) and in combined population in the nation was 14.90 persons per 1,000 . an epidemiological review of prevalence studies of psychiatric disorders from , 1960 to 2009 conducted by math and srina , et al . ( 2010 ) found that the prevalence of mental illness falls in the range of 9.5 - 370 persons per 1000 . the wide variation in prevalence rate is attributed to several factors such as diagnostic criteria , methodology adapted in survey , lower sample size , and the type of instruments used in screening . the prevalence estimated in this study falls in the lower side of the spectrum found by math and srinivasaraju . ( 1985 ) estimated prevalence of 14.5/1000 in rural population in vellore ; shaji , et al . a prevalence study conducted by surya ( 1964 ) , also in southern india has estimated a low prevalence of mental illness ( 9.5/1000 ) in urban population in pondicherry . compared to urban population in india , this study found significantly higher prevalence of mental illness in rural population . considering the fact that larger proportions of the rural population live in poverty , poverty may be a significant determinant of mental illness . the findings of this study can be supported with other studies conducted in low and middle income countries . however , the difference in prevalence rate based on rural and urban settings is not well supported in many indian epidemiological studies , except one , that estimated psychiatric morbidity in children and adolescents . researchers have reported that the prevalence rate of psychiatric disorders is underreported in india as compared to the developed nations . until now , most of the prevalence studies are conducted with the average population of 5,000 or less , with many of the southern states of india , overrepresented in survey than any other study in the nation . under this survey , 45,571 households , in 4637 randomly selected villages , and 24,731 in urban blocks were interviewed for mental illness . random selection of villages and urban blocks in different states of the country makes the research data and its findings , representative of the different socioeconomic groups , and caste . despite the fact that this survey is much more representative of the entire population of the country , its findings have limited scope in representing true estimation of prevalence rate , association with the age , and difference in two settings , because of the limitations of the survey itself . the nsso report , on which this study is based , does not provide information on which icd standards definitions were used , how surveyors were prepared for survey , what were their trainings and how mental disorders were confirmed . case definition used in the survey was also vague , which might have covered few persons with intellectual disabilities by chance or excluded mentally ill people mistakenly , considering them intellectually disabled . to keep balance , this survey identified more people with severe mental illness , while people with mild mental illness might have remained unidentified and uncounted . despite its limitations , the findings of this study identified high prevalence rates of mental illness in india and its association with age and rural settings . compared to other studies , this study is based on larger sample size . in future , large epidemiological population studies

background : the indian population suffers with significant burden of mental illness . the prevalence rate and its association with age and other demographic indicators are needed for planning purpose.objective:this study attempted to calculate age - wise prevalence of mental illness for rural and urban settings , and its association with age.materials and methods : data published in national sample survey organization ( 2002 ) report on disability is used for the analysis . spearman correlation for strength of association , z - test for difference in prevalence , and regression statistics for predicting the prevalence rate of mental illness are used.result:overall population have 14.9/1000 prevalence of mental illness . it is higher in rural setting 17.1/1000 than urban 12.7/1000 ( p < 0.001 ) . there is a strong correlation found with age in rural ( = 0.910 , p = 0.001 ) and urban ( = 0.940 , p = 0.001).conclusion : results of this study confirm other epidemiological research in india . large - population epidemiological studies are recommended .

the traditional approach to low back pain ( lbp ) has failed as an effective treatment for lbp patients1 . accordingly , some researchers have recently suggested the necessity of a patient - centered approach to lbp1 . the decreased lumbar spine lordosis induces changes in spinal discs , creating abnormal pressures when absorbing shock between vertebrae , and creating stresses in spinal muscles , tendons and ligaments2 , 3 . flat - back syndrome is characterized by forward inclination of the trunk , inability to stand upright , and lbp pain4 . therefore , the exercises for flat back syndrome include trunk backward extension and pelvic anterior tilt exercises3 , 5 . clinicians recommend various anterior pelvic tilt exercises for lbp with flat back in the lying , sitting , quadriped or standing positions3 , 5 . however , the anterior pelvic tilt motion in these positions does n't apply powerful resistance for anterior pelvic tilt muscle strengthening . the purpose of this paper was to report showed the effect of individual strengthening exercises for anterior pelvic tilt muscles on back pain , pelvic tilt angle , and lumbar rom of a lbp patient with flat back . a 37 year - old male , who complained of lbp pain in l3 - 5 levels with flat back , was participated . ethical approval was obtained from yonsei university faculty of health science human ethics committee , and the subject provided written informed consent to participation prior to the commencement of the study . he complained of continuous lbp for 10 months , and an examination revealed that his pelvis was tilted posteriorly . he had not undergone any specific treatment for his condition , which included mechanical lbp without radiating pain , and in forward flexion in the standing position with his knees fully extended , he experienced pain and stiffness in his lower back . the visual analogue scale ( vas ) score of this back pain was 6 . pelvic inclination was measured with a palpation meter ( palm ; performance attainment associates , st . the intra - test and inter - test reliabilities of the palm are greater than 0.86 . the subject removed his shoes and spread his feet during the measurement , stood upright with the anterior aspect of the thighs against a stabilizing table . the sagittal plane rotation was measured with the caliper tips of the palm in contact with the ipsilateral anterior superior iliac spine ( asis ) and posterior superior iliac spine ( psis ) . at the initial assessment , the anterior pelvic tilt angles were 2 and 2 on the right and left sides ( normal range , 11 4 ) , respectively . the dual inclinometer ( acumar , lafayette instrument co. , lafayette , usa ) was used to measure the trunk flexion and extension angles . the intra - test and inter - test reliabilities of the dual inclinometer are greater than 0.8 . initially , the lumbar flexion angle was 55 and the extension angle was 34. the subject performed individual strengthening exercises for the anterior pelvic tilt muscles ( erector spinae , iliopsoas , rectus femoris)5 . the strengthening exercise for erector spinae was as follows : stand with the feet shoulder width apart with both hands holding 5 kg weights ; then flex the trunk slowly ( 5 seconds ) until parallel with the floor while keeping the natural arch of the back with the shoulder blades back ; then slowly return ( 5 seconds ) to the starting postition . the strengthening exercise for the iliopsoas was an above 90 hip flexion ( so - called psoas isolation ) exercise for both legs with 10 kg weights . the initial position was sitting with the hips and knees flexed at 90 on a table . reciprocal flexion to above 120 hip flexion on both sides was performed with knee flexion of 90. the strengthening exercise for the rectus femoris was an 80 knee extension exercise for both legs with 10 kg weights on a nk table . the subject performed the three individual strengthening exercises for two weeks in three sets of 30 repetitions per day . after the exercise intervention , the anterior pelvic tilt angle increased , the angles were 7 and 8 on the right and left sides , compared to the initial angles of 2 and 2 on the right and left sides . the lumbar roms were increased : the flexion angle was 62 and extension angle was 45 , compared to the initial flexion angle of 55 and extension angle of 34. when in backward trunk extension , the vas score of back pain decreased to a score of 3 , compared to the initial score of 6 . pelvic anterior tilt motion is produced by couple - force of the erector spinae , iliopsoas and rectus femoris muscles5 . during anterior pelvic tilt motion , clinicians ca n't directly apply a powerful resistance to patients for strengthening of pelvic anterior tilt muscles . so , in this study , we tried prescribing individual resistance exercises for pelvic anterior tilt for a lbp patient with flat back . after the intervention , pelvic tilt angles of the right and left sides had recovered to normal ranges . the patient 's lumbar roms had increased , and the vas score of low back pain had decreased . we think that these individual strengthening exercises for the strengthening of pelvic anterior tilt muscles are an effective approach for the treatment of lbp with flat back . therefore , we suggest that individual resistance exercises are necessary for effective and fast strengthening of pelvic anterior tilt muscles in lbp with flat back .

[ purpose ] the purpose of this paper is to report the effect of individual strengthening exercises for the anterior pelvic tilt muscles on back pain , pelvic tilt angle , and lumbar rom of a low back pain ( lbp ) patient with flat back . [ subject ] a 37 year - old male , who complained of lbp pain at l3 - 5 levels with flat back , participated . [ methods ] he performed the individual strengthening exercises for anterior pelvic tilt muscles ( erector spinae , iliopsoas , rectus femoris ) . [ results ] pelvic tilt angles of the right and left sides were recovered to normal ranges . his lumbar roms increased , and low back pain decreased . [ conclusion ] we suggest that individual resistance exercises are a necessary approach for effective and fast strengthening of pelvic anterior tilt muscles in lbp with flat back .

chronic recurrent non - specific parotitis is characterized by recurrent episodes of swelling and pain of unknown etiology in the parotid gland . sialography is a hallmark in the diagnosis of salivary gland disorders ; newer imaging modalities like ct - sialography , sialoendoscopy and mri can be used . various treatment modalities have been tried , from conservative approach to surgical excision depending on the recurrence rate and severity of the condition . although symptomatic treatment with antibiotics and analgesic , injection of intraductal medicament , aggressive treatment like duct ligation or excision of gland are some of the treatment modalities , there is no established algorithm as to which treatment method should be opted in such clinical situation . a 20 years old male patient reported with pain and salty taste in the mouth that had began before a week . examination revealed an elevated right parotid papilla ; ropy , cloudy appearing saliva was oozing out on milking the gland . sialography as a treatment showed a good response with no recurrence after two years of follow - up . recurrent attacks significantly affect the quality of life and also lead to progressive gland destruction . hence , conventional sialography is useful in the diagnosis and also effective as a therapeutic aid in recurrent parotitis . acute refers to sudden onset of pain and swelling in parotid gland whereas chronic recurrent parotitis ( crp ) is characterized by intermittent , painful and swelling of the gland which may or may not be associated with food intake ( 1 ) . the term chronic recurrent non - specific parotitisis used in cases where no definite etiology is identified ( 2 ) . researchers have suggested that recurrent parotitis arises due to retrograde infections eventual to stasis of saliva , allergic , immune deficiency , genetic and hereditary factors ( 2 , 3 ) . however , none of these factors have been proven as an actual cause for the disease . there is lot of disagreement regarding the treatment of recurrent parotitis due to ambiguity about its etiology . treatment of acute phase is aimed at relieving symptoms and prevention of damage to gland parenchyma ( 4 ) . proposed treatments for crp include steroids , tetracycline and 1% methyl violet as intra - ductal medicament ( 5 , 6 ) . conventional sialography can also be used as a therapeutic aid in cases of recurrent infection as it helps in salivary gland lavage , removal of small calculi and mucous plugs within the ducts ( 7 , 8) . our primary aim in this case was to relieve the pain and reduce the frequency of recurrence . to achieve this history : a 20 years old male patient presented with pain in front of the right ear and salty taste on having food that had began before a week . pain in the right parotid gland region was sudden , intermittent , throbbing in quality and initiated while the patient was chewing food and increased in intensity especially on taking citrus food . the patient gave history of at least two episodes of recurrent swelling and pain per year on the right side of the face since two - three years . physical examination : on general physical examination , the patient was febrile and lymph nodes were palpable in the submandibular region bilaterally which was single , firm , freely mobile and tender . on extra oral examination , the right parotid gland was tender on palpation and firm in consistency whereas the left parotid gland was normal . intra - oral examination revealed an elevated right parotid papilla ( figure 2 ) . on milking the gland a thick , ropy , cloudy appearing saliva was oozing out of the duct extra oral view showing the bilaterally symmetrical face intra oral view showing elevated right parotid papilla investigation : although antibiotic sensitivity test was the norm of investigation , it was not advised as the patient was already taking antibiotic which was prescribed by a private practitioner . salivary flow rate was assessed using drooling method . before unstimulated whole saliva was collected , the patient was instructed to refrain from eating and drinking for 90 minutes to avoid any salivary stimulation . later , the patient was asked to drool the saliva in a vial at every one minute for five minutes . for stimulated method , 2% citric acid was placed on the tongue at every 30 seconds for five minutes and the patient asked to drool the saliva in a vial . salivary flow rate of unstimulated and stimulated saliva was 0.3ml / min and 1ml / min respectively suggesting normal salivary flow rate . sialography was performed with 2ml of sodium diatrizoate contrast media which was slowly injected into the gland until some resistance was felt , and the patient reported slight pain in the gland area . digital opg showed uniform normal course and caliber of stensen 's duct measuring about 23 mm in diameter from opening till the periphery of the gland . terminal ductules showed areas of blobs and dots of contrast media indicating sialectasis ( figure 3 ) . fifty percent excretion of the dye was observed in digital opg after one minute ( figure 4 ) , and complete excretion of dye was observed in five minutes suggesting normal functioning of the gland . the patient was instructed to use secretogogues ( lime juice ) for three days to clear the debris and to stimulate the salivation . sialograph shows the duct which is normal in course and caliber with dots and blobs appearance at the terminal ductules approximately 50% excretion of contrast medium after 1 diagnosis and treatment : based on patient history , clinical finding , investigation and sialographic appearance a final diagnosis of chronic recurrent non - specific parotitis was made as we were not able to find out any specific etiologic factor . sialography was performed not only for the diagnostic purpose but also for gland lavage which helped in clearing the mucus plug or cellular debris . the patient was advised to continue antibiotics and analgesic for seven days and was kept under regular follow - up once in six months for a two years ' duration . the treatment seemed to be effective as there was no recurrence during the two years ' follow - up . crp patients suffer from recurrent swelling and tenderness of the involved gland which gradually leads to the destruction of the gland . reducing the frequency of recurrence and improving the quality of life are the objective of treatment . key to the successful treatment of crp is the complete removal of cellular debris and precipitated serum proteins from the ductal lumen . this can be skillful achieved with sialography , ductal dilation with lacrimal probe and gland lavage ( 9 ) . elevated parotid papilla , reduced salivary flow and secretion are viscous and milky in appearance with clumps of material interspersed ( 10 ) . the etiology of the disease is multifactorial .there are various theories to explain the pathogenesis , one theory postulates that reduced salivary flow results in decreased mechanical cleansing , allowing bacteria to colonize and invade the duct . whereas the other proposes that repeated episodes of acute infection may lead to mucus metaplasia of ductal epithelium resulting in increased mucus content of secretions , stasis and further episodes of inflammation . secretory disorders like difference in the secretion and excretion of fluid are also considered as having an important role in the pathogenesis(10 ) . studies have reported that the ultrasonagraphy and sialography appearance for recurrent parotitis is characterized by sialectasis with strictures and dilatation of the major duct ( 9 ) . sailoendoscopy revealed white wall and lack of vascularity in the ductal layer in 75% of crp cases and multiple fibrinous debris and mucous plug in 45% of juvenile recurrent parotitis ( 11 ) . in our case although sialography is primarily used for diagnostic purpose , it can also be used as treatment for recurrent parotitis and obstructive disorders ( 12 ) . sialography improves patency of duct during cannulation by flushing action of irrigant which helps in removing any epithelial debris and mucous plug . the iodine content of the contrast medium acts as an antiseptic agent , thus reducing symptoms and preventing recurrence . this treatment should be repeated once in every two days along with sialogouges until the swelling is subsided and saliva is clear . in our case , sialography was done only once and the patient showed no recurrence during the two years ' follow - up , similar with many other reported cases ( 5,7,8,13 ) . other intracanal medicaments have been tried by many authors - bowling etal reported intraductal tetracycline instillation causing acinar atrophy in rats ( 6 ) . mandel and kaynar ( 1995 ) stated that although steroid reduces swelling and inflammation , it is not effective in preventing recurrence ( 5).nahileli et al . ( 2004 ) stated that use of sailoendoscopy facilitates direct visualization of the intraglandular structures and combination of steroid lavage with ductal dilatation will help in reducing the symptoms as well as recurrence(14 ) . however , the success of the treatment depends on intraductal lavage of the affected gland rather than the type of intraductal medicament used as various studies showed no difference in the frequency of recurrence rate . watkin and hobsely found that 56% of adult and 64% of children showed good response to conservative treatment in a five years ' follow - up study ( 15 ) . bilateral sailoendoscopy and lavage with intraductal hydrocortisone resulted in 92% recurrence free rate upto 36 months in juvenile recurrent parotitis cases ( 16 ) . few case reports showed sialography as alternative treatment for this condition as it is minimally invasive procedure with favorable outcome in juvenile recurrent parotitis ( 58 ) . however , if the symptom persists or worsens , then an aggressive treatment should be opted such as duct ligation , parotidectomy and tympanic neurectomy . in conclusion , as the cause for crp is multifactorial , patients should be educated to take higher liquid content in the diet , to do self - massaging of the gland and to maintain oral hygiene so as to avoid retrograde infection . in spite of various advanced imaging techniques , there is no established algorithm as to which imaging modality should be done in a given clinical situation . in our case we preferred sialography as it is simple to perform and cost - effective . it also has added therapeutic effect , especially in conditions where it can prevent recurrence and provide maximum benefit to the patient .

backgroundchronic recurrent non - specific parotitis is characterized by recurrent episodes of swelling and pain of unknown etiology in the parotid gland . sialography is a hallmark in the diagnosis of salivary gland disorders ; newer imaging modalities like ct - sialography , sialoendoscopy and mri can be used . various treatment modalities have been tried , from conservative approach to surgical excision depending on the recurrence rate and severity of the condition . although symptomatic treatment with antibiotics and analgesic , injection of intraductal medicament , aggressive treatment like duct ligation or excision of gland are some of the treatment modalities , there is no established algorithm as to which treatment method should be opted in such clinical situation.case detaila 20 years old male patient reported with pain and salty taste in the mouth that had began before a week . examination revealed an elevated right parotid papilla ; ropy , cloudy appearing saliva was oozing out on milking the gland . unstimulated and stimulated whole salivary flow rate was assessed using drooling method . sialography was used as a diagnostic and a therapeutic aid . in our case , sialography as a treatment showed a good response with no recurrence after two years of follow - up . we highlighted the role of sialography as a therapeutic aid.conclusionrecurrent attacks significantly affect the quality of life and also lead to progressive gland destruction . preventing or reducing the frequency of recurrence remains the goal of therapeutic procedure . hence , conventional sialography is useful in the diagnosis and also effective as a therapeutic aid in recurrent parotitis .

the primary function of the immune system is to protect the host from infectious microbes in its environment . this system has evolved over millions of years , in response of coexistence with microorganisms . basically , the system can be divided in two components , the innate and adaptive immunities . the innate also called natural immunity refers to a nonspecific response that involves the recruitment of diverse components of the immune system such as macrophages , neutrophils , natural killer cells ( nk cells ) , cytokines , several cellular receptors , complement components , cytokines , toll - like receptors ( tlrs ) , and antimicrobial peptides ( amps ) . this response is phylogenetically older in comparison to the adaptive immunity , which involves recognition of specific antigen , conferring both specificity and a memory effect . t cells recognize antigen in the form of peptide bound to major histocompatibility complex ( mhc ) molecules . b cells have immunoglobulin receptors that recognize the antigenic portions of determined molecules . in organ transplantation , the adaptive immunity is considered the main response exerted to the transplanted tissue , since the principal target of the immune response is the mhc molecules expressed on the surface of donor cells . however , we should not forget that the innate and adaptive immunities are divided only by educational purposes , since both are codependent . for example , t - cell activation leads to the production of cytokines and chemokines which in turn may recruit components of the innate immunity like nk cells or macrophages . furthermore , local tissue production of complement components seems to be essential for full t - cell activation , and some amps like defensins and cathelicidin have chemoattractant properties on t lymphocytes . because the immune system uses many different effector mechanisms to destroy the broad range of microbial cells and particles that it encounters , it is critical for the immune response to avoid unleashing these destructive mechanisms against its own tissues . this avoidance of destruction of self - tissues is referred to as self - tolerance . mechanisms to avoid reaction against self - antigens are expressed in many parts of both the innate and the adaptive immune responses . unfortunately , transplanted tissues from individuals of the same species ( allogenic ) or different species ( xenogeneic ) are recognized as nonself , causing graft rejection . the process by which the immune system recognizes pathogens , tumors , and transplantation antigens involves the same antigen recognition molecules . the rejection response to grafted tissue is caused by cell surface molecules that induce an antigenic stimulus . a wide variety of transplantation antigens have been described , including the mhc molecules , minor histocompatibility antigens , abo blood group antigens , and monocytes / endothelial cell antigens . the minor histocompatibility antigens are processed peptides derived from cellular antigens that are presented by mhc molecules but are not derived from the mhc . however , abo incompatibility can result in hyperacute rejection of primarily vascularized grafts , such as kidney and heart . as we mentioned before , the principal target of the transplantation immune response is the mhc molecules expressed on the surface of donor cells . according to their relative potencies in eliciting rejection , the major antigens in mammalian species are encoded by a closely linked series of genes called mhc . in humans , these genes reside in the short arm of chromosome 6 ( figure 1(a ) ) . organs transplanted between mhc identical individuals are readily accepted , whereas organs transplanted between mhc antigen - mismatched individuals are rejected in the absence of immunosuppressive therapy [ 8 , 9 ] . since the mhc was first defined in mice by gorer and snell [ 10 , 11 ] , the world health organization nomenclature committee has named hla ( human leukocyte antigen ) to the human mhc . the hla complex genes and their protein products have been divided into three classes ( i , ii , and iii ) on the basis of their tissue distribution , structure , and function [ 13 , 14 ] . mhc class i and ii genes encode codominantly expressed hla cell surface antigens , and class iii genes encode several components of the complement system ; all share important roles in immune function . class i mhc antigens are present on all nucleated cells and are composed of a 45-kd transmembrane heavy chain encoded by genes of the hla - a , hla - b , or hla - c loci on chromosome 6 ; the heavy chains are associated noncovalently with a 12-kd protein , 2-microglobulin , encoded by a gene on chromosome 15 ( figure 1(c ) ) . additional ( nonclassical ) class i molecules , like those encoded by the hla - e , -f , -g , -h loci , have been described and show limited variability and tissue distribution . the precise functions of these molecules are not yet clear , although they have been implied in presenting carbohydrate and peptide fragments to t cells and mother 's immunological tolerance of the fetus [ 1417 ] . mhc class ii antigens are expressed only on b lymphocytes , activated t lymphocytes , monocytes , macrophages , langerhans cells , dendritic cells , endothelium , and epithelial cells . class ii molecules are heterodimers composed of noncovalently associated and polypeptide chains chains encoded by genes of the hla - d region ( figure 1(b ) ) . there are 3 major class ii proteins designated , hla - dp , hla - dq , and hla - dr . class iii genes are located between the hla - b and hla - d loci and determine the structure of three components of the complement system : c2 , c4 , and factor b [ 13 , 19 ] . class i mhc molecules present cytoplasm - derived peptides , or intracellular parasites , principally viruses ; whereas mhc class ii molecules bind peptides derived from extracellular proteins . hla class i and ii molecules are recognized by cd8 and cd4 positive t cells , respectively [ 2022 ] . also , nk cells may recognize hla classical and nonclassical type i molecules [ 2325 ] . hla genes are almost always inherited together , thus the antigens of the entire hla region inherited from one parent collectively are called haplotype . because chromosome 6 is an autosome ( a chromosome with two pairs ) , all individuals have two hla haplotypes ( one for each chromosome ) . according to this , any sibling pair has a 25% chance of inheriting the same two parental haplotypes , a 50% chance of sharing one haplotype , and a 25% chance of having two completely different haplotypes . since the biologic function of the hla molecules is presenting endogenous and exogenous antigens , they manifest high structural polymorphism . until 2010 , mutations in microbial antigens might permit the microbe to avoid binding ( and , consequently , recognition ) by a few hla alleles , but no mutations will permit the microbe to avoid recognition broadly throughout the population ; assuring then , the continuity of species in the presence of pandemic infection . in transplantation immunology , the major impact in graft loss comes from the effects of hla - b and -dr antigens . hla - dr mismatch effect is the most important in the first 6 months after transplantation , the hla - b effect emerges in the first 2 years , and hla - a mismatches have a deleterious effect on long - term graft survival [ 2832 ] . the phenomenon by which the recipient immune system reacts with donor antigens that are considered to be non - self is named allorecognition . the main and strongest responses to alloantigens are mediated by host t cells , which recognize peptide antigens presented in the context of mhc , by antigen - presenting cells ( apcs ) . however , evidence that the innate alloimmunity has an important role in graft rejection has recently been proposed by land and coworkers [ 33 , 34 ] . they state in their injury hypothesis that initial allograft injury reflected by reactive oxygen species ( ros ) during reperfusion is associated with generation of damps ( meaning damage - associated molecular patterns ) such as heat shock proteins ( hsp ) and hyaluronan fragments ( fha ) among others , all of which are recognized by tlr4 and/or tlr2 . subsequent tlr4- and tlr2-triggered signaling pathways utilize adaptor proteins including myd88 ( myeloid differentiation marker 88 ) , which in turn initiate downstream signaling pathways that lead to activating the 3 master transcription factors nf-b ( nuclear factor - kappa b ) , ap-1 ( activator protein-1 ) , and irf-3 ( interferon regulatory factor 3 ) . nf-b seems mainly to be responsible for maturation of donor - derived and recipient - derived dendritic cells , which represents the bridge to development of an adaptive alloimmune response that results in rejection . certainly , further studies are needed to determine the extension and importance of this branch of the immune system in transplant rejection and/or tolerance . in adaptive allogenic immune response , the foreign or donor antigen presentation to t cells may occur by three ways ( figure 2 ) : ( 1 ) indirect recognition : donor 's hla molecules can be processed by apc ( antigen presenting cells ) from a receptor , then they are fractionated into peptides as well as other bacterial antigens and are presented according to the same route as the hla in the receptor . this type of mechanism has a dominant role in chronic rejection [ 3741 ] ; ( 2 ) direct recognition : the donor 's hla molecules can be recognized directly on the donor - presenting cells , without requiring antigen processing by receptor . in these circumstances , it could be said that the receptor identifies the foreign hla molecule as an own molecule with a foreign peptide . this mechanism determines a strong immune response in the acute rejection [ 37 , 38 , 4250 ] ; ( 3 ) a third mechanism could be mediated by immunoglobulin - like receptors of natural killer ( nk ) cells . in this mechanism , the activation of nk receptors promotes the inactivation of nk cells and cytotoxic t lymphocytes as well . these receptors recognize polymorphic sequences of hla - c , -b , or -a in the target cells . the absence of these sequences in the cell would make them sensitive to cytolysis and therefore the loss of tolerance [ 5156 ] . recently , it was shown that both nave and memory cd4 and cd8 t cells are frequently cross - reactive against allogeneic hla molecules and that this allorecognition exhibits exquisite peptide and hla specificity . such advances in the understanding of the immunogenetics of allorecognition have led some researches to suggest a new model for allorecognition whereby the majority of t cell alloresponses may occur via direct recognition ( cross - reactivity ) by thymically educated nave and memory t cells against allogeneic hla molecules presenting self - peptides . according to this model , thymically educated t cells are commonly and specifically allo - hla reactive and are activated by viral infection or vaccination to become alloreactive memory t cells which are a major barrier to successful tolerance . to support the transplant programs , several clinical laboratories perform various hla tests , including hla typing of the recipient and the donor , screening of hla antibodies in the recipient , and detection of antibodies in the recipient that are reactive with lymphocytes of a prospective donor ( cross - matching ) . historically , hla typing was conducted by serologic testing by using antiserum in complement - dependent cytotoxic assays . recently , more precise dna - based hla typing methods using molecular techniques , such as sequence - specific oligonucleotide probe hybridization , sequence - specific primer amplification , sequencing - based typing , and reference strand - based conformation analysis , have been developed and are frequently used . there is a clear relationship between the degree of hla matching and kidney graft survival in transplants from living - related donors . simultaneous analysis of 5,262 one haplotype - matched living - related allografts , and 973 hla identical allografts showed 10-year projected survival rates of 52% and 73% and graft half - lives of 11.9 and 23.6 years , respectively . conversely , the influence of hla matching on the survival of liver and thoracic organs is yet uncertain . to avoid hyperacute rejection , it is very important to identify recipient anti - hla antibodies to antigens expressed on donor with blood cells . the pioneer method to detect such antibodies , the complement - dependent cytotoxicity ( cdc ) , has been gradually replaced by more - sensitive solid - phase assays , such as the enzyme - linked immunosorbent assay and the bead - based technology ( i.e. , flow cytometry : flowpra and flow analyzer : luminex ) . however , the new techniques have been associated with decreased specificity , and some non - hla antigens with no clinical relevance have been able to give a positive crossmatch . these false - positive antibody results have as a consequence a decreased chance of the patient to receive an organ by way of exchange organizations , thus decreasing chances for the patient . thus , the experts recommend that the information these tests provide should complement that of the direct cdc assay . development of the field of organ and tissue transplantation has accelerated remarkably since the human major histocompatibility complex ( mhc ) was discovered in 1967 . however , has been elusive avoid the graft rejection . this is due to that the transplantation immunobiology is very complex , because of the involvement of several components such as antibodies , antigen presenting cells , helper and cytotoxic t cell subsets , immune cell , surface molecules , signaling mechanisms , and cytokines , which play a role in innate and adaptive immunities .

the transplant of organs is one of the greatest therapeutic achievements of the twentieth century . in organ transplantation , the adaptive immunity is considered the main response exerted to the transplanted tissue , since the principal target of the immune response is the mhc ( major histocompatibility complex ) molecules expressed on the surface of donor cells . however , we should not forget that the innate and adaptive immunities are closely interrelated and should be viewed as complementary and cooperating . when a human transplant is performed , hla ( human leukocyte antigens ) molecules from a donor are recognized by the recipient 's immune system triggering an alloimmune response matching of donor and recipient for mhc antigens has been shown to have a significant positive effect on graft acceptance . this paper will present mhc , the innate and adaptive immunities , and clinical hla testing .

radicular back pain is an important public health issue that can result in long term disability and poor quality of life . conservative therapy is the initial treatment of choice , but fails to provide relief in a substantial number of patients . central and foraminal stenosis with entrapment of descending and/or exiting nerve roots is a common cause of radicular pain , with an estimated incidence of 8 to 11% 1 2 3 . spinal stenosis of the thoracic vertebrae is less common than that of the cervical and lumbar regions . in our experience , patients tend to be older and are more commonly male . due to the close proximity to thoracic and abdominal organs , open surgical operations can be difficult and carry a greater risk of complications due to the requirement of a transthoracic approach . the most efficacious intervention for thoracic stenosis refractory to conservative management is uncertain at this time . here we report on our experience with 12 patients diagnosed with thoracic radiculopathy due to central or foraminal stenosis treated with endoscopic laminoforaminoplasty via a small incision , of less than one inch . twelve patients were treated with endoscopic laminoforaminoplasty ( elfp ) of the thoracic spine for radicular pain . all patients were diagnosed with radicular pain involving the lower thoracic levels ( at or below t6 ) . prior to surgery , all patients were treated with conservative therapy , including physical therapy and epidural steroid injections , which failed to provide adequate relief . intravenous ( iv ) antibiotics were administered perioperatively ; cefazolin was used unless there was an allergy , in which case ciprofloxacin was substituted . remifentanil and midazolam were the most commonly used sedating agents . utilizing fluoroscopy , the entry site was then determined and a 3/4-inch incision was made at a 30-degree angle to the vertebrae . through this incision , a guide wire was inserted down to the lamina of the stenotic vertebra . over this guide wire a bullet system was inserted to dilate the tissues to a final diameter of 14.5 mm . a 5 mm laparoscopy scope , with 3.2x magnification , was used to visualize the procedure . pituitaries and kerrisons were then used to remove bulk tissues and bone to open up the spinal canal . a standard burr with a 6 mm bit was used to remove bone and smooth the bony edges of the opening . a holmium outcome measures were percent change from baseline in oswestry disability index ( oswestry ) and visual analog scale ( vas ) pain scores . the author acknowledges that there are no conflicts of interest or financial benefits with the results of the study . all twelve patients ( 10 males , 2 females ) completed the surgery without complication . average age was 60.2 years ( range : 49 - 73 ) . at baseline , most patients reported moderate to disabling pain , with average scores of 6.7 and 24.75 on the vas and oswestry , respectively and the individual patient data is presented in table 1 . utilizing the student 's t - test , the data was separated into pre and post surgical scores . even though the sample size is small , the improvement is significant with a p value of 0.005 . with all patients , average follow - up scores were 2.9 and 12.08 on the vas and oswestry , respectively . one patient with moderate symptoms , two with severe symptoms , and two with crippling symptoms did not report significant improvement on vas or oswestry . of the twelve patients , 8 had foraminal stenosis and 4 had central issues per both mri and surgical report . thoracic radiculopathy is rare , as evidenced by the paucity of literature regarding the appropriate management of these patients . in our experience , patients with thoracic central and foraminal stenosis are more likely to be male , and tend to be of older age than patients with cervical or lumbar disease . also , the stenosis tends to be foraminal and not central since 66% of patients had foraminal stenosis . the correct surgical management of these patients is based largely on data regarding lumbar and cervical radiculopathy . however , in the thoracic vertebrae proximity to both thoracic and abdominal internal organs as well as prominent vascular and neural structures increases the risk of adverse events with invasive approaches . open surgical correction is the current standard of care for foraminal stenosis of cervical and lumbar vertebrae . open surgery requires a longer operative time , hospital stay , and postoperative recovery period and carries significant risks . the anterior approach requires a transthoracic approach with close proximity to the major abdominal and thoracic organs and neurovasculature 4 , and posterior approaches require subperiosteal of the paraspinal muscles , which can result in increased pain and spasms 5 . as with any deeply invasive procedure , blood loss , infection , prolonged hospital stay , and postoperative pain are potential complications . in contrast , interventions that are less invasive , such as endoscopic laminoforaminoplasty , should decrease the risk of major adverse events , allow for same day hospital discharge , and decrease the need for postoperative analgesia and immobility 5 6 . in the current study , at the same time , reports in the literature suggest similar patient outcomes to conventional open approaches 7 4 8 9 . in this study , 7 of 12 patients ( 58.3% ) experienced noticeable improvement as evidence by decreased vas and oswestry scores at postoperative follow - up , results consistent with published data . patients additionally benefit from a decrease risk of complications , short hospital stay , and faster recovery . this approach should be considered in patients with simple thoracic radiculopathy due to central or foraminal stenosis who fail to benefit from conservative management . finally , we do recommend that a larger study would be beneficial in confirming our data due to our small study group .

background : spinal stenosis of the thoracic spine is less common than that of the cervical and lumbar regions . due to the close proximity to thoracic and abdominal organs , surgical operations can be difficult and carry a greater risk of complications . the most efficacious intervention for thoracic stenosis , whether central or foraminal , refractory to conservative management is uncertain . we aimed to evaluate the efficacy of endoscopic laminoforaminoplasty ( elfp ) in the treatment of thoracic radiculopathy.methods : twelve patients with radicular pain involving the lower thoracic levels ( at or below t6 ) were treated with elfp.results : seven of twelve patients showed marked improvement in pain scores . average follow - up scores were 2.9 and 12.08 on the visual analog scale ( vas ) and oswestry disability index , respectively . the significance was 0.005 between the pre and post surgical data . one patient with moderate symptoms , two with severe symptoms , and two with crippling symptoms did not report significant improvement on vas or oswestry . no complications were encountered.conclusions : endoscopic laminoforaminoplasty offers an alternative to fusion or conventional laminotomy with similar success rates . patients additionally benefit from a decrease risk of complications , short hospital stay , and faster recovery .

error ! hyperlink reference not valid.forty-one clinical c. sakazakii strains were included in the study . the strains included those of recent ( 13,1012 ) and those of more historic interest ( > 25 years 1315 ; ) . strains used in this study , along with patient details and clinical signs , are shown in table 1 . details of clinical signs were collated from information in the associated publication or supplied by the strain provider ( centers for disease control and prevention , atlanta , ga , usa ) . primers and conditions for amplification and sequencing of the 7 mlst genes atpd ( 390 bp ) , fusa ( 438 bp ) , glns ( 363 bp ) , gltb ( 507 bp ) , gyrb ( 402 bp ) , infb ( 441 bp ) and ppsa ( 495 bp ) were as described ( 9 ) . * ega , estimated gestational age ; st , sequence type ; unk , unknown ; nec , necrotizing enterocolitis ; csf , cerebrospinal fluid ; icu , intensive care unit ; czech rep , czech republic ; cdc , centers for disease control and prevention . comparative analysis with the online cronobacter mlst database ( covering isolates from all sources ) showed that the clinical isolates were in 10 of 30 sts defined for c. sakazakii spp . . of particular interest was that half ( 20/41 ) of the strains were st4 ( table 2 ) . the remaining strains were st8 ( 7 ) , st1 ( 4 ) , st12 ( 3 ) , st3 ( 2 ) , st13 , st15 , st18 , st31 , and st41 ( 1 each ) . of the 20 st4 strains , 10 were from neonates , 7 from infants , and 1 from a child ; 2 had no patient details . similarly , most ( 9/12 ) isolates from meningitis cases were st4 strains ; 7 were isolated from cerebrospinal fluid and the others from blood and the trachea . the remaining st4 strains were from bacteremia cases ( 1 ) , nec ( 2 ) , and undefined infection ( 1 ) , with 6 from unknown sources . st4 was the main st associated with neonates ( 10/18 ) ; this st has been reported by baldwin et al . age < 28 d. age 28364 d. the st4 clinical strains were from 6 countries ( the netherlands , france , united states , new zealand , czech republic , and canada ) and had been isolated during 19772008 ( table 1 ) . of the 30 strains with known patient details , only 1 isolate ( st1 ) was from an adult patient . to date , all other isolates from adults have been identified as c. malonaticus ( s. joseph , unpub . data ) . the 7 housekeeping genes for mlst analysis are not virulence related , but a large proportion of severe neonatal infections were caused by a single sequence type . whether this is caused by survival characteristics increasing persistence under desiccated conditions , and hence neonatal exposure or particular virulence capabilities , is uncertain . it is plausible that different age groups are exposed to different genotypes of c. sakazakii according to their diet and lifestyle . c. sakazakii st4 appears to be a stable clone because strains have been isolated from 7 countries for > 50 years . the earliest ( 1951 ) nonclinical isolate was from a can of dried milk ( 13 ) .

a 7-loci ( 3,036 nt ) multilocus sequence typing scheme was applied to 41 clinical isolates of cronobacter sakazakii . half ( 20/41 ) of the c. sakazakii strains were sequence type ( st ) 4 , and 9/12 meningitis isolates were st4 . c. sakazakii st4 appears to be a highly stable clone with a high propensity for neonatal meningitis .

we present here a case of a 54-year - old male who had presented to the psychiatry o.p.d . of s.c.b . medical college , cuttack with dementia like features . he had presented with complaints of forgetfulness , irritability , crying spells , fearfulness , and urinary and fecal incontinence . he was unable to take care of himself and was unable to go to work . his symptoms had started with features of withdrawn behavior which the family members considered to be due to work - related stress . he used to keep to himself and would not share his concerns or day to day happenings . he would often get up early in the morning and would rush for doing his daily activities . he was taken to a psychiatrist who diagnosed him to be having bipolar affective disorder with the current episode manic . he had started remaining fearful and would prefer to stay indoors and keep the doors and windows of the house closed . he would soil his trousers with urine or stool . in spite of taking the treatment , he gave a history of suffering from a penile ulcer 15 years back which was treated . he denied having contact with any commercial sex worker or extramarital affair and had no history of substance use . he took the chair when offered by the examiner but did not greet the examiner in spite of the examiner 's greeting . his attention span was decreased , immediate , and recent memories were impaired but remote memory was intact . a provisional diagnosis of dementia was made , he was hospitalized , and neuropsychological evaluation and appropriate investigations were planned . neuropsychological tests included pgi - bbd which gave a score of 32 suggesting significant cognitive dysfunction indicating organic brain pathology . both igm and igg , florescent treponemal antibody absorption test ( fta - abs ) was positive . csf protein was 50 mg / dl , sugar 52 mg / dl ( raised ) , leucocyte count was 20/cu.mm/ ( raised ) . he was started on 24 million units of aqueous penicillin g i / v qid and donepezil 5 mg . he was discharged after 20 days with minimal improvement in mmse scores and was advised to report after 1 month . this case had classical presentation of general paresis of insane as it typically started with affective symptoms which gradually progressed to cognitive decline leading to frank dementia . general paresis of insane is a parenchymal brain disease where antibiotics can only stop progression of the disease but can not bring complete cure . a high index of suspicion as needed to diagnose the cases of neurosyphilis which generally lack the typical neurological and ophthalmological findings . this case underlines the need to consider the diagnosis of neurosyphilis when investigating for the cause of dementia in middle age populations . in addition to appropriate medical management , prompt diagnosis would also help in arresting the transmission of the disease in the community .

there is a widely held clinical opinion that syphilis has disappeared . contrary to this , there are sporadic cases being reported across the country . the classical cases of neurosyphilis have given way to the milder asymptomatic forms , making them even more difficult to be diagnosed . conventional presentation of neurosyphilis such as tabes dorsalis and general paresis of insane are read in textbooks only and rarely encountered in clinical practice in the 21st century .

cutaneous squamous cell carcinoma ( scc ) is the second most common type of non - melanoma skin cancer . in general , the management of cutaneous scc depends on its tumor stage . however , concerning high - risk patients or tumors on the cosmetic areas , the management of cutaneous scc differs in each case [ 1 , 2 ] . though no standard treatment for cutaneous scc has been formulated , the therapeutic effects of several anti - cancer drugs , including bleomycin , have been reported [ 3 , 4 , 5 ] . in this report , we describe two cases of scc developing on the ear , for which complete remission was achieved with intra - arterial administration of peplomycin , a bleomycin derivative antibiotic , through a superficial temporal artery using an intravascular indwelling catheter . an 86-year - old japanese man visited our outpatient clinic with a 4-month history of a red nodule on his ear . on his initial visit , physical examination revealed a red , dome - shaped , easy - to - bleed nodule with necrotic tissue on his right ear ( fig . a biopsy specimen revealed dermal infiltration of the tumor , which was composed of atypical keratinocytes with dyskeratotic cytoplasm ( fig . we screened for a possible internal malignancy with a ct scan but found none , except for slight swelling of a cervical lymph node . from the above findings , we diagnosed this patient as poorly differentiated scc , and for functional and cosmetic reasons , we selected intra - arterial administration of peplomycin through a superficial temporal artery using an intravascular indwelling catheter . we indwelled the point of the catheter at the feeding artery of the tumor by using indigo carmine ( fig . 1b ) , and continuously administered 5 mg of peplomycin per day intra - arterially for 12 days . four weeks after we finished the administration of peplomycin , the tumor mass had rapidly regressed , leaving a scar ( fig . a biopsy specimen revealed that no tumor cells remained at this time point ( fig . 2c , we added oral administration of 100 mg tegafur for 8 weeks , and there has been no sign of local recurrence or systemic lesions for 18 months . a 70-year - old japanese man visited our outpatient clinic with a 1-month history of a red nodule on his ear . on his initial visit , physical examination revealed a red , dome - shaped nodule with crust on his left ear ( fig . a biopsy specimen revealed dermal infiltration of the tumor , which was composed of atypical keratinocytes with dyskeratotic cytoplasm ( fig . we screened for possible internal malignancy with a ct scan but found none . from the above findings , we diagnosed this patient as well - differentiated scc , and for functional and cosmetic reasons , we selected intra - arterial administration of peplomycin through a superficial temporal artery using an intravascular indwelling catheter . three weeks after we finished the administration of peplomycin , the tumor mass had rapidly regressed , leaving a scar ( fig . 3b ) . a biopsy specimen revealed that no tumor cells remained at this time point ( fig . we added oral administration of 100 mg tegafur for 2 months , and there has been no sign of local recurrence or systemic lesions for 12 months . an 86-year - old japanese man visited our outpatient clinic with a 4-month history of a red nodule on his ear . on his initial visit , physical examination revealed a red , dome - shaped , easy - to - bleed nodule with necrotic tissue on his right ear ( fig . a biopsy specimen revealed dermal infiltration of the tumor , which was composed of atypical keratinocytes with dyskeratotic cytoplasm ( fig . we screened for a possible internal malignancy with a ct scan but found none , except for slight swelling of a cervical lymph node . from the above findings , we diagnosed this patient as poorly differentiated scc , and for functional and cosmetic reasons , we selected intra - arterial administration of peplomycin through a superficial temporal artery using an intravascular indwelling catheter . we indwelled the point of the catheter at the feeding artery of the tumor by using indigo carmine ( fig . 1b ) , and continuously administered 5 mg of peplomycin per day intra - arterially for 12 days . four weeks after we finished the administration of peplomycin , the tumor mass had rapidly regressed , leaving a scar ( fig . a biopsy specimen revealed that no tumor cells remained at this time point ( fig . 2c , we added oral administration of 100 mg tegafur for 8 weeks , and there has been no sign of local recurrence or systemic lesions for 18 months . a 70-year - old japanese man visited our outpatient clinic with a 1-month history of a red nodule on his ear . on his initial visit , physical examination revealed a red , dome - shaped nodule with crust on his left ear ( fig . a biopsy specimen revealed dermal infiltration of the tumor , which was composed of atypical keratinocytes with dyskeratotic cytoplasm ( fig . we screened for possible internal malignancy with a ct scan but found none . from the above findings , we diagnosed this patient as well - differentiated scc , and for functional and cosmetic reasons , we selected intra - arterial administration of peplomycin through a superficial temporal artery using an intravascular indwelling catheter . three weeks after we finished the administration of peplomycin , the tumor mass had rapidly regressed , leaving a scar ( fig . 3b ) . a biopsy specimen revealed that no tumor cells remained at this time point ( fig . we added oral administration of 100 mg tegafur for 2 months , and there has been no sign of local recurrence or systemic lesions for 12 months . in this report , we describe two cases of scc on the ear successfully treated with intra - arterial administration of peplomycin through a superficial temporal artery . in addition to this selective chemotherapy , we administered oral tegafur , which achieved complete remission of the tumor . these findings suggest that the effect of intra - arterial administration of peplomycin with oral tegafur is one of the optimal therapies for the treatment of scc developing on the ear . recently , chitwood et al . reviewed the efficacy of topical or intralesional treatment of non - melanoma skin cancer . concerning scc , the cure rate of imiquimod is 76% for scc in situ ( 78/102 ) and 71% for invasive scc ( 5/7 ) . the cure rate of topical 5-fluorouracil is 61% for scc in situ ( 58/95 ) . in contrast to topical administration of drugs , the cure rate of intralesional administration of interferon alpha-2 ( ifn-2 ) for scc is 100% ( 3/3 ) , that of ifn-2b for scc in situ is 89% ( 8/9 ) and that of ifn-2b for invasive scc 89% ( 25/28 ) . these data suggest that the route for drug delivery is correlated with the clinical outcomes for the treatment of non - melanoma skin cancer . peplomycin is a bleomycin derivative antibiotic and its cytotoxicity toward mammalian cells is due to its ability to induce single- and double - strand dna breaks by the induction of g1-phase specific apoptosis [ 7 , 8 ] . for clinical application , peplomycin has recently been used as preoperative chemotherapy for scc in japan [ 3 , 4 , 5 ] . the total dose for conventional ways of peplomycin administration depends on its protocol ( 20110 mg , bolus injection of 510 mg / day ) [ 3 , 4 ] . though this reagent is useful for the treatment of scc , especially in combination with radiation or other cytotoxic drugs , the dose for the administration of this reagent is limited because of its dose - dependent fatal side effects , such as interstitial pneumonia [ 3 , 4 , 5 ] . therefore , an optimal method to keep a high concentration of peplomycin only in the tumor site is necessary . for the above reason , we selected intra - arterial , continuous administration of peplomycin through a superficial temporal artery for the treatment of cutaneous scc on the ear . indeed , in both of our two cases , the tumor mass decreased rapidly within 1 month . moreover , skin biopsy after the administration of peplomycin revealed that no tumor cells remained . in addition , we administered oral tegafur , which is generally used as adjuvant chemotherapy or combination chemoradiotherapy for scc in japan [ 9 , 10 ] . notably , a previous report also suggested that oral intake of tegafur after radical therapy significantly improves survival in cancer patients . therefore , in our present cases , we administered oral tegafur for the purpose of keeping the complete remission . since the additional administration of oral tegafur might have prolonged the tumor - free time in our two cases , our present cases suggest the possibility of continuous intra - arterial administration of peplomycin through a superficial temporal artery using an intravascular indwelling catheter for the treatment of cutaneous scc on the ear .

cutaneous squamous cell carcinoma ( scc ) is the second most common non - melanoma skin cancer and tends to develop in sun - exposed cosmetic areas , including the ear . in this report , we describe two cases of scc on the ear successfully treated with intra - arterial administration of peplomycin through a superficial temporal artery . in addition to this selective chemotherapy , we administered oral tegafur , which achieved complete remission of the tumor . these findings suggest that intra - arterial administration of peplomycin with tegafur is one of the optimal therapies for the treatment of scc developing on the ear .

the supratentorial region is the most frequent site for meningiomas ; however , they are sometimes observed in other locations , such as the spine12 ) . however , a few of these tumors are thought to arise from the extradural component12 ) . here , we have reported our experience involving a case of extra - intradural calcified meningioma . a 49-year - old woman presented with low back and left leg pain of 5 years duration and a history of medication use for treatment of hypertension and diabetes mellitus for over 20 years . neurological examination revealed hypesthesia of the left leg and no motor deficit , with normal deep tendon reflexes . magnetic resonance imaging ( mri ) showed an extradural mass , 1.8 cm in size , with rim enhancement in the spinal canal at the t12 level ( fig . the mass extended to the midline and the left t12-l1 foramen . computed tomography ( ct ) revealed dense calcification within the mass ( fig . a linear durotomy was performed at the midline , and the intradural portion was removed using an ultrasonic surgical aspirator and a kerrison punch ( fig . the adjacent dura was severely ossified , and the left t12 nerve root sleeve was thickened . the extradural portion was not separable from the adjacent dura and the left t12 root , and it was removed by dural excision using a # 15 blade and edson forceps ( fig . the dural margin was coagulated using a bipolar coagulator , and the dural defect was repaired with artificial dura ( fig . spinal meningiomas account for 25 - 45% of all spinal tumors4 ) and 1.2 - 12.5% of all meningiomas10,12 ) . most spinal meningiomas are intradural , with only 3.3 - 21.4% of them being extradural12 ) . a previous study reported that 85% of spinal meningiomas are intradural , 7% have an extradural extension , and 8% are entirely extradural10,11 ) . spinal meningiomas generally arise from arachnoid cap cells or dural fibroblasts , and from the arachnoid in the case of cranial nerves and the choroid plexus1 ) . some investigators have suggested the possibility of islands of arachnoid tissue migrating into the extradural spaces or aberrant arachnoid islets in the extradural spaces , as seen with other extracranial meningiomas such as those of the nose or skin3,9 ) . the differential diagnosis of meningioma includes schwannoma , metastatic tumors , lymphoma , and tuberculoma2 ) . misdiagnosis can lead to an incorrect operative plan . in our patient , the mass was more likely to be a schwannoma at the point of passing the path of the left t12 nerve , but the ct finding of ossification supported the diagnosis of meningioma . intraoperative histologic examination is crucial for an optimal surgical plan and so are the preoperative imaging studies in tumors mimicking other pathology5 ) . the four common microscopic patterns of meningiomas are psammomatous , syncytial , transitional , and fibrous12 ) . of these , the most common type is the psammomatous meningioma in which calcification is comparatively more likely to be present12 ) . in our patient , the long term prognosis of extradural spinal meningiomas is not clear , but recurrence rates might depend on whether total tumor excision was performed1 ) . if a tumor is excised totally , recurrence - free survival rates are 93% , 80% , and 68% at 5 , 10 , and 15 years , respectively11,12 ) . in cases of subtotal resection , recurrence - free - survival rates are 63% , 45% , and 9% at 5 , 10 , and 15 years , respectively1 ) . other factors associated with poor outcomes are the presence of an extradural component , young age ( < 50 years ) , multiple lesions , calcification , ossification , and anterior location of the lesion2,7,8 ) . the presence of an extradural component , calcification , and ossification make total resection of spinal meningiomas more difficult . in our patient , the adjacent dura was resected , and the left t12 nerve root was sacrificed for gross total resection . although there is no consensus on the degree of total excision , nakamura et al . reported that recurrence rates are significantly different according to the simpson grade8 ) . in our patient , although the left t12 nerve root was sacrificed , the patient experienced improvement in her leg pain . there was no aggravation of pain or development of any other complication observed at the 6-month follow up . when surgical treatment is not feasible in case of recurrent , residual , or multiple lesions , radiosurgery can be considered as an option . reported 11 cases of spinal meningiomas ( who grade i ) treated with cyberknife radiosurgery ( ckrs ) . the median prescription dose was 14gy ( 95% confidence interval 13 - 15gy ) and isodose was 70%6 ) . after a median follow - up of 18 months ( range , 6 - 50 months ) , no local tumor progression was observed . in 1 of the 3 patients with pain before ckrs , the initial symptom was improved . in this report , we have presented our experience with a case of meningioma and a literature review of similar cases . extradural meningiomas are uncommon , and it is important to clearly distinguish them from other types of tumors as misdiagnosis can lead to an incorrect operative plan . the long term prognosis of extradural meningiomas is not clear but total excision is thought to be essential .

extradural spinal meningiomas are uncommon , and their pathophysiology is not entirely understood . here , we present the case of a 49-year - old woman with low back and left leg pain of 5 years duration . magnetic resonance imaging revealed a mass , 1.8-cm in size , with rim enhancement in the spinal canal at the t12 level and extending into the left t12-l1 foramen . in the surgical field , the mass presented with the characteristics of an extra - intradural spinal meningioma . the patient underwent a t12 total laminectomy . a linear durotomy was performed at the midline , and the intradural portion was removed . the extradural portion was not separable from the adjacent dura and the left t12 root , and it was removed by dural excision . pathological examination confirmed the diagnosis of psammomatous meningioma . we also conducted a literature review of similar cases . based on our experience with this case , we believe that it is important to clearly distinguish extradural meningiomas from other types of tumors as misdiagnosis can change the operative plan . the long term prognosis of extradural meningiomas is not clear but total excision is thought to be essential .

during the past year , the health care financing administration ( hcfa ) has conducted a number of meetings to discuss quality of care measurement , data development and release , and research priorities . in june 1987 , hcfa convened a quality of care research symposium for the purpose of detailed discussion of the current status of quality of care research and identification of research needs . eighteen experts in various aspects of quality of care measurement and analysis gave presentations , followed by four smaller work groups in which speakers and attendees contributed to the discussions . the purpose of this article is to provide an overview of some of the issues addressed at the symposium , the general themes of the discussions , and the research priorities identified . since the mid-1970 's there has been a plethora of literature regarding many aspects of quality assurance and utilization review . despite the marked surge in quality assessment literature , the caliber has been varied and the status of the conceptualization and measurement instrumentation of health care quality has not progressed much beyond that of the early 1970 's . through his lectures and his numerous writings over the past 20 years , avedis donabedian has developed an integrating conceptual framework , which has come to be utilized by most researchers in the field . the framework is often verbally reduced to the major components : structure , process , and outcome . donabedian has noted that these are not attributes of quality , but are approaches to the acquisition of information about the presence or absence of the attributes that constitute or define quality . donabedian proposed an integration of the dimensions of quality and their analysis through an emphasis on : the need to adequately conceptualize the components of health ( physical - physiological function , psychological function , and social function ) . the levels of aggregation and organization of the providers of care ( such as individual physician , team , department , hospital , etc . ) . the levels of aggregation of the actual or potential recipients of care ( such as individual or groups of patients and entire populations or subpopulations ) . by emphasizing the various possible levels of aggregation of patients , populations , and providers , donabedian has begun to enumerate the many aspects of medical care quality assessment ( donabedian , 1980 ) . the speakers at the symposium reaffirmed the multifaceted nature of quality and reiterated donabedian 's point that there is no single definition of quality for medical care and , therefore , there is no single measure of it . no one composite index of quality of health care has been , or probably ever can be , developed . the symposium discussions made clear that there is a need for several levels of analysis and monitoring . there was strong support expressed for the use of epidemiologic techniques for monitoring health care at one level of aggregation and diagnosis - specific criteria development for chart review at another level . there was an expressed need for : epidemiologic monitoring of patient outcomes such as mortality , morbidity , and disability . local area analyses to identify problems in both patient outcomes and health care processes . analysis and monitoring of both the outcomes and processes of care at the institution or medical care plan level . although historically there have been heated debates about the relative merits of the use of structural measures , procedural criteria , or patient outcome measures , the speakers at the symposium supported the appropriateness of the use of both process and outcome measures of quality . there was a strong expression of overriding need for determinations of the interrelationships among the structural , the procedural , and the outcome measures of quality of care . during the past 20 years , progress in the assessment of the quality of health care has been impeded by lack of agreement about the appropriate indicators of good health care as well as lack of detailed data bases on the condition of and the care provided to patients . although these necessary data can be made available in clinical trials or other types of special studies , in the day - to - day world of practicing medicine , the detail of available data is often insufficient to analyze and understand complex interrelationships . to date , uniformly collected data have not been sufficiently detailed to permit process studies of health care quality to be conducted . in addition , the data are neither uniform nor easily accessed , and errors in recording and abstraction are other long - recognized problems . in particular , there is need for uniform reporting of patient characteristics , particularly a uniform clinical data base . development in the following area was considered a high priority : a global measure of patient physiologic status and physiologic reserve that can provide a reliable determination of patient prognosis ( likelihood of responding to treatment ) . such a measure does not represent quality , but is important for interpretation of other process and outcome measures . robert brook ( the rand corporation ) opened the symposium with the provocative question : will imperfect information about health care quality lead to better health or will it lead to increased social divisiveness ? as with all research , the readily available health care data do not always adequately measure the desired theoretical concepts . therefore , quality of care analyses often have been limited to those aspects for which data exist or that are relatively inexpensive to obtain . although hospital discharge abstract data bases and administrative data bases such as that of the medicare program have facilitated analyses of patient length of stay and patient - based mortality and readmission , these are admittedly either poor proxies for quality or they are vulnerable to ambiguous interpretation . the symposium participants recognized the concerns of health care providers regarding the use of imperfect measures of quality of care ; however , several speakers urged that research and the dissemination of data and research results should not await the perfect data base . it was pointed out that a number of existing surveys contain data that , if linked with medicare utilization data , could provide a more thorough analysis . it was emphasized that sampling is an appropriate means of estimating phenomena in a population and that surveys can be used to periodically collect specific , necessary data . linkages among extant data bases , such as tumor registries , state - maintained death certificates , national center for health statistics surveys of disease incidence and prevalence , surveys of functional status , etc . , are feasible , particularly the linkage of these clinically oriented data bases with the utilization data from the medicare statistical system . this , however , was not felt to be a thoroughly satisfactory solution to the need for improved and expanded routine data bases for the types of priority data previously described . there was also felt to be a need for information on all sectors of health care , including ambulatory care in physician offices , home health care , and nursing home care , as well as the frequently studied inpatient care . in particular , given the increasing interest in health maintenance organizations and other forms of capitated health care , there is a strong demand for information on both the capitated and fee - for - service sectors . mark blumberg ( kaiser foundation health plan , inc . ) emphasized the need for measures and data collection that permit analysis of comparability across provider types and across larger health care systems . the participants also expressed a need for more analysis of the quality of care provided to specific subpopulations . in particular , concern was raised that cost - saving efforts might motivate providers to discriminate in the types of patients accepted and/or in the types of care provided . although there is need for analysis of the appropriateness of clinical decisionmaking , there is also clearly a role for population - based analyses of health status , mortality , morbidity , disability , and health care utilization that is independent of the adquacy of the medical processes employed by health care practitioners . currently there are no quality of care data bases on regional , state , or federal levels . but as the pressure for comparable information on health care quality measures increases so that consumers may make enlightened decisions regarding selection of individual providers , health care plans , and insurance packages , there will likely be increased pressure for better , comparable data bases . it appears that researchers , practitioners , and purchasers of care are beginning to agree that it is desirable , even imperative , to develop information on attributes felt to reflect aspects of quality in health care . this heightened awareness , verging on impatience , is likely to further the development and refinement of measures , data bases , routine monitoring mechanisms , and the analytic skills of all concerned parties . it is generally believed that improvements in the measurement and monitoring of health care will ultimately improve both the quality of health care and the utilization of resources . in summary , the thoughtful presentations and discussions at the symposium acknowledged that there is reason for concern about the effects of incomplete data on quality of care , but that there is also reason for moving ahead with carefully designed measurement , analysis , and feedback . , codman research group , hanover , new hampshire ; mark blumberg , m.d . , kaiser foundation health plan , inc . , , associate professor and chairman , division of geriatric medicine , medical college of virginia ; william munier , m.d . , practicing physician in wellesley , massachusetts ; robert keller , m.d . , practicing physician in belfast , maine ; kathleen lohr , ph.d . , assistant director , pennsylvania health care cost containment council ; anne flood , ph.d . , college of medicine , university of illinois ; duncan neuhauser , ph.d . , professor of epidemiology and community health , case western reserve university ; christopher r. blagg , m.d . , , d.sc , senior staff health services researcher , the rand corporation , santa monica , california ; douglas wagner , ph.d . , intensive care research unit , george washington university , washington , d.c . ; kathleen m. griffin , ph.d . , cae , executive vice president , american college of health care administrators , bethesda , maryland ; gary gaumer , ph.d . , vice - president , abt associates inc . , cambridge , massachusetts ; kenneth manton , ph.d . , director , center for demographic studies , duke university ; james prevost , m.d . , director of research , joint commission on accreditation of healthcare organizations ; joseph d. restuccia , ph.d . , associate professor of health care and operations management , boston university .

the research issues in the assessment of quality of health care have not changed significantly during the past 20 years . what has changed is the increased interest among providers , consumers , and policymakers for ways to measure and compare quality among providers . clearly there is an increased sense of urgency in the need for research in such areas as the development of improved measures of physiologic status , physiologic reserve , studies of all health care providers , studies of various subpopulations , more use of existing population and sample survey data bases through linkages , and implementation of uniform clinical reporting .

although priapism has been reported as a complication of malignant tumor metastasis , leukemia , sickle cell disease , embolism and spinal canal stenosis [ 1 , 2 , 3 , 4 , 5 ] , there are few reports of priapism as a complication of colorectal cancer in the absence of penile metastasis . here we report a patient with rectal cancer with no penile metastasis in whom chemotherapy resulted in an improvement of priapism . a 65-year - old man was admitted to our hospital for priapism with tenderness of the penis and dysuria . enhanced abdominal computed tomography demonstrated metastatic tumors in the liver , lung , sacrum ( fig . ultrasonography of the penis revealed no tumor and normal blood flow in the penis vessel . chemotherapy ( folfox4 ; levofolinate 25 mg , fluorouracil 250 mg , oxaliplatin 100 mg ) was administered , and although the primary rectal cancer showed no change ( fig . brain or splenic metastasis and hypercalcemia arising from bone metastasis have been reported as rare complications of colorectal cancer [ 6 , 7 , 8 ] . chemotherapy regimens for metastatic colorectal cancer include fluorouracil , leucovorin , either oxaliplatin or irinotecan , and the vegf inhibitor bevacizumab . priapism is a complex involuntary behavioral response that depends on the integration of vascular , endocrine and neurological mechanisms . stimuli for erection can be classified as psychogenic and reflexogenic . when visceral nerves at the sacrum are stimulated electrically , this results in persistent penile erection . nervi erigentes. a second , thoracolumbar erection centre at the level of t12l1 plays a role in psychogenically mediated erections via sympathetic efferent fibers . disturbances in penile blood flow due to metastasis in the penis have been reported to cause priapism . in this case , the cause of priapism might have been micrometastasis in the penis , metastatic tumors that affected the spinal cord , or continuous stimulation of nervi erigentes by a metastatic tumor . chemotherapy , which reduced the metastatic tumor in the sacrum , may also have reduced the level of nervi erigentes stimulation . the results from this case suggest that chemotherapy can be effective for treating rare complications of rectal cancer such as priapism .

a 65-year - old man was admitted with penile tenderness and dysuria due to priapism . enhanced computed tomography revealed metastatic tumors in the liver , lung , sacrum and lymph nodes . advanced rectal cancer , detected by colonoscopy as a primary tumor , was treated with chemotherapy ( folfox4 ) . although the rectal cancer showed no change , five months of chemotherapy improveid the priapism , suggesting that chemotherapy can improve rare symptoms of rectal cancer .

the hemangioma is vasoformative tumour , characterized by an excess of blood vessels especially veins and capillaries in a focal area of submucosal connective tissue . there are various subtypes of hemangioma like capillary hemangioma , lobular hemangioma , cellular hemangioma and epithelioid hemangioma ( eh ) . eh is an uncommon benign vascular lesion which is composed of well - formed immature vessels . eh typically arises on the head and neck , but most frequently affected intraoral sites are lips , buccal mucosa and tongue . the extra - cutaneous sites are bone , salivary gland and muscular area or extremities . this entity typically presents as a small angioma like nodule , red to brown in color and may be located intradermally or subcutaneously in young adults . eh can mimic lymphoproliferative disorders , especially when the lesion arises in atypical location such as the extremities . the purpose of this case report is to describe a rare association between eh and oral mucosa . a thirty year old pregnant ( third trimester ) female reported to the department , with painless mobile nodular swelling in lower left buccal and lingual area [ figure 1 ] . after clinical examination a solitary exophytic growth measuring 1 cm 2 cm 1.5 cm was present on mandibular buccal and lingual gingiva in relation to 33 since last one month . radiographic findings showed no overt alveolar bone destruction in the area of soft tissue enlargement . this time swelling was decreased in size , and surgically removed . clinical picture showing exophytic growth on lingual surface of mandibular the biopsy sections revealed focally ulcerated squamous epithelium . underlying proliferation of variably sized blood vessel was seen which were lined by plump endothelial cells . a dense cellular inflammatory infiltrate , mainly lymphocytes , plasma cells and eosinophils and mast cells were found , surroundings the vessels . a photo micrograph showing variably sized blood vessel which were lined by plump endothelial cells it was done using the cd31 marker and revealed the positivity of the cells for cd31 proving that the epithelioid cells seen are vascular in origin . the biopsy sections revealed focally ulcerated squamous epithelium . underlying proliferation of variably sized blood vessel was seen which were lined by plump endothelial cells . a dense cellular inflammatory infiltrate , mainly lymphocytes , plasma cells and eosinophils and mast cells were found , surroundings the vessels . there were no signs of mitosis and atypical cells [ figure 2 ] . a photo micrograph showing variably sized blood vessel which were lined by plump endothelial cells it was done using the cd31 marker and revealed the positivity of the cells for cd31 proving that the epithelioid cells seen are vascular in origin . eh is a superficial , often multifocal lesion has a strong predilection for the head and neck region ( specially face , ear and scalp ) but rare in oral mucosa . eh in the oral mucosa is a rare disease and often confused with other vascular disease . in the past various terms have been used to describe this lesion , including angioblastic hyperplasia with eosinophilia , nodular angioblastic lymphoid hyperplasia with eosinophilia , lymphofolliculosis , pseudopyogenic granuloma , atypical pyogenic granuloma . in 1982 , a broad term eh was given to describe angiolymphoid hyperplasia with eosinophilia ( alhe ) and some other vascular diseases . but , the diagnosis of epithlioid hemangioma is based upon its histopathological and clinical findings . oral eh seems to have a predilection for men , mostly at young age ( male : female = 23:13 ) . the lips are the most frequent site ( 16 out of 36 ) , followed by the tongue ( 10 out of 36 ) , buccal mucosa ( 6 out of 36 ) , and palate ( 3 out of 36 ) . only 21 cases of eh have been reported in the oral cavity and the gingiva is the most common site . one case has been reported by misselevich et al . which affect alveolar mucosa and gingiva by the direct extension from lesion in mucobuccal fold . oral eh clinically present as a solitary asymptomatic nodule , plaques , ulcers or even tumours . histologically , the vessels were lined by epithelioid or histiocytoid endothelial cells which extend considerably into the lumen , imparting a tombstone effect . a mixed chronic inflammatory cell infiltrate , including eosinophils and occasional germinal centers , was seen . there is a dilemma between various authors whether eh is a reactive lesion or a true neoplastic growth . it is possible that reactive condition caused by trauma may trigger cellular proliferation and growth . pregnancy along with trauma may exaggerated the cause of exophitic growth as reported in our case . other hypothesis regarding etiology is infection , allergy , trauma , overgrowth of atypical endothelial cells and inflammatory skin manifestations . some authors suggested that eh is a true benign neoplasm which has oestrogen receptors on the lesion and respond to oestrogen therapy very well . macroscopically , eh is differentiated from kimura 's disease , salivary gland tumour , squamous cell carcinoma , lymphoma and pyogenic granuloma whereas histological findings are different in bacillary angiomatosis , epithelioid angiosarcoma and epithelioid hemangioendothelioma . in kimura 's diseases , prominent cellular areas of lymphocyte forming follicles are seen , which are surrounded by inflammatory infiltrate and fibrosis . bacillary angiomatosis is an infectious disease caused by rochalimeae henselae , presented as a lesion with abundant neutrophils with nuclear dust and clumps of bacteria . epithelioid hemangioendothelioma is composed of short cord of spindle shaped endothelial cells . in this lesion the line of treatment of oral eh is complete surgical excision and follow - up . other treatment modalities for cutaneous eh are laser cauterization , diathermy , cryotherapy , retinoids , pentoxifyline and intralesional corticosteroids . local recurrence is common in one third of patients with cutaneous eh but rarely seen in oral mucosa and treated with re - excision . hemanigioma is solitary in nature surgical excision is the treatment modality but in case of multifocal involvement , re - excision is required .

the aim of this case report is to present a rare case which has been reported with the history of small nodule like growth on mandibular buccal and lingual area . thirty year old pregnant women reported a nodule on left mandibular buccal and lingual region . the lesion was surgically excised and sent for biopsy to differentiate from kimura 's disease , pyogenic granuloma , epithelioid angiosarcoma ( eh ) . histologically lesion shows proliferation of endothelial cells along blood vessels suggesting epithelioid hemangioma . the purpose of this report is to discuss and differentiate eh and other vascular rare entities occurring in the oral cavity .

development of renal replacement therapies such as hemodialysis ( hd ) , peritoneal dialysis ( pd ) and renal transplantation in children with end - stage renal disease ( esrd ) has resulted in improved long - term survival1 ) . however , esrd influences virtually every organ system and thus , has a major impact not only on morbidity and mortality but also on the quality of life ( qol ) of children with esrd2 ) . in general , qol can be defined as a patient 's sense of well - being and functional outcome within several life domains including physical , psychological status , and social interaction3 ) . qol should not be confused with the concept of standard of living , which is based primarily on income . based on previous studies of qol , spilker4 ) concluded that qol is a multifaceted / multidimensional phenomenon and there are next five domains in a conceptual definition of qol : 1 ) physical status and functional abilities , 2 ) psychological status and well - being , 3 ) social interaction , 4 ) economic and/or vocational status , and 5 ) religious and/or spiritual status5 ) ( fig . 1 ) . actually , we , pediatric nephrologists , should confront a lot of medical problems in children with esrd . these problems consist of general symptoms such as fatigue and malaise , hematologic problems such as anemia and dysfunction of platelet , gastrointestinal problems such as anorexia , nausea and vomiting , electrolyte imbalances such as hyperkalemia , metabolic acidosis , hyponatremia , hyperuricemia and hyperphosphatemia , genitourinary problems , nerve system , endocrine , musculoskeletal , cardiovascular , and dermal problems , etc . except for these medical problems , however , there are additional problems that we must resolve in children including the change of body image , too many medicines , side effects , psychiatric problems , growth , and development . if we do n't have concern about these issues , normal growth and development in these children can not be accomplished . kurtin et al.6 ) suggested that the definition of success in the care of pediatric esrd patients should not be limited to mortality rates , but must include the degree to which these children are allowed to grow , develop , and behave in the same manner as their healthy peers . the goal of this review was to help the understanding of clinical usefulness of assessment of qol in children and adolescents with esrd . the qol of adults with esrd has been evaluated more comprehensively than in children . in 1985 they concluded that transplantation can give better qol than dialysis because qol of transplant recipients compared well with that of the general population , whereas patients with dialysis did not work at the similar level as people in the general population . in the choice health experience questionnaire ( cheq ) study , the difference of qol according to dialysis modality in adults with esrd was evaluated by 36-item short - form survey ( sf-36 ) and it was reported that pd can give better qol than hd in various domains including physical functioning , bodily pain and emotional functioning8 ) . in 2002 , kidney disease outcomes quality initiative ( k / doqi ) reported that impairment in functioning and well - being are associated with worse outcomes in chronic kidney disease ( ckd ) and compared with healthy population , dialysis patients tend to have more dysfunctions and limitations of behavior due to more bodily pain , poorer vitality , and poorer general health9 ) . so , k / doqi clinical practice guidelines for ckd recommended that patients with glomerular filtration rate ( gfr ) < 60 ml / min/1.73 m should undergo regular assessment for impairment of functioning and well - being9 ) . in korea , park et al.10 ) suggested that lower residual renal function is a risk factor for depression and impaired qol in korean pd patients . up to the present , several pediatric qol tools have been developed such as these lists ; child health questionnaire ( chq ) , child health and illness profile - adolescent edition ( chip - ae ) , dartmouth primary care cooperative functional health assessment charts ( coop ) , functional status ii ( r ) , pediatric quality of life inventory ( pedsql ) and the vineland adaptive behavior scale ( vineland ) . the chq consists of 12 domains of health status ( physical functioning , limitations in schoolwork and activities with friends , general health , bodily pain , discomfort , limitations in family activities , emotional / time impact on the parent , impact of emotional or behavior problems on school work and other daily activities , self - esteem , mental health , behavior , family cohesion and change in health ) and is suitable for children aged 10 to 19 tears11 ) . the chip - ae is 6 domain/153 item self - report instrument ( discomfort , satisfaction , disorder , achievements , resilience and risk ) and sensitive to age , gender and socioeconomic influences12,13 ) . the coop chart system has 6 domains of health status including physical fitness , emotional feeling , school work , social support , family communication , and health habits14 ) . the vineland is suitable for evaluating both handicapped and nonhandicapped persons from birth to age 19 years unlike the other qol instruments15 ) . pedsql 4.0 generic core scale created by varni et al.16 ) is a 23-item generic health status instrument that assesses five domains of health including physical , emotional , psychosocial , social and school functioning in children and adolescents ages 2 to 18 years . although these modules have internal reliability and clinical validity and can be completed easily by children and their parents , they have some limitations because they were not disease - specific module . after then , varni et al.17 - 20 ) have developed disease - specific modules to assess qol in children with chronic diseases such as esrd , asthma , cancer , and rheumatoid arthritis . the 34-item pedsql 3.0 esrd module developed in 2002 includes 7 scales : 1 ) general fatigue ( 4 items ) , 2 ) about my kidney disease ( 5 items ) , 3 ) treatment problems ( 4 items ) , 4 ) family and peer interaction ( 3 items ) , 5 ) worry ( 10 items ) , 6 ) perceived physical appearance ( 3 items ) , and 7 ) communication ( 5 items ) . this module consists of 4 age categories of 2 - 4 , 5 - 7 , 8 - 12 , and 13 - 18 years . the scales are composed of both the child - self report and parent - proxy report formats for children aged 5 to 18 years and a parent - proxy report format for children aged 2 to 4 years . items are reverse - scored and linearly transformed to a 0 - 100 scale ( 0=100 , 1=75 , 2=50 , 3=25 , 4=0 ) . , we translated the original english version of the pedsql 3.0 esrd into new korean version based on the guideline of linguistic validation provided by the original developer ( mapi research trust , lyon , france ; on behalf of dr . unfortunately , there are few studies of qol in children with esrd because first , it is very difficult to obtain suitable questions for children and second , proxy assessment is always needed . initially , there are several limited studies of qualitative status in children with esrd instead of typical qol . morton et al.22 ) reported that living with parents , lack of experience of close relationship , lack of educational qualifications and unemployment were more common in young adults with esrd . in other study , 30% of adolescents with esrd were neither enrolled in an educational program nor were employed23 ) . recently , there have been several attempts to quantitate in systematically analyzable terms , the net outcome of a disease and its treatment on the patient 's perception of his / her ability to live a useful and fulfilling life during childhood . in 1994 , kurtin et al.6 ) created parent - completed questionnaire validated in the children 's health and quality of life project and suggested that less compliant adolescents consistently reported more pain and poorer general and mental health than more compliant adolescents , as well as lower family involvement . it was also reported that qol scores of children with esrd were considerably lower than healthy controls24 ) . in addition , marciano et al.25 ) suggested that children with ckd showed a higher proportion of behavioral and emotional disorders and there was a negative correlation between the presence of behavior and emotional disorders and qol score . there have been several studies of difference of qol between treatment modalities such as dialysis and transplantation in children with esrd . according to study of qol in children with esrd using chip - ae , transplantation can produce improved physical activity , better work performance , more satisfaction , and less discomfort compared with dialysis26 ) . in other study using pedsql module , transplant patients reported better physical and psychosocial health than dialysis patients24 ) . in addition , pediatric kidney transplant recipients also reported a higher qol score than other published studies of chronic illness cohorts27 ) . some studies have been reported the difference of qol between child - self and parent - proxy reports . mckenna et al.28 ) reported that caregivers score their children lower in almost all categories than the child - self reports . on the other hand , goldstein et al.29 ) reported that although parent - proxy reports show a positive impact from renal transplantation on the majority of qol domains compared with dialysis , child - self reports show nonsignificant differences in favor of renal transplantation . therefore , buyan et al.30 ) concluded that parent - proxy scores on the qol were not equivalent to child - self scores and that evaluating both children 's and parents ' perspectives were important . comorbidities including cardiovascular , gastrointestinal , endocrinologic , hematologic and neurologic disorders can be also one of the significant factors to decide the qol in children with esrd . especially , hypertension , diabetes , and cardiovascular disorders khan32 ) classified patients into high , medium and low risk groups according to comorbidity and age and reported the significant difference of patients ' perception of health score among the 3 risk groups . in 2012 , we published a cross - sectional study of the korean translations of the pedsql esrd module comparing child - self reported and parent - proxy reported hrqol of children with esrd based on a national - wide pediatric esrd registry , the so called ' the korea pediatric ckd registry'21 ) . participants included children aged 2 to 18 years who received maintenance dialysis treatment or renal transplant care for at least 6 months and their parents . total 92 pediatric patients ( 11 hd , 44 pd , and 37 transplant ) were enrolled . we reported that patients with pd had better qol than hd in several domains ( including treatment problems in the child - self reports , about my kidney disease and worry in the parent - proxy reports ) and transplant patients had better hrqol than dialysis patients in one domain of the child - self report ( treatment problems ) and in two domains of the parent - proxy reports ( about my kidney disease and worry ) . however , there were no significant differences in the total qol scores of the child - self reports between the pd and transplant patients . compared with adults , studies of qol in children with esrd have been not popular yet . however , we should consider that assessment of qol can be essential to achieve normal growth and development in children with chronic diseases including esrd . in addition , although various assessment tools for children have been recently developed , the optimized qol instrument in our country should be developed to overcome the language problems and cultural gap . pediatric quality of life inventory 3.0 end - stage renal disease module child - self report item content ( korean version ) .

quality of life in addition to various medical problems in children with end - stage renal disease ( esrd ) should be objectively assessed to accomplish normal growth and development during childhood . however , unfortunately , studies of quality of life ( qol ) in children with esrd have been not popular yet and there are only fewer suitable assessment tools compared with adults . recently , disease - specific modules to evaluate qol in children with chronic disease such as esrd have been developed . this review was made to introduce these qol instruments for children and help the clinical application of them .

the primary goal of periodontal treatment is the maintenance of the natural dentition in health and comfortable function . when periodontal disease has caused a loss of the attachment apparatus , optimal care seeks to regenerate the periodontium to its predisease state . complete and predictable restoration of the periodontium following trauma or infection remains a critical objective in periodontics and bone replacement grafts remain among the most widely used therapeutic strategies for the correction of periodontal osseous defects . to preserve the interdental soft tissue for maximum soft tissue coverage following surgical intervention involving the treatment of proximal osseous defects , takei et al . later cortellini et al . gave modifications of the flap design modified papilla preservation flap and simplified papilla preservation flap to be used in combination with regenerative procedures . the whale 's tail technique , which was designed for the treatment of wide intrabony defects in the esthetic zone . this technique involved the elevation of a large flap from the buccal to the palatal side to facilitate access and visualization of the intrabony defect and was created , especially to perform regeneration while maintaining interdental tissue over grafting material . the aim of our study is to assess the clinical efficacy of this new surgical technique three systemically healthy subjects with probing depths 67 mm and radiographic evidence of bone loss in relation to the maxillary anterior teeth were included in the study . probing depths and attachment loss were recorded , and complete scaling and root planing were done for all the subjects . preoperative probing depth incision points were marked [ figure 2 ] , and two vertical full - thickness incisions were traced from the mucogingival line to the distal margin of the tooth neighboring the defect on the buccal surface . a horizontal incision whale 's tail - shaped incision joined the apical margins of the first two incisions , and the coronal margins of the vertical incision were continued intrasulcularly in the buccal , interproximal , and palatal aspects of the defect - associated tooth [ figure 3 ] . a full thickness mucoperiosteal flap was reflected from the buccal to the palatal side following which complete removal of granulation tissue and scaling and root planing was done [ figure 4 ] . bone graft ( perioglas ) was placed in the intrabony defect , [ figure 5 ] following which flap was repositioned from the palatal to buccal [ figure 6 ] . 4 - 0 ethicon , nonresorbable , perimeter sutures were placed , without tension , away from the margins [ figure 7 ] . postoperative instructions were given , and the patient was asked to use 0.2% chlorhexidine mouth rinse 48 h after the procedure for a period of 2 weeks . the subjects were recalled after 2 weeks for suture removal and were recalled after the duration of 3 months and 6 months [ figure 9 ] . subjects 2 and 3 were treated similarly and per - operative and post - operative probing depths were recorded [ figures 1015 ] . whale 's tail incision placed flap reflected from buccal to palatal aspect with intrabony defect with relation to 11 debridement done and bone graft placed perimeter sutures placed away from incision lines six months postoperatively preoperative probing depth = 7 mm ( subject 2 ) postoperative probing depth = 3 mm ( subject 2 ) preoperative probing depth = 7 mm ( subject 3 ) postoperative probing depth = 3 mm with recession ( subject 3 ) three systemically healthy subjects with probing depths 67 mm and radiographic evidence of bone loss in relation to the maxillary anterior teeth were included in the study . probing depths and attachment loss were recorded , and complete scaling and root planing were done for all the subjects . incision points were marked [ figure 2 ] , and two vertical full - thickness incisions were traced from the mucogingival line to the distal margin of the tooth neighboring the defect on the buccal surface . a horizontal incision whale 's tail - shaped incision joined the apical margins of the first two incisions , and the coronal margins of the vertical incision were continued intrasulcularly in the buccal , interproximal , and palatal aspects of the defect - associated tooth [ figure 3 ] . a full thickness mucoperiosteal flap was reflected from the buccal to the palatal side following which complete removal of granulation tissue and scaling and root planing was done [ figure 4 ] . bone graft ( perioglas ) was placed in the intrabony defect , [ figure 5 ] following which flap was repositioned from the palatal to buccal [ figure 6 ] . 4 - 0 ethicon , nonresorbable , perimeter sutures were placed , without tension , away from the margins [ figure 7 ] . postoperative instructions were given , and the patient was asked to use 0.2% chlorhexidine mouth rinse 48 h after the procedure for a period of 2 weeks . the subjects were recalled after 2 weeks for suture removal and were recalled after the duration of 3 months and 6 months [ figure 9 ] . subjects 2 and 3 were treated similarly and per - operative and post - operative probing depths were recorded [ figures 1015 ] . whale 's tail incision placed flap reflected from buccal to palatal aspect with intrabony defect with relation to 11 debridement done and bone graft placed perimeter sutures placed away from incision lines six months postoperatively preoperative probing depth = 7 mm ( subject 2 ) postoperative probing depth = 3 mm ( subject 2 ) preoperative probing depth = 7 mm ( subject 3 ) postoperative probing depth = 3 mm with recession ( subject 3 ) following the treatment , 6 months postoperatively , patient 1 had a probing depth reduction of 3 mm and a gain in clinical attachment of 3 mm ; patient 2 had a probing depth reduction of 4 mm and a gain in attachment of 4 mm ; and patient 3 had a probing depth reduction of 4 mm and a gain in attachment of 1 mm but an increase in recession by 3 mm . the surgical technique , we used in this case series , allows regeneration of wide intrabony defects involving the maxillary anterior teeth with notable interdental diastemas , maintaining interproximal tissue to recreate a functional attachment with esthetic results . it was possible to elevate a large flap from buccal to palatal , which allowed the preservation of a large amount of soft tissue and resulted in good primary closure . besides , positioning of incisions away from the defect area and placement of sutures distant from the regenerated defects decreased the chances of bacterial colonization of the biomaterials , which is often responsible for regenerative failures . bianchi and bassetti used this technique and showed a mean probing attachment level gain of 4.9 1.8 mm and a probing pocket depth reduction of 5.8 2.5 mm . our cases showed similar results with a mean probing depth reduction of 4 mm and a mean gain in the clinical attachment of 3 mm . furthermore , the systematic use of incisions distant from the defects and biomaterial margins drastically reduced the percentage of flap dehiscence . primary closure of the interdental space after surgery and during the follow - up period was achieved in 100% of treated sites . another case report by damante et al . showed recession in the maxillary right central incisor . esthetic considerations always pose therapeutic dilemmas in the selection of the appropriate surgical technique in the maxillary anterior region to prevent or minimize esthetic problems such as loss of interdental papilla or increased tooth length without compromising the main goal of periodontal surgery . to overcome the disadvantage of conventional papilla preservation technique ( takei et al . , ) cortellini modified the technique by reflecting the flap from buccal to the palatal aspect ( modified papilla preservation technique ) . a study done by retzepi et al . , to compare the gingival blood flow during healing of simplified papilla preservation flap and modified widman flap , showed when the gingival blood flow during healing was compared between the two , the simplified papilla preservation technique may be associated with faster recovery of the gingival blood flow postoperatively . a higher gingival blood flow to different parts of the periodontium can have a positive effect on the speed and on the quality of the healing process . furthermore , an improved healing process would be of paramount importance for the final outcome of various regenerative procedures . one of the limitations of this case series is the occurrence of recession associated with subject 3 which increased postsurgically . this could be attributed to the relatively thin gingival biotype , handling of the tissue , and placement of the incision . however , the main advantages of the technique include good access to the defect area and placement of margins away from the regenerative material , which will prevent the inflammatory response near the regenerative material , thereby increasing the chances of graft uptake . furthermore , the handling of the interdental papilla is easier and more convenient than the conventional papilla preservation technique . the indications of this technique include therapies aimed at regeneration of periodontal defects such as bone grafts , membrane , or combination of these materials , surgical treatment of anterior tooth region with diastema present .

the whale 's tail technique performed to obtain maximum interdental papilla fill in the anterior region after placement of bone grafts . this study aims to assess the clinical efficacy of this new technique . this report describes a series of three cases with a probing depth of 67 mm in the maxillary anterior teeth and their treatment with whale 's tail technique to obtain regeneration and maximum papilla preservation . the cases in this report showed a pocket depth reduction of 3 - 4 mm and a clinical attachment gain of 3 - 4 mm . the application of the whale 's tail flap leads to clinically significant improvement of hard and soft tissue conditions and allows regeneration of wide intrabony defects involving the maxillary anterior teeth with notable interdental diastemas , maintaining interproximal tissue to recreate a functional attachment with esthetic results .

the implication of gene environment interactions in the etiology of psychiatric diseases , such as depression and drug addiction is well established in humans ( caspi et al . 2002 ; nilsson et al . 2007 ) and non - human primates ( barr et al . is widely used to assess long - term consequences of different early experiences ( ladd et al . 2000 ; pryce and feldon 2003 ) . ms has been shown to strongly affect the neurocircuitries involved in drug addiction and also cause long - term effects on the propensity to voluntarily drink ethanol ( gustafsson et al . 2008 ; oreland et al . 2009 ; ploj and nylander 2003 ; ploj et al . 2002 , 2003b ) . in the compulsive use of ethanol , neurotransmitter systems such as dopamine , serotonin , noradrenaline and opioids are involved ( koob and volkow 2010 ) . one common factor affecting the development of these neural systems is the transcription factor activator protein ( tfap ) 2 ( comb et al . 1988 ; damberg 2005 ) . the tfap-2 may , therefore , be a target for early environmental influences and a mediator of the effects seen after ms . interestingly , early environmental factors have been associated with altered tfap-2 family gene expression in rats ( meaney et al . 2000 ) . in the present study , the aim was to examine possible differences in brainstem tfap-2 levels in animals genetically or environmentally predisposed to prefer high ethanol drinking and high ethanol concentration . besides rats subjected to ms , the ethanol - preferring alko , alcohol ( aa ) and the ethanol - avoiding alko , non - alcohol ( ana ) rats were studied . the aa and ana lines are among the first rodent lines produced by bidirectional selection for high ethanol preference in a two - bottle choice between ethanol and water ( for review see sommer et al . three experiments were performed : i comparative analysis of tfap-2 levels in the aa and ana rats , ii assessment of tfap-2 levels in juvenile and adult rats subjected to different early environmental conditions using the ms model , and iii analysis of the impact of long - term voluntary ethanol consumption on adult rats reared in different early environmental conditions . experiment i twelve alcohol - nave adult male aa and ana rats were obtained from the national public health institute , finland . upon arrival , the rats were housed with 3 rats per cage in standard macrolon cages ( 59 38 20 cm ) containing wood - chip bedding material . experiment ii and iii time - mated pregnant wistar rats ( scanbur ab , sweden ) arrived at the animal facility on gestational day 1415 ( experiment ii ) and 1213 ( experiment iii ) . the pregnant rats were singly housed in macrolon cages . on the day of birth , postnatal day ( pnd ) 0 , the litters were divided into litters of 910 pups ( males , n = 56 ; females , the rat pups were subjected to daily 15 min ( ms15 ) or 360 min ( ms360 ) ms or conventional animal facility rearing ( afr ) . the ms procedures have previously been described in detail elsewhere ( gustafsson and nylander 2006 ) . in adulthood , animals in experiment iii were singly housed from pnd 7375 and were then given free access to 5 , 10 and 20% ( v / v ) ethanol solutions and one bottle with water ( ms15e , ms360e and afre ) or just water ( ms15w and ms360w ) for 54 days . the four - bottle choice paradigm is described in detail elsewhere ( gustafsson and nylander 2006 ) . the rats exposed to ms in experiment ii were sacrificed at 3 and 10 weeks , respectively , and rats in experiment iii at the end of the ethanol - drinking period . the brainstems were removed and immediately frozen on dry ice and stored at 80c until further analysis . all animals had free access to water and r36 labfor food pellets ( lactamin ab , sweden ) in a humidity- and temperature - controlled environment . all animal experiments were performed in accordance with the european communities council directives ( 86/609/eec ) . afr animal facility rearing , aa alko , alcohol , ana alko , non - alcohol , e rats having access to ethanol and water , ms15 15 min of maternal separation , ms360 360 min of maternal separation , w rats having access to only water a schematic overview of the experimental design of the three studies . afr animal facility rearing , aa alko , alcohol , ana alko , non - alcohol , e rats having access to ethanol and water , ms15 15 min of maternal separation , ms360 360 min of maternal separation , w rats having access to only water with some modifications , tfap-2 levels were analyzed using enzyme - linked immunosorbent assay as earlier described ( berggard et al . 50 l of 14 g / ml goat polyclonal tfap-2 primary antibody ( sds biosciences , sweden ) together with 50 l of 1.5 g / ml donkey anti - goat igg ap conjugated secondary antibody ( sds biosciences , sweden ) was added per well . 25 min after adding 50 l of phosphatase substrate solution , an additional 50 l of stop solution ( 3 m naoh ) was added . the immunoreactive ( ir ) tfap-2 in each sample was deciphered from a standard curve , where known log10 transformed concentrations of ir tfap-2 peptide ( sds biosciences , sweden ) were plotted against optical density using assayzap v3.1 ( biosoft , uk ) . a one - way analysis of variance ( anova ) followed by fisher s protected least significant differences ( plsd ) post - hoc test was performed to compare ir tfap-2 levels between i aa and ana male rats , ii ms15l , ms360l , and afr male rats at 3 and 10 weeks of age , respectively , and iii ms15w , ms360w , ms15e , ms360e and afre male rats . two - way anova followed by fisher s plsd post - hoc test was used for comparison between the rearing environment ( ms15 or ms360 ) and fluid intake ( water or ethanol ) . significant differences in immunoreactive ( ir ) tfap-2 protein levels ( f1,21 = 5.136 ; p < no ms - induced effects on ir tfap-2 protein levels were detected in either the juvenile ( f4,44 = 1.379 ; p = 0.257 ) or adult = 0.64 ) were seen between the ms15w , ms15e , ms360w , ms360e and afre rats . comparing the water- and ethanol - drinking ms groups , no significant effects of rearing environment ( f1,38 = 0.498 ; p = 0.48 ) , fluid intake ( f1,38 = 0.036 ; p = 0.85 ) or interaction between rearing environment and fluid intake ( f1,38 = 0.021 ; p = 0.89 ) with regard to ir tfap-2 protein levels were observed ( table 1 ) . the voluntary ethanol consumption has been described in detail elsewhere ( gustafsson and nylander 2006).table 1the immunoreactive levels of tfap-2 protein in the brain stem of male ratsrearing environmentageneffect of heredityeffect of rearing environmenteffect of rearing environment long - term voluntary ethanol intakeaaadult98.76 0.37anaadult116.81 0.34ms15juvenile1027.45 1.20ms360juvenile1027.86 0.73afrjuvenile925.36 0.47ms15adult1028.64 1.18ms360adult1033.52 1.71afradult1031.70 1.37ms15 wadult1014.57 0.95ms360 wadult1015.37 1.10ms15eadult1014.89 0.91ms360eadult1215.42 0.80afreadult1113.62 0.95results are shown in mean ng ir tfap-2 protein per mg total protein semafr animal facility rearing , aa alko , alcohol , ana alko , non - alcohol , e rats having access to ethanol and water , ms15 15 min of maternal separation , ms360 360 min of maternal separation , n number of rats , w rats having access to only water * * p < 0.01 compared to aa rats ( anova followed by fisher s post - hoc test ) the immunoreactive levels of tfap-2 protein in the brain stem of male rats results are shown in mean ng ir tfap-2 protein per mg total protein sem afr animal facility rearing , aa alko , alcohol , ana alko , non - alcohol , e rats having access to ethanol and water , ms15 15 min of maternal separation , ms360 360 min of maternal separation , n number of rats , w rats having access to only water * * p < 0.01 compared to aa rats ( anova followed by fisher s post - hoc test ) previous clinical studies have suggested an association between a gene variation in tfap-2 and personality ( damberg et al . 2000 ) , severe female alcoholism ( nordquist et al . 2009 ) and depression in adolescents ( nilsson et al . it has further been proposed that tfap-2 may be a target for factors known to influence psychopathological behavior via its effect on transcription of several monoaminergic genes in the central nervous system ( for review see damberg 2005 ) . further support for this notion stems from findings of effects of antidepressive drugs on brainstem tfap-2 protein levels in male rats ( berggard et al . 2005 ) , indicating a change in the serotonin network in this brain region . in addition , the levels of tfap-2 protein in the brainstem area are inversely correlated to monoamine turnover in the male rat forebrain ( damberg et al . 2001 ) . having these factors in mind , we selected the brainstem region , where the serotonin cell bodies are located . differences in serotonin , dopamine , noradrenaline and opioid systems between the aa and ana rats have been reported ( for review see sommer et al . several genes of importance for these neurocircuitries have consensus sites for tfap-2. interestingly , higher levels of ir tfap-2 levels were seen in the predisposed ethanol - preferring aa rats compared to the non - preferring ana rats . ms affects various brain networks , including the dopamine , serotonin and opioid systems ( arborelius and eklund 2007 ; gustafsson et al . 2008 ; oreland et al . 2009 ; ploj and nylander 2003 ; ploj et al . , it was hypothesized that the early life environment could affect the levels of tfap-2 and thereby cause alterations in gene expression of various transmitters , receptors and transporters . in one previous study , it was reported that short ms is associated with altered hippocampal tfap-2 gene expression in rats ( meaney et al . however , our findings suggest no ms - induced differences in brainstem ir tfap-2 levels in either juvenile or adult male rats . we also measured the ir tfap-2 brainstem levels in juvenile and adult female rats subjected to litter - wise and individual ms15 and ms360 as well as afr . also in this case no differences in ir levels were observed ( data not shown ) . first , the ap-2 gene in the meaney study was measured in another brain area than in our study , thus , making it difficult to compare the results . the tfap-2 family consists of five known isoforms ( for review see damberg 2005 ) and one of the isoforms other than tfap-2 could have been engaged in the differences observed by meaney and co - workers . third , alterations in gene expression do not necessarily have to mirror alterations in protein levels . the early rearing environment has been suggested to be either a protective ( short ms ) or a risk ( prolonged ms ) factor for high voluntary ethanol consumption ( roman and nylander 2005 ) . in addition , wistar rats subjected to ms were induced to changes in dopamine receptors and opioid peptide levels after long - term , voluntary ethanol self - administration ( ploj et al . 2003a ) . in another study but using the same animals as experiment iii , differences in ethanol consumption and opioid peptide levels between the experimental groups have previously been reported ( gustafsson and nylander 2006 ; gustafsson et al . therefore , we further examined whether different early life experiences would alter ir tfap-2 levels after long - term voluntary ethanol drinking . however , no differences in ir tfap-2 levels were observed . furthermore , no ethanol - induced effects on ir tfap-2 levels were observed indicating that tfap-2 is not affected by voluntary ethanol consumption in any of the experimental groups . it is worth mentioning that the standard curve for the immunoassays between the three experiments did not differ from each other . the variations seen between the three experiments are speculated to be due to differences in rat lines ( wistar versus aa / ana lines ) or emotional stress level ( due to different housing conditions ) . the rats in experiment ii , i.e. rats solely exposed to different early rearing conditions , were housed in groups until they were sacrificed . however , the rats in experiment iii , i.e. having access to either water and ethanol or only water , were housed individually for 8 weeks during the entire ethanol access period . therefore , we speculate that the differences between the rats in these two experiments might be due to the emotional stress applied in the isolated rats in experiment iii . in conclusion , our data show that the genetically predisposed ethanol - preferring aa rats and ethanol - avoiding ana rats differ in ir tfap-2 protein levels . no differences in ir tfap-2 protein levels induced by the different early rearing environments were seen in the brainstem of juvenile and adult rats . furthermore , long - term voluntary ethanol consumption did not alter brainstem tfap-2 protein levels in male wistar rats subjected to ms .

genes involved in alcoholism have consensus sites for the transcription factor activator protein ( tfap ) 2. in the present study , we investigated tfap-2 protein levels in the ethanol - preferring alko , alcohol ( aa ) and the ethanol - avoiding alko , non - alcohol ( ana ) rat lines . furthermore , basal and ethanol - induced tfap-2 levels were examined in wistar rats exposed to different early postnatal environments that are known to affect later ethanol consumption . taken together , we found differences in brainstem tfap-2 protein between the aa and ana rats .

emphysematous pyelonephritis ( epn ) is a condition in which there is gas forming necrotizing infection of the renal parenchyma and perinephric tissue . workup for other etiological agents should be carried out if patient does nt respond to antibiotic therapy or deteriorates clinically . fungal etiology has rarely been reported with candida albicans , candida tropicalis , candida glabrata and cryptococcus usually implicated . we report a case of epn where candida parapsilosis was grown from urine culture and patient responded to medical management in the form of antifungals . this case is being reported because of two reasons : ( 1 ) to our knowledge , this case is the first report of epn caused by candida parapsilosis in a diabetic patient . a 60 year old female known case of hypertension and diabetes mellitus was on angiotensin ii receptor blocker and oral hypoglycemic agents presented to the emergency department with complaints of fever with rigors and chills and right side abdominal pain . at initial examination , patient was conscious , oriented with a heart rate of 110 beats per minute , respiratory rate of 46 per minute , temperature of 102 f. patient was pale with no signs of heart failure . systemic examination revealed tenderness in right lumbar region , tender right renal angle and a palpable mass in right lumbar region . investigations revealed hypochromic microcytic anemia with hemoglobin ( hb ) of 7.1 g / dl , total leukocyte count ( tlc ) of 21,000/mm with 84% of neutrophils , platelet count of 118000/mm . kidney function test ( kft ) revealed urea of 29 mg / dl and creatinine of 0.72 mg / dl . arterial blood gas ( abg ) analysis revealed ph-7.52 , sodium ( na)- 138 mmol / l , potassium ( k)- 2.5 mmol / l , pco2- 30 mmhg , po2 - 50 mmhg , ultrasonography ( usg ) revealed large right kidney ( 14 6 mm ) with gas in the pelvis and perinephric area . patient clinically showed features of severe sepsis in the form of tachycardia , tachypnea , hyperventilation , respiratory alkalosis and hypoxic respiratory failure . an abdominal computed tomography ( ct ) scan was done which showed gas in the right renal calyces , renal paranchyma and in the perinephric area [ figure 1 ] . gas collection can be seen in perinephric area ( green arrow ) , renal parenchyma ( red arrow ) and renal pelvis ( black arrow ) patient was started on oxygen inhalation , intravenous antibiotics ( imipenem and vancomycin ) . repeat laboratory parameters were as under hb - 8.0 g / dl , tlc - 10.7/mm , polymorphs-72% , lymphocytes- 20% , platelets- 284,000/mm , ph- 7.35 , na- 136 mmol / l , k- 4.0 mmol / l , pco2- 25 mmhg , po2- 74 mmhg , sao2- 96% . repeat usg showed right kidney of 11 5 mm in size with normal left kidney . yeast cells can be seen ( black arrow ) along with pseudohyphae ( red arrows ) epn is a necrotizing gas producing infection of the renal parenchyma and perinephric tissue . in 1962 , schultz and klorfein first coined the term epn to describe an acute infectious process resulting in gas formation in the renal parenchyma . various factors for gas formation have been postulated which include high tissue glucose concentrations , impaired immunity , tissue ischemia and mixed acid fermentation by gas - forming bacteria . other predisposing factors include urinary tract obstruction , polycystic kidneys , end stage renal disease and immunosuppression . it is a rare infection caused by gas producing bacteria which inhabitate the urinary tract and includes escherichia coli , klebsiella pneumoniae , proteus mirabilis and pseudomonas aeruginosa . certain candida species like candida albicans , candida guilliermondii and candida parapsilosis are capable of producing gas in vitro . sugar fermentation test is used to detect fungus in laboratory and positive sugar fermentation test is one which shows presence of acid and gas in the tube . the patient did not require any form of surgical intervention which is usually required in most of the cases . type i included patients showing parenchyma destruction with streaky or mottled gas but with no fluid collection . type ii patients had renal or perirenal fluid collections that contained bubbly or loculated gas or gas within the collecting system . epn is a fatal complication commonly seen in diabetic patients and requires early diagnosis and management for a favorable outcome . although uropathogens are the common etiological agents , other etiological agents like fungi can act as a sole pathogenetic factors or a part of mixed infection in unfavorable settings . although most cases require surgical intervention , a selected number of patients can be management by medical management only .

emphysematous pyelonephritis ( epn ) a rare complication commonly seen in diabetic patients is a necrotising gas producing infection of the renal parenchyma and perinephric tissue predominantly caused by uropathogenic bacteria . fungi have been rarely reported as the etiological agents , isolated from blood and/ or urine culture . we report a case of epn caused by a rare etiological agent . a 60 year old diabetic female with no previous history of hospitalization presented to us with a short history of febrile illness associated with abdominal pain . investigations revealed unilateral epn wan type 1 . patient was treated with systemic antifungal therapy as per culture sensitivity and it alone proved to be an effective treatment of this clinically difficult condition . patient was discharged in a satisfactory clinical condition . a rare etiology should always be kept in mind while evaluating a case of epn .

a 26-year - old female was referred to our department of oral and maxillofacial surgery with a chief complaint of deviated nose and smaller nostril on the right side . past surgical history revealed that she had undergone cleft lip repair at the age of 3 years . extra oral examination findings were nasal pyramid was tilted to the cleft side , the columella was short on the cleft side and deviated towards the noncleft side , the lateral crux of the lower lateral cartilage was displaced lower and to the cleft side resulting in excessive skin on the dome of lower lateral cartilage on the cleft side , nasal tip was asymmetrical , nostril on the cleft side was small and the entire nostril was retropositioned [ figure 1a c ] . columella short on the cleft side and deviated towards the noncleft side ; the lateral crux of the lower lateral cartilage was displaced lower and to the cleft side intraoral examination revealed a class i molar relation on the right and left the side with generalized spacing of upper and lower anteriors and a missing left upper lateral incisor with an alveolar cleft [ figure 2 ] . ( lateral incisor absent ) a definitive open rhinoplasty was planned for the cleft nasal deformity . the surgery was carried out under general anesthesia through orotracheal intubation . an inverted - v transcolumellar incision with bilateral marginal incisions was made , the lower lateral cartilage and septal cartilage were exposed [ figure 3a ] , the cartilaginous septum was separated from the maxillary crest and secured to the midline using 50 pds suture , deviated portions of the septum were then removed and the excess cartilage is preserved for graft in future use [ figure 3b ] , while preserving an adequate dorsal and caudal strut . the tip projection and symmetry was increased with a strut graft in the columella in a pocket between medial crura , medial advancement of lower lateral cartilage was done [ figure 4 ] . alar hooding was improved and alar collapse was prevented by placing a spreader graft [ figure 5 ] . ( a ) inverted - v transcolumellar inscision with marginal extention . exposure of nasal septum and lower lateral cartilatge . ( b ) harvested excess septal cartilage columellar strut graft to support the columella spreader graft is placed to prevent alar collapse postoperatively the healing was satisfactory with no evidence of infection or wound dehiscence . the symmetry of the nasal tip was achieved , nostril on the cleft side was of the same size as the noncleft side , there was good projection of the nasal dorsum and nasal tip postoperatively [ figure 6 ] . the results were stable with no evidence of relapse with a period of follow - up of 1-year . unilateral cleft lip nasal deformity is the result of undue forces to which the nasal tip is subjected as a consequence of uncoupling of the palatal shelves . the drawbacks of primary rhinoplasty are relapse and growth impairment , however the studies by mccomb and salyer stated that nasal cartilage growth is unaffected by nasal surgery but in our case a definitive rhinoplasty was done . the goals of definitive rhinoplasty include creation of symmetry , definition of nasal base and tip , relief of nasal obstruction and management of nasal scarring and webbing . one of the cleft lip nasal deformities is the alar columellar web deformity in which excess skin overhangs the superomedial side of the nostril . tajima and maruyama described a reverse u incision with a suture suspension of repositioned cleft lower lateral cartilage . nakajima et al . modified the technique by adding a z - plasty in the lateral nasal vestibule . cronin and denkler reported on v - yplasty of nasal mucosa left by the advancement of the lateral crus . they proposed that the vestibular lining of the lateral crus remain attached to add circulation and support especially when scoring of the cartilage is needed . maeda et al . reported using a bilateral reverse u incision in combination with cronins method . nakajima and yoshimura used a bilateral reverse u incision combined with a short banked forked flap in bilateral cleft lip nasal deformity . a traditional inverted - v transcolumellar incision advocated by potter and merville and popularized by goodman was used in this case and there was good visibility and access to the displaced structures with this incision . some stress the need for lateral to medial advancement and lateral release of the lateral crus , others prefer a medial to lateral rotation , however , only a few use total detachment of the lateral crus from the vestibular skin . some surgeons mobilize the lateral crus together with vestibular skin to create a medially based chondrocutaneous flap . a lateral to medial advancement was preferred in our case . different techniques are described to repair the lateral vestibular wall following medial advancement of the crus . tajima and maruyama state that there is no redundant skin whereas gubisch uses a surplus of vestibular skin to close a gap between two flaps at the lateral nostril . millard excises not only part of the lateral crus but also the skin excess from the vestibular fold . most authors report a defect in the lateral wall and suggest direct approximation or standard flaps such as z - plasty or v - y advancement . published a series of cases where composite conchal cartilage was used in various forms to repair columellar deficit , to form nasal tubercle and nostril sill in cleft lip nasal deformity patients and concluded that conchal cartilage achieved symmetric and functional results . turkaslan et al . described a technique to place a cartilage graft at the posterior dome area after the release of cleft side ala from vestibular mucosa and skin to elevate the ala depression and tip projection . septal cartilage was used in presented case and was satisfactory and a second donor site morbidity was avoided . flores published a retrospective review where a combination of dibbell and tajima was used and concluded that there was a statistically significant decrease in alar base width , increase in columellar height and nostril height on the affected side . there are very few studies to assess the outcomes of cleft lip rhinoplasty in terms of patients satisfaction . evaluated esthetic and respiratory outcome with active change in nasal airflow and hydraulic diameter could be found and hence stated that while esthetic improvement of the cleft nose is a goal , which can be achieved in regularity nasal respiration still seems to be a challenge in cleft patients . analysis of respiratory outcome was not done in the case presented though the patient was satisfactory about the aesthetic result . there are very few studies to assess the outcomes of cleft lip rhinoplasty in terms of patients satisfaction . evaluated esthetic and respiratory outcome with active change in nasal airflow and hydraulic diameter could be found and hence stated that while esthetic improvement of the cleft nose is a goal , which can be achieved in regularity nasal respiration still seems to be a challenge in cleft patients . analysis of respiratory outcome was not done in the case presented though the patient was satisfactory about the aesthetic result . sandor and ylikontiola in their study on 35 patients with cleft nasal deformity treated by external rhinoplasty evaluated for satisfaction and perception of outcomes . the highest improvement was seen for the tip , followed by alar position , dorsum and symmetry of nostrils . leipzig in a similar study described high satisfaction rates by patients undergoing surgery for cleft nasal deformities . correction of the deformity requires a thorough and in detail understanding of the anatomy of cleft pathology and accurate assessment of both esthetic and functional impairments . open external approach rhinoplasty allows maximum exposure for structural graft placement to improve tip projection , definition , support , and function .

it is universally accepted that correction of cleft lip nose deformity remains a formidable challenge for any cleft surgeon . the nose is a prominent part of the face , and hence a masterly executed cleft lip repair directs the beholders eyes from the deformed lip to the deformed nose . a deformed nose that results from unilateral cleft of the lip and palate is likened to a tent whose one side is depressed . many investigators believe that the deformity of the nose is produced by the malpositioning of essentially normal structures , on the other hand some cleft surgeons contend that it is the intrinsic defects in nasal structures that result in cleft nasal deformity . depressed and hypoplastic bony scaffolding is the most important aspect of cleft nose deformity and addressing this aspect of cleft nose deformity is the secret of success of a perfect secondary rhinoplasty . controversy still exists on timing of cleft nasal deformity . proponents of delayed nasal repair suggest that altering the cartilages in early nasal repair at the time of lip repair would complicate future corrective nasal surgeries if the primary repair would prove unsatisfactory . the correction of nasal deformity could be performed with closed or open technique . this paper highlights one such challenging unilateral cleft lip nasal deformity in a adult patient treated by secondary rhinoplasty by open technique .

brain fingerprinting is a variant of the guilty knowledge or concealed information test ( gkt / cit ; lykken 1959 , 1960 ) . the cit aims to determine the presence or absence of crime - related information in a suspect s memory . it has been used with a variety of dependent measures , most notably with recordings of autonomic nervous system ( ans ) measures , such as skin conductance ( ben - shakhar and elaad 2003 ) . the variant of the cit with erps was first investigated in the late 80ties ( farwell and donchin 1986 ; rosenfeld et al . a number of different protocols that use the p300 waveform to assess recognition of crime details have been developed , including the farwell and donchin ( 1991 ) protocol , which farwell later labeled brain fingerprinting. the brain fingerprinting approach is based on research on the p300 component , a positive brain potential that occurs between approximately 300 and 800 ms after stimulus presentation . the p300 is typically elicited in a so called oddball paradigm ( donchin 1981 ) . in this paradigm the participants are presented with a sequence of events , with each event belonging to one of two categories . normally events belonging to one of the categories are presented only rarely , and these events elicit a more pronounced p300 . the logic underlying p300-based cit is that as the crime relevant stimuli form a distinct - rare category relative to more frequently presented irrelevant stimuli and consequently they will elicit an enhanced p300 only in knowledgeable ( guilty ) participants . farwell ( 2012 ) misrepresents the status of brain fingerprinting throughout his article . using grandiloquent language [ prior to the invention of brain fingerprinting , the state of the art in forensic science , investigations , and criminal justice was as follows ( farwell 2012 , p. 116 ) ] , brain fingerprinting is a variant of the cit , which has been successfully applied with ans measures for decades . farwell erroneously claims that the ans measures used in the cit measure deception , while his brain fingerprinting measures recognition of crime details ( farwell 2012 p. 117 ) . in fact , even though ans measures and erps do not necessarily tap the same psychological process , both can and have been successfully used for the detection of crime details . ( 1965 ) , has established that the p300 is elicited by any event that violates the subject s expectancies . in fact , in various studies conducted in donchin s lab in the 70s and 80s , it was noted that occasionally some frequent events that were meaningful to some participants elicited a p300 , and it was these observations that ultimately led to the p300 based cit published in farwell and donchin ( 1991 ) . thus , there is no simple one - to - one relationship between the p300 and memory . even though information stored in memory may very well cause some events to be identified as distinct and therefore elicit a p300 , reducing the p300 to a simple aha ! response driven by recognition of the relevant information contained in the probes as significant in the context of the crime ( farwell 2012 , p. 149 ) is quite at variance with what is known about the p300 . the p300-mermer , a response that farwell claims to have discovered and for which he obtained a patent , is unlikely to solve the problem caused by the lack of a one - to - one relationship between p300 and memory . farwell describes this p300-mermer as the response including the p300 , a late negative peak and a short - term shift in the frequency of the eeg signal . yet the exact definition of the p300-mermer remains vague and unclear ( see rosenfeld 2005 for an extended discussion ) , and as far as we can tell , farwell never published any data in peer reviewed journals showing that the p300-mermer has any incremental validity beyond the p300 alone . interestingly , the university of illinois patented the original p300 based cit as published in farwell and donchin ( 1991 ) . and conveniently , the discovery and patenting of the mermer liberates him from the constraints of this earlier patent . farwell ( 2012 ) reviewed and summarized 13 of his own studies ( see tables 2 and 3 in farwell ( 2012 ) ) . more specifically , these tables include 3 laboratory studies with a total of 73 participants and 10 field / real - life studies with a total of 132 participants . all these studies show 100 % accuracy in the detection of both the presence or absence of critical information . however , a close inspection of the studies listed by farwell ( 2012 ) leads to a much less optimistic view of the brain fingerprinting technology . first , of the 3 laboratory studies listed , only 1 ( farwell and donchin 1991 ; experiment 1 ) was published in a peer reviewed journal . farwell lists 40 participants under this study ( see farwell 2012 ; table 2 ) , but in fact it included only 20 participants , each tested twice ( once in a guilty and once in an innocent condition ) in a within subject design . the other two studies are merely brief conference abstracts ( farwell and donchin 1988 ; farwell and richardson 2006a ) , and not articles published in peer reviewed journals . needless to say , such conference abstracts do not contain sufficient details to judge the merits of the study , let alone allow for replication . moreover , the 4 participants from farwell and donchin ( 1988 ) are reported twice as they were also included in experiment 1 of farwell and donchin ( 1991 ) . in sum , laboratory research on brain fingerprinting published in peer - reviewed journals amounts to a single study containing 20 participants . of the 10 studies that farwell calls field / real - life studies , farwell and donchin ( 1991 ; experiment 2 ) contained 4 participants not 8 as listed in table 3 of farwell ( 2012)who were tested on minor real life crimes such as underage drinking ( guilty condition ) and on crimes committed by other participants ( innocent condition ) . the other peer reviewed article ( farwell and smith 2001 ) contained 6 participants who were tested on specific issues such as presence at a birthday party celebration in a restaurant . three of them were tested on their own biographical data ( guilty ) , while the other 3 were tested on information they were not aware of ( innocent ) . all other studies listed are either conference presentations ( farwell 2009 ) , or abstracts ( farwell 1992 , 2008 ; farwell and donchin 1986 ; farwell and richardson 2006b ; farwell et al . once again , the same 4 participants are listed twice in table 3 of farwell ( 2012 ) , as two different studies ( each time as 8 participants ) , once under farwell and donchin ( 1986 ) and then again under real life experiment 2 ( farwell and donchin 1986 , 1991 ; farwell 1992 ) . in sum , the peer reviewed data on brain fingerprinting published by farwell and his colleagues is limited to 3 datasets with a total of 30 participants , published in two peer reviewed articles . in total , 48 correct and 6 indeterminate decisions were made in these data sets ( see table 1).table 1overview of studies on brain fingerprinting published in peer reviewed journals by farwell and colleaguesstudyn participantscorrect guilty verdicts ( indeterminates)correct innocent verdicts ( indeterminates)laboratory studies farwell and donchin 1991 , experiment 12018 ( 2)17 ( 3)autobiographical studies farwell and donchin 1991 , experiment 244 ( 0)3 ( 1 ) farwell and smith 200163 ( 0)3 ( 0)total3025 ( 2)23 ( 4 ) overview of studies on brain fingerprinting published in peer reviewed journals by farwell and colleagues farwell s finding of 100 % accuracy stands in sharp contrast with the available literature ( see rosenfeld 2011 for a review ) , and is based upon a highly selective review . these twenty standards , however , represents merely farwell s subjective views , rather than a consensus within the relevant scientific community . he neglects to mention that studies demonstrating high detection accuracy rates also fail to meet some of these standards . in fact , his own work ( farwell and donchin 1991 ) fails to meet some of these standards . a case in point here is farwell s standard 4 stipulating that stimuli designated as targets should also be crime related . the original design of farwell and donchin ( 1991 ) embedded the crime relevant details in a classical oddball sequence among frequent irrelevant events . some of the frequent irrelevant events were designated as targets and required a deviant button press . these targets had absolutely no relationship to the crime ( relevant to task , not to crime ; farwell and donchin 1991 , table 1 ) and merely created a known rare category thereby providing a baseline of the subject s normal p300 . it is only under these circumstances that the elicitation of a p300 by the crime relevant events can be properly interpreted . farwell , for some unexplained reason , now advocates the use of crime relevant events as targets , creating a different protocol . yet he fails to discuss that farwell and donchin ( 1991 ) does not meet this standard . besides failing to meet standard 4 , farwell and donchin ( 1991 ) also fails to meet standards 8 and 10 . yet for studies demonstrating less impressive accuracy rates , he hastens to indicate which of the standards they fail to meet . similarly , studies demonstrating that brain fingerprinting is sensitive to countermeasures are dismissed because they do not meet all of the 20 standards , while no peer reviewed data showing that farwell s technique is highly resistant to countermeasures are provided . it is important to realize that the need to publish data in refereed journals is not a merely formal requirement . only experts in the field are capable of conducting a proper evaluation of the methods employed , the research methodology and statistical analyses used by the researcher and consequently assess the merits of the reported results . furthermore a recent article ( simmons et al . 2011 ) demonstrated that inflated effect sizes are often reported even in peer reviewed journals when the methods , procedures and data analysis techniques are not properly described . all the cited farwell studies except perhaps two did not even come close to meeting the recommendations made by simmons et al . share a positive view towards the use of erps for the detection of concealed information ( see also iacono 2008 ) . the cit is regarded a valid paradigm ( verschuere et al . 2011 ) , the p300 waveform is a well - established phenomenon researched in over a thousand peer reviewed publications , and many studies on the use of erp for the detection of concealed information have been published in leading peer reviewed journals . yet , the publication by farwell ( 2012 ) has no place in a peer reviewed journal . by selectively dismissing relevant data , presenting conference abstracts as published data , and most worrisome , deliberately duplicating participants and studies he misrepresents the scientific status of brain fingerprinting . thus , the review violates some of the cherished canons of science and if dr .

in a recent issue of cognitive neurodynamics farwell ( cogn neurodyn 6:115154 , 2012 ) published a comprehensive tutorial review of the use of event related brain potentials ( erp ) in the detection of concealed information . farwell s review covered much of his own work employing his brain fingerprinting technology . all his work showed a 100 % accuracy rate in detecting concealed information . we argue in this comment that farwell ( cogn neurodyn 6:115154 , 2012 ) is misleading and misrepresents the scientific status of brain fingerprinting technology .

aquatic insects are a major group of arthropods which at least one stage of their life cycle occurs in water . most of them live in water in primary stages that fallowed by terrestrial adult ( eg , ephemeroptera , odonata , plecoptera , trichoptera , megaloptera ) . semi aquatic insect are only associated with aquatic and semi aquatic vegetation , the water s surface , or the margins of water habitats ( merritt and cummins 1996 ) . some species of aquatic insect are medically important vectors that transmit diseases such as malaria , dengue , filariasis , yellow fever , and some other main arboviruses ( foil 1989 ) . furthermore few numberof them have a painful bite that cause dermatological effect on human and animal host ( villiers 1987 ) . some of them act as a host of termatods such as dragonflyand damselfly ( chae et al . 2000 ) . in some countries dragonfly are considered as a threat to the poultry industry because they transmit a parasitc flatworm of prosthogonimus spp ( angel 1973 ) . water quality is evaluated by comparing the number of tolerant species ( some midge larva ) to the number of intolerant species ( ephemeroptera , plecoptera , and trichoptera orders ) ( voshell 2002 ) . furthermore some of these insects are used in toxicological researches in primary stages ( merritt and cummins 1996 ) . aquatic insect are found in a wide variety of aquatic habitats from pond , spring , stream to rivers which are different in salinity , ph and other characteristics . apart from medically importance of aquatic insects , they play an important role in the ecosystem . for instance they serve as food for fish , amphibians , and water birds . some of the aquatic insects are responsible for breaking down the dead leaves and plant parts that fall on the water surface . some of them filter suspended particles in water and cause light reach to bottom of streams where algae grow . another kind of aquatic insects mix soft sediment of bottom while searching for food and this makes bottom appropriate for organisms and this phenomen is due to oxygen enreachment of the bottom . additionally , predator quatic insects reduce the numbers of other invertebrates and help keep to have a balance among different organism and food reservoir ( voshell 2002 ) . apart from researches that have been conducted on culicidae family members , there is a few studies on aquatic insects . the isfahan province located in the center of iran and situated 340 kilometers far away of iran s capital . isfahan region has generally arid climate with hot summer with maximum temperature around 36 c and cool winter . it has an average annual rainfall of 150 millimeter zayandeh roud river in this region provides a suitable habitat for aquatic insect . isfahan province is surrounded by qoum , semnan and markazi provinces to the north , fars and kohkiloiye province to the south , yazd province to the east , and lorestan , khuzestan and chaharmahal to the west . with a total area of around 105 , 937 square kilometers ( 6.57 % total area of iran ) . it lies at an altitude of 1575 meters above sea level at a latitude of 30 42 n to 34 30 n and a longitude 49 36 e to 55 32 e. the climate is temperate . it has the warm and semi - humid climate in north and east parts and cold climate in south . the studied areas were selected by clustered random sampling consist of several localities in the study area . 1684 m ( 32 22 n , 51 22 e ) to baghbahadoran city , ca . 1 ) . map of study area in isfahan province , iran aquatic insects collected in different habitats . the sampling was carried out from rifles , under stones , aquatic vegetation , over hanging terrestrial vegetation , within burrows , leaf packs and fine sediment . the specimens collected by d frame net - collector , plastic pipette and forceps . after collection , all specimens were preserved in 70% alcohol , date and time of sampling and place of collection were recorded on each container . the samples were transferred to the laboratory of medical entomology department , tehran university of medical sciences . then the samples were identified using stereo - typed microscope , and valid identification keys ( clifford 1991 , borror and white 1998 , epler 2001 , bouchard 2004 , sangradub and boonsoong 2006 , subramanian and sivaramakrishnan 2007 , azari - hamidian and harbach 2009 , mullen and durden 2009 ) . the isfahan province located in the center of iran and situated 340 kilometers far away of iran s capital . isfahan region has generally arid climate with hot summer with maximum temperature around 36 c and cool winter . it has an average annual rainfall of 150 millimeter zayandeh roud river in this region provides a suitable habitat for aquatic insect . isfahan province is surrounded by qoum , semnan and markazi provinces to the north , fars and kohkiloiye province to the south , yazd province to the east , and lorestan , khuzestan and chaharmahal to the west . with a total area of around 105 , 937 square kilometers ( 6.57 % total area of iran ) . it lies at an altitude of 1575 meters above sea level at a latitude of 30 42 n to 34 30 n and a longitude 49 36 e to 55 32 e. the climate is temperate . it has the warm and semi - humid climate in north and east parts and cold climate in south . the studied areas were selected by clustered random sampling consist of several localities in the study area . 1684 m ( 32 22 n , 51 22 e ) to baghbahadoran city , ca . aquatic insects collected in different habitats . the sampling was carried out from rifles , under stones , aquatic vegetation , over hanging terrestrial vegetation , within burrows , leaf packs and fine sediment . the specimens collected by d frame net - collector , plastic pipette and forceps . after collection , all specimens were preserved in 70% alcohol , date and time of sampling and place of collection were recorded on each container . the samples were transferred to the laboratory of medical entomology department , tehran university of medical sciences . then the samples were identified using stereo - typed microscope , and valid identification keys ( clifford 1991 , borror and white 1998 , epler 2001 , bouchard 2004 , sangradub and boonsoong 2006 , subramanian and sivaramakrishnan 2007 , azari - hamidian and harbach 2009 , mullen and durden 2009 ) . during several times sampling in the study area a total of 741 aquatic insects were collected that including : 2 orders , 7 families and 12 genera witch summarized in table 1 . in the diptera order there are 3 families : culicidae ( n=384 , 51.82% ) , syrphidae ( n=4 , 0.54% ) and chironomidae ( n=296 , 39.95% ) and coleoptera order was including 4 families : gyrinidae ( n= 6 , 0.81% ) , dytiscidae ( n=24 , 3.23% ) , haliplidae ( n=7 , 0.94% ) , hydrophilidae ( n=20 , 2.7% ) and culex theileri belong to culicidae family was the most frequent ( 51.82% ) moreover peltodytes in the haliplidae family with 0.40% of all collected samples was the least frequent ( table 1 and fig . 2 , 3 ) . the prevalence of some aquatic insects in the study area aquatic insect genus and family composition in study area families of collected aquatic insects , a : hydrophilidae b : haliplidae c : gyrinidae d : dytiscidae e : culicidae f : chironomidae g : syrphidae total number of 741 samples belongs to 2 orders and 7 families and 12 genera were identified using stereo - typed microscope . culex theileri with 51.82% of collected sample was the most abundance frequent ( table 1 and fig . 2 ) . in the same study that conducted in the our study area by shayeghi et al . in 2011 , their result were compatible with our result , for the study on the aquatic insects of isfahan province and also their probable use of biological control , coleoptera order was one of the abundance collected aquatic insect and this result was likely to our result ( shayeghi et al . theileri was the most abundance frequency and their results were agree with our results ( mousa - kazemi et al . this species is the more prevalent species at higher altitudes in rural areas of zanjan province ( ghavami and ladonni 2005 ) and east azerbaijan province ( abai et al . ( 2007 ) conducted a study for studying fauna of aquatic insects in sewage maturation ponds of kashan . the families of chironomidae and hydrophilidae were prevalent . in the other study that conducted by vafaei et al . 2007 for surveying of the aquatic beetles ( coleoptera : polyphaga ) of markazi province ( central iran ) after investigation in freshwater habitats of study area , 24 species ( coleoptera : hydrophilidae , helophoridae , hydraenidae , elmidae , and dryopidae ) belonging to 13 genera and five families were identified and in this study hydrophilidae family was one of the collected samples like present study ( vafaei et al . some aquatic insect are an important for biological control of larvae and adults of mosquitoes in the breeding places also some of these insects play an important role in transmission of some human and animal diseases , for example in iran several species belong to anophelinae sub family including anopheles culicifacies s.l . 2012a , 2012b , 2012c , vatandoost and abai 2012a , soleimani - ahmadi et al . therefore the ecological specifications of these insects could provide a clue for further arthropod - borne disease control . according to the results it could be concluded that there are several species of insects in the study area . they also could be considered as biological control agent for vectors as well as bio indicators .

background : aquatic insects are the major groups of arthropods that spend some parts of their life cycle in the water . these insects play an important role for transmission of some human and animal diseases . there is few information about the aquatic insects fauna of iran.methods:to study the aquatic insects fauna , adult , nymphal and larval collections were carried out from different habitats using the standard technique in zayandeh roud river , isfahan province , central iran , during summer 2011.results:in total , 741 speimens of aquatic insects were collected and morphologically identified . they include 7 families and 12 genera representing 2 orders . the order of diptera ( 92.31% ) and coleoptera ( 7.69% ) . the families culicidae , syrphidae and chironomidae from diptera order , gyrinidae , dytiscidae , haliplidae , hydrophilidae from coleoptera order were identified.conclusion:some aquatic insects play an important role for transmission of human and animal diseases . these insects also are important for biological control . therefore ecological study on aquatic insects can provide information about ecology of insects in an area for any decision making .

it has a propensity for leptomeningeal spread via the cerebrospinal fluid ( csf ) circulation , and approximately 3035% of the patients present with evidence of metastatic disease . currently , patients with disseminated medulloblastoma are classified according to chang 's operative staging system , where the extent of metastasis is subdivided into m0 ( no metastasis ) , m1 ( presence of tumor cells in the csf ) , m2 ( nodular seeding in the cerebellar or cerebral subarachnoid space or in the third or lateral ventricle ) , m3 ( metastasis in spinal subarachnoid space ) , and m4 ( metastases outside the cerebrospinal axis ) . this sensitive operative system was initially determined from operative records and autopsy specimens and has been later adapted to modern imaging techniques such as mri . neither the extent nor the various aspects of the metastases are taken into account , and only the location is considered . the relevance of intracranial ( m2 ) and spinal ( m3 ) leptomeningeal spread for classification as high - risk disease is unequivocal and the outcome for m2 patients is not significantly different from m3 patients [ 1 , 3 ] . since the original classification in 1969 that did not separate the outcome of patients with m0 and m1 disease , there is still some uncertainty about the prognostic impact of m1 stage [ 38 ] . in addition , the assessment of response to therapy of the metastatic disease is often difficult and limited by the sensitivity of mri . following personal observations , we made the hypothesis that metastases could be further subclassified on the basis of specific phenotypic criteria with potential correlation with patient outcome . in the present study , we investigated whether the mri appearances of metastases and the response to chemotherapy could predict survival in disseminated medulloblastoma . the medical records and imaging of all children with newly diagnosed disseminated medulloblastoma treated at our institution from 1988 to 2008 were reviewed . inclusion criteria for this study were ( 1 ) children < 18 years at diagnosis and ( 2 ) complete medical records including pre- and postoperative cerebral imaging , analysis of csf , and interpretable cranial and spinal mri scans . exclusion criteria were ( 1 ) recurrent medulloblastoma and ( 2 ) previous treatment for malignancy . parents / guardians gave written informed consent for the retrospective analysis of clinical data according to the irb of the gustave roussy institute . for patients entered into ongoing protocols , written informed consent was obtained from their parents / guardians . all patients received the same sandwich chemotherapy , with a combination of carboplatin and etoposide . patients older than 5 years of age were treated by conventional chemotherapy with craniospinal irradiation ( csi ) ( 3035 gray ( gy ) ) [ 3 , 11 ] or sequential hdct with asct followed by standard dose csi ( 36 gy ) [ 12 , 13 ] . children younger than 5 years of age were treated by high - dose chemotherapy ( hdct ) with autologous stem cell transplantation ( asct ) followed by local radiation therapy to the posterior fossa ( 5055 gy ) or sequential hdct with asct followed by reduced dose csi . cytological analysis of csf collected by lumbar puncture was performed between the 7th and 15th postoperative day . the presence of metastases was evaluated by the initial cranial and spinal mri according to chang 's staging system . metastases were described according to their phenotype ( nodular , laminar ) ( figure 1 ) and their extension ( localized , extensive ) . nodular metastases were defined as an abnormal deposit with gadolinium enhancement measurable in two dimensions . laminar metastases were defined as abnormal appearances with gadolinium enhancement that were not measurable in two dimensions . metastases were classified as laminar where there was coexistence of metastases of laminar and nodular appearance . extent of disease was defined as localized in the case of a single metastasis or in the same area ( e.g. , periventricular , spinal conus ) and extensive when there was more than one metastasis in 2 different sites . according to these radiological criteria , we considered two classifications : qualitative classification ( positive csf , nodular , laminar ) and quantitative classification ( positive csf , localized , extensive ) . after each cycle of chemotherapy , cranial and spinal mri were performed , and children underwent cytological analysis of csf if initially positive for tumor cells . patients were considered as having incomplete followup if they were not seen 6 months before the time of analysis . ( chang 's , qualitative and quantitative classifications ) with overall survival and with early complete response was investigated as well as the influence of age at diagnosis ( age < 5 years or age 5 years ) and treatment . overall survival ( os ) was defined as the time from the date of diagnosis to the date of death or last contact and progression - free survival ( pfs ) from the date of diagnosis to the date of first recurrence or death . complete response was defined as the total disappearance of a residual primary tumor and metastases ( radiological and/or csf metastases ) during or at the end of chemotherapy . because classical criteria of partial response ( > or < 50% ) are difficult to apply to both leptomeningeal lesions and csf involvement , data were classified as partial response when radiological response of lesions was observed in combination with a negative csf cytology , as stable disease in the case of ( a ) positive csf at diagnosis ( m1 ) which remained positive or ( b ) stable radiological imaging ( without progression in csf cytology ) , and as progressive disease when progression on imaging was noted or when negative csf cytology became positive . response rates were compared using nonparametric tests : chi - square or exact fisher test . os and pfs were estimated using the kaplan meier method and rothman 's 95% confidence intervals [ 95% ci ] and compared using the logrank test . median followup was estimated using the inverse kaplan - meier method . in a multivariate analysis of os , the hazard ratios ( hrs ) of death and their 95% ci were estimated using the cox proportional hazards model . in a multivariate analysis of complete response , the hazard ratios ( hrs ) of event and their 95% ci were estimated using logistic regression . all the median age at diagnosis was 4 years ( range , 014 ) , and 68 ( 58% ) were less than 5 years . thirty - eight children ( 32% ) were treated by conventional chemotherapy ( etoposide and carboplatin ) followed by csi at conventional doses . hdct with asct followed by local radiation therapy to the posterior fossa was performed in 10 patients ( 9% ) . forty - seven ( 40% ) children received sequential hdct with asct followed by reduced dose csi , and 22 patients ( 19% ) were treated with sequential hdct with asct followed by standard dose csi . table 1 presents the pattern of metastatic disease according to the 3 classification systems . among the 36 patients with nodular metastasis , 15 ( 42% ) for the 51 patients with laminar metastasis , 10 ( 17% ) were m2 and 49 ( 83% ) were m3 . of the 26 children with localized metastasis , 18 ( 69% ) were m2 stage and 8 ( 31% ) were m3 , and of the 69 with extensive metastasis , 7 ( 10% ) were m2 stage and 62 ( 90% ) were m3 . sixty - one percent of patients older than 5 years of age had nodular metastases . the median followup was 8 years ( range , 117 ) . for 19 children , the followup was incomplete with a median time between the last followup and the time of analysis of 22 months ( range , 778 months ) . sixty - six deaths were noted : 64 patients from disease and 2 from treatment - related toxicity . there were two cases of second tumor , one with brainstem glioma 58 months after the initial diagnosis and one renal carcinoma 106 months after the initial diagnosis . the estimated five - year overall survival ( os ) and progression - free survival ( pfs ) rates among the 117 children were 45% ( 95% ci : 3655% ) and 38% ( ci 95% : 2947% ) , respectively . the early response rate to sandwich chemotherapy the median delay from the date of diagnosis to the date of assessment of response to sandwich chemotherapy was 67 days ( range , 26340 ) . a complete response to sandwich chemotherapy was observed in 27 ( 23% ) of the 117 patients . os was higher among these 27 patients than among the 90 patients with residual disease , p = 0.0008 ( figure 2 ) . univariate analysis identified age less than 5 years as significantly associated with poor survival and poor early response rate . overall survival was lower for children younger than 5 years than for those aged 5 or more ( hr : 2.5 ( 1.54.2 ) , p = 0.001 ) . the hr of no early complete response for children younger than 5 years compared to children of 5 years or more was 3.1 ( 1.37.5 ) , p = 0.014 . there was no significant association between initial treatment and os ( p = 0.290 ) . thus the multivariate analysis was adjusted for age ( < 5 years/5 years ) only . in the univariate analysis , the qualitative classification was significantly correlated ( p = 0.04 ) with os ( table 3 ) . os was higher for children with nodular metastasis ( hr = 0.6 ( 0.31.2 ) ) and lower for children with laminar metastasis ( hr = 1.3 ( 0.72.5 ) ) , compared to children with positive csf . the five - year os rates were 47% , 59% , and 35% for patients with positive csf , nodular metastases , and laminar metastases , respectively ( figure 3 ) . there was no significant correlation of os with either the chang classification ( p = 0.95 ) or the quantitative classification ( p = 0.12 ) . according to chang 's staging system , the five - year os rates were 47% , 51% , and 42% for m1 , m2 , and m3 stage , respectively ( figure 4 ) . in the multivariate analyses , after adjustment on age , none of the three classifications was associated with os , even when qualitative and quantitative classifications were combined . chang 's , qualitative and quantitative classifications are significantly associated with early complete response rate after sandwich chemotherapy in univariate and multivariate analyses ( table 2 ) . in this retrospective review of 117 children with disseminated medulloblastoma treated at a single institution , we found that the phenotype of metastasis had an impact on os . patient with nodular metastasis had a better survival than the patients with other metastatic groups . diffuse metastases ( i.e. , laminar metastases , m1 disease ) were associated with a more aggressive disease than those with nodular disease . the impact of the phenotype of metastases on os has not been published previously . in this study , the qualitative classification was significantly correlated with os ( p = 0.04 ) in univariate but not in multivariate analysis . since the phenotype of the metastases was associated with age in our study , we may have lost its effect on prognosis by adjusting the multivariate analysis on age . moreover , since response to chemotherapy is associated with the phenotype of the metastases and is the strongest prognostic factor identified in our study , different treatment policies according to age may confound the results of the multivariate analysis . we can hypothesize that there are intrinsic biological differences linked to age that drive the phenotype of the metastases and their response to chemotherapy . the chang 's operative staging system was initially shown to predict outcome according to the t stage , that is , tumor size and invasion , although recent publications have failed to show an impact of t stage on survival [ 19 , 20 ] . the chang system did not , however , include prognostic information with respect to the different m stages . subsequent studies have clearly shown the adverse prognostic factor of the presence of metastasis . in many studies , the high - risk group was defined as chang m2 and m3 stage , and the outcome for m2 patients was not significantly different from m3 patients [ 1 , 3 , 8 , 21 , 22 ] . there remained doubt , however , about the prognostic significance of m1 stage and whether patients with m1 disease constituted a truly high - risk group . several studies have found an intermediate risk for m1 metastases , with outcomes rates lower than in m0 but superior to m2/3 dissemination [ 38 ] . in our study , we found that patients with m1 disease ( with / without residual mass ) are truly high - risk patients with no significantly different outcome compared with solid metastases . sanders et al . showed recently that patients with m1 disease have reduced rates of efs and os compared to those with m0 disease . children younger than 3 years of age with m1 mb had significantly decreased efs compared to those with m0 disease and in fact fared as poorly as those with macroscopic metastatic disease ( m2/m3 ) . on the other hand , in the german hit 91 trial , patients with m1 disease had a similar outcome to those with m0 with 3-year efs of 72% , 65% , and 30% for patients with m0 , m1 , and m2/3 disease , respectively . one has to take into account the type of treatment since the hit'91 trial randomizing sandwich against maintenance chemotherapy found a better outcome for the m1 patients in the maintenance arm ( i.e. , with early radiotherapy ) and a better outcome for the m2/m3 patients in the preirradiation chemotherapy arm . since our policy was to give the same sandwich chemotherapy to all patients , this may have been detrimental to m1 patients , while beneficial for m2/m3 patients . the earlier response to we found that patients in complete remission after preirradiation had significantly a better os compared those not in complete remission . the prognostic impact of early response to chemotherapy found in our study is consistent with others ' reports [ 24 , 25 ] . in summary , findings in this study suggest that the phenotype of metastases should be taken into account when describing a population of children with metastatic medulloblastomas . if confirmed by further prospective studies , this report suggests that treatment strategies for metastatic medulloblastoma need to be refined taking into account the nature as well as the presence of metastases . the early response to sandwich chemotherapy may also help us to stratify the treatment of children with disseminated medulloblastoma .

purpose . to correlate the radiological aspects of metastases , the response to chemotherapy , and patient outcome in disseminated childhood medulloblastoma . patients and methods . this population - based study concerned 117 newly diagnosed children with disseminated medulloblastoma treated at the institute gustave roussy between 1988 and 2008 . metastatic disease was assessed using the chang staging system , their form ( positive cerebrospinal fluid ( csf ) , nodular or laminar ) , and their extension ( positive cerebrospinal fluid , local , extensive ) . all patients received preirradiation chemotherapy . results . the overall survival did not differ according to chang m - stage . the 5-year overall survival was 59% in patients with nodular metastases compared to 35% in those with laminar metastases . the 5-year overall survival was 76% in patients without disease at the end of pre - irradiation chemotherapy compared to 34% in those without a complete response ( p = 0.0008 ) . conclusions . radiological characteristics of metastases correlated with survival in patients with medulloblastoma . complete response to sandwich chemotherapy was a strong predictor of survival .

a 56-year - old man was observed in the emergency room ( er ) 4050 min after the onset of acute de - novo stabbing , pulsating and diffuse headache with subsequent appearance ( within few minutes ) of dysarthria , postural instability with retropulsion , mild objective vertigo and vomiting , acral paresthesias of upper limbs , minimal confusional state without loss of consciousness or seizures . neurological examination was relevant for reagent anisocoria ( left smaller than right ) , slight speech disorder ( dysarthria ) , retropulsion , moderate bilateral incoordination at the index - nose test , absence of fever and meningeal signs . blood pressure ( bp ) was unstable with recurrent hypertensive crises ( 200/120 mmhg ) during observation , in the absence of definite previous history of hypertension as well as of diabetes , headache , or cardiovascular problems . electrocardiographic monitoring excluded paroxysmal arrhythmias , while cardiac enzymes and creatine - kinase were negative . in the er , he was started on intravenous ( i.v . ) nimodipine ( 2 mg / hour ) with progressive normalization of bp values within 4 h. urgent brain computerized tomography ( ct ) was negative for hemorrhage and focal lesions . considering the unstable bp and the low nihss ( national institutes of health stroke scale ) score ( =3 ) at presentation , i.v . thrombolysis for possible brainstem ischemia was excluded , and the patient was put on antiplatelet therapy with salicylic acid ( i.v . 250 mg for 24 h , followed by oral administration ) as for a minor ischemic events . under i.v . salicylic acid , headache severity gradually decreased over the next 3 h , leaving only a slight diffuse , pulsating pain which remitted over the next 6 h. all the neurological signs and symptoms had completely recovered within 12 h. in order to investigate the vertebro - basilar ( vb ) district , the patient also underwent urgent brain ct - angiography with maximum intensity projection ( mip ) , multiplanar ( mp ) and three - dimensional ( 3d ) reconstructions , with the detection of left persistent primitive hypoglossal artery ( ppha ) as a large vessel originating from the internal carotid artery ( ica ) at the c2 vertebral level , entering the posterior cranial fossa through an enlarged hypoglossal canal and thus joining the lower portion of the basilar artery ( fig . 1 ) . the study was then completed through 3d volume - rendering ( vr ) reconstructions for a better definition of the anatomical details ( fig . 1 ) . collateral findings were represented by bilateral vertebral artery hypoplasia together with a small saccular aneurysm ( not - surgical ) of the anterior communicating artery , confirmed by digital subtraction angiography ( dsa ) which revealed no additional vascular abnormalities . brain magnetic resonance ( mr ) with mr - diffusion weighted imaging ( mr - dwi ) was performed 24 h after onset of symptoms and did not show recent ischemic lesions . the electroencephalogram performed 12 h after admission did not record epileptic / focal abnormalities . uncommon causes of stroke ( thrombophilia , patent foramen ovale and other relevant metabolic risk factors for stroke ) were excluded during the course of the observation.fig . 1a axial brain ct - angiography , b , c mip and 3d - reconstruction ct - angiography showing left ppha ( arrows ) . d three - dimensional - vr ct - angiography showing ppha ( arrow ) entering the posterior cranial fossa through an enlarged hypoglossal canal and thus joining the lower portion of the basilar artery , and in e ppha ( arrow ) as a large vessel originating from the internal carotid artery at the c2 vertebra level a axial brain ct - angiography , b , c mip and 3d - reconstruction ct - angiography showing left ppha ( arrows ) . d three - dimensional - vr ct - angiography showing ppha ( arrow ) entering the posterior cranial fossa through an enlarged hypoglossal canal and thus joining the lower portion of the basilar artery , and in e ppha ( arrow ) as a large vessel originating from the internal carotid artery at the c2 vertebra level the patient was then discharged with ramipril ( 5 mg per day ) plus oral salicylic acid ( 100 mg per day ) and at the 6-month control no further episode of headache with or without neurological symptoms was reported . headache associated to vb signs and symptoms , once excluded critical conditions , could suggest at least four possible diagnoses : ( 1 ) basilar - type migraine , ( 2 ) posterior reversible encephalopathy syndrome ( pres ) , ( 3 ) headache attributed to benign ( or reversible ) angiopathy of the central nervous system , and ( 4 ) headache attributed to transient ischemic attack ( tia ) or minor stroke , whose diagnostic criteria are summarized in table 1.table 1diagnostic criteria for basilar - type migraine , posterior reversible encephalopathy syndrome ( pres ) , headache attributed to benign ( or reversible ) angiopathy of the central nervous system , and headache attributed to transient ischemic attack ( tia)basilar - type migraine migraine with aura symptoms clearly originating from the brainstem and/or from both hemispheres simultaneously affected , but no motor weakness(a ) at least 2 attacks fulfilling criteria b d(b ) aura consisting of at least two of the following fully reversible symptoms , but no motor weakness : dysarthria , vertigo , tinnitus , hypacusia , diplopia , visual symptoms simultaneously in both temporal and nasal fields of both eyes , ataxia , decreased level of consciousness , simultaneously bilateral paraesthesias(c ) at least one of the following : ( 1 ) at least one aura symptom develops gradually over 5 min and/or different aura symptoms occur in succession over 5 min ( 2 ) each aura symptom lasts 5 and 60 min(d ) headache fulfilling criteria b d for 1.1 migraine without aura begins during the aura or follows aura within 60 min(e ) not attributed to another disorderposterior reversible encefalophathy syndrome ( pres ) acute or subacute neurologic presentation of headeache , nausea , vomiting , altered mental function , seizures , stupor , visual disturbancesradiological hallmarks : reversible bilateral subcortical and cortical edema with a predominantly posterior distribution ( parieto - occipital ) at fluid - attenuated inversion recovery ( flair ) mri imagingheadache attributed to benign ( or reversible ) angiopathy of the central nervous system ( a ) diffuse , severe headache of abrupt or progressive onset , with or without focal neurological deficits and/or seizures and fulfilling criteria c and d(b ) strings and beads appearance on angiography and subarachnoid hemorrhage ruled out by appropriate investigations(c ) one or both of the following : ( 1 ) headache develops simultaneously with neurological deficits and/or seizures ( 2 ) headache leads to angiography and discovery of strings and beads appearance(d ) headache ( and neurological deficits , if present ) resolves spontaneously within 2 monthsheadache attributed to transient ischemic attack ( tia ) ( a ) any new acute headache fulfilling criteria c and d(b ) focal neurological deficit of ischemic origin lasting < 24 h(c ) headache develops simultaneously with onset of focal deficit(d ) headache resolves within 24 h diagnostic criteria for basilar - type migraine , posterior reversible encephalopathy syndrome ( pres ) , headache attributed to benign ( or reversible ) angiopathy of the central nervous system , and headache attributed to transient ischemic attack ( tia ) according to the current criteria of the international classification of headache disorders2nd ed . ( ichd - ii ) , our case potentially fulfills only some of the diagnostic criteria for basilar - type migraine ( 1.2.6 ) : headache , dysarthria , vertigo ( with onset / worsening in few minutes ) , ataxia , decreased level of consciousness and simultaneous bilateral paraesthesias . however , the neurological symptoms have lasted over 60 min and were associated with de - novo headache ( first episode ) , thus excluding the above hypothesis ( table 1 ) . the second diagnosis we have considered , is pres , a rare and still poorly understood condition characterized by acute or subacute headache ( usually thunderclap type ) , nausea , vomiting , altered mental function , seizures , stupor and/or visual disturbances , with the radiological hallmarks of reversible bilateral subcortical and cortical edema with a predominantly posterior distribution ( parieto - occipital ) at fluid - attenuated inversion recovery ( flair)-mr sequences . pres has been described in association with hypertensive encephalopathy , immunosuppressive and cytotoxic medications , puerperal eclampsia , collagen disease , renal failure , thrombotic thrombocytopenic purpura , human immunodeficiency virus infection , acute intermittent porphyria , and organ transplantation . in our case , the lack of the typical mr findings and the negative electroencephalogram tend to rule out this diagnosis . headache attributed to benign ( or reversible ) angiopathy of the central nervous system ( ichd - ii 6.7.3 ) . in our case , despite the complete reversibility of all neurological signs , the lack of the radiological hallmarks strings and beads and the full headache recovery within 12 h , excludes this nosological entity ( table 1 ) . the last possible and more suitable diagnosis is that of headache attributed to transient ischemic attack ( tia)ichd - ii 6.1.2 in fact , headache occurs frequently in patients with acute cerebrovascular disorders with a frequency according to different studies ranging from 7 to 65% . several authors have stressed the greater incidence of headache among patients with ischemic events , particularly vb infarcts , due to the anatomical relationship between the posterior circulation and the trigeminal system . although relatively less frequent during tia , sudden and acute headache of unknown cause , associated to dizziness or loss of balance , may represent a warning sign of vb failure . the most common symptoms of extracranial vertebral artery involvement are represented by dizziness , blurred vision and imbalance , while vertigo is more typical of intracranial vertebral artery disease . on the other hand , tia due to basilar artery failure produces , more frequently , dizziness , double vision , dysphagia , slurred speech and unilateral / bilateral weakness . symptoms and signs due to tia ( either carotid or vb ) must resolve by definition within 24 h but sometimes they may be very brief lasting few minutes probably due to sudden and temporary bp failure . in this perspective , sacco et al . have suggested to review the ichd - ii diagnostic criteria for 6.1.2 in the agreement with the new definition of tia proposed by the american heart association study group . accordingly , tia is now defined as a transient episode of neurological dysfunction caused by focal brain , spinal cord or retinal ischemia , without acute infarction thus reducing the importance of the traditional temporal criterion for the definition of tia ( duration < 24 h ) . as a consequence , brain - mr imaging becomes now the crucial recommended tool for tia diagnosis . besides the above conditions discussed in the differential diagnosis versus the most probable hypothesis of headache attributed to transient ischemic attack ( tia ) or minor stroke , we can also exclude ichd - ii 10.3.2 ( headache attributed to hypertensive crisis without hypertensive encephalopathy ) , due to the presence of long - lasting focal neurological signs . in the present case , de - novo acute headache and transient ischemia in the posterior circulation are associated with the evidence of ppha , a rare vascular anomaly of the posterior circulation that ensures a pathological anastomosis between carotid and basilar system . at the intracranial level , four embryonic arteries ( trigeminal , otic , hypoglossal and proatlantal ) participate to the vb development : once completed , these vessels gradually regress , but in some cases they may persist . the detection is often fortuitous during angiographic examination . the trigeminal artery is generally associated with disorders of the 3rd , 4th , 5th and 6th cranial nerves , while the otic artery may cause acoustic or facial nerves palsy . the hypoglossal artery may lead to 12th nerve palsy , glossopharingeal neuralgia or vascular disorders in the posterior circulation . it originates as a branch of the cervical part of the ica between c1 and c3 levels , passes through the hypoglossal canal and joins the lower portion of the basilar artery after a tortuous course . consequently , any significant alteration of the blood flow in the proximal ica may affect the posterior circulation with possible reversible vb symptoms . less frequent is usually associated to ischemic lesions . from a pathogenetic point of view , it seems therefore reasonable to consider , in our case , the particular vulnerability of the posterior circulation due to the ppha , the associated vascular abnormalities , and its possible secondary , transient , hemodynamic failure during hypertensive phases . our clinical picture may be classified as a real tia of the posterior circulation , also considering the complete clinical recovery within 24 h and the absence of ischemic lesions ( including lacunar events ) on mr investigations . moreover , the headache presented by the patient , meets the ichd - ii diagnostic criteria for headache attributed to transient ischemic attack ( tia)subgroup 6.1.2 . in conclusion , the persistence of carotid - basilar anastomoses , although rare entities , must be considered not only in patients with isolated or combined cranial nerve deficit , but also in the presence of cerebrovascular events involving the vb system . their association with other vascular abnormalities ( hypoplasia ) can confer increased vulnerability to other factors ( hypertension ) as in the present case .

we report the case of a 56-year - old man with acute onset of de - novo stabbing , pulsating and diffuse headache with subsequent appearance ( within few minutes ) of posterior fossa symptoms ( vomiting , postural instability , anisocoria , incoordination , dysarthria , retropulsion ) lasting 912 h. recurrent hypertensive crises were detected during the acute observation in the emergency room , even in the absence of previous history of hypertension . once subarachnoid hemorrhage and focal lesions ( vascular and non - vascular ) were excluded , brain computerized tomography - angiography and digital subtraction angiography disclosed the presence of left persistent primitive hypoglossal artery with bilateral vertebral artery hypoplasia and a slight aneurysmal dilation of the anterior communicating artery . brain magnetic resonance study performed 24 h after onset of symptoms was negative for recent ischemic lesions . the clinical features of this rare vascular condition are discussed as a possible cause of magnetic resonance ( diffusion weighted imaging ) negative vertebro - basilar transient ischemic attack .

the midface comprises the medial portion of the face including the upper maxillary region and the zygomatico - orbito - maxillary complex . facial bones , especially of the middle - third of the face , readily fracture more than bones in other parts of the body because they are composed of a network of fragile bones held together across sutures , which easily give way to minimal trauma . maxillofacial injuries in general can occur in isolation , but most of the time when these injuries are as a result of high energy traumatic forces , patients often have other concomitant injuries . these injuries can be very severe and life - threatening often requiring multidisciplinary management . an attempt is made in this present study to determine the pattern of injuries associated with trauma to the midface in an effort to emphasize the multidisciplinary nature of the care needed by many of these patients . this was a prospective descriptive analysis of patients with midfacial injuries seen at our center over a period of 1 year . we defined the midface as the area that lies between the lateral canthus of the eye superiorly and the angle of the mouth inferiorly , which on the facial skeleton extends downwards from the frontal bone to the level of the upper teeth or , if the patient is edentulous , the upper alveolus . midfacial injuries were categorized into soft and hard tissue injuries after clinical and radiographic examinations . for each of the 101 patients seen , the following data were collected : age , gender , mechanism of trauma , type of midfacial injuries and concomitant / associated injuries . concomitant injuries were categorized into fractures other than those of the midface , head / neurological , orbital , thoracic and abdominal injuries . out of the 150 patients that presented to our center with maxillofacial injuries during the period of this study , 101 had midfacial injuries . the 20 - 29 year age group were mostly affected ( 44.6% ) , followed by the 30 - 39 years group ( 19.8% ) [ figure 1 ] and the most common cause of midface injuries was road traffic accident ( rta ) ( 92 patients , 91.1% ) [ figure 2 ] . age incidence of patients presenting with midface injuries mechanism of injury / etiology abrasion was the most common midfacial soft - tissue injury seen ; accounting for 81 ( 40.1% ) out of a total of 202 soft tissue injuries [ table 1 ] , whereas zygomatic complex fracture was the most common hard tissue injury , accounting for 46 ( 46.0% ) fractures among the 100 fractures of the middle - third facial region recorded [ table 2 ] . midfacial soft tissue injuries midfacial hard tissue injuries a total of 144 concomitant injuries were recorded among the patients . out of these , head injury was highest ( 49 ; 34% ) followed by ocular injuries ( 35 ; 24.3% ) [ table 3 ] . the main stay of treatment for midfacial fractures from the above study was conservative management and closed reduction with maxillomandibular fixation . the zygomatico - maxillary complex , due to its prominent position in the face bears the impact of trauma in majority of the cases and has been shown to have the highest incidence of fractures in the maxillofacial region . this assertion is further corroborated by the present study in which most of the patients here were men within the 20 - 29 year age bracket . the main reason among others is the fact that motorbikes are mostly ridden by young men for commercial purpose in our environment and motorbike - related accidents accounted for 45.5% of all the midface injuries in this series . this pattern is in keeping with similar studies both in the developed and the developing world . the 20 - 29 years age group from this study was more involved with middle - third facial injuries than any other age group . the reason is not far - fetched as this age group shows high activity in assaults , sports , industry and high speed transportation . this accounted for the injuries in 92 ( 91.1% ) out of the 101 patients seen . the remaining 8.9% was accounted for by other causes such as assaults , falls , sports injuries and industrial accidents . although this is in consonance with previous nigerian studies and indeed studies from other developing countries , it contrasts reports from the developed countries where assaults and interpersonal violence has replaced rta as the major cause of maxillofacial injuries the reason for this is attributable to the poor state of most nigerian roads , traffic rules are disobeyed and road signs are non - existent . they are often neglected where they exist and most drivers / riders are not properly licensed . the prominence of the zygomatic complex as well as its multiple articulations with other bones of the facial skeleton renders it exceptionally vulnerable to fracture when injuries affect the maxillofacial region . this was our finding from the present study in which zygomatic complex fracture accounted for 46% of all the midface fractures , making it the commonest occurring midface fracture as in some other earlier reports . moreover , it has also been documented by lee et al . in a study on patterns of facial laceration from blunt injury that as the zygoma would fracture more readily than the frontal bone , the soft - tissue overlying the zygoma would therefore suffer a smaller magnitude of force resulting in contusions rather than open wounds . this could possibly explain the results obtained from the present study in which the soft - tissue overlying the zygoma was more affected by contusions and abrasions instead of lacerations [ table 1 ] . upper lip on the other hand was the most common site for open wounds or lacerations as has been previously documented . this is due to the fact that the upper incisors act as sharp objects in cases of injuries to the face , sometimes giving a through and through laceration of the upper lip . maxillofacial injuries in general may occur in isolation or can be associated with other injuries and the same is the case for midfacial injuries . fasola et al . reported 79.6% of associated injuries in their study population and the authors argued that such a high figure was expected because of rta being the major etiological factor . though there is ambiguity about the definition of injuries associated with maxillofacial fractures , the rate of injuries associated with maxillofacial trauma is thought to be quite high , the present study also recorded a rate as high as 83.2% of associated injuries . these associated injuries are reportedly more common when maxillofacial fractures occur from road crashes and high velocity gunshot injuries resulting in multiple organs and systems involvement . in fact , haug et al . was able to show from their series that motorcycle accidents were associated with the most severe head injury . neurological injuries were the commonest occurring concomitant injuries in this study accounting for 47.2% followed by ocular injuries with 24.3% , [ table 3 ] . the proximity of the midface to the eyes and the content of the cranium could as well have accounted for this . hogg et al . also reported head injuries to have accounted for 87% of the associated injuries in their study in ontorio , canada , whereas obuekwe and etetafia reported 55.8% of head injuries in benin city , nigeria . this wide range is probably due to different selection criteria and methods of detecting brain injury . recognizing concomitant injuries in patients with facial fracture is important for rapid assessment and further management of these patients . these results support the use of head computed tomography scan and cervical spine radiographs in most general trauma work - ups , but specifically validates their use in patients with suspected facial fracture . despite the obvious advantages of open reduction and rigid internal fixation of facial fractures , it has not become popular in most developing countries ( including nigeria ) mainly because of the cost . only four patients representing 5.6% had open reduction and internal fixation with trans - osseous wires while the rest had closed reductions [ table 4 ] . nevertheless , previous nigerian reports have attested to the satisfactory results obtained using simple methods of closed reduction and mandibulo - maxillary fixation . knowledge of injuries associated with maxillofacial fractures and coordination of trauma teams , is vital for the early stabilization and treatment of these patients . irrespective of the severity of injury , patients who sustained maxillofacial injury were more likely to be discharged earlier than those with concomitant injuries . the presence of moderate to severe head injury , chest injury and orthopedic injury significantly prolong hospital stay . the usage of protective elements by road users especially motorcycle riders and their passengers should be enforced to reduce the rate of head injury and indeed other associated injuries among trauma patients in general .

aim : the aim of this study was to determine the pattern of midface trauma with associated concomitant injuries seen in our environment.methodology:this was a prospective analysis of trauma patients with midfacial injuries presenting at a referral center in south west nigeria . in addition to socio - demographic data , the following information was also obtained : mechanism of injuries , type of midfacial injuries , concomitant / associated injuries and treatment.results:a total of 101 patients with midfacial injuries were involved . they were made up of 85 males and 16 females . the 20 - 29 year age group was mostly affected ( 44.6% ) and the most common cause of midface injuries was road traffic accident ( 91.1% ) . the zygoma was fractured more than any other midfacial bone ( 46.0% ) . a total of 144 associated injuries were recorded among these patients , head and ocular injuries accounted for 49 ( 34% ) and 35 ( 24.3% ) respectively . the patients were mostly treated conservatively or by closed reduction.conclusion:the rate of head and ocular injuries among patients with midfacial injury was high . knowledge of these associated injuries provides useful strategies for patient care and prevention of further complications . a multidisciplinary approach is important for optimum management of these patients .

patients are often asymptomatic and the anomaly is discovered during imaging studies carried out for other reasons . however , when symptoms are present , they are related to hydro - nephrosis , infection , or calculus formation . the incidence of renal tumor in a horseshoe kidney is higher than in normal population . we present a case of renal cell carcinoma ( rcc ) in a horseshoe kidney . presence of the kidney malformation can change the surgery plan for preserving the organ without removing any functional tissue . a 62-year - old male patient presented to our institute , as a referral case from another hospital , with an abdominal mass . computed tomography ( ct ) scan of abdomen and pelvis was performed utilizing routine ct renal mass protocol . the scan revealed presence of a horseshoe kidney anomaly with a well - enhanced isthmus [ figure 1a ] . by using a power injector , we administered 150 ml of intravenous contrast material at a minimum rate of 3 ml / s . using , a multi - detector row ct scanner , contrast material - enhanced imaging was performed during the corticomedullary and nephrographic phases of enhancement using scanning delays of 40 s and 100 s , respectively . large lobulated mass was identified in the left side of the horseshoe kidney associated with an area of central cystic necrosis . the mass measured about 12 cm 13 cm 15 cm in anterior - posterior , width , and crainio - caudal maximum dimensions , respectively [ figure 1b and c ] . the renal vein and intravenous vena cava were patent and there was no evidence of significant enlarged intra - abdominal lymph nodes . the diagnosis made was rcc with a horseshoe kidney and patient was sent for urology consultation and surgical resection . ( a - c ) ct scan images of the abdomen obtained at the level of inferior mesenteric artery . ( a ) before administration of the contrast material shows a horseshoe kidney anomaly ( arrow ) . post - contrast images in b ) axial and c ) coronal planes show a large mass arising from the left part of the horseshoe kidney ( arrow ) . the mass is multi - lobulated and heterogeneous in attenuation with a central area of cystic necrosis hemi - nephrectomy was performed at our institute . follow - up ct scan of the abdomen and pelvis obtained in the post - operative period revealed resection of the previously described large mass within the left part of the horseshoe kidney . single selected axial computed tomography scan image of the abdomen performed in the post - operative period shows resection of the large mass in the left part of the horseshoe kidney with organ preserving surgery . the surgically removed gross specimen was a large mass , which had replaced more than 2/3 of the left side of the horseshoe kidney . the mass was lobulated and variegated , ranging from tan and yellow to dark brown . pathology specimen shows a large multi - lobulated mass associated with an area of hemorrhage and cystic necrosis . hematoxylin - eosin ( h and e ) stained histology slides of the above described mass revealed clear cell rcc with prominent borders and profuse network of small , thin - walled sinusoid - like blood vessels [ figure 4a and b ] . hematoxylin and eosin stained slides of the clear cell renal cell carcinoma ( rcc ) mass in a horseshoe kidney . ( a ) at 6 magnification shows the tumor margin ( arrow ) in relation to the reminder of the kidney , ( b ) at 300 shows clear cells with prominent cell borders ( black arrow ) and vascularity ( yellow arrow ) no genetic determinant is known , although , it has been reported in identical twins and in siblings within the same family . horseshoe kidney consists of two distinct functioning kidneys on each side of the mid - line , connected at the lower poles by an isthmus of functioning renal parenchyma or fibrous tissue that crosses the mid - line of the body . nearly , one - third of all patients with a horseshoe kidney remain asymptomatic and the pathology is discovered incidentally during physical examination or ct and ultrasound scans . when symptoms are present , they are related to hydro - nephrosis , infection , or calculus formation . the incidence of renal tumor in a horseshoe kidney is approximately 3 to 4 times greater than in normal population , and is possibly the result of chronic obstruction , lithiasis , and infection . the tumor can localized at any part of the kidney but it mostly found within the isthmus . ct utilizing routine renal mass protocol is the primary imaging modality of choice for localization and staging of any renal tumor . however , in case of rcc and horseshoe kidney , ct angiography is highly recommended to check the renal vascularity , which generally varies and is essential for pre - operative planning . if ct scanning is performed specifically to evaluate a known renal mass , the study must include an unenhanced examination prior to the administration of intravenous contrast material . after administration of contrast , scans are taken at intervals of 40 s and 100 s during the enhancement phase . the dataset can be manipulated by using a 3d workstation to produce volume - rendered and 3d images when necessary . it is becoming increasingly important for radiologists to produce 3d reconstructed images as more laparoscopic surgery is being performed for the treatment of renal cancer , and these images are helpful in such procedures . thus , pre - operative surveillance is highly recommended for early identification of metastatic activity and positive surgical margin . surgical approach is through the mid - line in order to have better exposure of the isthmus for isthmectomy . clear cell rcc , the pathology subtype , as found in our case , is typically a solitary tumor and the tumor commonly presents as bosselated , well - circumscribed mass with fibrosis and with a capsule or pseudo - capsule . lipid - rich cells in clear rcc impart the classical golden yellow color seen on gross pathology analysis . clear cell rcc may exhibit a variety of histo - architectural patterns including , solid , alveolar , and acinar forms . horseshoe kidney is the most common renal fusion anomaly and is more predominate in males and it is detected mostly as incidental finding on ct or us examination . rcc is one of the malignancies associated with this malformation , as was seen in our case .

renal cell carcinoma ( rcc ) is encountered in about 3% of all adult neoplasms . presence of any kidney malformation can change the plan for surgical treatment of rcc with organ preserving surgery . we report a case of clear cell rcc in a horseshoe kidney . computed tomography scan revealed a horseshoe kidney anomaly with a large mass in the left side . the diagnosis of rcc was confirmed by pathology and histology findings .

these tumors arise from the sex - cord stromal cells of the ovary ( colombo et al . , 2007 ) . characteristically , gcts produce inhibin ( lapphn et al . , 1989 ) and express aromatase activity promoting estrogen synthesis ( kato et al . , 2015 ) . there are two subtypes of gcts , adult and juvenile , with the former comprising 95% of cases . most cases of gct are diagnosed with stage i disease and have a 10-year survival rate of 6090% ( lauszus et al . , 2001 ) . these tumors may recur years to decades after the initial diagnosis , thus necessitating life - long disease surveillance . cytotoxic chemotherapy and radiation therapy for women with advanced - stage or recurrent disease have shown limited benefit ( schumer and cannistra , 2003 ) . a systematic review of gct cases reported in the literature suggested that most respond to hormonal therapy ( van meurs et al . , 2014 ) . however , a multi - institutional retrospective cohort study showed only ~ 18% objective response rate among patients with measurable adult gct treated with hormonal therapy ( van meurs et al . , 2015 ) . although data are sparse , in several reported cases aromatase inhibitors have been useful in the management of gct ( freeman and modesitt , 2006 , lamm et al . , we present herein a unique case of recurrent gct that previously progressed on the aromatase inhibitor anastrozole but subsequently had a sustained partial response of 24 months duration during re - treatment with another aromatase inhibitor letrozole . a 65-year - old ( gravida 1 , para 1 ) caucasian woman presented with her 4th recurrence of gct in july 2012 . she was overweight ( body mass index of 27 kg / m ) and had an excellent performance status ( ecog score = 0 ) . treatment history : she had a total abdominal hysterectomy , bilateral salpingo - oophorectomy , lymph node dissection and omentectomy in 2003 with a diagnosis of figo stage ia gct of the ovary . intra - operatively , the ovarian mass was 9 cm diameter and confined to the ovary . the patient underwent a tumor debulking surgery involving the lower abdominal wall in april 2005 . post - operatively she transferred her care to our institution and completed adjuvant external beam radiation . a second recurrence was diagnosed in november 2006 with an elevated serum inhibin b and an enlarged left para - aortic lymph node ; a fine needle aspiration ( fna ) of the para - aortic lymph node confirmed gct . the patient received 4 cycles of bleomycin , etoposide and cisplatin ( bep ) , completed in february 2007 with resolution of the left para - aortic lymphadenopathy accompanied by normalization of the inhibin b. in august 2008 , a third recurrence was noted after a surveillance ct scan showed an enlarging left para - aortic lymph node to 3.4 2.0 cm with concomitant increase in inhibin b to 126 pg / ml the patient was treated with the aromatase inhibitor anastrozole with rapid normalization of the inhibin b level and after 3 months of treatment , a ct showed a partial response with decrease in para - aortic nodal mass to 1.95 1.05 cm . however , a follow - up ct showed disease progression with enlargement of the left para - aortic lymph node in april 2009 . anastrozole was discontinued and the patient went to the operating room in july 2009 for a complete surgical resection of the para - aortic mass . subsequently , the patient received adjuvant external beam radiation therapy 45 gy to the para - aortic region . the patient was monitored closely by physical examination , inhibin b , and surveillance ct scans , and remained disease - free for 3 years . present management : at presentation of her 4th recurrence , the inhibin b level was elevated to 265 pg / ml and a ct scan in july 2012 revealed a new pelvic mass involving the posterior bladder wall . a ct scan following cycle 4 demonstrated a > 30% increase tumor diameter of the pelvic mass now measuring 8.0 7.4 6.7 cm , indicating disease progression on chemotherapy . the patient declined surgery . in light of the patient 's prior partial response to anastrozole , another course of hormonal therapy was initiated on january 18 , 2013 , consisting of the aromatase inhibitor letrozole 2.5 mg by mouth daily . concurrently , the patient began atorvastatin and an exercise program for management of her hyperlipidemia . after beginning letrozole therapy , her inhibin b levels consistently declined until becoming undetectable ( < 10 pg / ml ) in december 2013 . on physical examination , the pelvic mass was increasingly cystic and compressible by palpation , concordant with ct imaging findings , which after 7 months of therapy decreased solid components of the mass and a slight increase in the pelvic cyst diameter . follow up ct imaging at 14 and 18 months showed decreasing size of both cystic and solid components of the pelvic mass . in december 2014 , the inhibin b remained undetectable < 10 pg / ml , 23 months after initiating letrozole therapy . in january 2015 , a ct scan confirmed a sustained partial response to letrozole therapy with a significant reduction in her pelvic mass , now measuring 4.0 2.6 2.5 cm , 24 months after initiating letrozole therapy . during month 25 of treatment , the patient developed a detectable inhibin b level of 16 pg / ml , which increased to 32 pg / ml 6 weeks later . cytotoxic chemotherapy regimens such as bep have anti - tumor activity but are associated with significant side effects and tumor responses are usually transient ( brown et al . , 2005 ) . hormonal therapy is often employed in the management of surgically unresectable gct , due to the limited efficacy and toxicities of chemotherapy . foxl2 is required for the normal development of granulosa cells . in > 90% of ovarian adult - type gct , foxl2 has a specific single point mutation c134w ( shah et al . , 2009 ) . recent studies showed that mutant foxl2 binds the aromatase promoter and increases its activation to a higher level compared to wildtype foxl2 ( fleming et al . , 2010 ) . upregulation of aromatase by mutant foxl2 could be a common event promoting the development and progression of adult gct . extrapolating from studies done in hormone receptor positive breast cancer , the treatment of granulosa cell tumors , the data on aromatase inhibitor therapy is sparse , with fewer than 20 evaluable cases reported . the responses to aromatase inhibitor therapy among cases reported in the literature are highly variable . in the current case , the duration of response differed between her initial treatment with anastrozole and her later treatment with letrozole . one possible explanation is the greater reduction in plasma estradiol and estrone sulfate levels in postmenopausal women taking letrozole 2.5 mg once daily compared with anastrozole 1 mg once daily ( dixon et al . , 2008 ) . as determined by highly sensitive radioimmunoassay , only 2% of women taking letrozole had a plasma estradiol level 3 we speculate that the antiestrogen efficacy of aromatase inhibition may also have been further potentiated by the patient 's concurrent statin therapy . a primary metabolite of cholesterol , 27-hydroxycholesterol acts as a selective estrogen receptor modulator ( serm ) capable of promoting tumor growth in estrogen - receptor - positive breast cancer models ( nelson et al . , inhibition of cholesterol synthesis using the statin atorvastatin reduces 27-hydroxycholesterol and negates the pro - tumorigenic effect of a high - fat diet in animal models of breast cancer . thus , the concurrent statin therapy in this patient may have potentiated the efficacy of aromatase inhibition by lowering total cholesterol thereby lowering levels of the endogenous serm 27-hydroxycholesterol . to our knowledge , this is the first case report to describe retreatment with aromatase inhibitor therapy for the management of gct . despite disease progression on her initial aromatase inhibitor , 4 years later retreatment with another aromatase inhibitor resulted in a sustained partial response for 24 months . during this time , the patient enjoyed an excellent quality of life and avoided the morbidity associated with surgery or cytotoxic chemotherapy . we propose that aromatase inhibitor therapy should be considered in the management of recurrent and advanced gct , even in patients who have progressed on prior hormonal therapy . in addition , combination treatments to increase the efficacy of hormonal therapies should be prioritized for further investigation in the management of this disease . a copy of the written consent is available for review by the editor - in - chief of this journal on request .

highlightsover 90% of granulosa cell tumors have a foxl2 mutation that contributes to aromatase upregulation.chemotherapy has demonstrated limited efficacy in the treatment of granulosa cell tumors.a patient with recurrent granulosa cell tumor responded briefly to anastrazole treatment.retreatment with another aromatase inhibitor letrozole led to a durable response of 24 months .

pws is caused by the lack of expression of paternally inherited imprinted genes on chromosome 15q11-q13 . , we discuss a case of pws , who presented to our out - patient department with uncontrolled diabetes . patient was born of non - consanguineous marriage , full - term cesarean section delivery and cried normally after birth . although he did not have a history of poor suck or floppiness in infancy , he had a delay in motor milestones and started to walk by himself at 2 years of age and speak sentences at 5 years age . patient had severe increase in appetite by 6 years of age and progressive weight gain since 8 years of age with no active weight reduction measures . patient underwent lt orchiopexy with rt orchidectomy at 15 years age . at 16 years age detected to have diabetes with osmotic symptoms and initial plasma glucose f-140 mg / dl , pp-250 mg / dl with no h / o ketosis at presentation or thereafter . he was initially started on oral antidiabetic drugs for 1 year with diet advice , which he could not follow due to intense hunger and craving for food and is on insulin for last 3 years . parents were troubled by his compulsive lying , craving for food , cigarettes and beedis . what was striking was that , he used to cry for food during the day as well as night and complain to doctor on duty saying if he felt so hungry and what was his fault that he ate ! , he had a height of 145 cm ( mid parental height was 173 cm ) , weight of 79 kg , body mass index of 37.57 and abdominal circumference 112.5 cm . muscular tone was decreased and muscle power was normal bilaterally in upper and lower limbs . . stretched penile length was 4 cm , testes was absent on the right side ( orchiectomy ) and was 1 - 2 ml on the left side . his obesity associated with hypogonadism , history of delayed milestones , hyperphagia , subnormal iq , insatiable hunger with difficult to control diabetes , led us to think of genetic cause . the genomic deoxyribonucleic acid ( dna ) was processed for studies of the methylation status of the promoter region of the sprpn gene for confirmation of the diagnosis of pws . dna extraction was followed by sodium bisulfite modification using ez dna methylation - gold kit ( zymo research , usa ) . this was followed by methylation specific polymerase chain reaction ( pcr ) using primer pairs specific for methylated and unmethylated alleles of the snrpn promoter region . his obesity associated with hypogonadism , history of delayed milestones , hyperphagia , subnormal iq , insatiable hunger with difficult to control diabetes , led us to think of genetic cause . the genomic deoxyribonucleic acid ( dna ) was processed for studies of the methylation status of the promoter region of the sprpn gene for confirmation of the diagnosis of pws . dna extraction was followed by sodium bisulfite modification using ez dna methylation - gold kit ( zymo research , usa ) . this was followed by methylation specific polymerase chain reaction ( pcr ) using primer pairs specific for methylated and unmethylated alleles of the snrpn promoter region . no changes were detected on chromosome 15 at 475 band levels on doing giemsa trypsin banding . methylation specific pcr revealed a methylated and unmethylated band in the parents , whereas patient showed the presence of only the methylated band of the promoter region of the snrpn gene proving the diagnosis of pws in the patient . patient was put on multiple subcutaneous insulin injections , regular exercise , metformin and 1400 calorie diabetic advice . patient was put on multiple subcutaneous insulin injections , regular exercise , metformin and 1400 calorie diabetic advice . in this case , the diagnosis was suspected on the basis of historical points of obesity , uncontrollable hyperphagia , developmental delay , subnormal intelligence , behavioral abnormalities , undescended testes and hypogonadotropic hypogonadism . however , this case was special as the patient did not have a history of hypotonia , low birth - weight or poor feeding in early life . according to the consensus diagnostic criteria , he had 6 major and 6 minor criteria with the total score 9 ( 8 required for diagnosis ) . the syndrome shows great variability , with different features during a patient 's life 's different stages . as a new born , the individual might suffer from severe hypotonia with feeding problems and global developmental delay . during infancy , these characteristics impede the acquisition of gross motor and language milestones . as a child this is most probably caused by a hypothalamic dysfunction , which is also responsible for growth - hormone and tsh deficiencies , central adrenal insufficiency and hypogonadism . during infancy , the child with pws shows a characteristic problematic behavioral pattern , which has been reported to worsen with age . the features which are sufficient to prompt a genetic testing for prader- willi syndrome according to age at assessment include the following : birth to 2 years , hypotonia with poor suck . history of hypotonia with poor suck ( hypotonia often persists)global developmental delayexcessive eating ( hyperphagia ; obsession with food ) with central obesity if uncontrolled . history of hypotonia with poor suck ( hypotonia often persists ) global developmental delay excessive eating ( hyperphagia ; obsession with food ) with central obesity if uncontrolled . 13 years through adulthood : cognitive impairment , usually mild mental retardationexcessive eating ( hyperphagia ; obsession with food ) with central obesity if uncontrolledhypothalamic hypogonadism and/or typical behavior problems ( including temper tantrums and obsessive - compulsive features ) . cognitive impairment , usually mild mental retardation excessive eating ( hyperphagia ; obsession with food ) with central obesity if uncontrolled hypothalamic hypogonadism and/or typical behavior problems ( including temper tantrums and obsessive - compulsive features ) . with the rising incidence of obesity , we need to be aware of genetic causes of obesity and when to suspect them . a case of pws - one of the genetic causes of obesity , which has been diagnosed in adulthood , this case was special for the lack of history of floppiness in infancy and for predominance of behavioral problems .

prader - willi syndrome ( pws ) is a rare cause of obesity . with the rising incidence of obesity , clinicians need to be aware of genetic causes of obesity and when to suspect them . a case of pws , which was diagnosed in adulthood , has been discussed . this case is special because of lack of history of floppiness in infancy and predominance behavioral problems .

urinary stones are rarely seen in the urethra and are usually encountered in men with urethral stricture or diverticulum . urethral diverticula can present in many ways , including recurrent urinary tract infections ( utis ) , dysuria , increased urinary frequency , urgency , and hematuria . in addition to causing the symptoms above , diverticula also can be complicated with stones or malignancy , both of which can lead to bladder outlet or urethral obstruction . stone formation has been reported to occur in 1% to 10% of patients with urethral diverticula . urinary stasis and chronic infection have been identified as the causes of calculi formation within urethral diverticula . the case of a woman with a giant calculus in a urethral diverticulum is reported . a 62-year - old woman was first seen in the urology clinic complaining of a 1-year history of constant lower abdominal pain , dysuria , and dyspareunia . she also noted an increase in the volume of the vaginal wall that coincided with an increase of pain in this area . written informed consent was obtained from the patient for the publication of this case report and any accompanying images . the general patient examination was normal , but a focused genital examination revealed a large mass of approximately 4 cm near the urethra . when compressing the urethra , leakage of purulent discharge from the meatal orifice was noted . a kidney , ureter , bladder x - ray showed a giant calculi ( figure 1 ) , and cystoscopy revealed an extrusion of the posterolateral distal urethra . on admission , vital signs were all normal and laboratory tests demonstrated microscopic pyuria ( 2030/high power field ) . the diverticulum was punctured by electrocautery and dissected with periurethral tissue , which allowed total removal of the calculi ( figure 2 ) . a tagged 3 - 0 with silk suture the foley catheter was kept in place for 7 days . oral antibiotic therapy with ciprofloxacin the estimated prevalence of urethral diverticula in adult women is between 0.6% and 6% , and associated stone formation is reported in 1.5% to 10% of cases . the cause of diverticula remains largely unknown and ranges from congenital to traumatic ( instrumentation , childbirth ) to infectious causes . the formation of abscesses and these may rupture into the urethral lumen , forming the diverticula . the quality of life of patients who have a diverticulum ( especially with calculi ) may be significantly disturbed because of complications such as dysuria , dyspareunia , uti , and postvoid dribbling . any patient with lower urinary tract symptoms that have proved to be unresponsive to traditional treatment should be suspected of having a urethral diverticulum . in patients with urethral diverticula other ways to confirm a diagnosis of urethral diverticula are voiding cystourethrogram , intravenous pyelography , and ultrasonography . presumably , a stone should also be visualized within the diverticula by one of these diagnostic modalities . the issues that remain focus on determining symptomatic relief by conservative therapy , assessing satisfactory long - term treatment of diverticulum , and determining the possible benefit from surgical excision . however , the confirmation of number , site , and size of the diverticulum is important before operation to prevent complications such as urethral stricture , urethro - vaginal fistula and incontinence due to injury of sphincter . diagnosis of a complicated diverticulum can be easily achieved if one possesses a high degree of clinical suspicion . thus , this diagnosis should be considered in the case of recurrent utis , hematuria , and dysuria , as well as in patients with masses felt on pelvic examination . surgical approach with litholapaxy followed by diverticulectomy

abstracturethral diverticula with calculi have a low incidence as reported in the literature . diverticulum of female urethra is rare , often discovered due to associated complications . we report a case of diverticulum of the female urethra containing giant calculi in a 62-year - old multiparous woman . she consulted with our office due to dysuria and a hard , painful periurethral mass in the anterior vagina wall . the diverticulum was approached surgically by a vaginal route , and local extraction of the calculi and subsequent diverticulectomy successfully treated the condition.diagnosis of a complicated diverticulum can be easily achieved if one possesses a high degree of clinical symptoms .

nonunion following surgical stabilization of humeral shaft fractures , although infrequent , remains a challenge as limited surgical options are available . the difficulties in re - fixation are due to osteolysis produced by the loose implant components and disuse osteopenia of the entire bone segment . we share our experience in the management of a long standing diaphyseal nonunion of humerus following titanium lcp fixation . a 58 years old woman presented with 20 months old nonunion following titanium lcp fixation of her closed humeral shaft fracture , done elsewhere . the interesting intraoperative findings , noteworthy , are about the extensive metallosis and the gross cortical defect measuring 10 cm x 1 cm x 1 cm , corresponding to the foot print of the previous plate with exposed medullary canal . it was managed by debridement , dual plate fixation using 9 holed and 12 holed stainless steel lcps in an orthogonal fashion and autologous bone grafting . the nonunion healed in 5 months and she regained all the movements except for terminal 10 of elbow extension and 15 of shoulder abduction at her final follow up of 30 months . according to stewart and hundley classification the final result was found to be good . we recommend the judicious use of long and short plates in 90 - 90 orientation along with autogenous bone grafting in the management of a long standing humeral shaft nonunion having extensive cortical resorption following surgical stabilization by plating . it has up to 8% incidence for fractures treated non - operatively , however , the same increases up to 13% if treated either by plating or nailing . failure to unite after surgical treatment may be due to poor contact between the bone ends , inadequate stabilisation , devitalisation of fracture fragments , infection , osteopenia and bone defects . we describe our experience about using two plates in 90 - 90 construct along with autologous bone grafting to treat a long standing diaphyseal nonunion with extensive metallosis and cortical bone loss following surgical stabilisation by a titanium lcp ( locking compression plate ) . a 58-years - old right hand dominant retired teacher presented to our out - patient clinic with nonunion of left humerus shaft following surgical stabilisation by plating , done 20 months ago . it was a closed injury to begin with , which resulted from a road traffic accident and the initial radiographs ( fig . she was operated on the following day by open reduction and internal fixation using a six holed lcp with six screws ( fig . she was comfortable for two months after which she developed pain , abnormal mobility with difficulty in using the operated limb for daily activities . she had a bmi of 36 , was a nonsmoker and nonalcoholic . on clinical examination , there was a healed linear surgical scar measuring about 15 cm along the anterolateral aspect of left arm . abnormal mobility was noted at the fracture site alongwith significant limitation of left shoulder and elbow movements . current radiograph corresponding to 20 months postoperative duration revealed a gap nonunion of the shaft of left humerus with osteolysis and backed out distal screws ( fig.1c ) . b ) immediate postoperative radiograph ap & lateral views showing six holed lcp and three screws on either side with visible gap at the fracture site . c ) 20 months post - operative radiograph ap & lateral views showing gap nonunion with osteolysis and backed out distal screws . surgery was performed under general anaesthesia in supine position with the operating left upper limb placed over a flat radiolucent side table and intravenous prophylactic antibiotics were administered . a six holed narrow titanium lcp fixed with six titanium locking head screws was noted along the anteromedial surface of the shaft of humerus . extensive metallosis was found around the implants and the surrounding soft tissues , giving a charred appearance ( fig . the anteromedial cortex corresponding to the foot print of the extracted plate was found to be eroded leaving a cortical defect of 10 cm x 1 cm x 1 cm across the fracture zone with exposed medullary canal ( fig.2c ) . the proximal and distal fragment ends were debrided of all the soft tissue and freshened back to bleeding bone , whichr esulted in the sacrifice of a centimeter of length of each fragment . no signs of deep sepsis were found , however , tissue samples were sent for culture study and histopathology . c ) a 10 cm x 1 cm x 1 cm anteromedial cortical defect seen after implant extraction . [ inset magnified view ] . d ) extracted 4.5 mm narrow six holed titanium lcp and six titanium locking head screws . the primary stabilization was achieved by a nine holed 3.5 mm stainless steel lcp placed along the anterolateral surface of the fragmentswith four screws on either side ( fig.3a ) . multiple cortico - cancellous slivers were harvested from the left iliac crest and were placed in a longitudinal fashion filling the cortical defect of the anteromedial humeral surface ( fig.3b ) . a second12 holed 3.5 mm stainless steel lcpwas placed over this grafted surface , perpendicular to the previous plate and was stabilized with two locking head screws at either ends ( fig.3c ) . supervised physiotherapy of the shoulder and elbow joints was started soon after the pain controlled , followed by muscle strengthening and passive range of motion exercises . a ) a 3.5 mm , nine holed lcp on the anterolateral humeral surface with compression at the fracture site . b ) multiple cortico - cancellous autograft strips in a longitudinal fashion filling the deficient anteromedial cortex . c ) a second 3.5 mm , 12 holed lcp over the grafted surface at 90 to the first plate . the immediate postoperative radiographs showed satisfactory alignment with secure fixation in both anteroposterior and lateral planes ( fig . the culture study showed no growth of microorganisms and the histological examination revealed macrophages with intracellular black particulate matter . functional range of motion of the shoulder and elbow was regained by six weeks of supervised physiotherapy . the nonunion site healed in five months(fig . 4b ) . at the final follow up of 24 months , the radiograph showed consolidation of the nonunion . she regained all the movements except for the terminal 10 of elbow extension and 15 of shoulder abduction . the final shortening of her operated arm segment was two cm . according to stewart and hundley classification3(table 1 ) a ) immediate film showing satisfactory alignment with dual plates in 90 - 90 orientation . c ) radiograph at 24 months showing consolidation of the fracture . steward and hundley s scoring system of functional results . nonunion can be a complication of both conservative and operative interventions of humeral shaft fractures . however , if it happens after surgical stabilization , it is notoriously difficult to treat . the possible reasons of nonunion in the given case could be,(a ) distraction at the fracture site ( fig . 1b ) , which was evident in the immediate postoperative radiograph , ( b)possible devitalisation due to wide exposure of bone fragments for plate fixation , ( c ) lcp usage with all locking head screws . infection as a possible cause was ruled out by haematological , microbiological and histopathological examinations . persistent nonunion of 20 months duration resulted in osteopenia , fatigue failure of implants , increased gap across the fracture zone , progressive osteolysis around the backed out screws and cortical resorption of the foot print of the plate . the available implant options for re - fixation are interlocking nail , single plate , dual plates , plate and antegrade rush rod combination and ilizarov frame . however , large diameter locked nails are essential to maintain both axial and rotational stability . difficulty in achieving compression at the nonunion site is a potential drawback that can result in significant failure rate . additional problems would be rotator cuff damage , shoulder pain and stiffness when inserted antegrade and the risk of iatrogenic fracture at the insertion site when placed in a retrograde fashion . understanding the limitations , such as the narrow medullary canal , significant bone defect and difficulty to achieve compression , a locked intramedullary implant as a fixation device it may be possible to achieve stable fixation with the ilizarov frame , even in the presence of osteopenia or bone defects . however , the potential complications are pin - site infections , nerve injuries , and frame impingement over the chest wall resulting in constant discomfort with sleep disturbances . compression plating using a 4.5 mm narrow plate with at least eight cortices of fixation on either side of the fracture and autogenous bone grafting have been considered as the gold standard in the management of humerus shaft nonunion with a reported success rate of up to 90% . the traditional narrow 4.5 mm plate was not applicable in the given situation as the humerus was thin and slender making only a 3.5 mm design suitable . double plating is indicated for a long standing nonunion where the fixation strength achieved by a single plate is questionable due to extensive bone loss and cortical resorption . a two plate construct was found to be significantly stiffer than a single plate construct as per the biomechanical and clinical study by rubel et al . the procedure , however , is technically demanding , as the significant soft tissue dissection needed to apply two plates is likely to be associated with increased rate of infection , nonunion and nerve palsies . the torsional stability of a locked plate is three times greater than that of a conventional plate . in situations of poor bone stock , the lcp permits application of cortical and locking head screws to achieve compression at the fracture ends and increased pull out resistance . both the plates used here belong to 3.5 mm lcps , placed in 90 - 90 orientationto each other . the first nine holed anterolateral lcp achieved compression at the nonunion site and the second 12 holed lcp , placed perpendicular to the previous one , buttressed the graft strips and was intended to improve the biomechanical stability of the entire construct over a long working length . the important point noteworthy was all the 12 screws of both the plates could get new fixation points in the bone fragments without landing in the holes made by the previous implant , thus achieving superior screw purchase . also the combination of short and long plate avoided the generation of severe stress risers at either ends . liberal use of autogenous bone graft was a must to help the biology when the bone loss was particularly severe as in the given situation . the problem of metallosis is more common after the usage of titanium implants than the stainless steel alloys . this results in charring of the surrounding tissue in long standing cases and debridement has a potential risk of neurovascular injury . metallosis secondary to titanium - alloy wear debris has been associated with osteolysis in arthroplasty . however , metallosis following plate osteosynthesis of long bones has limited literature support . applying the same concept to the present situation , we speculated that the nonunion as a result of distraction at the fracture ends , lead to persistent motion between the titanium implant components , generating the wear debris . these titanium - alloy wear particles may have produced a net catabolic or osteolytic effect at the fracture site contributing to such an extensive cortical resorption of the entire under surface of the plate with exposure of the medullary canal . we do agree that fixation of two plates for a single bone resulted in additional soft tissue stripping , although bare minimal . however , the quality of mechanical stability that a two plate construct provided must be kept in mind in this osteopenic situation without which the rapid functional recovery would not have been possible . shortening of the operated arm segment by two cm noted at the final follow up was a fair compromise in a non - weight bearing bone . success in this case was believed to be due to adequate mechanical stability achieved bythe dual lcps in an orthogonal patterncoupled with debridement and liberal use of autogenous bone graft . we recommend the judicious use of long and short plates in a 90 - 90 orientation along with autogenous bone grafting in the management of a long standing nonunion of humerus shaft fracture with metallosis and extensive cortical resorption following surgical stabilization by plating . nonunion with extensive osteolysis could result from titanium implants if the fracture is stabilized with visible gap . double plating is recommended where the fixation strength achieved by a single plate is questionable due to profound bone loss and cortical resorption . thorough debridement followed by judicious autogenous bone grafting is of paramount importance for successful healing of a longstanding nonunion

introduction : nonunion following surgical stabilization of humeral shaft fractures , although infrequent , remains a challenge as limited surgical options are available . the difficulties in re - fixation are due to osteolysis produced by the loose implant components and disuse osteopenia of the entire bone segment . we share our experience in the management of a long standing diaphyseal nonunion of humerus following titanium lcp fixation.case report : a 58 years old woman presented with 20 months old nonunion following titanium lcp fixation of her closed humeral shaft fracture , done elsewhere . the interesting intraoperative findings , noteworthy , are about the extensive metallosis and the gross cortical defect measuring 10 cm x 1 cm x 1 cm , corresponding to the foot print of the previous plate with exposed medullary canal . it was managed by debridement , dual plate fixation using 9 holed and 12 holed stainless steel lcps in an orthogonal fashion and autologous bone grafting . the nonunion healed in 5 months and she regained all the movements except for terminal 10 of elbow extension and 15 of shoulder abduction at her final follow up of 30 months . according to stewart and hundley classification the final result was found to be good.conclusion:we recommend the judicious use of long and short plates in 90 - 90 orientation along with autogenous bone grafting in the management of a long standing humeral shaft nonunion having extensive cortical resorption following surgical stabilization by plating .

patients who underwent maxillectomy due to benign or malignant tumor , will have defect in palatal area . because of this defect , patients will be more likely to have oro - nasal communication , change of facial profile , difficulty in speaking , mastication , and even deglutition . to overcome these problems , surgical intervention or prosthetic treatments are used . often , surgical reconstruction is very difficult to achieve when the defect area is large . when treating these patients with prosthetic means , several factors should be considered ; the size and location of the defect , accessibility , degree of jaw opening , and the condition of oral tissue after radiation therapy . the factors affecting general treatment planning are the age of the patients , presence of any systemic factors , prognosis of the tumor itself , esthetic and functional expectations of the patient along with the motivation . in the course of the treatment of the disease , much of the oral tissues must be surgically removed . when it happens , surgical reconstruction or implants placement becomes prohibitive and removable prosthesis becomes only remaining option to cover large defects . aramany categorized the defect areas after maxillectomy into six classes based on the relationship of the defect to the remaining abutment teeth.1 class i : the resection is performed along the midline of the maxilla , teeth are maintained on one side of the arch . class ii : the defect is unilateral , retaining the anterior teeth on the contralateral side . class iii : the palatal defect occurring on the central portion of the hard palate and may involve part of the soft palate class iv : the defect crosses the midline and involves both sides of the maxilla . class v : the surgical defect is bilateral and lies posterior to the remaining abutment teeth . class vi : anterior maxillary defect with abutment teeth present bilaterally in the posterior segment . removable prosthesis gets retention , support and resistance mainly through anatomical structures such as teeth , alveolar bones and palate . when surgical intervention removes much of these structures , remaining tissue becomes too vulnerable to support the necessary prosthesis . the prognosis for prosthesis becomes worse for class iv defect which has too few remaining teeth or for class i defect which has disadvantages in retention , support or resistance.23 therefore , considerations should be given to attain extra retention , support and resistance when planning for obturators of maxillary defects . swing - lock attachment design uses vertical retentive strut and palatal bracing component , making many labial and lingual contacts . it enables the prosthesis to have extra retention , support and resistance.456 in this case , aramany class ii defect was restored . if conventional partial denture were to be used , the prognosis of the abutment teeth would be uncertain . to distribute the load to many healthy abutment teeth while getting a rigid closure , swing - lock design framework was used to fabricate obturator closing palate - maxillary defect . a 56-year - old female patient had malignant melanoma removed at ajou university medical center in 2014 . the results of radiographic examination did not reveal anything specific except missing tooth number # 37 in the mandible . it did not bother the patient and she did not want any treatment for it . tooth number # 12 had grade i mobility and distal bone loss due to the long use of surgical obturator . # 26 and # 27 were restored with gold crowns ( fig . 1 , fig this patient who went through maxillectomy has overall sound teeth alignment and periodontal health except the mobility of # 12 due to the bone loss and tissue undercut . conventional removable partial denture design deemed unreliable to achieve adequate retention , support and seal . proper hybrid gate framework design with swing - lock attachment on # 12 as a removable splint would bring more retention to the remaining teeth . also , post - operative tissue undercut superior to distal of # 12 would bring more advantageous path of insertion . the goals for the new obturator were to enhance the retention and stability and to better fit the palatal closure so that patient can speak better as well . disadvantages of swing - lock attachment are that it is unaesthetic and it ca n't be used when labial vestibule is shallow . the patient in this case had a lower lip line , showing less than 75% of the central incisors when smiling . diagnostic cast was made by alginate impression ( aroma fine df ii , gc , tokyo , japan ) ( fig . teeth # 11 , 21 , 22 , and 23 had lingual rest seat and # 24 had mesial rest seat to improve stability and support of the obturator ( fig . border molding was done by modeling compound in the same way as conventional partial denture fabrication . impression was taken by silicone impression material ( express light and regular body , 3 m espe , st . acrylic teeth were set on the semi - adjustable articulator ( kavo protar evo 7 , kavo , biberach , germany ) ( fig . " gate clasp " was suggested for the first time by ackerman in 1955.7 simmons introduced the swing - lock design concept . 8 it 's mechanical retention was explained by javid and dadmanesh.9 on this foundation , obturator restoration by swing - lock design frameworks was discussed by several authors.1011 swing - lock design gets mechanical retention and support by labial or buccal bar which is made of hinge and latch.11 for the labial bar , at least 6 - 8 mm of labial vestibule is needed . labial bar should be at least the length of 4 teeth or more and there is no maximum limit as long as the anatomy allows . patients with maxillectomy get retention , support and stability from remaining tissues which are hardly optimal . the advantage of swing - lock attachment design is having multiple contacts on labial and lingual side of the abutment teeth by retentive strut and palatal bracing component.1213 because the force is distributed equally to abutment teeth , abutment teeth of poor prognosis can be benefited from it . it is a viable option even when canine is missing , or when abutment teeth are not aligned optimally . rotated or tipped teeth would need endodontic , prosthodontic treatment or even splinting to support the key abutment teeth in conventional removable prosthodontics . however , swing - lock attachment design could bypass all those procedures , making it a more financially attractive option . it is also more advantageous to cover soft tissue defects which are hard to reach with conventional prosthesis . swing - lock attachment design is not indicated when the patient does not understand the concept or can not wear it due to the lack of cognitive or motor skills . patient with unrealistic esthetic expectation would not be satisfied with showing labial bar or strut.1415 this case belongs to class ii arch form . edentulous area is located ipsilateral to the midsuture line , extending from upper right canine to the posterior area . in this case , support is achieved from the near and far rests of the edentulous area and the palate . in conventional design , the retention is achieved from the nearest abutment tooth from the missing area by circumferential clasp , cast i bar and wrought wire . retention is often achieved by circumferential clasp in posterior teeth while rests are made on first bicuspid or canine as indirect retainers . therefore , flexible clasp is encouraged in planning while the undercut should be less than the usual . meanwhile , swing - lock attachment enables the most of the residual teeth as abutment teeth , enabling the prosthesis to be more stable . abutment teeth are stabilized and protected by palatal plate , labial strut and proximal plate . swing - lock attachment design has many advantages over conventional design , while having esthetic disadvantages due to the presence of labial strut and bar .

patients who underwent resection of maxilla due to benign or malignant tumor , or accident will have defect in palatal area . they get retention , support and stability from remaining tissues which are hardly optimal . the advantage of swing - lock attachment design is having multiple contacts on labial and lingual side of the abutment teeth by retentive strut and palatal bracing component . because the force is distributed equally to abutment teeth , abutment teeth of poor prognosis can be benefited from it . it is also more advantageous to cover soft tissue defects which are hard to reach with conventional prosthesis . a 56-year - old female patient who had undergone a maxillectomy due to malignant melanoma complaining of loose and unstable surgical obturator . surveyed crowns were placed on # 12 , 26 , and 27 . teeth # 11 , 21 , 22 , and 23 had lingual rest seat and # 24 had mesial rest seat to improve stability and support of the obturator . this clinical report presents the prosthetic management of a patient treated with obturator on the maxilla using swing - lock attachment to the remaining teeth .

coronary artery disease complicated by severe left ventricular ( lv ) dysfunction is associated with high morbidity and mortality with increased risk of sudden death , ventricular arrythmias and worsening heart failure and the choice of optimal treatment strategy in such patients is often challenging . acute myocardial ischemia rapidly impairs contractile function which can persist for several hours but is eventually followed by full functional recovery which is called myocardial stunning.1,2 hibernating myocardium is chronically dysfunctional tissue in patients with coronary artery disease related to poor coronary perfusion . one third of the segments demonstrate early recovery whereas two - third of the segments may take upto twelve months for recovery . in these patients with multi - vessel disease , increased lv volumes , coronary revascularization may lead to symptomatic and prognostic improvement and these clinical benefits are accompanied by evidence of reverse lv remodeling . however , prospective identification of patients with ischemic heart disease and heart failure who may benefit from high risk revascularization remains a clinical challenge . this lead to the concept of viable myocardium to distinguish between lv dysfunction caused by infarction and scar tissue formation versus lv dysfunction due to ischemic but viable myocardium which has important clinical implications.3,4 several imaging techniques looking at myocardial viability were developed with the aim of selecting patients in whom recovery of lv function and improvement of prognosis would outweigh the risk of surgical revascularization . low dose dobutamine ( 510 mcg / kg / min ) can lead to increased contractility in dysfunctional segments that are viable . at higher doses , the biphasic response is highly predictive of viable myocardium and improvement of function after revascularization.1,5 myocardial contrast echocardiography produces myocardial opacification and facilitates the identification of lv borders compared with conventional echocardiography.6 a study by shimoni et al considered microvascular integrity to be a significant determinant of maximal myocardial contrast intensity ( mci ) in humans and proved that preservation of microvascular integrity and perfusion by intravenous myocardial contrast echocardiography ( mce ) predicts recovery of dysfunctional ischemic myocardium.7 another study by korosoglou et al in 2004 compared the diagnostic accuracy of myocardial contrast echocardiography with low dose dobutamine stress echocardiography ( dse ) and of combined technetium-99 sestamibi single - photon emission computed tomography and fluorodeoxyglucose-18 positron emission tomography . it involved 41 patients with ischemic heart disease who underwent cardiac imaging and a control group of 25 patients . it showed that mce had 86% sensitivity and specificity of 43% to predict recovery of myocardial function , nuclear imaging had 90% sensitivity and 44% specificity whereas low dose dse had 83% sensitivity and 76% specificity.8 single photon emission computed tomography ( spect ) is widely available modality with well established clinical and prognostic validation . initial acquisition soon after thallium-201 injection indicates delivery of tracer through blood flow and images acquired four to twenty four hours later are a marker of sarcolemmal integrity which reflects tissue viability.9 fdg - pet ( fluoro - deoxyglucose positron emission tomography ) is another modality to assess viability . regions that show concordant reduction in both myocardial blood flow and fdg uptake are considered irreversibly injured whereas regions in which fdg uptake was relatively preserved or increased despite reduced myocardial perfusion is a mismatch pattern and represents hibernating myocardium and is associated with high likelihood of functional recovery after revascularization.10 cardiac mri is another helpful tool which provides information on global lv function , regional wall motion and thickening . application of gadolinium contrast agents can be used to detect perfusion defects , microvascular obstruction and areas of scarred tissue or fibrosis . sensitivity and specificity of the above mentioned non - invasive modalities to assess myocardial viability are compared1,11,12 in figure 1 . in the 1970s , randomized controlled trials of cabg versus medical therapy for chronic stable angina excluded patients with lv dysfunction . major advances in surgical care and medical therapy render previous data obsolete for clinical decision making . meta - analysis by allman et al in 2002 reported on results of 24 non - randomized studies carried out between 19921999 including 3088 patients with lvef < 40% . it demonstrated significant association between revascularization and improved survival rate in patients with lv dysfunction and viable myocardium ( 79.6% reduction in annual mortality rate was observed - fig . 2 ) and no benefit was seen with revascularization in absence of viability.13 the magnitude of the potential reduction in mortality increased as the severity of lv dysfunction increased . however , it had limitations including observational bias , non - randomized study designs and lack of standardization of medical therapy . there have been significant advances in the medical management of heart failure in the past decade . more randomized trials were done recently evaluating the benefit of viability study guided management of ischemic cardiomyopathy . surgical treatment for ischemic heart failure ( stich ) trial published in 2010 was a prospective randomized study testing the hypothesis that cabg improves survival in patients with ischemic lv dysfunction compared to aggressive medical therapy.14 it also assessed the interaction between myocardial viability and survival in randomized patients who were all eligible for medical therapy alone and also eligible for cabg . in this substudy , the hypothesis was tested that assessment of myocardial viability identifies patients with cad and lv dysfunction that have the greatest survival benefit with cabg compared to medical therapy.14,15 it enrolled 1212 patients with ischemic cardiomyopathy and lv function < 35% . all randomized patients were eligible for viability testing with spect myocardial perfusion imaging or dobutamine stress echocardiography . a 17 segment model was used for the spect myocardial perfusion imaging and patients were considered viable if 11 segments manifested viability based on relative tracer activity and 16 segment model was used for dobutamine stress echocardiography and was considered viable if 5 segments with dysfunction at rest and manifesting contractile reserve with dobutamine . out of 1212 patients , 618 patients underwent myocardial viability test , 487patients were considered viable ( 243 patients : 49.9% underwent medical therapy and 244 patients : 50.1% underwent cabg ) , 114 patients were considered non - viable ( 60 patients : 52.6% underwent medical therapy and 54 patients : 47.4% underwent cabg fig . 3 ) . the trial failed to demonstrate a significant interaction between myocardial viability and medical versus surgical treatment with respect to all cause mortality ( p - value of 0.53- fig . 4 ) , thus signifying that in patients with cad and lv dysfunction , assessment of myocardial viability does not identify the patients who will have greatest survival benefit from cabg versus medical therapy . the viability testing was performed by two different imaging techniques and a standardized protocol with a single imaging technique was not used . moreover , analysis was limited to spect and dobutamine stress echocardiography whereas cardiac mri which is a gold standard technique for assessment of myocardial viability by late gadolinium enhancement was not used . prior to stich study , parr -2 ( pet and recovery following revascularization ) trial in 2007 was done to assess the effectiveness of fdg - pet assisted management in patients with left ventricular dysfunction and suspected coronary artery disease which included 430 patients from nine centers between 20002004 . although , the event rate in the fdg - pet arm was less than the standard arm ( 36% in pet arm versus 30% reduction in standard arm , hazard ratio of 0.79 ) , the overall study was inconclusive because there was no statistically significant difference for the primary outcome measure.16 thus , it did not demonstrate any significant difference in the reduction of cardiovascular events in fdg - pet assisted management versus standard care . there is another dilemma in the management of patients with depressed ejection fraction , congestive heart failure and complex coronary anatomy who have limited treatment options . the majority of these patients may not be eligible for cabg as the surgical risk is often thought to be prohibitive . it raises the question : does multi - vessel pci give similar outcomes to cabg in patients with severe lv dysfunction ? several head to head randomized controlled trials done over the past years have compared the outcomes of the two modalities in patients with multi - vessel cad ( bari , arts , syntax , freedom ) . they demonstrated that pci is non - inferior to cabg for the outcomes of death and major cardiovascular events . so far , only diabetic patients have shown a survival advantage with cabg over multi - vessel pci , although bari 2d trial showed no significant difference in the rates of death and major cardiovascular events between patients undergoing medical therapy versus prompt revascularization.17 another meta - analysis of 19 studies involving 4766 patients was done by kunadian et al in 2012 utilizing pci among patients with lv dysfunction ( ef < 40% ) to determine in - hospital and long term one year mortality . it demonstrated that pci among patients with lv dysfunction is feasible with acceptable in - hospital and long term mortality and yield similar outcome to cabg.18 however , in all these studies , assessment of myocardial viability was not a prerequisite thus creating a dilemma as to which patient population ( viable versus non - viable myocardium ) actually benefited from any of the revascularization procedure in terms of mortality , major adverse cardiovascular and cerebrovascular events and quality of life . bcis-1 ( balloon pump - assisted coronary intervention study ) was the first randomized controlled trial of elective intra - aortic balloon pump insertion prior to high risk pci versus pci with no planned iabp use . it enrolled 301 patients with impaired lv function ( ef < 30% ) and extensive myocardium at risk with bcis-1 jeopardy score of 8 or target vessel supplying occluded vessel which supplies 40% of myocardium . it was found that in patients with severe ischemic cardiomyopathy treated with pci and elective iabp use , 34% reduction was observed in long term all cause mortality.19 the protect ii trial was the first prospective , multi - center study for patients requiring hemodynamic support during high risk pci comparing outcomes between iabp and impella 2.5 . the impella 2.5 device is a percutaneously placed left ventricular assist device that produces a non - pulsatile cardiac output of up to 2.5 l / minute . it included 447 patients out of which 223 underwent iabp and pci and 224 patients underwent impella guided pci . primary outcome was major adverse events ( death , stroke , tia , mi , repeat revascularization , acute renal dysfunction , increase in aortic insufficiency , severe hypotension , cpr or ventricular arrythmia requiring cardioversion ) at 30 days and 90 days . the study concluded that superior hemodynamic support of impella appears to have led to significant procedural differences between the two arms and impella arm had strong trends towards superior clinical outcomes for the entire intention - to treat population with a significant reduction of major adverse events at 90 days follow up ( fig . decisions about revascularization in patients with heart failure symptoms and left ventricular dysfunction are influenced by factors that do not always correlate with documented lv functional improvement . lack of interaction between myocardial viability and benefit from revascularization in these studies suggest that assessment of myocardial viability might not be the sole deciding factor in selecting the best therapy for patients with left ventricular dysfunction due to coronary artery disease and medical management or multi - vessel pci may also have similar outcomes to surgical revascularization . however , it is difficult to draw a definite conclusion according to the existing data and more randomized studies will be needed in this sector , grouping patients to three treatment arms including optimal medical therapy versus multi - vessel pci versus cabg with blinded assessment of myocardial viability by cardiac mri in all patients .

left ventricular dysfunction is a powerful prognostic predictor in patients with coronary artery disease and increasing number of patients with cad and ischemic left ventricular ( lv ) dysfunction is a major clinical problem . congestive heart failure is a frequent complication which is associated with significant health care costs and two third of cases have ischemic cardiomyopathy . in such patients , coronary revascularization can lead to symptomatic and prognostic improvement and reversal of lv remodeling which led to the concept of viable myocardium to select patients in whom recovery of lv function and improvement of prognosis will outweigh the risk of surgical revascularization . the aim of this review article is to understand the different modalities for assessing myocardial viability and clinical impact of revascularization in relation to the evidence of viability in patients with lv dysfunction .

uterine lipoleiomyoma is a rare benign tumor with an estimated incidence of 0.03% to 0.2% . a 48 year - old , gravida 1 para 1 , had a slowly - growing cervical mass . on ultrasound , the mass was around 5 cm in diameter and had fibroid tissue consistency with components of fat consistency ( figure 1 ( fig . the tumor appeared encapsulated and measured 6.25.2 cm with some areas of what looked like necrosis suggestive of a degenerating fibroid . the uterus was hypertrophic , sounding to 10 cm , and curettage showed no malignancy . after consultation with the patient , we decided to proceed with total laparoscopic hysterectomy and bilateral salpingo - oophorectomy . operative findings included a large cervical fibroid that appeared somewhat fleshy and soft in texture ( figure 2 ( fig . , the adhesions of the sigmoid colon to the left pelvic sidewall were taken down . the infundibulopelvic ligaments , after visualizing the ureters to be separate from them , were bilaterally coagulated and transected . the broad ligament anterior peritoneum was undermined and transected from round ligament to round ligament . the broad ligament posterior peritoneum was undermined and transected to the level of the uterosacral ligament on each side allowing the ureters to retract laterally away from the uterus , increasing the safety of the procedure . with some trouble , the vessels on the left side were then coagulated with bipolar cautery and transected with harmonic scalpel . on the right side , again with difficulty the uterine vessels were skeletonized then coagulated and transected the same way as before . the cardinal ligament on this side was transected the same way . a sponge stick was placed in the anterior vagina and transverse incision was made over it and around the vagina separating it from the cervix . with the help of a tenaculum , the uterus with the cervical mass and adnexa were all removed and passed off . the operation was completed in 68 minutes and blood loss was approximately 150 cc . on opening of the resected tumor , no necrotic areas were noted . pathological report showed a 258 gram uterus with a lipoleiomyoma that originated in the parametrial soft tissue along the endocervical canal near the lower uterine segment . incidentally , a 2.1 cm adult granulosa cell tumor was found within the parenchyma of the right ovary . so , on ultrasound , a lipoleiomyoma can closely resemble a well - differentiated liposarcoma requiring more definitive imaging ( ct or mri ) , biopsy , or both to confirm its benign nature , , . 2001 who described a woman of the same age with a 5-cm well - circumscribed complex mass that arose from the lower uterine segment and was markedly echogenic on sonography . our case describes a combination of cervical lipomeiomyoma and ovarian adult granulosa cell tumor which has not been reported before . moreover , our case demonstrates the feasibility of total laparoscopic extirpation of a uterus with a large cervical lipomeiomyoma attached to it if the surgeon has the experience and the will to do it .

uterine lipoleiomyomas are rare benign tumors that mostly affect the uterine corpus . we are reporting the imaging and operative procedure of a very rare case of a large lipoleiomyoma of the uterine cervix combined with an occult adult ovarian granulosa cell tumor . the patient was treated with minimal invasive surgery .

to assess the prevalence of alcohol use among the students entering a public university in alagoas , brazil . this was a cross - sectional study , analytically performed with young college graduates enrolled in all courses at a public university in alagoas , brazil , in 2006 . a closed questionnaire , based on cage , was used in classrooms during the months of april and may in 2006 . an exchange ofcourse happened whit the intent of not matching the ones used on the research . after explanations and clarifications were given , students who agreed to participate in research signed an informed and free consent term , forming a non - probabilistic sample , representing 44% of the universe of students enrolled . social variables were studied ( gender , age , course , marital status and residential and occupational situations ) and related to drug use ( frequency of consumption , types of alcoholic beverages consumed , opinions on the issues concerning the use of drugs and the consequences and experiences after the use of drugs ) . the research was approved by the ethics committee of the federal university of alagoas with the number 000878/2005 - 17 . the group was made up of 51.5% female students , 91.0% singles , 27.3% were working , 55.4% of the catholic religion and the majority ( 95.9% ) who lived with the family . slightly more than half of the respondents ( 54.5% ) had age less than or equal to 20 years , the majority being of age 18 years ( 25% ) . of the total number of students , only 12.4% said they had never drunk alcohol . as for the consumption of alcohol during the year , it was observed that 71.3% had done it . among the 1435 students , 56.7% of those who said they had drunk to intoxication were men , and data were statistically significant ( odds = 0.43 ; ci = 0.34 - 0.53 ; p - value = 0.000000 ) [ table 1 ] . significant variables related to drinking habit by gender ( maceio - al , brazil , 2006 ) the most cited place of the first dose was their own home ( 25.5% ) , followed by the homes of friends and colleagues ( 23.7% ) and bars , concert halls ( 21.3% ) [ table 2 ] . the most consumed alcohol beverages by students were beer or draft beer ( 32.2% ) and wine ( 16.7% ) [ figure 1 ] . distribution of first alcohol dose places ( maceio - al , brazil , 2006 ) drink varieties which are most consumed ( maceio - al , brazil , 2006 ) among all the respondents , by studying the fact of intoxication , it was found that 5.9% of women and 11.5% of men participated in fights after getting drunk ( odds = 0.48 , ci = 0.33 - 0.70 ; p - value = 0.000071 ) . of the total sample studied , 17.7% of male students and 9.8% females refrained from class due to alcohol use ( odds = 0.52 ; ci = 0.38 - 0.72 ; p - value = 0.000023 ) [ table 3 ] . of the total sample , 258 ( 18.6% ) reported that they had used other drugs in combination with alcohol , tobacco being highlighted ( 34.6% ) followed by solvent ( 32.0% ) [ figure 2 ] . significant consequences that are related to the gender and drunkenness act ( maceio - al , brazil , 2006 ) association of alcohol with other drugs ( maceio - al , brazil , 2006 ) friends or colleagues were the most frequently cited in relation to those who offered alcohol for the first time ( 37.6% ) , followed by relatives ( 21.6% ) , and 158 of them ( 11.0% ) bought the first dose alone [ table 4 ] . man and woman had different choices when they answered the question with whom do you usually drink ? . ( odds = 0.71 ; ci = 0.58 - 0.88 ; p - value = 0.00088 ) [ table 1 ] . people who offered the first alcohol dose ( maceio - al , brazil , 2006 ) the option for the question regarding the use of alcoholic beverages , unwise under any circumstances , was chosen by 46.2% , and 50.4% of respondents considered that their drug misuse was due to psychiatric issues and/or emotional ( anxiety , distress , depression , fear , complex ) reasons . this group , despite having achieved the goal of approval at the selection exam , can present problems with stress and are prone to make use of drugs in general . this pattern differs from others because this specific population has developed typical patterns of alcohol use and its risks are related to drinking too much , with social norms that approve it . peers influence the consumption of beverage and show which behaviors are accepted and admired in a particular social context , which leads to acceptance and its reinforcement . whereas most teenagers think just about the present moment , with no concern about social expectation , a large portion of them feel free to consume alcoholic beverages intensely . the proportion reaches 65% of the students in elementary and high schools , who have made use of drugs at least once in life , with alcohol being the highlight amongst others . the literature indicates that the university is not the starting point for the alcohol consumption , but a factor that magnifies it , determinedly maintaining the practice , given the respondents age characteristic . the distance from family can be an important factor in determining the problematic behavior of drinking , providing a possible looseness for the act and its consequences . yet , it was realized that this factor had no significant influence on alcohol use by the study group , since almost every student reported living with family . incentives and tolerance from the family members for the act of drinking , especially the members of the family nucleus ( parents and siblings ) , give sufficient support for teenagers to consume alcohol . according to who , brazil was at 63 position amongst 153 countries in alcohol consumption among people of age 15 , in 1999 , showing a very moderate use in adolescence . friends and colleagues were those who offered the first dose of alcohol to the majority of respondents . nevertheless , it is observed that the place of the first dose was their own home for the majority , which confirms the complicity of the family members . students who abuse alcohol are more likely to develop risky behaviors with negative consequences for them and the whole society , this profile being responsible for the increased number of deaths due to external factors . epidemiological data show that in a capital city in brazil , 53.6% of victims and 58.9% of the authors were under the influence of alcohol at the time of the crime . in another capital , amongst those drivers who had been involved in car accidents , 37.7% had consumed alcoholic beverages on the day of the incident , indicating that this population group is the more exposed to the external injuries . there are laws that seek to limit the opening hours of establishments in which alcoholic beverages are sold and prohibit driving after its consumption . brazilian law n 11.705 , known popularly as prohibition of alcohol , aims to punish those drivers who have ingested alcohol . however , it is perceived lack of control necessary to prevent this practice which shows negligence of the government 's authorities and , therefore , actions to inhibit the association of alcohol and driving do not happen . a study found that the young brazilian college males with blood alcohol content ( bac ) drive after alcohol use more often than females , and men get involved in fights with friends and police also , more than the females . this finding was confirmed in this university , proving the fact that gender is associated with the recreational use of alcohol and risk behaviors of beginners . the relative frequencies of all the consequences of alcohol use for men are higher than for women , especially the act of driving while they are intoxicated and presenting aggressive behaviors . most of those surveyed students believe that alcohol use is not advisable to any situation . this is not coherent with the way and intensity of alcohol use among the students that had consumed alcohol at least once in their lifetimes . in other brazilian universities , the use was justified as an opportunity to socialize and get drunk , more consistent with the reality presented . the fact that drug use is linked to psychiatric / emotional disorders such as anxiety and distress explains the possible exposure to the stress that students undergo during the graduation . the advertisements are associated with the expectation of consumption , initiation of use and intensity of use . the alcoholic beverages advertisings connect the consumption of alcohol with an easy - going style of life . it is exemplified when national holidays , soccer games , beautiful young people and celebrities are present on this kind of advertisements . according to this study , beer and wine were the beverages most consumed by the sample of students surveyed , following the same pattern as that found in brazilian university students . beer is the most nationally well - publicized alcohol product and has recorded a consumption of 54 l per capita a year in the country , occupying the first position in the consumption and production among the other alcoholic beverages . a study conducted in 2009 at public universities in alagoas found that this profile of consumption was among college students , with beer being more used by men and wine , by women . by observing the results there are different effects amongst those who abuse alcohol ( binge - drinkers ) and moderate drinkers , but everyone is exposed to weaknesses in the cognitive functions . in general , on the day after use , there is confusion and decreased level of attention , which negatively influences the actions for the start of an activity , in this case , go to class . like most of the students in the sample reported never having been drunk , it is possible to see that respondents are more exposed to acute effects of alcohol , justifying the higher rate of abstentions to classes . it is very common for the user to combine both substances because alcohol has a depressive action on the central nervous system ( cns ) and nicotine is a stimulant of cns . since this was a cross - sectional study , data collection took place in just a moment , which made it impossible obtaining a larger sample , and the characteristic of the theme precluded obtaining a representative sample . since this was a cross - sectional study , data collection took place in just a moment , which made it impossible obtaining a larger sample , and the characteristic of the theme precluded obtaining a representative sample . it was felt that the students at this public university in alagoas showed the prevalence of alcohol use similar to several universities in brazil and the world , exposing them to risks of abuse and drug dependency . the family 's influence could be observed even if living alone allows the student more freedom to consume more alcoholic beverages . in addition , men tend to become heavy drinkers with friends and colleagues predominantly and apparently do not worry about the consequences of the act . since we observe a high prevalence of alcohol use at this university and risky behaviors to society with considerable frequency , prevention measures must be created emphasizing the importance of reducing the problems , the consequences of use , and also make laws to avoid drugs .

background : alcohol is the number one toxic substance consumed by people of all age groups , which makes its use a public health problem . the overall trend shows that university students are those who suffer the most pressure.objective:to assess the prevalence of alcohol use among students newly enrolled at a public university in alagoas , brazil.materials and methods : we conducted an analytical sectional study at the federal university of alagoas , with 1435 ( 44% of total ) newly enrolled students of all courses in 2006 . they answered a questionnaire based on the cage . some points such as sex , age , marital status , course , housing , family characteristics and how drugs fit into in the student life were studied with the resources of epiinfo version 3.3.2 . the survey was approved by the research ethics committee of the federal university of alagoas ( number 000878/2005 - 17).results : of the group studied , 95.9% lived with family and 87.6% reported ever drinking alcohol at some time in their life . of all the respondents , 55.4% of men reported having the habit of drinking with friends or colleagues ( odds = 0.71 ; ci = 0.58 - 0.88 ; p - value = 0.00088 ) . among all respondents , 17.7% of male students and 9.8% females skipped class after using alcohol ( odds = 0.52 ; ci = 0.38 - 0.72 ; p - value = 0.000023 ) . the transition from adolescence to youth and study time at university is marked by greater vulnerability to alcohol abuse . the family is decisive for the initiation of alcohol use , and the university is a factor that increases the possibility of maintaining the practice . the fact that not all students were present in the classroom at the time of the application questionnaire may have limited the search because this was a sectional study.conclusion:alcohol consumption in this university is similar to that in other higher education institutions in the world , which is a cause for concern , since the external lesions are accentuated with the practice of using alcohol , characterizing the risk of violence .

protein domains are distinct units of molecular evolution , usually associated with particular aspects of molecular function such as catalysis or binding . in general , they represent discrete units of three - dimensional ( 3d ) structure . the identification of functionally characterized domains in protein sequences may give the first clues as to their molecular and cellular function . a dazzling array of functional diversity , and a large number of clusters grouped by obvious sequence similarity , can be reduced to anywhere between several hundred and a few thousand domain superfamilies , depending on how aggressively one groups clusters based on 3d - structural and/or functional similarities . in many cases , a single or a few search models are sufficient to uniquely identify all members of a large , diverse superfamily in a sequence database . in fact , it is possible to identify and label domains in more than two - thirds of the known protein sequences with only a few thousand domain models , as exemplified by the comprehensive collection pfam ( 1 ) . however , even a compact collection such as pfam can not help but create separate models for what are truly homologous families . the conserved domain database ( cdd ) also mirrors other collections , which are largely redundant with pfam : smart ( 2 ) and cog ( 3 ) . users of the cd - search resource ( 4 ) may face multiple overlapping annotations , sometimes with very similar scores but distinct functional association . this often - confusing redundancy is a necessary , but not desired property of a multiple - source collection such as cdd . one can take certain obvious steps to reduce the redundancy , and this is what we have begun to do in cdd version v2.00 . search models are clustered based on overlapping hits in the protein database . members of a cluster that do not significantly add to the cluster 's total coverage are removed from entrez 's default cdd collection . we have also removed search models , which annotated very few or no sequences , and search models that seem to be specific for proteins and/or domains found only in narrow phylogenetic lineages . however , redundancy can be a good thing , if it provides more specific functional annotations , and the relationships between related models are clear and well explained to the user . there are practical limits to subdividing domain superfamilies : a large number of domain models will affect the database search time , and experimentally backed functional annotation is sparse in many cases . for cdd , we have adopted a principle of creating subfamilies only for ancient conserved domains , present in diverse organisms . we create subfamilies only when the phylogenetic distribution of member sequences suggests an origin of a domain orthology group by gene duplication occurring 0.5 byr in the past or earlier . this principle helps us to maintain what we hope will be a uniform and understandable level of granularity . in subfamilies , we attempt to identify function from the sequence annotation and the published literature . the core model in a subfamily alignment can be mapped onto the often less extensive alignment in the to identify ancient subfamilies for splitting out individual search models , we perform phylogenetic analysis on the multiple sequence alignments and construct sequence trees . this procedure requires fairly accurate alignments , and frequently we do revise alignment models imported from outside sources . in alignment curation , we consider information from 3d structure and structure superposition , when possible , to define structurally conserved cores , accurately delineate domain boundaries and resolve conflicts between sequence - based alignment methods and structure superposition ( 5 ) . alignments curated at the ncbi conform to a simple block - structure , with uniformly aligned , gap - less , structurally conserved blocks separated by unaligned regions , which capture length variation . alignment models from both curated and imported sets are converted into position - specific scoring matrices , and the latter are assembled into search databases for use with rps - blast ( 6 ) . cdd is accessible through the entrez data retrieval system ( 7 ) , and can be queried as entrez 's domain names and terms found in functional descriptions are indexed , and additional search capabilities are provided through reciprocal links to other entrez resources , such as the ncbi taxonomy database , pubmed and entrez 's protein database . pre - calculated cd - searches for proteins are recorded in the cdart database ( 8) , which provides summaries of domain architecture for all proteins in entrez . pre - calculated search results are readily accessible , and provide data for protein domain links , protein protein links based on similar domain architecture and domain domain links based on overlapping hit - lists . most of the domain models in cdd have been imported from two outside sources , pfam and cog . cdd also contains models from smart , and several hundred ncbi - curated domain models , identifiable by accessions starting with cd. while cd - search continues to mirror pfam version 11.0 , smart version 4.0 and cog as individual search sets , the default non - redundant cdd v2.01 , as available in entrez , currently retains only 5252 of 7255 pfam models , 575 of 663 smart models and 4101 of 4873 cog models . search models for use with local rps - blast installations , as well as cdd alignments are available at ftp://ftp.ncbi.nlm.nih.gov / pub / mmdb / cdd/. the source code for rps - blast is part of the ncbi toolkit distribution , accessible at ftp://ftp.ncbi.nlm.nih.gov/toolbox . protein blast searches , they are submitted to cd - search by default , and the resulting domain annotation is displayed graphically on the intermediate blast results page . pre - calculated cd - search results are also readily available for proteins in entrez , following the [ domains ] links . one might , for example , study a family of plant kinesins , exemplified by gi|10130006 from zea mays . cd - search produces a graphical display as shown in the upper half of figure 1 . the central coiled - coil region scores well with a variety of coiled - coil models contained in the uncurated subset of cdd . the c - terminal motor domain scores well with several models curated at the ncbi . cd01366 or kisc_c_terminal , to see the query sequence embedded in its multiple sequence alignment . what will become evident is that cd01366 is one terminal node in a larger hierarchy of related domain models , summarizing kinesin and myosin motor domains in this example . the second - best , third - best scoring hits , and so on , for the c - terminal region of gi|10130006 are to other nodes in this hierarchy . one may want to compare scores and e - values to understand whether the query sequence scores significantly better with one particular subgroup or not . at the level of each individual subgroup , the similarity of the query sequence to other members of that family may be examined . we record conserved features in cd alignment models , such as active sites or binding interfaces , and their locations and residue conservation patterns may be examined in the context of the query . we provide additional annotation , such as links to literature in pubmed and links to textbooks in entrez , so that the user can learn more about the biology of the respective families . building the domain family hierarchies and recording conserved features are major goals of ncbi 's curation effort . we record conserved features together with evidence , such as structure evidence , particular 3d complexes that exemplify binding , for example , or literature citations . we also record the sequence trees used in making decisions about subfamily splits , as an evidence for the domain family hierarchy . beginning in 2005 , we plan to distribute the software used to build and maintain these hierarchies , to serve as a helper application for the web - browser , enabling users to visualize cd family hierarchies , sequence trees and taxonomic diversity across nodes in sequence trees . figure 2 displays a sequence - tree calculated for the myosin / kinesin motor domain family , which was used as an example in figure 1 . having access to the alignment data and analysis algorithms used by the ncbi curators should make the hierarchy editing process more transparent , should users want to investigate . interested users of the hierarchy editor and of cn3d ( 9 ) , the associated structure - based alignment editor , will be able to import additional sequences and examine their behavior in phylogenetic clustering . we thank the authors of pfam , smart and cog , for creating invaluable resources and for helping with access to data . we are grateful to the ncbi blast group for developing rps - blast and for continuous support .

the conserved domain database ( cdd ) is the protein classification component of ncbi 's entrez query and retrieval system . cdd is linked to other entrez databases such as proteins , taxonomy and pubmed , and can be accessed at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=cdd . cd - search , which is available at http://www.ncbi.nlm.nih.gov/structure/cdd/wrpsb.cgi , is a fast , interactive tool to identify conserved domains in new protein sequences . cd - search results for protein sequences in entrez are pre - computed to provide links between proteins and domain models , and computational annotation visible upon request . protein protein queries submitted to ncbi 's blast search service at http://www.ncbi.nlm.nih.gov/blast are scanned for the presence of conserved domains by default . while cdd started out as essentially a mirror of publicly available domain alignment collections , such as smart , pfam and cog , we have continued an effort to update , and in some cases replace these models with domain hierarchies curated at the ncbi . here , we report on the progress of the curation effort and associated improvements in the functionality of the cdd information retrieval system .

a male baby , delivered normally and spontaneously after a full - term pregnancy , was well during the first 28 hours of life . he then became lethargic and hypotonic , and the shallow respiration which began at that point progressed to intermittent apnea , requiring mechanical ventilation . on the 4th day , brain computed tomography and ultrasonography were performed , to exclude the possibility of hemorrhage in the posterior cranial fossa : the findings were normal . on the 5th day , amino acid analysis of the csf and plasma was requested , to exclude the possibility of metabolic disorders , and on the 6th day , brain magnetic resonance ( mr ) imaging and spectroscopy were performed using a 1.5-tesla system ( ge signa , milwaukee , wis . , u.s.a . ) . again , the imaging findings were normal . using a single - voxel stimulated - echo acquisition mode ( steam ) sequence ( repetition time / echo time / mixing time , 3000 / 166 / 13.7 ; number of excitations , 96 ; spectral width 2500 hz ; number of points , 2048 ; voxel size , 222 cm ) , proton mr spectra of the right parietal white matter were obtained . the raw data were post - processed by water - referenced correction of the eddy current effect , lorenz - to - gauss transformation , gaussian line broadening of 0.5 hz , zerofilling of 8k , fourier transformation , and zero - order phasing of the transformed spectra . major spectral peaks occurring at 2.01 , 3.03 , 3.22 and 3.55 ppm were assigned to n - acetylaspartate ( naa ) , creatine and phosphocreatine ( total cr ) , choline - containing compounds ( cho ) , and glycine , respectively ( 3 , 6 ) . the spectra obtained were compared with those from an age - matched control subject ( fig . 2a ) , but his spectrum revealed that the peak intensity , observed at 3.55 ppm , had increased markedly , and this was assigned to glycine . glycine / cho and glycine / total cr ratios were found to be 1.58 and 2.42 , respectively ( fig . csf and plasma amino acid analysis revealed glycine levels of 184 ( normal , < 13 ) nmol / ml and 1411 ( normal , 232 - 740 ) nmol / ml , respectively . the csf : plasma glycine concentration ratio was 0.13 ( normal , < 0.02 ) . the results of amino acid analysis and other laboratory tests indicated nkh , and on the basis of this diagnosis , the patient was treated with dextromethorphan ( 8.5 mg / kg / day ) and sodium benzoate ( 300 mg / kg / day , intravenous infusion ) , followed by a double - volume exchange transfusion , peritoneal dialysis and total parenteral amino acid - free nutrition . after intensive medical treatment , his respiration and consciousness level improved slowly over several days , and on the 12th day , follow - up amino acid analysis revealed decreased csf and plasma glycine concentrations of 69 and 346 nmol / ml , respectively . on the same day , follow - up mrs of the same parietal white matter showed decreased glycine / cho ( 1.05 ) and glycine / total cr ( 1.31 ) ratios , in accordance with decreased csf and plasma glycine concentrations ( fig . 2c ) . after amino acid ( 0.5 g / kg / day ) was added to the parenterally administered nutritional mix , the patient again developed seizure - like motion and intermittent apnea . over several days , he developed intractable generalized tonic - clonic seizure and his clinical condition deteriorated rapidly , requiring mechanical ventilation . final follow - up mrs on the 17th day revealed , in comparison with the second mrs study , a prominently increased glycine / cho ratio ( 1.80 ) , a slightly increased glycine / total cr ratio ( 1.60 ) and a newly occorring lactate , at 1.3 ppm ( fig . nkh is a rare metabolic brain disease , though is well known to neonatologists and pediatricians . in more than 80% of nkh patients , because most patients die at this time , there have been very few neuro - imaging studies . ( 7 ) reported that in seven patients with nkh , mr imaging studies revealed progressive atrophy , abnormal thinning of the corpus callosum , and decreased or absent myelination in the supratentorial white matter . these morphologic changes can be observed in patients who survived the neonatal period , and may be a late sequela of previous metabolic brain damage . in the acute phase of this disease , routine brain mr imaging findings are usually normal , despite serious clinical symptoms . mrs has , during the last decade , been applied extensively to various kinds of metabolic brain diseases , in the hope of detecting any specific abnormal metabolites . in the majority of such diseases , however , the findings have been non - specific , especially from a diagnostic point of view ( 8) . nkh is one of the few metabolic brain diseases in which mrs can detect a specific metabolite that accumulates in the brain . in our case , using long echo - time ( 166 msec ) steam mrs , we observed that glycine concentration increased , peaking at 3.55 ppm ( fig . 2b - d ) . because absolute quantification of metabolite concentrations was not feasible , we used glycine / cho and glycine / total cr ratios , as determined at serial mrs , to estimate cerebral glycine levels . after intensive medical treatment and some symptomatic improvement , glycine / cho decreased from 1.58 to 1.05 , in accordance with a decrease in csf glycine from 184 to 69 nmol / ml . after symptomatic aggravation , glycine / cho increased again , from 1.05 to 1.80 , reflecting close correlation between glycine / cho levels and the clinical status of the patient . the glycine / total cr ratio tended to be similar to that of glycine / cho , and in this respect , heindel et al . ( 3 ) reported good correlation between glycine / cho , glycine / total cr , the glycine concentration estimated by mrs , and clinical findings . ( 4 ) reported that the time course of glycine / total cr corresponded to changes in plasma and csf glycine levels , and gabis et al . ( 5 ) reported that glycine levels measured by mrs corresponded to changes in plasma glycine levels . our results are similar to those of previous reports and we agree with the opinion that mrs can be used as a non - invasive diagnostic or monitoring tool in patients with nkh . 2d ) may reflect anaerobic glycolysis of brain tissue , probably caused by respiratory difficulty and hypoxia . in our case , it is difficult to draw definite conclusions regarding changes in naa , total cr , and cho levels . in order to clarify changes in cerebral metabolites occurring in nkh , absolute quantification of their concentrations may be necessary . the clinical outcome of neonatal nkh may depend on the severity of the involved enzyme defect . most neonatal forms of the disorder are usually fatal despite intensive medical treatment , but in some transient forms , the outcome of appropriate treatment is generally excellent ( 9 ) . these milder or atypical forms of nkh usually present a greater diagnostic challenge ( 10 ) , however , and close monitoring of their clinical course and glycine levels may be necessary even after the condition is diagnosed . in this situation , mrs can be used as a non - invasive diagnostic or monitoring tool . in summary , the most characteristic feature of mrs was a marked increase in peak glycine intensity , to 3.55 ppm , in the spectra obtained using a long echo - time . we believe that in patients with nkh , mrs not only provides diagnostic information but is also a suitable noninvasive monitoring tool .

nonketotic hyperglycinemia ( nkh ) is a rare metabolic brain disease caused by deficient activity of the glycine cleveage system . localized proton mr spectroscopy ( echo - time 166 msec ) , performed in an infant with the typical clinical and biochemical features of neonatal nkh , showed a markedly increased peak intensity at 3.55 ppm , which was assigned to glycine . serial proton mr spectrosocpic studies indicated that glycine / choline and glycine / total creatine ratios correlated closely with the patient 's clinical course . proton mr spectroscopy was useful for the non - invasive detection and monitoring of cerebral glycine levels in this infant with nkh .

alzheimer s disease ( ad ) and related dementias cause impairment in functional abilities , including ability to drive . over half a million individuals in canada have a diagnosis of ad , and in nova scotia , approximately 5,400 individuals with a diagnosis of ad continue to drive . following a diagnosis of ad , almost 50% of individuals will be involved in a motor vehicle collision ( mvc ) within five years . ad affects driving by reducing reaction time and the ability to shift visual attention from one stimulus to another for example , from a car in front of the vehicle to a pedestrian crossing the street . early loss of insight may prevent individuals with ad from accurately appraising their driving abilities and foster optimistic bias , the idea that bad things ( mvcs ) only happen to other people . thus , individuals with ad rarely relinquish their driving privileges voluntarily and often cease driving only after being involved in an mvc . caregivers frequently do not plan for driving cessation , and there is often a lag between the recognition of cognitive deficits on the part of the caregiver and the initiation of the driving cessation process . this lag may be due to the caregivers lack of knowledge about dementia and its impact on driving or fear over increased burden of care if the affected individual can no longer drive . therefore , physicians are routinely responsible for initiating the driving cessation process by contacting the appropriate authorities . in canada , reporting guidelines concerning fitness to drive vary by province and territory . all but three canadian provinces mandate that physicians report potentially unsafe drivers to provincial licensing authorities ; however , national survey data indicate that many physicians , regardless of mandatory reporting , do not feel comfortable in assessing driving safety . the canadian medical association ( cma ) guidelines for the assessment of driving in dementia are designed to provide a unified physician approach to the assessment of dementia patients ; however , these guidelines does not offer conclusive answers for case - by - case usage , and there is no failsafe test to predict which individuals with dementia are at significant risk of mvc . in nova scotia , reporting of unsafe drivers is at the discretion of the physician . physicians must therefore consider not only the underlying disease , but also the interest of the patient and family ( many of whom reside in rural areas and are highly dependent on personal vehicles for transportation ) , the welfare of the community , medical ethics , and their own personal comfort and confidence in assessing fitness to drive . this study sought to assess perceived barriers to addressing driving safety in dementia among nova scotian primary care physicians ( pcps ) and to determine whether these barriers differ between urban and rural physicians or according to years of practice . this cross - sectional study targeted nova scotian pcps . for study inclusion , physicians surveyed were required to be english speaking with a practice in nova scotia that included patients with dementia . drawing upon published literature an anonymous 33-item survey was developed with questions evaluating pcp demographics and general practice ( n = 7 questions ) , practices in evaluating fitness to drive ( n = 13 ) , opinions regarding the assessment and reporting of fitness to drive ( n = 8) , and resource use ( n = 6 ) . the survey was reviewed by four geriatricians who provided feedback on content validity and readability prior to survey circulation . surveys ( n = 134 ) were distributed to pcps attending a canadian medical education refresher held in halifax , nova scotia in 2008 . an electronic version of the questionnaire ( hosted on dalhousie university s opinio web server ; opinio version 5 , object planet , inc , oslo , norway ) was distributed via email to a registry of approximately 700 pcps practicing in nova scotia . as an incentive survey participants were asked to email their name and address to a generic email account for entry into a draw for a $ 100 gift card to a nova scotian gas station . the institutional research ethics board of the capital district health authority in halifax approved the study protocol . implied consent was obtained ; pcps reviewed a cover letter describing the research and decided whether to complete and submit the survey . survey response data were examined using descriptive statistics and multivariate linear and logistic regression controlling for sex , community of practice , and years of practice . all descriptive statistics reported are based on the number of responses obtained for each question . this cross - sectional study targeted nova scotian pcps . for study inclusion , physicians surveyed were required to be english speaking with a practice in nova scotia that included patients with dementia . drawing upon published literature an anonymous 33-item survey was developed with questions evaluating pcp demographics and general practice ( n = 7 questions ) , practices in evaluating fitness to drive ( n = 13 ) , opinions regarding the assessment and reporting of fitness to drive ( n = 8) , and resource use ( n = 6 ) . the survey was reviewed by four geriatricians who provided feedback on content validity and readability prior to survey circulation . surveys ( n = 134 ) were distributed to pcps attending a canadian medical education refresher held in halifax , nova scotia in 2008 . an electronic version of the questionnaire ( hosted on dalhousie university s opinio web server ; opinio version 5 , object planet , inc , oslo , norway ) was distributed via email to a registry of approximately 700 pcps practicing in nova scotia . as an incentive survey participants were asked to email their name and address to a generic email account for entry into a draw for a $ 100 gift card to a nova scotian gas station . the institutional research ethics board of the capital district health authority in halifax approved the study protocol . implied consent was obtained ; pcps reviewed a cover letter describing the research and decided whether to complete and submit the survey . survey response data were examined using descriptive statistics and multivariate linear and logistic regression controlling for sex , community of practice , and years of practice . all descriptive statistics reported are based on the number of responses obtained for each question . of the 159 surveys completed ( 79 paper , 80 electronically ) , 134 met the inclusion criteria and were included for analysis . surveys excluded were completed by physicians who did not practice in nova scotia ( n = 19 ) or did not treat patients with dementia ( n = 6 ) . physicians were primarily female ( 71 , 53% ) , practicing in an urban community ( 77 , 58% ) with a mean sd of 17.911 years experience as a pcp . driving evaluations for patients with a diagnosis of dementia were typically considered to be a part of routine practice ( 95 , 71% ) , with assessments most often being done on diagnosis ( 73 , 55% ) or by mild stage ( 42 , 31% ) and taking less than 30 minutes ( 124 , 93% ) . physicians reported referring patients for on - road assessment ( 94 , 70% ) and to other health care professionals ( 88 , 66% ) , usually a geriatrician ( 66/88 , 75% ) . number of years of practice was associated with more lengthy discussions about driving cessation ( p = .03 ) , and was positively associated with the probability both of having a routine discussion about driving and dementia ( p = .03 ) and of referring for an on - road assessment ( p = .02 ) . some ( n = 17 ) physicians reported feeling comfortable in assessing driving safety ( 10 , 59% male , 10 , 59% rural ) . however , more than half of those surveyed ( 93 , 69% ) said they at least sometimes avoid discussions about driving cessation . neither comfort in assessing driving safety nor avoidance of discussions was associated with type or years of practice . concern about personal or corporate liability was most common , as indicated by 78% ( n = 105 ) of respondents . physicians were instructed to select all of the tools they used to assess fitness to drive for patients with dementia and were given the opportunity to include items not listed . almost all pcps reported using the mini - mental state examination ( mmse ) when assessing driving ability ( 124 , 92% ) . of those surveyed , 84% ( n = 112 ) were aware of the cma guidelines for determining medical fitness to operate a motor vehicle . while 60% ( n = 80 ) reported using the guidelines in practice , only half of respondents rated it as useful ( 63 , 47% ) . no association was found between use of the national guidelines and years of practice , sex , or type of practice . few physicians ( 32 , 24% ) indicated that they used other resources regarding driving cessation in dementia ( such as information from the nova scotia registry of motor vehicles and the alzheimer society of canada ) . when asked specifically , 97% ( n = 130 ) of respondents indicated their interest in accessing more education tools and resources such as a website regarding driving cessation in dementia . most respondents considered discussions about driving safety to be a part of the routine assessment of patients with dementia and recognized their role in reporting elderly drivers . the results of a recent american study examining physician attitudes and practice regarding fitness to drive for individuals with dementia are comparable with our findings that physicians with more years experience are more likely to routinely address driving issues . many of our respondents reported lack of familiarity with current guidelines as a barrier to assessing driving safety in dementia . physician relationships was a common barrier to driving assessment in a national survey , regardless of discretionary or mandatory reporting policies , our result may be in part related to nova scotia s provincial discretionary reporting policy , whereby physicians are not obligated to report concerns about unsafe drivers to the registry of motor vehicles . interestingly , national data indicate that physicians in provinces with mandatory reporting are less likely to assess fitness to drive than those practicing under a discretionary reporting system , but are more likely to report unsafe drivers . ultimately , until there is a reliable and validated office tool , pcps will continue to face challenges in assessing fitness to drive in dementia . although it has been proposed that fitness to drive is not maintained once mmse scores fall to 24 , a recent meta - analysis found that mmse scores are no more reliable than a simple driving knowledge test in predicting on - road driving performance ( e.g. , recognizing traffic signs ) during driving assessments . the clock draw test , less often used by nova scotian pcps , has been shown to predict poor performance on driving simulators ( overall prediction 90% ) . however , these results have yet to be replicated and confirmed with on - road performance . furthermore , while the american academy of neurology recently recommended using the clinical dementia rating ( cdr ) scale combined with caregiver input , driving history , changes in driving behavior , an mmse score 24 , and aggressive behavior as useful for identifying patients at increased risk for unsafe driving , the cdr is not often used by pcps . few respondents listed the montreal cognitive assessment ( moca ) as a tool they use to inform driving assessment . while screening tools for mild cognitive impairment ( mci ) such as the moca are gaining popularity among general practitioners , there is no evidence supporting the use of the moca as an indicator of fitness to drive in mci or dementia . in particular , the implications of a diagnosis of mci for driving safety are not addressed by national guidelines . further , the moca has variable specificity for the diagnosis of mci and dementia , and research indicates that individuals with mild dementia may still drive safely . given the discomfort associated with addressing driving safety for patients with dementia , and the lack of a validated in - office assessment tool , it is not surprising that many physicians refer their patients either for additional assessment by another health care professional or for on - road assessment . the recently released screen for the identification of cognitively impaired medically at - risk drivers , a modification of the demtec ( simard md ) tool a pen - and - paper test that evaluates memory , attention , judgment , and decision making is being pilot tested in british columbia . unfortunately , at least one - half of patients tested will still need on - road evaluation due to an indeterminate result . we do not have data regarding the practices of pcps who did not complete the survey . however , our sample did include a variety of practice profiles in terms of urban compared with rural practice , practitioner s sex , and number of years of practice , and our results are consistent with those of other studies of physician s attitudes toward assessing fitness to drive for dementia , as well as the elderly in general . nova scotian pcps continue to report discomfort with assessing fitness to drive in dementia and are eager to access information and resources . in response to this identified gap in knowledge transfer , we partnered with the canadian dementia knowledge translation network ( www.lifeandminds.ca ) to create an online educational resource for nova scotian physicians and caregivers of individuals with dementia ( www.notifbutwhen.ca ) . the resource contains educational materials , assessment information , and tools for both physicians and caregivers to promote healthy driving cessation . further study , following release and promotion of a provincially relevant online resource , will help clarify the impact of the resource on practice habits .

background and purposeover half a million canadians have a diagnosis of dementia , approximately 2530% of whom continue to drive . individuals with dementia have a risk of motor vehicle collision up to eight times that of drivers without dementia . in nova scotia , the responsibility of reporting unsafe drivers is discretionary , but national survey data indicate that many physicians do not feel comfortable assessing driving safety . we report on barriers to addressing driving safety as identified by nova scotian primary care physicians ( pcps).methodswe conducted a cross - sectional study of surveys completed by 134 english - speaking , nova scotian pcps ( mean years of practice 17.911 ; 53% female ; 58% urban ) . statistical analysis included descriptive statistics and multivariate linear and logistic regression ( controlling for sex , urban / rural , and years of practice).resultsmost pcps ( 96% ) routinely address driving safety in dementia , but physicians at all levels of experience find these discussions uncomfortable and sometimes avoid them . pcps experience multiple barriers to assessing driving in dementia and desire further education and resources.conclusionsin nova scotia , driving assessment is considered part of routine care in dementia , but general lack of comfort in administering these assessments is a risk . to improve physician comfort further education and resources are required .

the first symptom of soft rot on apple fruit was a water - soaked appearance to the affected tissue . the diseased parts later disintegrated into a mushy mass of disorganized cells that sloughed off . white mycelia formed on infection sites of apples and gradually covered the fruit with tufted whisker - like gray sporangiophores and sporangia ( fig . sporangiospores , sporangia , and sporangiophores were observed under a light microscope ( table 1 ) . the fungal colonies that grew on potato dextrose agar were initially white and cottony , then became heavily speckled with sporangia , and finally became brownish - grey to blackish - grey and spread rapidly with stolons fired at various points to the substrate by rhizoids ( fig . the optimum temperature for mycelial growth was 30 , with good growth still apparent at 37. sporangiospores were unequal , numerous , irregular , sub - globose or oval , angular with striations , and 4~8 m ( fig . smooth - walled , simple or branched , non - septate , long , and arose from stolons opposite rhizoids usually in groups of 3~5 or more . sporangia were globose , white at first , and then turned black with many spores , mostly 40~200 m ( fig . 2c ) . columella were globose to sub - globose , pale brown , and mostly 85~110 m ( fig . twelve apple fruits were artificially inoculated with a representative fungus using the wound infection method . a conidial suspension ( 0.1 ml ; 3 10 conidia / ml ) of the causal fungus was placed on the surface of apple fruit . the inoculated fruit was kept in a moist chamber with 100% relative humidity at 30. after a 3 day incubation , the same fungal symptoms were reproduced : soft rot was observed on inoculated fruits that was identical to symptoms observed at the commercial markets ( fig . 1c and 1d ) . to confirm the identity of the causal fungus , the its rdna of the isolate was amplified and sequenced using its1 ( 5'-tccgtaggtgaacctgcgg-3 ' ) and its4 primers ( 5'-tcctccgcttattgatatgc-3 ' ) , as described by white et al . . a phylogenetic analysis was performed using mega4 with the neighbor - joining method and the tajima - nei distance model . previously published its sequences from r. oryzae strains were included for reference , and mucor miehei ( genbank accession no . the present isolate was placed within a clade comprising r. oryzae references isolates ( fig . soft rot of apple caused by r. stolonifer has been reported previously , but soft rot caused by r. oryzae has not been recorded in korea . the representative culture of the causal fungus was deposited in the korean agricultural culture collection ( kacc 45815 ) , national academy of agricultural science , suwon , korea . based on the mycological characters , molecular data , and pathogenicity testing of the host plant , the fungus was identified as rhizopus oryzae went & prisen geerligs .

soft rot in apple caused by rhizopus oryzae was found for the first time in korea . a detailed description of the specimen is given along with its internal transcribed spacer rdna sequence . the fungus was identified as rhizopus oryzae based on the mycological characteristics , molecular data , and pathogenicity testing .

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

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

wounds , especially chronic ones , are now a major health concern affecting a large number of patients and causing a considerable reduction in their health - related quality of life [ 1 , 2 ] . for this reason , research on wound healing agents is currently an attractive and developing field in biomedical sciences [ 2 , 3 ] . one group of drugs that has shown significant capabilities in the area of wound care and management is herbal medicines . the use of plant materials has been a common medical practice since early times , especially in eastern countries ; even now , various wound care products contain herbal ingredients [ 2 , 3 ] . one such herbal medicine presently available in iran and claimed to improve wound healing is alpha ointment [ 4 , 5 ] . alpha ointment contains the active ingredient lawsone ( available in natural henna ( lawsonia inermis linn . ) ) and unsaturated fatty acids [ 46 ] . according to previous research , this composition has antioxidant and anti - inflammatory features [ 5 , 6 ] . as we see in our daily clinical practice , alpha ointment is one of the prescriptions commonly used for the management of lower extremity chronic wounds , particularly diabetic ulcers . however , data regarding its efficacy in wound management is insufficient , and there are no strong and well - documented recommendations for its use . based on these facts , the current experimental study evaluated the ability of alpha ointment to improve skin wound healing and compared it with the effects of medical - grade honey ointment , a product that received u.s . food and drug administration ( fda ) approval for use in conditions like leg ulcers , burns , diabetic foot ulcers , traumatic wounds , and so forth . the study protocol was approved by the animal ethics committee of shiraz university of medical sciences , shiraz , iran . all procedures were performed under general anesthesia , and all efforts were made to minimize the animals ' suffering . in this study , we used a previously examined method . a total of 22 healthy adult male sprague - dawley rats ( mean weight : 350 g ) were selected for this experimental study . the rats were kept in separate clean cages and had free access to equal amounts of standard food ( center of comparative and experimental medicine , shiraz university of medical sciences , shiraz , iran ) and water . they were housed in temperature - controlled ( 22 2c ) and humidity - controlled ( 55 15% ) rooms with 12-hour light / dark photoperiods and allowed to adapt to their environment for one week before experiments began . the rats were randomly and equally allocated into two groups ( n = 11 ) : ( 1 ) rats for which alpha ointment ( rejuderm , iran ) was applied to the wound surface area ( alpha - treated group ) and ( 2 ) rats for which medical - grade honey ointment ( medihoney , comvita ltd . , new zealand ) was applied to the wounds ( honey - treated group ) . during the 21-day study period , the ointments were applied to the wound surface areas at 24-hour intervals with disposable applicators in a manner that created a thin layer that fully covered the wound . to generate the wounds , the rats were first anesthetized with an intramuscular injection of thiopental sodium ( 40 mg / kg ; biochemie , gmbh , austria ) and xylazine ( 10 mg / kg ; alfasan international , woerden , netherlands ) . then , their back hair was shaved , and the wound site was disinfected using alcohol ethylic solution . next , a full - thickness circular excisional skin wound ( 20 mm in diameter and 2 mm deep ) was created on the back of each rat using scissors and forceps . throughout the study period , the rats ' wounds were carefully examined every day for any possible complications , particularly any macroscopical manifestation of infection . of note , rats were to be excluded from the experiment if death occurred . wound contraction was assessed photographically with images taken using a digital camera ( powershot g9 12.1 megapixel camera ; canon , tokyo , japan ) on days 0 , 7 , and 21 after wounding . the camera was fixed at a distance of 10 cm from the wound surface ( in a vertical view ) , and a fine - line ruler was held at wound level at the time of photography in order to calibrate the magnification of the photographs . photos were analyzed using adobe photoshop cs program ( adobe systems , san jose , ca , usa ) ( analysis menu > record measurements command ) . semicircular full - thickness skin biopsies from wound sites in both groups were taken on days 7 ( half of the wound site with a margin of 2 mm ) and 21 ( the remaining part with a 2 mm margin ) after wounding . animals were first anesthetized with inhaled ether on day 7 and then euthanized with ether on day 21 . tissue samples were immediately fixed in buffered formaldehyde ( 10% formalin ) and then sent for histopathological assessments ( haematoxylin and eosin and masson - trichrome staining and light microscopic evaluation ) . the scoring system described by abramov et al . for the histopathological evaluation of physiological parameters involved in the wound healing process was adapted for use in this study ( table 1 ) . abramov 's scoring system examines the following criteria : amount of acute and chronic inflammatory infiltrates , amount of granulation tissue , maturation of granulation tissue , collagen deposition , neovascularization , and reepithelialization . all investigators who assessed tissue samples or analyzed images in this study were blinded to the agents given . whitney u test ( spss statistics software , version 16 ; chicago , illinois , usa ) . the mean sd values of wound surface area were calculated for each group using images taken on days 0 , 7 , and 21 after wounding ( table 2 ) . the results indicated no statistically significant difference between the two groups on the aforementioned study days . of note , all rats survived the experiment , and their wounds showed no apparent signs of infection during the study period . the results of the histopathological assessment ( figures 1 and 2 ) are summarized in table 3 . according to the findings , there was no statistically significant difference between the alpha- and honey - treated groups regarding the factors of acute and chronic inflammation , amount and maturation of granulation tissue , and reepithelialization on days 7 and 21 . however , significant differences in collagen deposition ( p value : 0.007 ) and neovascularisation ( p value : 0.002 ) between the two groups were observed on day 21 . the histopathological examination of the skin biopsies revealed no tissue necrosis following the application of alpha ointment . finding new agents to accelerate wound healing and improve currently available products is the main concern for researchers in biomedical sciences . one such agent , alpha ointment containing lawsone from henna and some other ingredients , has been produced in iran in recent years [ 46 ] . issues concerning herbal - derived wound care products are their efficacy and possible adverse dermatological effects associated with their use . because of these issues and the fact that documented evidence about alpha ointment is insufficient , this study examined the effects of this product on the parameters involved in the skin healing process and compared it with the fda - approved product medical - grade honey ointment . some previous studies defend the antibacterial properties of lawsonia inermis and its efficacy in acceleration of wound repair [ 1214 ] . the experiment of shivananda nayak et al . , who conducted an animal study to evaluate the impact of ethanol extract of lawsonia inermis ( the plant on which alpha ointment is based ) , is an example for this case . according to their results , this agent had the ability to increase the rate of wound contraction , decrease the period of epithelialization , and significantly increase the granulation tissue weight when compared with controls . these authors ' histological findings from the extract - treated group showed an increased amount of well - organized collagen bands ( consequently the increased skin - breaking strength ) , increased number of fibroblasts , and reduced number of inflammatory cells compared with the controls . however , few studies have directly assessed the efficacy of alpha ointment for wound healing [ 46 ] . ansari et al . , using their study criteria , compared the efficacy of topical alpha ointment with that of topical hydrocortisone ( 1% ) in healing radiation - induced dermatitis in cases of breast cancer . after following up the patients for three weeks , the authors concluded that the topical application of alpha ointment was more effective in healing radiation - induced dermatitis than topical hydrocortisone cream ( 1% ) . compared the impact of alpha ointment with that of silver sulfadiazine on the healing process of standard third - degree and pseudomonas aeruginosa infected burn wounds . according to their results , alpha ointment significantly decreased the rate of wound infection , positive cultures , and scar formation compared with the other groups . the authors reported that another notable advantage of alpha ointment compared with some other products used in burn wound care , like silver sulfadiazine , was its lower price . moreover , they noted that alpha ointment had very few and acceptable adverse reactions . in the current study , significant differences were observed between alpha- and honey - treated groups regarding the two factors of collagen deposition and neovascularisation on day 21 . 's work , this study revealed significantly lesser collagen deposition in the alpha - treated group than in the honey - treated one . this phenomenon reduces the possibility of excessive scar formation after the wound healing process ( similar to what was seen in hosseini et al . 's work ) [ 4 , 1517 ] . due to the role of collagen matrix and its organization in tissue tensile strength , the other probable aspect of reduced collagen deposition is its impact on the strength of the final healed tissue [ 18 , 19 ] . however , a prerequisite for commenting about the significance of this event is examining it using standard methods and devices , a matter that was not evaluated in this work . another important point is the angioinhibitory property of alpha ointment . it is evident that neovascularization ( neoangiogenesis ) is critical during wound healing to provide tissues with essential materials [ 20 , 21 ] . therefore , the inhibition of such event could negatively affect the healing process . however , in spite of the angioinhibitory function of alpha ointment , photographical examinations in the current study revealed no statistically significant difference between the two examined groups regarding wound contraction and wound surface areas on the specified days . first of all , for each rat , biopsies were obtained from the same healing wound on days 7 and 21 ( half of the wound area was biopsied in each day ) , and this restricted the interpretation of wound surface area on day 21 . another limitation of this work was the limited number of skin biopsies obtained from each rat . in fact , to better monitor the healing process and better recognize possible differences , additional biopsies should have been taken early after wounding ( e.g. , on day 4 ) and between days 7 and 21 . according to this histopathological study , daily topical usage of alpha ointment on a skin wound in rats can negatively affect the healing process by inhibiting neovascularization . furthermore , because of the reduced collagen deposition within the healing tissues , there is lesser possibility of excessive scar formation after the topical application of alpha ointment . however , further human in vivo studies are recommended to examine the clinical importance of these findings .

introduction . this study compared the healing efficacy and possible adverse effects of topical alpha and medical - grade honey ointments on cutaneous wounds in rats . methods . to conduct the study , 22 male sprague - dawley rats were randomly allocated into two equal groups : ( 1 ) rats with alpha ointment applied to the wound surface area and ( 2 ) rats with medical - grade honey ointment applied to their wounds . the ointments were applied daily during the 21-day study period . wound contraction was examined photographically with images taken on days 0 , 7 , and 21 after wounding . the healing process was histopathologically assessed using skin biopsies taken from the wound sites on days 7 and 21 . results . no statistically significant difference in mean wound surface area was observed between the two study groups . according to histopathological assessment , a significant reduction in the amount of collagen deposition ( p value : 0.007 ) and neovascularisation ( p value : 0.002 ) was seen in the alpha - treated rats on day 21 . no tissue necrosis occurred following the application of alpha ointment . conclusion . daily topical usage of alpha ointment on a skin wound can negatively affect the healing process by inhibiting neovascularization . topical alpha ointment can reduce the possibility of excessive scar formation by reducing collagen deposition .

es cell lines including the g9a knockout were cultured based on the standard protocol of the es core laboratory at johns hopkins university ( see full methods for details ) . we differentiated es cells for 1824 days by removing leukemia inhibitory factor ( lif , chemicon ) from the medium and culturing in plates without feeder cells . chromatin was isolated without sonication or formalin cross linking , by digested with micrococcal nuclease ( mnase , ge healthcare , piscataway , nj ) , and then chromatin immunoprecipitation was performed with an antibody specific to h3k9me2 ( abcam , cambridge , ma ) . chip and input dna were amplified , labeled by cy5 and cy3 respectively , and hybridized to nimblegen tilling arrays as described4 . we first conducted within - array normalization to correct the probe sequence effects and position bias . locks are defined as the genomic regions where smoothed values are above 97.5th quantile of log ratios in reference regions ( see full methods for details ) . the pdf files containing all the pictures of locks can be obtained through our website : http://rafalab.jhsph.edu / k9locks/. es cell lines including the g9a knockout were cultured based on the standard protocol of the es core laboratory at johns hopkins university ( see full methods for details ) . we differentiated es cells for 1824 days by removing leukemia inhibitory factor ( lif , chemicon ) from the medium and culturing in plates without feeder cells . chromatin was isolated without sonication or formalin cross linking , by digested with micrococcal nuclease ( mnase , ge healthcare , piscataway , nj ) , and then chromatin immunoprecipitation was performed with an antibody specific to h3k9me2 ( abcam , cambridge , ma ) . chip and input dna were amplified , labeled by cy5 and cy3 respectively , and hybridized to nimblegen tilling arrays as described4 . we first conducted within - array normalization to correct the probe sequence effects and position bias . locks are defined as the genomic regions where smoothed values are above 97.5th quantile of log ratios in reference regions ( see full methods for details ) . the pdf files containing all the pictures of locks can be obtained through our website : http://rafalab.jhsph.edu / k9locks/.

higher eukaryotes must adapt a totipotent genome to specialized cell types with a stable but limited repertoire of functions . one potential mechanism for lineage restriction is changes in chromatin , and differentiation - related chromatin changes have been observed for individual genes12 . we have taken a genome - wide view of histone h3 lysine-9 dimethylation ( h3k9me2 ) . we find that differentiated tissues exhibit surprisingly large k9-modified regions ( up to 4.9 mb ) , that are highly conserved between human and mouse , and differentiation - specific , covering only ~4% of the genome in undifferentiated mouse embryonic stem ( es ) cells , compared to 31% in differentiated es cells , ~46% in liver and ~10% in brain . they require histone methyltransferase g9a , and are inversely related to expression of genes within them , and we term them large organized chromatin k9-modifications ( locks ) . locks are substantially lost in cancer cell lines , and they may provide a cell type - heritable mechanism for phenotypic plasticity in development and disease .

lobular capillary hemangioma ( lch ) , also known as pyogenic granuloma , is a benign , rapidly growing , hypervascular lesion . its usual locations are the skin and mucous membranes of the head and neck , the nasal cavity being a rare site of origin.1 2 its etiopathogenesis is not fully established , although an association with traumatic and hormonal factors has been identified . these lesions tend to occur more frequently after nasal surgery or nasal packing and in women during pregnancy or taking oral contraceptive pills.3 here , we present the first reported case of a nasal lch following an endoscopic transsphenoidal resection of a gonadotrophin - producing pituitary adenoma , reflecting a possible but rare complication of this procedure . the neurologic examination revealed a bitemporal hemianopsia and the laboratory studies , including endocrinological investigation were normal . she was diagnosed with a pituitary cystic macroadenoma and underwent an endoscopic transsphenoidal removal of the lesion in our institution by a team of two neurosurgeons experienced in endoscopic procedures . nasal packing was done bilaterally with merocel ( medtronic ) ( polyvinyl - alcohol sponge ) nasal tampon lubricated with antiseptic cream , maintained for 5 days and then removed uneventfully . the histopathologic review established the diagnosis of a gonadotropin ( luteinizing hormone and follicle - stimulating hormone)-producing adenoma . one month after the surgery , the patient presented with a progressively growing right nasal mass ( fig physical examination revealed a reddish , smooth - surfaced mass , filling the right nasal cavity . the mass was mobile and appeared pedunculated with its base attached to the anterior portion of the nasal septum . the polyp was removed surgically , under general anesthesia and using nasal forceps and electrical cautery . her blood pressure was normal , hemoglobin levels were discretely low , and coagulation tests were normal . the bleeding was controlled with the insertion of a nasal inflatable balloon catheter and cautery with silver nitrate . nasal endoscopy was repeated after 1 week , 6 months , and 1 year , showing no signs of lesion recurrence . grossly , it appears as a friable polypoid mass , which can present ulcerations on its surface . on histopathological examination its typical pattern is characterized by multiple , varying - sized capillaries in a lobular arrangement , surrounded by a loose fibromyxoid stroma.4 the most common locations for these lesions are the skin and mucous membranes of head and neck , particularly the gingiva of the oral cavity , the nasal cavity being a rare site of origin.1 2 within the nasal cavity , these lesions have been described to arise more frequently from the anterior portion of the nasal septum ( little area ) or the anterior portion of the inferior turbinate.5 6 it can occur at all ages and affects both the sexes equally.2 it presents usually by unilateral recurrent epistaxis and nasal obstruction , though in some cases smell alterations can be involved.1 the lesion is usually identified on direct examination of the anterior nasal cavity.7 the exact etiopathogenesis of this lesion is unclear , although some predisposing factors have been implied , such as local trauma or hormonal influences . regarding traumatic factors , the most commonly reported are nose picking and nasal packing , which are thought to trigger an inflammatory process in response to traumatic injury to the surface exposed.2 7 also , hormonal stimulation has also been implicated , with some cases reported in association to pregnancy and oral contraception.8 in this case , the lesion developed after an endoscopic transsphenoidal pituitary access , which induces traumatic injury to the nasal mucosa both through intraoperative manipulation and postoperative nasal packing . the pituitary adenoma removed was gonadotrophin - producing which can also provide a favorable hormonal environment . the differential diagnosis of an exophytic hypervascular mass in the nasal cavity presenting with intermittent episodes of epistaxis includes juvenile nasopharyngeal angiofibroma , which occurs typically in adolescent male patients , angiomatous polyp and rare malignant lesions , such as nasopharyngeal carcinoma or metastasis.1 7 imaging studies might be required in larger lesions which pose diagnostic difficulties and require an evaluation of extent and relation to adjacent structures.6 ct - scanning reveals an intensely enhancing mass and an iso- or hypoattenuating cap of variable thickness . bony changes ( erosion or displacement ) are not uncommon.3 treatment consists of total surgical excision that can be achieved through direct visualization endoscopically without significant complications . this technique might also be used in follow - up and early detection of recurrences , which are uncommon after complete excision.1 7 pregnancy - related lesions might regress spontaneously after delivery.8 this clinical case combines two predisposing factors to the development of a nasal lch hormonal influence ( gonadotrophin - producing pituitary adenoma ) and local traumatic injury ( surgery and postoperative nasal packing ) . nasal lch is a rare but possible complication of endoscopic transsphenoidal resection of pituitary adenomas .

background lobular capillary hemangioma is a rare benign tumor , most frequently located in the head or neck region , the nasal cavity being uncommonly affected . its etiopathogenesis is not fully established , although traumatic and hormonal factors have been implied . case description a 50-year - old female patient underwent an uneventful endoscopic transsphenoidal removal of a pituitary cystic macroadenoma at our institution . nasal packing was used in postoperative hemostasis . histopathology was compatible with a gonadotrophin - producing adenoma . one month after the surgery , the patient presented with frequent episodes of epistaxis and a progressively growing nasal mass , which was removed endoscopically . its pathological examination confirmed a lobular capillary hemangioma . conclusions the authors present a clinical case combining two possible predisposing factors to the development of a nasal lobular capillary hemangioma : local traumatic injury through surgery and postoperative nasal packing and hormonal influence . this lesion is a rare complication of endoscopic transsphenoidal resections of pituitary adenomas .

giant intracranial aneurysms have a lower propensity to bleed than small and medium - sized lesions and they may present with symptoms secondary to mass effect . while the diagnosis of a giant aneurysm can be readily made on radiology if there is any circulating component within the aneurysmal sac , establishing a pre - operative diagnosis becomes difficult if the aneurysm is completely thrombosed . the absence of a circulating component and the visualization of a large thrombus would lead to consideration of various other differentials depending on the location of the lesion . a 45-year - old male presented with complaints of progressivelyworsening vision in his left eye and headache since 6 months . he also complained of gait ataxia and occasional social incontinence of urine . on examination , visual acuity in mri brain revealed a large left basifrontallesion extending superiorly and distorting the corpus callosum [ figure 1 ] . the lesion was hyperintense on t1-weighted images ( wi ) [ figure 1a ] and hypointenseon t2wi[figure 1b ] . the lesion did not enhance on gd - contrast sequences and no blood flow was demonstrated within the lesion on contrast mr angiography ( mra ) . ct angiography ( cta ) demonstrated displacement of left anterior and middle cerebral arteries ; there was no enhancement within the lesion [ figure 1d ] . ( a ) t1-weighted coronal image showing a t1 hyperintense lesion . ( b ) t2wi demonstrating the hyppointense capsule as well as contents . ( d ) ct angiogram demonstrating the distortion of the left mca and acas based on the location and presence of a large thrombus , adifferential of giant cavernous hemangioma was considered . however , the mri appearance of a well - delineated sac with a thrombus within it was not entirely concordant with this diagnosis . however , digital subtraction angiogram ( dsa ) did not reveal any filling of contrast within the sac of the lesion . the dsa also revealed that the left middle cerebral artery was displaced inferiorly by the lesion [ figure 2a ] . the left a1 was not well visualized ; both a2s were filling on right carotid injection and a round shift of the a2s was noted [ figure 2b ] . since dsa did not demonstrate any contrast within the lesion , a possibility of intracerebral intravascular papillary endothelial hyperplasia ( masson 's tumor ) was also considered , although this is a rare lesion within the brain . the a2s are shifted to the right due to the mass effect of the lesion . no contrast is seen within the lesion a left pterional craniotomy was made and the lesion approached via the trans - sylvianroute . there was a good plane of cleavage and capsular resection was performed in a piecemeal manner . , a portion of the capsule was found to be significantlyadherent to the left a1-a2 junction . there were areas of calcification in this area that further rendered dissection from the a1-a2 complex difficult [ figure 3a ] . multiple perforators were found arising from the a1a2 junction and traversing posteriorly ; these were adherent to the capsule . postoperative contrast - enhanced ct and mri revealed no residual capsule[figure 3b ] and subsequent dsa revealed preserved flow in all vessels and no fresh abnormality [ figure 3c ] . histopathology of the resected specimen was diagnostic of aneurysmal wall with thrombus [ figure 3d ] . follow - up dsa is planned to ensure that no regrowth of the aneurysm has occurred . ( a ) intraoperative image showing the optic chiasm ( star ) ; the lesion ( horizontal arrow ) is closely adherent to the left a1 ( vertical arrow ) . ( c ) postop angiogram demonstrating the right internal carotid artery supplying both a2 arteries across a patent acoma . ( d ) photomicrograph of the aneurysm wall composed of fibrocollagenous wall , congested blood vessels , lymphocytic infiltrate and hemosiderin laden macrophages ( h and e 400 ) spontaneousand complete thrombosis of giant intracranial aneurysm is reported to occur in 3 - 20% of cases . the majority of giant aneurysms that have been reported to have undergone spontaneous thrombosis arose from the cavernous segment of the internal carotid artery . there are singlecase reports of giant posterior cerebral artery , superior cerebellar artery and pericallosal artery aneurysmsthat underwent spontaneous thrombosis . there exist no previous reports of giant anterior communicating artery aneurysms undergoing spontaneous thrombosis . in the present instance , aneurysm was not considered as the top preop differential since the lesion did not enhance on contract administration . intra - operatively , the only clues to the nature of the lesion werethe presence of a multi - lamellatedthrombuswithin the cavity and the attachment to the anterior communicating artery . totally thrombosed giant aneurysms can be confused with other tumors like cavernous hemangiomas , masson 's tumor , oligodendrogliomas and occasionally meningiomas . there are several hypotheses to explain the phenomenon of spontaneous thrombosis in giant intracranial aneurysms . the fundus of a giant aneurysm may itself compress the parent artery , resulting in stenosis and a low - flow state . this may lead to intra - aneurysmal clot formation ultimately resulting in thrombosis of the aneurysm . a large aspect ratio ( indicative of a small neck ) could also result in a low - flow state . extension of the thrombus to the neckwould result in a further reduction of blood flow within the sac resulting in total thrombosis . it is possible that in the present case similar mechanisms could have been responsible for complete isolation of the aneurysmal sac from the circulation . the formation of a neo - intimal layer in the narrow neckcould explain the absence of bleedingdespite close dissection of the sac from the a1a2 junction . pre - operative dsa is an absolute imperative to establish the diagnosis of large thrombosed intracranial mass lesions . this lesion was not recognized as an aneurysm at surgery owing to the complete absence of bleeding and the calcification at the neck ; thus , the neck was not clipped . however , it is generally recommended that a clip be placed across the neck since there have been several reports of regrowth of giant aneurysms that have not been clipped and completely excluded from circulation . spontaneous thrombosis of giant intracranial aneurysms is a rare phenomenon . but aneurysms need to be considered in the differential diagnosis of mass lesions located in close proximityto cerebral vasculature . the aim of surgery would be to decompress the surrounding neural structures . a clip application across the neck may not be necessary if there is no filling of the sac while dissecting close to the neck .

giant anterior communicating artery aneurysms are rare . apatient presented with visual dysfunction , gait ataxia and urinary incontinence . mri showed a giant suprasellar mass . at surgery , the lesion was identified as being an aneurysm arising from the anterior communicating artery . the difficulty in preoperative diagnosis and relevant literature are reviewed .

whenever such an anomaly is diagnosed it is the duty of the caregiver to provide accurate information about the findings as quickly as possible . although prenatal diagnosis of urinary tract anomalies is relatively easy ( detection rate of 89% ) based on sonographic images corresponding to dilated urinary tract , using the sonographic finding to provide prognostic counseling to the couple is a difficult task . counseling regarding prognosis becomes a dilemma for obstetricians and pediatric nephrologists and urologists more so as many anomalies may be manifested late in the second trimester . data on antenatal diagnosis and post - natal follow - up is important for assessing prognosis and hence counseling of parents . there are many published studies evaluating the use of fetal urinary metabolites in prospectively predicting postnatal renal function ; however , a recently published systematic review evaluating the diagnostic ability of fetal urinary analytes to predict outcome concluded that there was insufficient evidence to commend such investigation . previous papers have reported that early gestational age at diagnosis by usg , renal parencymal cystic appearance and echogenicity , and severe oligohydramnios are associated with good predictive accuracy . however no consensus exists on most specific ultrasound parameter or combination of features that prospectively predict postnatal renal function . this may be because of heterogeneity of previous studies or may be due to retrospective study design of previous studies . the objective of the study was to do prenatal sonographic evaluation regarding renal function impairment after diagnosis and to provide prognostic counseling accordingly . postnatal correlation was done in all cases in order to see the accuracy of prognostic counseling . the outcome of the study was to provide better counseling for women and families dealing with prenatally diagnosed renal anomalies . all patients with prenatally detected renal malformation by ultrasound referred to the fetal medicine opd for first 2 years of the 3-year study period ( jan 2008 - dec 2010 ) were included . after diagnosis women underwent targeted scanning for appropriate counseling regarding prognosis , ultrasound was done especially with respect to rule out other congenital malformations , to see the renal involvement whether unilateral or bilateral , the amount of liquor , bladder visualization and cortical differentiation . relevant maternal investigations were done . in women with gestation less than 20 weeks having gross renal anomaly in fetus , the fetuses with suspected major extra renal malformations along with renal malformation were grouped as group i. in cases with bilateral renal malformation , we looked for sonographic findings suggesting functioning kidneys by seeing the amount of liquor and visualization of bladder , if the cases had oligohydramnios and non - visualization of bladder showing poorly functioning kidney , they were grouped as group ii . group iii constituted those fetuses with bilateral renal malformation , oligohydramnios but bladder seen with or without presence of corticomedullary differentiation . in group iv were fetuses with unilateral or mild bilateral renal affection , shown by corticomedullary differentiation present , with slightly decreased or normal liquor , bladder was visualized . termination was offered in group i and group ii women between 21 and 24 weeks having lethal syndromic etiology as the prognosis was poor . rest cases were followed at regular intervals ( usg every 2 - 3 weekly ) to detect the course of the disease . the cases in which there was stillbirth or termination of pregnancy , fetal autopsy was done according to the routinely followed protocol . this included a photograph , x - ray of fetus ( ap and lateral ) , external and internal examination including histopathological examination of the kidneys and other viscera . the chromosomal analysis was done whenever fetal sample was available and the parents gave consent . all live born babies underwent ultrasound within 3 - 5 days of birth and renal function tests were done . the babies were followed up after 1 month , 6 months and one year , 2 years after delivery ; minimum period of follow - up was one year . out of 24,160 deliveries , there were 422 cases ( 1.8% ) with gross congenital anomaly registered in the study period ; there were 63 cases with renal anomaly ( 14.9% ) . there were 8 cases , which were lost to follow - up and total 55 cases were fully followed up . diagnosis was done at less than 20 weeks ( mean 19 weeks ) in 9 cases ( 16.4% ) , termination of pregnancy was offered in them as the anomaly was severe . fetal autopsy was done after termination of pregnancy in 8 cases , and diagnosis was confirmed in all of them [ table 1 ] . fetus with renal malformation detected at less than 20 weeks there were 46 cases in which diagnosis was done after 20 weeks ( 83.6% ) , after targeted scan women were divided into groups according to the findings on prenatal evaluation . the women in group i ( 11 cases ) had suspected gross extra renal malformations ; the mean gestational age was 31weeks . termination was offered in 4 cases , which had suspected lethal syndromic etiology and who presented before 24 weeks [ figures 1 and 2 ] . there were 3 live births , all of them died within hours to 2 days after delivery . lower segment cesarean section ( lscs ) was done in 3 cases for maternal indication only ( one case each of placenta previa , previous 2 lscs and transverse lie ) [ table 2 ] . baby had urethral atresia ( case 13 ) ultrasound picture of limb body wall defect with enlarged cystic kidney . autopsy picture confirming the same ( case 19 ) fetus of more than 20 weeks gestation with gross extra renal anomaly the women who belonged to group ii were also counseled that the prognosis was poor as the renal function seemed to be impaired as bladder was not seen and liquor was reduced . there were 13 cases in this group , mainly cases with bilateral cystic kidneys ; mean gestational age was 27 weeks . there were 5 live births , but all of them died within days of delivery , one survived till 3 months and then succumbed to renal failure [ table 3 ] . histopathology confirmed multicystic kidney in 5 and autosomal recessive polycystic kidney disease ( arpkd ) in one fetus . in one patient with positive family history ( case 21 ) , the ultrasound finding of bright echogenic kidney was diagnosed on histopathology as multicystic kidney , showing the possibility of familial multicystic kidney disease [ figure 3 ] . fetus of more than 20 weeks gestation with oligohydramnios and bladder not visualized case 21 , with positive family history and bilateral echogenic kidneys on usg , autopsy showing cysts of varying sizes on autopsy , histopathology confirmed it to be multicystic kidney in women of group iii ( 9 cases ) , there was mainly lower urinary tract obstruction [ table 4 ] , in this group prognosis chiefly depended upon the gestational age of diagnosis , renal cortical appearance , and degree of oligohydramnios . the mean gestational age was 31 weeks , 5 cases survived after delivery , 2 had vesicouretral reflux , 3 underwent surgery , and one baby had deteriorating renal function . the diagnosis was after 32 weeks and renal cortical appearance was preserved in all cases that survived . fetus of more than 20 weeks gestation with bilateral renal involvement , oligohydramnios and bladder visualized ultrasound picture of bilateral hydronephrosis with enlarged bladder and typical keyhole sign . autopsy confirming the finding ( case 24 ) group iv consisted of total 13 cases , they had unilateral ( 7 cases ) or bilateral affection ( 6 cases ) with mild oligohydramnios or normal liquor , and bladder was seen in all cases [ table 5 ] . they were counseled that the prognosis was good and follow - up was required , the mean gestational age of presentation was 34 weeks . all of them were delivered live ; lscs was done for fetal indication in 2 of them . kidney function test in all but one were normal although the ultrasound after delivery showed mild hydronephrosis persisting in 5 of them ; 2 babies underwent surgery . fetus with unilateral or bilateral renal involvement , normal or slightly reduced liquor with normal bladder autopsy was done in 27 cases out of total 29 stillbirths . chromosomal analysis was done in 10 cases and this was abnormal in 3 cases ; in all 3 cases there were extra renal malformation as well . out of the total 55 cases , 17 survived ( 32.1% ) , surgery was done postnatally in 5 cases . the fetal kidneys and adrenal glands can be visualized by transabdominal ultrasound between the 1215 week of gestation . but once the abnormality is diagnosed it is equally important to delineate the prognosis of malformation . our criteria for determining the prognosis of the malformation was based on evaluation of sonographic findings suggesting functioning kidneys to find out the severity of the disease . the cases in group i with associated extra renal malformation had poor prognosis for survival . detection of any renal malformation should warrant a detailed examination of the fetus for other structural anomalies . associated anomaly in our study was 27.3% , other studies have reported the incidence of up to 50 % . chromosomal studies on amniotic fluid should be offered in cases with renal malformation ; the incidence of chromosomal abnormality in our study was 5.5% , and the incidence in other studies has reported to be 8 - 12% . the incidence of chromosomal abnormality was low in our study population as many parents did not opt for the test . the cases in which there were structural abnormality in kidneys coupled with loss of function , apparent in terms of non - visualization of bladder and absent or severely decreased liquor , the prognosis was believed to be poor and on follow - up none of the babies survived . severe oligohydramnios and non - visualization of urinary bladder is associated with poor renal function . it may be difficult to detect bilateral renal agenesis on usg due to severe oligohydramnios and fetal autopsy is necessary to confirm renal agenesis and also any other associated malformation . this will help in counseling for next pregnancy . in cases where there was lower urinary tract obstruction but the kidneys were functioning , prognosis depended upon the gestational age at presentation . almost all who survived presented after 34 weeks ; it helped in timing of delivery , with induction done at 37 weeks to salvage the kidneys if possible . ultrasound diagnosis when made early helps in the timing of delivery and also the route of delivery and early treatment . we did not attempt prenatal bladder drainage but the recent review on effectiveness of antenatal intervention for treatment of congenital lower urinary tract obstruction done by morris et al . , concluded that although bladder drainage improves survival but it may confer a high residual risk of poor postnatal renal function . in group iv , the cases were mild , renal function was preserved , as shown by appearance of normal liquor and normal bladder . the antenatal screening in these cases helps in follow - up and helps in early detection of anomaly . though many believe that the detection of mild dilatation have no therapeutic clinical significance and causes undue anxiety in many cases , in such situation they may be counseled and reassured that they may expect a healthy child with possibly minor problems without consequences for life and renal function . some authors suggest that the risk of surgery is minimal when the dilatation is less than 10 mm in late pregnancy . , suggested that prenatal dilatation is not a sensitive indicator of pathology but increasing dilatation is associated with morbidity and mortality . our prognostication was reasonably accurate in terms of preparing the couple and the physicians dealing with the case to the outcome of the anomaly . the criteria was simple and not too complicated so it was easy for the obstetrician dealing with the case to interpret them and counsel accordingly . the categorization helped them to take decision regarding route of delivery especially in severe cases , in timing of delivery particularly in cases which were gradually worsening and in post natal follow - up of mild cases . although we followed the babies postnatally for one year , prolonged follow - up of these cases would have been more useful and would have given even better estimate of renal function . the antenatal sonographic evaluation and counseling helps in delineating the prognosis and thus helping the couple to make reproductive decision .

objective : to determine the prognosis of antenatally detected renal anomalies by sonographic evaluation.materials and methods : this was a follow - up study of all antenatally detected renal anomalies from january 2008 to dec 2009 referred to fetal medicine clinic . prenatal evaluation was done and cases were divided into four groups depending upon their prenatal sonographic findings . post natal follow - up was done up to one year in cases of live babies . autopsy was carried out in still born fetus after consent.results:the renal anomaly was detected in 55 cases , which were fully followed . the prognosis was said to be poor for group i cases with gross extra renal anomaly along with the renal anomaly , and for group ii in which there was organic renal pathology with loss of renal function suggested by non - visualization of bladder and almost absent liquor . prognosis was guarded and depended upon the gestational age of presentation in group iii , which had obstructive uropathy ; prognosis was good in group iv cases , which were mild , unilateral or which presented late.conclusion:prenatal sonographic evaluation gives reasonably accurate picture of the prognosis and can be very helpful in counseling the parents regarding prognosis and help in deciding the timing and route of delivery .

the spherical aberration of the cornea is positive and that of the lens is negative in the young , healthy eye , and these differences have a compensatory relationship [ 1 , 2 ] . decreased optical quality occurs in the aging eye as the spherical aberration of the lens becomes gradually positive and thus loses its ability to compensate for the corneal aberration , which changes little with increasing age [ 15 ] . conventional spherical intraocular lenses ( iols ) act as an aging lens in which positive spherical aberration can not compensate for the corneal aberration . aspheric iols can decrease the total amount of ocular spherical aberration after cataract surgery due to their introduction of negative spherical aberration . it has been shown that aspheric aberration - correcting iols effectively reduce ocular aberration and improve contrast sensitivity in patients with age - related cataracts [ 615 ] . however , little is known about the safety and effectiveness of aspheric iols in patients with extreme myopia . therefore , we performed the current study to evaluate the clinical effects of aspheric iol implantation in cataract patients with extreme myopia by comparing the objective and subjective visual quality achieved with that achieved in nonextreme myopic eyes . we chose the mc x11 asp lens ( humanoptics ag ) as our experimental iol because it is currently the only aspheric iol with a negative power . the mc x11 asp lens is a one - piece hydrophilic acrylic iol with a prolate posterior surface that introduces negative spherical aberration to the ocular system . the optic diameter varies from 5.5 mm to 7.0 mm depending on the power of the iol . iols with a power of 18.0 diopter or less have an optic diameter of 7.0 mm . this prospective study included 33 eyes of 22 cataract patients ( 12 males and 10 females ) who were scheduled to undergo phacoemulsification and iol implantation surgery between june 2008 and march 2009 at the eye & ent hospital , fudan university , china . exclusion criteria included a history of previous ocular surgery , ocular disorders other than cataract , myopia , or macular degeneration , and patient refusal or inability to maintain followup . patients were divided into two groups according to their ocular axial length . those with an axial length longer than 28.0 mm were included in the extreme myopia group , and the others were included in the nonextreme myopia group . the study was approved by the ethics committee of eye & ent hospital , fudan university . after topical anesthesia , a 2.2 mm superior clear corneal incision was made , and a 5.56.0 mm continuous curvilinear capsulorhexis was created . after hydrodissection , endocapsular phacoemulsification of the nucleus and cortical aspiration were performed using the intrepid micro - coaxial system on the infiniti ( alcon laboratories inc . ) . preoperative measurements included visual acuity , intraocular pressure , axial length , and corneal endothelial cell density . at 1 day , 3 days , 2 weeks , and 1 month after surgery , visual acuity and slit - lamp examination were performed . six months postoperatively , visual acuity , refraction , contrast sensitivity , wavefront aberration , and subjective visual quality were assessed . complications such as posterior capsule opacification ( pco ) and retinal detachment were recorded at the last follow - up visit . subjective visual quality was evaluated using the self - administered edition of the national eye institute visual functioning questionnaire-25 ( nei vfq-25 ) . this 25-item questionnaire was designed to assess vision - related quality of life ( vrql ) . it includes one general health rating question and 11 vision - targeted subscales as listed in table 2 . , the answer was converted to a 0-to-100-point score according to the manual , with higher scores representing better vrql . contrast sensitivity was measured using the contrast glare tester cgt-1000 ( takaci ) under mesopic illumination ( 10 cd / m ) at a 350 mm testing distance . contrast sensitivity was defined as the reciprocal of the contrast threshold , and this value was converted to log contrast sensitivity for statistical analysis . after mydriasis , high - order aberrations were measured with the hartmann - shack aberrometer ( wasca analyzer , carl zeiss meditec ) . three consecutive measurements were performed on each eye . the lateral coma ( z3 ) , vertical coma ( z3 ) , and spherical aberration ( z4 ) as well as the root mean square ( rms ) values of the total high - order aberrations and 3rd - order to 7th - order aberrations over a 6.0 mm pupil diameter were automatically calculated by the aberrometer . independent t - test was used to compare demographic data , questionnaire scores , contrast sensitivity , and wavefront aberrations between the two groups . logarithm of the minimum angle of resolution ( log mar ) visual acuity values were tested by the wilcoxon rank - sum test . comparison of snellen visual acuity before and after surgery was performed using the cmh chi - square test . however , 7 eyes ( 38.9% ) in the extreme myopia group had preexisting maculopathy before surgery , including 6 eyes with degenerative myopic maculopathy and 1 eye with macular schisis . six months after surgery , 77.8% of eyes in the extreme myopia group achieved a bcva of 20/40 or better , including 22.2% of eyes with 20/25 or better . four eyes demonstrated poor vision of less than 20/60 due to severe macular degeneration or macular schisis . in the nonextreme myopia group , 86.7% of eyes achieved a bcva of 20/40 or better , including 80.0% of eyes with 20/25 or better . the postoperative bcva of both groups was significantly better than the respective preoperative bcva values ( = 16.36 , p = 0.0001 ; = 20.94 , p = 0.0000 ) , and the nonextreme myopia group performed significantly better than the extreme myopia group ( = 5.98 , p = 0.0144 ) . however , evaluation of the vfq-25 subscale scores revealed that the nonextreme myopia group performed significantly better than the extreme myopia group in terms of mental health and dependency . data related to driving were not analyzed , because none of the patients in the extreme myopia group and only four patients in nonextreme myopia group drove . as illustrated in figure 2(a ) , contrast sensitivity without glare did not differ between the groups at each spatial frequency . however , patients in the nonextreme myopia group showed better contrast sensitivity with glare at intermediate frequencies ( visual angle of 2.5 degrees , p = 0.0277 and 1.6 degrees , p = 0.0181 ) ( figure 2(b ) ) . for a 6 mm pupil , the average spherical aberration ( z4 ) was 0.03 0.11 m in the extreme myopia group and 0.07 0.07 m in the nonextreme myopia group , and total high - order aberrations were 0.50 0.17 m and 0.46 0.15 m , respectively . there were no significant differences in lateral coma , vertical coma , spherical aberration , total high - order aberrations , or 3rd - order to 7th - order aberrations ( figure 3 ) . one patient complained of glare in one eye ( 5.6% ) in the extreme myopia group , and three eyes ( 20% ) were associated with complaints of glare in the nonextreme myopia group , which did not represent a statistically significant difference ( p = 0.340 ) . the average follow - up period was 6.94 1.47 months ( range 6 to 10 ) in the extreme myopia group and 6.60 1.59 months ( range 6 to 12 ) in the nonextreme myopia group . at the last followup , two eyes in each group ( 11.1% and 13.3% , resp . ) had moderate pco but did not require further treatment . one eye in the extreme myopia group developed capsular block syndrome , and the eye achieved a final visual acuity of 20/30 following anterior capsulotomy . it is well known that myopia is more common in asia than in america , europe , and africa with a prevalence of 32.3% in the urban adult chinese population reported by the latest epidemiological study published in 2009 . high myopia prevalence also varies geographically , ranging from 1.7% to 3.3% in europe , while it affects up to 24% of university students in south - east asia . in this study , we carried out phacoemulsification and aspheric iol implantation with low or negative power on cataract patients with extreme myopia . we report the visual performance of aspheric iols in terms of functional vision in cataract eyes with extreme myopia in comparison to that achieved in patients with nonextreme myopia . our results show that aspheric iol implantation provided good visual outcomes in most eyes with extreme myopia , although some patients with extreme myopia had relatively worse retinal status than nonmyopia patients . when the seven eyes with maculopathy in the extreme myopia group were excluded from the data analysis , postoperative visual outcomes were similar between the two groups ( = 1.45 , p = 0.2288 ) . for the seven excluded eyes , visual acuity improved after surgery anyway : one improved from hand moving to 20/400 , one improved from 20/2000 to 20/250 , and the other 5 improved 2 to 8 lines ( snellen chart ) . in these patients , after objective visual acuity measurements , we assessed the subjective visual quality of the patients using the nei vfq-25 . this questionnaire was designed to capture the impact of visual problems on physical functioning , emotional well - being , and social functioning . it has been widely used to evaluate health - related quality of life in patients with various eye diseases and treatments [ 1925 ] . the score from the extreme myopia group was similar to that reported by lin et al . , who implanted the aspheric iq iol ( sn60wf , alcon laboratories inc . , interestingly , although the nonextreme myopia group had better postoperative bcva in the present study , the two groups reported similar subscale scores for near and distance activities ; that is , the patients ' perception of their visual function was similar . this might be attributed to the preoperative visual status of the patients with extreme myopia who always had poor visual function . therefore , the removal of the cataract along with the correction of the refractive errors likely resulted in a high level of patient satisfaction in terms of visual outcome . however , the subscale scores of mental health and dependency were significantly lower in this group , suggesting that these patients worried more about their eyesight and that their quality of life was more affected by vision . , we found that patients with nonextreme myopia had better contrast sensitivity at intermediate spatial frequencies under glare conditions . these data are in agreement with stoimenova 's findings , which showed that myopes exhibited reduced sensitivity to contrast in comparison to emmetropes and that contrast sensitivity decreased with an increasing degree of myopia . this difference may contribute to the aberrations of the myopic eyes or functional / morphologic changes in the retina of myopic eyes . we also compared high - order aberrations between the groups and found that postoperative ocular spherical aberration ( z4 ) was near zero in the two groups , which fulfilled the aim of compensating the corneal spherical aberration with an iol . the total effect of all monochromatic optical aberrations represents the optical quality of the eye . because the spherical and cylindrical refractive errors were fully corrected and high - order aberrations were similar between groups , the optical quality of the ocular system in the extreme myopia group was as good as that in the nonextreme myopia group . however , the extreme myopia group showed worse visual acuity and contrast sensitivity , mainly because of the poor retinal status . in the absence of macular degeneration , the eyes with extreme myopia would have achieved visual acuity as good as that of eyes with nonextreme myopia . glare disturbance occurred in 5.6% of patients in the extreme - myopia group and 20% of patients in the nonextreme myopia group , and this difference was consistent with the results of previous studies . franchini reported that glare occurred in 20% of patients who received the aspheric tecnis z9000 iol ( abbott laboratories ) . in the study by johansson et al . , 21.1% of patients who received an akreos adapt ao iol ( bausch & lomb laboratories inc . ) in one eye and a tecnis z9000 iol in the other eye experienced glare . in the current study , a possible cause may be that the macular disorder of some of the eyes was so severe that the patients could not detect the glare . in terms of the pco and retinal detachment the aspheric iol used in this study was the mc x11 asp , which features a large optic diameter ( 7.0 mm ) for middle to low iol powers . it has been shown that greater optic diameter can reduce postoperative glare [ 30 , 31 ] . larger optic diameter can also facilitate postoperative peripheral retinal examination and treatment , because eyes with high myopia are at high risk of lattice degenerations , retinal holes and tears , and retinal detachment . because of the larger optic diameter , a larger capsulorhexis of 6.0 to 6.5 mm was required . one patient developed capsular block syndrome , which may have been caused by a relatively small capsulorhexis opening . in conclusion , aspheric iols can provide good visual outcomes for cataract patients with extreme myopia . also , preoperative evaluation of the severity of maculopathy is very important and should be carefully performed in eyes of patients with extreme myopia before surgery .

objective . to evaluate the postoperative visual quality of cataract patients with extreme myopia after implantation of aspheric intraocular lenses ( iols ) . methods . thirty - three eyes were enrolled in this prospectivestudy . eighteen eyes with an axial length longer than 28 mm were included in the extreme myopia group , and the other 15 eyes were included in the nonextreme myopia group . phacoemulsification and aspheric iol implantation were performed . six months after cataract surgery , best - corrected visual acuity ( bcva ) , contrast sensitivity , and wavefront aberrations were measured , and subjective visual quality was assessed . results . the bcva improved significantly after surgery for both groups , and patients in the nonextreme myopia group achieved better postoperative bcva due to better retinal status of the eyes . the evaluation of contrast sensitivity without glare was the same in both groups , whereas patients in the nonextreme myopia group performed better at intermediate spatial frequencies under glare conditions . the two groups did not show a significant difference in high - order aberrations . with regard to subjective visual quality , the composite scores of both groups did not differ significantly . conclusions . aspheric iols provided good visual outcomes in cataract patients with extreme myopia . these patients should undergo careful evaluation to determine the maculopathy severity level before surgery .

gave a rare cause of upper gi bleed has prominent associations with autoimmune disorders and liver cirrhosis . we report a case of chronic kidney disease stage 5 with chronic liver disease who presented with blood loss anemia and was found to have vascular ectasia involving both the antrum and duodenum . a middle - aged woman , a known case of hypertension and stage v chronic kidney disease ( ckd ) since 10 years , and on maintenance hemodialysis ( mhd ) for 6 years , presented with complaints of blood in the stools since the past 8 months , and abdominal distention and discomfort since the past 2 months . she was diagnosed with chronic liver disease ( cld ) related to hepatitis c virus ( hcv ) 8 months back . as a result of continuous loss of blood in the stools , the patient had developed severe anemia , for which she had received multiple blood transfusions during the past 8 months . on examination , an abdominal examination revealed free fluid with no organomegaly , whereas the other systems were unremarkable . her laboratory investigations revealed severe iron - deficiency anemia with hemoglobin of 4.3 gm / dl . her hcv genotype was one with the rna copies of 8.5 10 iu / ml . ultrasonography ( usg ) of her abdomen was suggestive of cld with cirrhotic changes , with normal portal vein and bilateral contracted kidneys , without any organomegaly . the hepatic venous pressure gradient was 5 mmhg . during her hospital stay , she was given hemodialysis along with blood transfusion and intravenous ( iv ) iron in view of the severe iron deficiency . as she had melena , she was taken for upper gastrointestinal ( gi ) endoscopy and colonoscopy , where she was found to have multiple linear gastric vascular malformations in the antrum , compatible with gastric antral vascular ectasia ( gave ) , with spurt oozing [ figure 1 ] . argon plasma coagulation ( apc ) was done for gave to which she responded well [ figure 3 ] . subsequently the altered blood in stools decreased , her blood transfusion requirement decreased , and she was discharged on a conservative line of management . although previously reported in the literature , gave or watermelon stomach was first described definitively by jabbari et al . although known to be associated with a number of conditions like cirrhosis , ckd , collagen vascular diseases and pernicious anemia , the exact etiopathogenesis of gave remains unknown . the most common reported association is with autoimmune disorders , whereas cirrhosis accounts for 30% of the condition in these patients . the incidence of gave in ckd is unknown , with few relevant publications in the literature . our case was interesting as incidentally the patient had both ckd and cld , both of which are associated with gave . however , as the history of ckd was of 10 years , whereas hcv - related cld was recently diagnosed , the possibility of ckd - associated gave was more likely . moreover , her usg revealed a normal portal vein , with a normal size cirrhotic liver . absence of portal hypertension ruled out the possibility of portal hypertensive gastropathy , which has an endoscopic appearance similar to that of gave . besides the antrum , the patient also had vascular ectasias affecting the first part of the duodenum . there are reports of duodenal vascular ectasia in association with gave , even in patients with a normal antrum . pharmacological treatments with documented efficacy are tranexamic acid , estrogen progesterone therapy , especially in renal failure , and octreotide injections even as surgical antrectomy provides the most definitive therapy for gave , it is associated with significant morbidity and mortality . various endoscopic treatments have been described to manage gave , including neodymium : yttrium aluminum garnet ( nd : yag ) laser , apc , and a heater probe . of these , apc is the most frequently used endoscopic treatment , as it is easier and safer to use , with limited depth of penetration and a tendency for the ionized electric arc to deflect away from the coagulated tissue to the surrounding mucosa . the number of sessions needed to eradicate gave depends on the pattern , extent , and number of lesions . in our case , the patient was managed effectively with apc in a single session , with a decline in gastric blood loss and requirement of blood transfusion . to conclude , gave is a rare cause of persistent gi blood loss , with a known association with ckd . presenting as transfusion - dependent anemia , it can be effectively eradicated by endoscopic therapies , especially apc , as in our case .

gastric antral vascular ectasia ( gave ) , also called watermelon stomach , is a rare cause of gastrointestinal ( gi ) bleeding . gave is associated with a number of conditions , including portal hypertension , chronic kidney disease ( ckd ) , and collagen vascular diseases , especially scleroderma . limited reports of gave are present in ckd patients . argon plasma coagulation ( apc ) is an effective therapy for gave . we describe the case of a ckd , stage v patient , who presented with recurrent blood loss in stools and transfusion - dependent anemia . her endoscopy revealed gave , which was managed uneventfully with apc .

lumbosacral nerve root anomalies are the main causes of failed lumbar surgery and intraoperative neural injury . the most common ones are the adherent nerve root anomalies characterized by abnormal adherence of two adjacent roots . the prevalence of the disorder ranges between 1.2% and 17% , and it is as high as 6% in magnetic resonance imaging ( mri ) studies and 30% in cadaveric studies . some researchers have reported that radicular symptoms are more common in this disease owing to tension of the adherent nerve roots . combination of l5-s1 spondylolysis and adherent nerve root anomaly has been only rarely reported in the literature . in this paper , we aimed to discuss clinical , radiological signs and surgical therapy in a patient with a rare combination of lumbar disc herniation and spondylolysis with lumbosacral nerve root anomaly . this is a case report of a 49-year - old male with lumbosacral root anomaly accompanying l5/s1 lumbosacral spondylolysis and disc herniation . previous literature was reviewed and main findings were compared with literature data . our patient had occasional low back pain for 5 years and severe right leg pain for 1 week . bilateral and dynamic lumbosacral x - rays and three - dimensional computed tomography ( ct ) showed bilateral pars interarticularis defect and spondylolysis of l5 , and mri demonstrated l5/s1 disc herniation with right paramedian foraminal extension [ figures 1 and 2 ] . neurological examination was remarkable for hypoesthesia on a region corresponding to l5 and s1 dermatome , and loss of strength in extensor hallucis longus and tibialis anterior muscles . ( a and b ) preoperative axial and sagittal computed tomography images showing bilateral pars interarticular is defect ( a and b ) preoperative magnetic resonance imaging showing l5/s1 herniation and enlarged transverse diameter of the right root on axial sections l5 spinolaminar process was totally removed using the line of bilateral pars interarticularis , and l5/s1 posterior instrumentation was performed . whether the appearance thicker than normal is a disc or root anomaly is not differentiated ; it was noted that s1 root ascended with l5 root as a tense and single root when pushed medially [ figure 3 ] . lateral portion of the facet was partly removed and foraminotomy was performed followed by completion of bilateral l5/s1 discectomy and performance of posterior lumbar interbody fusion with spinolaminar process in the resulting space [ figure 4 ] . ( a and b ) perioperative view of right l5 and s1 roots emerging together ( a - c ) postoperative lumbar axial , coronal , and sagittal computed tomography showing intervertebral bone graft the visual analog scale of the patient , which was nine at the preoperative period , regressed to one . the patient mobilized at postoperative day 1 later and discharged at postoperative day 2 . during the review of the preoperative mri of the patient , it was noted that the root traversing the right l5/s1 level had a greater transverse diameter than that of the left root on axial cross - sections [ figure 2 ] . it has been reported that root anomalies may cause radiculopathy in the absence of mechanical compression such as in lumbar disc hernia or spinal stenosis . lumbosacral root anomalies are one of the main causes of neural injuries and surgical failure . it is particularly sensitive to retraction owing to tension on nerve roots and discectomy is more difficult to perform . clinical symptoms are more severe than expected in cases with root anomaly . in these patients , a prodromal claudication with or without radiculopathy should make one think of a diagnosis of root anomaly . a straight leg raising test is near normal . later , ct myelography has been used as the ideal imaging modality to define these anomalies . findings such as parallel , crescent fat , corner , or sagittal shoulder are present , especially on axial t1 and t2-weighted cross - sections . it should be always remembered during surgical exploration that a nerve root anomaly may be present . in the case of an unnoticed adherent nerve root the risk of nerve root injury is increased by excessive pulling of neural components by intraoperative manipulation . neural injury may also ensue , while the surgeon tries to find a piece of lumbar disc hernia during the operation . dural laceration , nerve root injury , or root avulsion can occur by excessive pulling an abnormal nerve root . this , in turn , may lead to persistent , or even worsened , leg pain , that is battered root syndrome . moreover , nerve root anomaly may be misperceived as a disc hernia and incised with resultant iatrogenic neural injury . pamir et al . in an article published in 1992 , reported that laminectomy , facetectomy , and pediculectomy are required , and a standard surgical procedure does not suffice to complete adequate decompression in such patients . in another report it was suggested that routine microdiscectomy would not suffice and foraminal decompression would be needed in the presence of root anomaly combined with disc herniation , as white et al . have reported , it is obvious that morbidity rate will increase due to excessive traction of neural components when an additional facetectomy is not performed , taghipour et al . operated all of 22 patients with root anomaly with additional laminectomy , medial facetectomy and pediculectomy . patients with lumbar spondylolysis and disc hernia with more severe clinical and neurological signs than expected should prompt physicians to consider coexisting lumbosacral root anomalies . in such circumstances , the diagnosis should be established with mri and meticulous preoperative assessments should be made when planning surgery . at perioperative period , the possibility of presence of a root anomaly should always be kept in mind to avoid neurological injuries .

lumbosacral nerve root anomalies are the leading cause of lumbar surgery failures . although co - occurrence of lumbar spondylolysis and disc herniation is common , it is very rare to observe that a nerve root anomaly accompanies these lesions . a 49-year - old male patient presented with sudden - onset right leg pain . examinations revealed l5/s1 lumbar spondylolysis and disc herniation . at preoperative period , he was also diagnosed with lumbosacral root anomaly . following discectomy and root decompression , stabilization was performed . the complaints of the patient diagnosed with lumbosacral root anomaly at intraoperative period were improved at postoperative period . it should be remembered that in patients with lumbar disc herniation and spondylolysis , lumbar root anomalies may coexist when clinical and neurological picture is severe . preoperative and perioperative assessments should be made meticulously to prevent neurological injury .

trabeculectomy remains the surgery of choice in patients with advanced glaucomatous optic neuropathy ( gon ) . in conventional trabeculectomy , efforts have been made to improve the outcomes and reduce the complications of trabeculectomy . in this regard , the ex - press glaucoma implant was introduced as a nonvalved miniature stainless steel device , designed with the intent of offering a simple and safe alternative to classic trabeculectomy , obviating the need for tissue excision or removal . express is easier than but not superior to trabeculectomy ; the problem is , that it is a very expensive alternative which the majority of patients in developing countries can not afford . therefore , we tried to use a low cost alternative which is universally available and can function as an alternative to classic trabeculectomy without the need for tissue excision or removal . herein , we describe an innovative , simple and cost effective technique using a 24 gauge ( 24 g ) polytetrafluoroethylene ptfe ) intravenous cannula ( ivc ) as an alternative to the classic trabeculectomy . the first patient was a 50-year - old man with intraocular pressure ( iop ) of 16 mmhg and 32 mmhg on maximal tolerable medical therapy in his right and left eyes , respectively . best corrected visual acuity ( bcva ) was 20/20 and light perception in his right and left eyes . the second patient was a 72-year - old male subject with iop of 12 mmhg and 38 mmhg on four topical ocular hypotensive medications , in his right and left eyes , repectively . bcva of the second patient was 20/20 and no light perception in the right and left eyes , respectively . both patients underwent glaucoma filtering surgery using a 24 g intravenous cannula ( ivc ) together with application of 0.1 mg / ml mitomycin - c subconjunctivally for 3 min under peri - bulbar anaesthesia . we specifically selected these end - stage patients due to unknown long - term results and complications of the surgery . an 8 - 0 polyglactin ( vicryl ) traction suture on a spatulated needle was placed through the superficial cornea near the superior limbus . consequently , a standard fornix - based conjunctival incision was made to gain exposure to the scleral bed adjacent to the limbus . gentle cautery was performed in this area . a limbus - based rectangular scleral flap ( 4 mm 4 mm ) of about half scleral thickness mitomycin - c ( mmc ) 0.1 mg / ml soaked pledgets were applied subconjunctivally for 3 min after coating the cornea with viscoelastic . a rectangle of deep sclera ( deep scleral groove ) measuring 1 mm 4 mm was made perpendicular to the limbus , leaving a thin layer of deep sclera covering the choroids [ figure 1 ] . a 24 g ivc with an internal diameter of 0.7 mm ( bd neoflon iv cannula , becton dickinson , helsingborg , sweden ) with bevel of the trocar facing up , was inserted into the anterior chamber ( ac ) at the limbal end of the deep scleral groove and at the center of the blue line , parallel to the iris plane and directed towards the pupil [ figure 2 ] . the trocar was completely withdrawn when the cannula was 1 mm inside the ac and the ptfe cannula was cut 4 mm from the site of insertion . the tube was then secured in the preformed deep scleral groove using 10 - 0 nylon sutures [ figure 3 ] . the function of the tube was ensured by noting the dilution of trypan blue dye applied over the cut end of the cannula . the scleral flap was sutured using four 10 - 0 nylon sutures and the conjunctiva was repaired meticulously with 8 - 0 polyglactin sutures . intra - operative photograph showing the 24 g cannula inserted into the anterior chamber ( ac ) through the centre of the blue line at an angle parallel to the iris plane and directed towards the pupil . intra - operative photograph showing the 24 g cannula placed in the preformed deep scleral groove , secured to the scleral bed using 10 - 0 nylon sutures . postoperatively , iop of the first patient at 3 , 6 and 9 months ranged from 12 mmhg to 15 mmhg with a well formed anterior chamber and a functioning diffuse bleb . gonioscopy and anterior segment oct showed the presence of the tube [ figure 4 ] . iop of the second patient at 6 weeks and 3 months ranged from 12 to 14 mmhg . anterior segment oct at 9 months follow - up , showing the presence of the tube ( 24 g cannula ) in situ . however , some of the problems associated with trabeculectomy are attributed to the need for tissue excision and lack of standardization of filtration . new drainage devices such as the express shunt are being used in an attempt to standardize the technique . the restricted internal diameter of these devices provides certain consistency and standardization of the filtration procedure and flow regulation is largely governed by the sutures applied to close the scleral flap . tissue excision or removal is not required , thereby reducing inflammation and complications associated with trabeculectomy . the major disadvantage of these devices is the added cost of surgery , especially in developing countries like ours . therefore , we present the use of an inexpensive and widely available 24 g intravenous cannula made of ptfe which is known to entail no toxicity in humans to date . the cannula functions by diverting aqueous humor through the implant from the ac to the intrascleral and subconjunctival spaces , similar to the express device , and offers the advantages of standardization of filtration without the need for any tissue excision , unlike in trabeculectomy where a sclerostomy and an iridectomy are mandatory . our technique is a simple modification of conventional trabeculectomy aimed at making the surgery simpler and reducing immediate postoperative complications by using a small ostium without any need for iridectomy . we have introduced a low cost innovation which will help standardize surgery , make it easier and also decrease its learning curve ; this procedure also avoids the need for a sclerostomy or iridectomy thereby minimizing tissue injury . in summary , the use of a 24 g intravenous cannula is a cost effective and simple alternative to glaucoma drainage devices in developing countries like ours , alongwith decreased learning curve of the procedure . we recommend further studies to evaluate the long - term safety and efficacy of this technique .

we describe an innovative technique for performing standardized low cost glaucoma filtration surgery using a polytetrafluoroethylene ( ptfe ) intravenous cannula . the trocar of a 24 gauge ( 24 g ) ptfe intravenous cannula was used to create a trabeculectomy ostium and its tube was inserted under a partial thickness scleral flap in 2 patients with advanced glaucomatous optic neuropathy , in whom intraocular pressure ( iop ) was not controlled on maximal tolerable hypotensive therapy . postoperatively , iop of the operated eyes at 3 , 6 and 9 months follow - up ranged from 12 to 15 mmhg with a well formed anterior chamber and a diffuse bleb .

healthcare systems , including those in prosperous and developed countries , are increasingly faced with huge challenges . with emerging needs vital for health reform , different approaches have been used to start programs in many countries . underpinning these approaches is the role of the client , and his / her increased participation in decision - making , greater accountability and better governance in the healthcare system . to achieve this , the client has to be health - literate , and here comes the role of health education . health education should go beyond traditional teaching to improve health behavior , empowerment , and increase the ability to participate in healthcare decisions at the individual and community levels . therefore , health education and promotion was the first of three areas identified by experts in the academic and community centre 's of excellence in women 's health , designated by the department of health and human services as the most important future indicators of women 's health . furthermore , it was felt that health education would help people to identify and prioritize their needs of the health services . these needs would be more valuable for planning and decision - making if they emanated from well - informed people . thus , one main criterion for judging health reform programs at present is health system responsiveness , and the extent to which community needs are integrated . health education interventions have had many successes in various domains in improving knowledge and changing behavior . this has been shown in community interventions for primary prevention , school - based dental hygiene education , as well as community - based nursing education programs . recipients preferences of information and participation which differ according to time , setting , as well as their characteristics must be taken into account . not much research has been done to investigate the differences in learning needs according to clients demographic characteristics . therefore , the aim of this study was to find out if there were gender differences in the needs and preferences in the health education of saudi patients attending riyadh military hospital in the kingdom of saudi arabia . this study was carried out at riyadh military hospital ( rmh ) , a 1000-bed hospital with 13 satellite primary health care centers . the hospital provides health services at all levels of care to military personnel and their families , and to hospital staff . a cross - sectional analytic design was used to compare two groups , men and women . the sampling population consisted of all patients attending of rmh during the time of the study . the inclusion criteria for the study participants were as follows : adult ( 18 years or older ) , ability to respond , and with a saudi nationality in order to preclude any effect of nationality on the study outcomes . the sample size was calculated to detect any difference between men and women in health education needs , barriers , or preferences , with a prevalence of 5% or more and an odds ratio 2 at 95% level of confidence and 80% study power . using epi - info computer software package , the required sample size was 474 per group . this was increased to 650 per group to compensate for an expected dropout rate of about 30% . a quota sampling technique was used in consecutive recruitment of the study participants to reach the required sample size . it was designed to include participants in proportion to the number of patients presenting at the outpatient and inpatient departments of the hospital and primary health care centers . this was done separately for men and women to obtain two equal groups representing the various settings . data were collected using a self - administered anonymous questionnaire comprising a total of 21 closed and open - ended questions . the questionnaire design was based on the review of pertinent literature , and revised by experts in family and community medicine , health education , and research . the final form included demographic data , health education history and needs , learning methods , and the preferred message provider . all principles of research ethics were applied , with informed oral consents obtained , along with ensuring participants rights to refuse or withdraw , and to confidentiality . data were collected during the period from april 2009 to may 2010 . those who consented to participate were given forms to be completed and returned during the waiting time at the same sitting . data entry and statistical analysis were done using the statistical package for social sciences ( spss ) version 14.0 . the study sample included almost equal numbers of men and women . of the target sample of 1300 individuals , the characteristics of men and women in the study sample showed statistically significant differences in their age , educational level , and marital status [ table 1 ] . there were more women in the youngest age group and more men in the oldest age group ( p < 0.001 ) . as regards education , there were more women at both extremes , i.e. illiterate and with university education , whereas the highest percentage of men ( 43.2% ) had secondary education ( p < 0.001 ) . although almost equal percentages of men ( 74.0% ) and women ( 77.9% ) indicated that they had been given some information on health education , significantly more women reported that the information had been helpful ( p = 0.014 ) . characteristics of studied men and women , and health education messages received assessment of the health education needs showed more emphasis on subjects related to patient 's own illness , while issues relating to prevention were given little mention as needs [ table 2 ] . also , there was a statistically significant difference between the needs of men and women on health education related to primary prevention ( p = 0.027 ) , and unhealthy practices ( p = 0.003 ) . comparison of health education needs of studied men and women the most frequently mentioned barriers and obstacles that study participants face with regard to health education , were the use of medical and technical terms , the little time the provider had to answer questions , and the problem of a different language [ table 3 ] . this last obstacle was reported by more men than women , and the difference was statistically significant ( p = 0.002 ) , even after adjustment for age and education . comparison of obstacles faced in health education as reported by studied men and women regarding preferred methods of health education , the majority of both men ( 72.7% ) and women ( 67.9% ) expressed their preference for the one - to - one method [ table 4 ] . on the other hand , group health education was the least preferred by men , while for women , it ranked third in preference , the difference being statistically significant ( p = 0.02 ) even after adjustment for age and education . concerning the preferred health education provider , about three quarters of both men and women chose doctors . the health educator came second in preference , but with much lower percentages of agreement , while nurses came fifth . also , significantly more men than women preferred the pharmacist and the dietitian as providers of health education . comparison of preferred health education methods and sources as reported by studied men and women # this study compared health education needs , barriers , and preferences between saudi men and women attending the riyadh military hospital , ksa . the findings indicated statistically significant differences in some of the preventive aspects needs , language barriers , and the preferred methods and providers . although the majority of the study participants indicated that they had received a health education message , about a quarter had not , which points to the need for a greater effort in this service . meanwhile , from the point of view of the women in particular , the benefits of the delivered information were high with a statistically significant difference . this gender difference might be attributed to the fact that language was less of a barrier for the women as the study findings indicated , but may also reflect a more attentive attitude among women , especially with regard to issues relating to their children . ( 2005 ) who found that the female gender predicted participation in health education interventions , and actual participation . similarly , wiesemann et al . as regards health education needs , men expressed significantly greater need for information on primary prevention issues and unhealthy health practices such as smoking . well woman and antenatal care clinics , which provide them with primary prevention services . besides , the well - baby and vaccination clinics are mostly attended by mothers with their children , rather than fathers . a well man clinic recently started , but not yet fully functional may achieve this unmet need for men . as for the unhealthy habit of smoking , it is primarily a men 's problem in our community . however , the wish for greater emphasis on preventive aspects expressed by men in this study is in contrast with ray - mazumder ( 2001 ) who found that female chinese students in the usa and their mothers had a more positive attitude towards preventive care and practice than males . ( 2009 ) did not find any gender difference in health education needs in the netherlands . therefore , it seems that gender - based differences in health education needs are influenced by factors relating to the setting such as culture and tradition , in addition to the extent to which new technologies like the internet and other media are utilized . nevertheless , the present study demonstrated fewer unmet needs in health education relating to prevention compared to needs on disease management . ( 2010 ) in the usa reported a low level of interest in preventive services . the first could be the good coverage given to primary prevention issues in our health education programs at the expense of patient education that relates to the patient 's own illness . the second which is more plausible could be the less perceived need or importance of issues of primary prevention on the part of the clients . this second explanation is more probable since our health education programs are balanced in covering both prevention and control issues , with even more emphasis on patient education . moreover , the importance of prevention is underestimated , for more resources even in developed countries , as reported in austria are usually directed towards curative care services . concerning the barriers and obstacles that study participants face in health education , men and women agreed on all types of barriers . this difference could not be attributed to differences in age or education as it was present even after adjustment . the explanation could be that there were more non - arab speaking male doctors than female doctors in the study setting . however , this language barrier can not be separated from the effect of lack of race concordance between providers and consumers . similar language problems were previously reported as a major barrier to health education and client satisfaction especially in settings with multinational providers and/or consumers . our study has also demonstrated significant differences in the preferences of men and women for the methods and providers of health education . the individualized face - to - face method was the most preferred by both groups . this is quite plausible since it allows personal interaction , using verbal and non - verbal communication , and providing a better chance to discuss personal needs . however , this method demands that more time is spent by the provider with each client . more women than men in the present study had a preference for group health education . also , the arrangement and scheduling of the process might take longer time , which men can ill afford , but which the women who were mostly housewives could . most men and women in the present study preferred to have a doctor as the provider of health education , with health educators , nurses , and other health professionals coming next in that order . very few , but more men than women , agreed to receive health education from pharmacists and dietitians . these preferences reflect a low level of awareness of the roles of various members of the healthcare team , with the deeply - rooted belief in the doctor as the only source of trustworthy health information . this belief , as shown in previous studies seems to be universal and not simply related to the level of country 's development . nevertheless , other studies have indicated an increasing role of nurses and pharmacists in health education . the study findings reveal a few significant differences between men and women regarding their health education needs , barriers , and preferences though there were areas of major agreement between the two groups . the programs should also present solutions to the main barriers identified , especially with regard to the use of medical terms , the provider 's lack of time , and the language problems by emphasizing the role of health educators , by recruiting arabic speaking male educators , and by taking gender differences into consideration when designing health education programs .

background and aim : health reforms that tend to increase the participation of clients in decision - making requires them to be health - literate ; hence , the importance of health education . however , not much research has been done to investigate the differences in health education needs according to demographic characteristics of the clients . the aim of this study was to find out any possible gender differences there may be in health education needs and preferences.subjects and methods : this cross - sectional study was conducted at riyadh military hospital , saudi arabia , on a convenience sample of adult saudis attending its clinics . data was collected from april 2009 to may 2010 using a self - administered questionnaire covering demographic data , history and needs of health education , methods , and preferred educator.results:of the 1300 forms distributed , 977 were returned completed ( 75.2% response ) . most men ( 74.0% ) and women ( 77.9% ) had had health education , but more women reported that it had been helpful ( p = 0.014 ) . more men mentioned health education needs relating to primary prevention ( p = 0.027 ) , and unhealthy practices ( p = 0.003 ) , and considered the different language a barrier ( p = 0.002 ) even after adjustment for age and education . the one - to - one method was the most preferred health education method for men ( 72.7% ) and women ( 67.9% ) . more women preferred group health education ( p = 0.02 ) after adjustment for age and education . significantly more men preferred pharmacists and dietitians as health educators.conclusion:the results point to a few significant differences between men and women regarding their health education needs , barriers , and preferences . these must be taken into consideration when planning health education programs .

a 28-year - old female born out of a second - degree consanguineous marriage presented with a gradual onset of decrease in vision in both eyes for 5 years . the patient was alright till the age of 10 years , when she developed skin changes , failure to gain weight , and had oligomenorrhea and irregular menses . she was on treatment for diabetes mellitus , high lipid profile and hypothyroidism , which developed as a consequence of radiotherapy for thyroid enlargement . , she had a short stature ( 134 cm ) , weighed 25 kg , looked emaciated , had gray , sparse scalp hair , bird - like facies , hoarse voice , thinned , hyperpigmented skin and lean arms and legs [ fig . ( a ) external photograph of a 28-year - old patient with ws with bilateral cataracts , emaciated look , gray sparse scalp hair , a bird - like facies , thin hyperpigmented skin ; ( b ) external photograph showing short stature and lean arms and legs on ophthalmic examination , best corrected visual acuity was 20/60 , n12 in the right eye ( re ) and counting fingers 6 ft , n36 in the left eye ( le ) . slit - lamp examination showed nuclear sclerosis grade 2 in the re and total cataract in the le . she underwent a clear corneal phacoemulsification with hydrophilic foldable intraocular lens ( iol ) implantation in the le under peribulbar anesthesia . intraoperatively , a thick posterior capsular calcified plaque was noticed which could not be removed by peeling with a 26 g needle . primary posterior capsulotomy ( ppc ) was avoided for the fear of inducing cystoid macular edema ( cme ) . after iol implantation , the corneal tunnel and side ports were closed with 10/0 nylon suture . postoperatively , the patient was started on ketorolac tromethamine ophthalmic solution 0.4% four times daily and gatifloxacin eye drops 0.3% four times daily . the patient was started on a weak steroid ( fluorometholone eye drops ) twice daily for a week on the 4th postoperative day because of the increased anterior chamber reaction . on subsequent visits , the eye was quiet . at 1 month , the best corrected visual acuity was 20/40 n12 . she was operated in the re 6 months after the first cataract surgery with similar precautions . yag capsulotomy was done 4 months from the date of surgery in le [ fig . ( a ) slit - lamp photograph of the le showing pseudophakia with posterior capsular plaque ; ( b ) slit - lamp photograph of the le showing pseudophakia after yag laser capsulotomy preoperative , postoperative and post yag capsulotomy endothelial cell counts about 1300 cases have been reported around the world from 1916 to 2002 , including about 1000 japanese patients . the international registry of ws ( www.wernersyndrome.org ) uses the above findings [ table 2 ] to establish a definite , probable , or a definitive diagnosis requires all the cardinal signs and two signs from other signs . our patient had all the cardinal signs and two others ( diabetes mellitus , hoarse voice ) , thus satisfying the criteria for a definitive diagnosis . showing clinical features of ws cataract is one of the typical ocular manifestations of ws . corneal decompensation occurred in 8 of the 18 eyes of patients with ws after cataract surgery when surgery was done by intracapsular or conventional extracapsular surgery . decreased endothelial function in ws is due to prematurely aged cornea the more recent studies in which cataract surgery was done by phacoemulsification show that it can be done safely without an increased rate of complications . in this patient , cataract surgery was done by phacoemulsification with the following precautions : ( 1 ) small incision size of 2.8 mm ; ( 2 ) liberal use of sodium hyaluronate 1.4% to protect the corneal endothelium ; ( 3 ) closure of the corneal tunnel and side ports using 10/0 nylon suture to prevent wound dehiscence ( impaired wound healing is a feature of ws ) ; ( 4 ) weak steroids were used postoperatively so as not to suppress fibroblast proliferation . decreased fibroblast proliferation rate has been proved by cell culture in ws and could be the cause for impaired wound healing . endothelial count in le , 4 months post surgery , showed a 7% ( 141 cells / mm ) reduction and , in re , 2 months post surgery , showed a 5% ( 110 cells / mm ) reduction which falls within the normal range . studies report endothelial cell loss rates from 4% to 15% after phacoemulsification by experienced surgeons . ppc was avoided as the incidence of cme after ppc was higher than without it . a study carried out by allan r. slomovic gives a cell loss of 2.3% after yag capsulotomy . in our patient , the cell count showed a 0.48% ( 9 cells / mm ) reduction , 4 months after yag capsulotomy . there was no change in the morphology of the cells . in case of ws with an already compromised cornea , we expected the cell loss to be more than the expected . the last follow - up 15 months postoperatively in the le and 9 months postoperatively in the re showed an 8.6% ( 174 cells / mm ) decrease in cells in le and 7.3% ( 160 cells / mm ) decrease in re , which is within the normal range of cell loss . we conclude that short - term results after cataract surgery and yag capsulotomy were excellent with modern microsurgical techniques in a patient with ws . through this case , we want to highlight that ws should be kept in mind when operating on any patient with features of premature aging and special precautions should be taken when doing the cataract surgery .

werner 's syndrome ( ws ) is a rare autosomal recessive disorder with multisystem manifestations of premature aging from the second decade of life . cataract is one of the features of ws . cataract surgery is complicated with postoperative wound dehiscence and bullous keratopathy when the surgery is done by intracapsular or conventional extracapsular method . we report the short - term result of phacoemulsification and neodymimum yettrium - aluminum - garnet laser ( nd yag ) capsulotomy in a case of ws with bilateral cataracts . postoperatively and post capsulotomy , there was no change in the endothelial cell morphology . there was an 8.6% decrease in endothelial cell count at the end of 15 months postoperatively and 11 months post yag capsulotomy . this decrease is within the acceptable range of cell loss after phacoemulsification and yag capsulotomy . to the best of our knowledge , this is the first reported case of yag laser capsulotomy in ws .

peripheral ossifying fibroma ( pof ) is a reactive soft tissue growth that is usually seen on the interdental papilla . it may be pedunculated or broad based , usually smooth surfaced and varies from pale pink to cherry red in color . it is believed to comprise about 9% of all gingival growths and to arise from the gingival corium , periosteum , and the periodontal membrane . it has also been reported that it represents a maturation of a pre - existing pyogenic granuloma or a peripheral giant cell granuloma . a 12-year - old girl reported with the chief complaint of soft tissue growth in the palate . intraoral examination revealed a painless pedunculated , cauliflower - like rubbery mass on the palatal aspect of the maxillary left permanent molar extending towards the occlusal surface [ figure 1 ] . the lesion was abnormally large about 2.5 cm mesiodistally and 1.5 cm buccopalatally and the side of the lesion facing the occlusal surface was focally ulcerated . the maxillary first permanent molar was buccally displaced . history revealed that the lesion started growing on its own since she first noticed it about a month back when it was a small nodule . the lesion was painless and occasionally bled on its own or when traumatized with toothbrush and in its present state was interfering with occlusion . radiograph revealed only soft tissue shadow and space between maxillary second premolar and first molar [ figure 2 ] . soft tissue growth extending toward the occlusal surface iopa showing the soft tissue shadow and space between premolar and molar after routine blood examinations , excisional biopsy of the growth was done [ figure 3 ] under antibiotic coverage and thorough curettage of the adjacent periodontal ligament , and periosteum was carried out to prevent recurrence . histomorphological examination revealed evidence of calcifications in the hypercellular fibroblastic stroma [ figure 4 ] confirming the lesion as pof . the follow - up of the case showed normal healing of the area [ figure 5 ] . pof has also been described by various synonyms such as peripheral cemento ossifying fibroma , peripheral odontogenic fibroma ( podf ) with cementogenesis , peripheral fibroma with osteogenesis , peripheral fibroma with calcification , fibrous epulis , calcifying fibroblastic granuloma , etc . almost 60% of the lesions occur in the maxilla and mostly occur anterior to molars . dental calculus , plaque , microorganisms , dental appliances , and restorations are considered to be the irritants triggering the lesion . the lesion though usually smaller than 1.5 cm in diameter can reach a much larger size and can cause separation of the adjacent teeth , resorption of the alveolar crest , destruction of the bony structure and cosmetic deformity . the term pof should not be confused with podf , which is the rare peripheral counterpart of central odontogenic fibroma . in north america , it is still synonymously used by many for pof as the lesion is thought by them to be derived from the periodontal ligament and hence to be odontogenic . the evidence for its odontogenic origin is circumstantial , being based partly on the demonstration of oxytalan fibers within its calcified structures and its exclusive occurrence on gingiva . however , oxytalan fibers have also been reported in the sites other than the periodontal ligament . a pof is more common in females and in the anterior maxilla , but podf has a predilection for males and the posterior mandible . the pof and ossifying fibroma ( of ) are the lesions that exhibit similar histomorphologic features and both originate from periodontal ligament cells . but a pof is a reactive lesion where as an of is a benign neoplastic lesion included in the group of benign fibro - osseous lesions of the jaws and both pof and of show different proliferative activities . the ulcerated lesions are more likely to be painful but in this case it was not painful . gingival lesions that imitate pof are peripheral giant cell granuloma , pyogenic granuloma , fibroma , calcifying epithelial odontogenic cyst , calcifying odontogenic cyst , etc . radiographically radiopaque foci within the soft tissue tumor mass are observed if the calcified element is significant , but in this case no radiopaque foci were seen but only shadow of the lesion was seen probably because the lesion was of short duration of time . histologically , pof can exhibit either ulcerated or intact stratified squamous epithelium . in a typical ulcerated lesion , three zones could be identified : zone i : the superficial ulcerated zone covered with the fibrinous exudate and enmeshed with polymorphonuclear neutrophils and debris . zone ii : the zone beneath the surface epithelium composed almost exclusively of proliferating fibroblasts with diffuse infiltration of chronic inflammatory cells mostly lymphocytes and plasma cells . zone iii : more collagenized connective tissue with less vascularity and high cellularity ; osteogenesis consisting of osteoid and bone formation is a prominent feature , which can even reach the ulcerated surface in some cases . the calcified material can generally take one or more of the following four forms : ( a ) mature lamellated trabecular bone ; ( b ) immature , highly cellular bone ; ( c ) circumscribed amorphous , almost acellular , eosinophilic , or basophilic bodies , and ( 4 ) minute microscopic granular foci of calcification . the nonulcerated lesions are typically identical to the ulcerated type except for the presence of surface epithelium . cementum - like material is found in less than one - fifth of the lesions and dystrophic calcifications are more prevalent in ulcerated lesions . treatment requires proper surgical intervention that ensures deep excision of the lesion including periosteum and affected periodontal ligament . thorough root scaling of adjacent teeth and/or removal of other sources of irritants should be accomplished . in children , reactive gingival lesions can exhibit an exuberant growth rate and reach significant size in a relatively short period of time . in addition , the pof can cause erosion of bone , can displace teeth , and can interfere or delay eruption of teeth . early recognition and definitive surgical intervention result in less risk of tooth and bone loss . it is suggested that there is no absolute histological distinction between bone and cementum , and as the so - called cementum - like globules of calcification are seen in fibro - osseous lesions in all membrane bones , it is unrealistic to separate the ossifying and cementifying lesions and it is speculated that the fibro - osseous lesions might represent stages in the evolution of a single disease process passing through the stages of fibrous dysplasia to ossifying fibroma to cementoid lesions . in conclusion , clinically it is difficult to differentiate between most of the reactive gingival lesions particularly in the initial stages . regardless of the surgical technique employed , it is important to eliminate the etiological factors and the tissue has to be histologically examined for confirmation .

the gingiva is often the site of localized growths that are considered to be reactive rather than neoplastic in nature . many of these lesions are difficult to be identified clinically and can be identified as specific entity only on the basis of typical and consistent histomorphology . peripheral ossifying fibroma is one such reactive lesion . it has been described with various synonyms and is believed to arise from the periodontal ligament comprising about 9% of all gingival growths . the size of the lesion is usually small , located mainly in the anterior maxilla with a higher predilection for females , and it is more common in the second decade of life . a clinical report of a 12-year - old girl with a large peripheral ossifying fibroma in the posterior maxilla showing significant growth and interference with occlusion is presented .

the prevalence of diabetes in korea has increased six- to sevenfold from 1.5 to 9.9% over the past 40 years . the number of people with diabetes worldwide is expected to increase 11.4% from 366 million in 2011 to 552 million by 2030 , affecting one in 10 adults . this global increase in the prevalence of diabetes will inevitably lead to increases in the prevalence of diabetic microvascular and macrovascular diseases , and consequently , significantly increased health care expenditure . in korea , diabetic patients with microvascular disease spend up to 4.7 times as much , patients with macrovascular disease up to 10.7 times as much , and patients with both complications 8.8 times as much as those with no complications . the medical cost of diabetes mellitus covered by the national health insurance corporation is 3.2 trillion won and accounted for 19.2% of all medical costs . diabetes and its complications have become major causes of morbidity and mortality in korea . although diabetes - related mortality has decreased recently from 25.1 per 100,000 persons in 2002 to 19.6 per 100,000 persons in 2009 the rate of death among patients with diabetes is about twice as high as that among persons without diabetes . the most common cause of death is cardiovascular disease ( 30.6% ) , followed by infectious disease ( 25.3% ) , cancer ( 21.9% ) , congestive heart failure ( 7.1% ) , renal disease ( 4.7% ) , liver disease ( 2.7% ) , and diabetes itself ( 1.9% ) . despite the seriousness of diabetic complications , 30% to 70% of patients receive inadequate care , and only 40% of treated diabetic patients achieve the optimal control , defined as an hba1c level < 7% . the serious outcomes from diabetic complications and inadequate glucose control in diabetic patients prompt the need for more aggressive efforts to provide optimal metabolic control . type 2 diabetes mellitus is associated with a high rate of complications related to cardiovascular disease and diabetic nephropathy , retinopathy , and neuropathy . in 2006 , 30.3% , 38.3% , and 44.6% of patients were found to have microvascular complications such as microalbuminuria , retinopathy , and neuropathy , respectively from korean nationwide survey . the prevalence of macrovascular complications including coronary artery disease , cerebrovascular disease , and peripheral artery disease was 8.7% , 6.7% , and 3.0% , respectively . the prevalence of diabetic foot was 4.4% , and 44.8% of patients with an amputated foot had diabetes mellitus . the prevalence of macrovascular complications seems underestimated in these data . in a study of 343 patients with diabetes mellitus , the prevalence of cardiovascular complication was 23.6% , and in another study of 406 patients with diabetes , extracranial internal carotid artery stenosis 40% was detected in 5.2% of the patients . in addition , the prevalence of macrovascular complication was 10.8% from recent the korean national diabetes program ( kndp ) data and there is reference from 2005 korea national health and nutrition examination survey ( knhanes ) data in table 1 . the role of hyperglycemia in the development of microvascular complications of diabetes , such as nephropathy , retinopathy , and neuropathy , is well documented . the incidence of microvascular complications begins to increase at an hba1c level > 7.0% and increases by 30% to 40% per 1% increase in hba1c level from over 8,000 patients ( fig . microvascular complications are closely related to age , duration of diabetes , and glycemic control , and this relationship is stronger than that with macrovascular complications . diabetic retinopathy is the most common microvascular complication of diabetes mellitus , and its prevalence is strongly related to the duration of diabetes . it is the most frequent cause of new cases of blindness among adults aged 20 to 74 years . in ansung cohort study ( prospective , rural , community cohort in korea ) , the prevalence of any diabetic retinopathy was 2.9% and the proper cutoff of hba1c value for detecting any diabetic retinopathy was 6.6% ( unpublished data ) . diabetic nephropathy is characterized by albuminuria ( 300 mg / day ) and a reduced glomerular filtration rate . it is often present at the time of the diagnosis of diabetes after the kidney has been exposed to chronic hyperglycemia during the prediabetic phase . patients with microalbuminuria who progress to macroalbuminuria ( 300 mg/24 hr ) are likely to progress to end - stage renal disease ( esrd ) . diabetes is a major cause of chronic kidney disease ( ckd ) and is recognized as the most common cause of esrd in the usa and korea . about 40% of united states adults with diagnosed or undiagnosed diabetes had some degree of ckd in the 1999 to 2006 national health and nutrition examination survey . the prevalence of peripheral neuropathy has been estimated at 40.0% to 44.6% . at present , there is no specific treatment for the underlying nerve damage other than to improve glycemic control , which may slow the progression modestly . the case fatality rate after myocardial infarction is higher in patients with diabetes than in patients without diabetes . the association between diabetes and coronary heart disease is likely to become more important for two reasons . first , the incidence of type 2 diabetes is increasing among both high - risk and low - risk populations . second , although the rate of death caused by coronary heart disease in the overall population has declined markedly over the past 35 years , this has not been the case among persons with diabetes . cardiovascular disease is the major cause of morbidity and mortality for individuals with diabetes and is the largest contributor to the direct and indirect costs of diabetes . older age , high blood pressure , and smoking history are major risk factors for the development of macrovascular complications . a smoking history in males can be both a risk factor and a predictive factor for earlier development of macrovascular complications in korean patients with type 2 diabetes . microvascular complications of diabetes increase the risk of cardiovascular events in diabetic patients . although diabetic retinopathy is not associated with the presence of atherosclerotic plaque , it is associated with increased carotid intima - media thickness , and the increase in intima - media thickness is associated with the presence of plaque , which predisposes patients to cardiovascular disease . microalbuminuria and a low glomerular filtration rate ( < 60 ml / min/1.73 m ) increase the risk of major cardiovascular events and death . diabetic polyneuropathy was also independently associated with a high prevalence of cardiovascular disease in type 2 diabetic patients . these data imply that the microvascular complications of diabetes are related indirectly to the macrovascular complications of diabetes , similar in korea . intensive glycemic control has been suggested as an effective treatment for reducing the burden of cardiovascular disease and microvascular complications in people with diabetes . the united kingdom prospective diabetes study and the kumamoto study showed that early intensive glycemic control can delay the onset and progression of diabetic retinopathy , nephropathy , and neuropathy compared with conventional treatment [ 21,24 - 26 ] . intensive glucose control involving gliclazide ( modified release ) and other drugs as required lowered the hba1c value to 6.5% and reduced by 10% the relative risk for the combined outcome of major macrovascular and microvascular events , primarily because of a 21% reduction in incidence of nephropathy . in addition , the legacy effect was observed after 10 years of trial in the rate of microvascular complication and myocardial infarction . in the steno-2 study , the intensive therapy group had a 46% lower risk for all - cause mortality and a 57% lower risk of death from cardiovascular causes . one patient in the intensive therapy group progressed to esrd compared with 6 patients in the conventional therapy group , and fewer patients in the intensive therapy group required retinal laser therapy . although there are many benefits of intensive glucose - lowering treatment for preventing macrovascular and microvascular events , it remains uncertain whether these benefits outweigh the risks . intensive blood glucose control decreases the risk of developing microvascular complications but not macrovascular disease in patients with type 2 diabetes . in the action to control cardiovascular risk in diabetes ( accord ) study , an intensive glucose - lowering regimen reduced rate of 5-year nonfatal myocardial infarctions but was associated with a 22% increase in mortality . a recent meta - analysis found that intensive glucose - lowering treatment has limited effect on the rates of all - cause mortality and death from cardiovascular causes . the data are conflicting : a 9% reduction to a 19% increase in all - cause mortality and a 14% reduction to a 43% increase in cardiovascular death rates . the harm associated with severe hypoglycemia might counterbalance the potential benefit of intensive glucose - lowering treatment . the microvascular benefits of intensive therapy should be weighed against the increase in total and cardiovascular disease - related mortality , weight gain , and high risk of severe hypoglycemia . however , multifactorial approaches in high risk patients with diabetes , such as tight glucose regulation and the use of anti - hypertensive medication , aspirin , and lipid - lowering agents , have been shown to reduce the risk of nonfatal cardiovascular disease among patients with type 2 diabetes mellitus and microalbuminuria . in high risk patients with type 2 diabetes , intensive treatment approaches with multiple drug combinations and behavior modification had sustained beneficial effects with respect to vascular complications and on rates of death from any cause and from cardiovascular causes . several adipokines are implicated in the metabolic syndrome , coronary heart disease , and insulin resistance . we want to discuss some adipokines , which showed correlation with diabetes and metabolic syndrome in korea . lipocalin family proteins , including adipocyte fatty acid - binding protein ( a - fabp ) , lipocalin-2 , and retinol - binding protein 4 ( rbp4 ) , have been identified recently as adipokines associated with obesity , type 2 diabetes , and the metabolic syndrome . serum a - fabp is associated with glucose dysregulation , and its level predicts the development of type 2 diabetes and the development of the metabolic syndrome independently of adiposity and insulin resistance . serum lipocalin-2 level is significantly elevated in patients with coronary heart disease and is independently associated with coronary heart disease . these findings suggest that serum lipocalin-2 levels may be useful for assessing coronary heart disease risk . plasma rbp4 concentration is elevated in persons with impaired glucose tolerance and type 2 diabetes . high rbp4 and low plasma adiponectin concentrations are associated with the severity of glucose intolerance in women with previous gestational diabetes mellitus . a low circulating vaspin level correlates with a high fitness level , whereas physical training in untrained individuals increases vaspin serum concentration . vaspin is also correlated with metabolic syndrome in men and coronary artery stenosis in women . however , another study reported that circulating visfatin may not be a useful clinical biomarker of metabolic status . a relationship between chemerin levels , cardiometabolic parameters , and degree of coronary stenosis has been reported in korean patients with coronary artery disease . serum osteocalcin , an osteoblast - specific protein , has several hormonal features and is secreted into the general circulation by osteoblastic cells . serum osteocalcin and osteoprotegerin levels are associated with glucose metabolism and atherosclerosis parameters in people with type 2 diabetes mellitus . even though there are many studies about adipokines and metabolic diseases , we need large number , prospective studies to see the causality between the candidate adipokines and diabetic complications more clearly . the increasing prevalence of diabetes mellitus and its related complications have contributed to a substantial increase in morbidity and mortality in korea . however , the proportion of patients with type 2 diabetes achieving adequate glucose control is relatively low . multifactorial treatment approaches that target hypertension , dyslipidemia , and microalbuminuria , and that provide intensive glycemic control are urgently needed to control diabetes . these comprehensive and integrated health interventions will lead to further improvement in the management of diabetes .

the prevalence of diabetes in korea has increased six- to sevenfold over the past 40 years with its complications becoming major causes of morbidity and mortality . the rate of death among patients with diabetes is about twice as high as that among persons without diabetes and the most common cause of death is cardiovascular disease ( 30.6% ) . despite the seriousness of diabetic complications , 30 to 70% of patients receive inadequate care , and only 40% of treated diabetic patients achieve the optimal control with hba1c level < 7% in korea . in 2006 , over 30 to 40% of patients with diabetes have microvascular complications and around 10% of them have macrovascular complications from our national data . despite there are some debates about intensive glycemic control resulting in the deterioration of macrovascular complication , multifactorial treatment approaches including proper glycemic control are important to prevent diabetic complications . there have been needs for finding proper biomarkers for predicting diabetic complications properly but we still need more longitudinal studies to find this correlation with causal relationship . in this article , we wanted to review the recent status of micro- and macrovascular complications of type 2 diabetes in korea from integration of many epidemiologic studies .

internal hernia is the protrusion of the intra - abdominal viscera through peritoneal or mesenteric orifices within the peritoneal cavity . internal hernias is an infrequent cause of small bowel obstruction with a reported incidence of up to 5.8% of intestinal obstruction , and paraduodenal hernias representing 50% of the 500 cases published up to the year 2000 [ 1 , 2 ] . there are several types of internal hernia as traditionally described , according to their location . sigmoid mesocolic hernia is a rare type of congenital hernia and intramesosigmoid hernia is the rarest amongst the sigmoid mesocolic hernia [ 46 ] . there are only three previous reports of laparoscopic surgery of sigmoid mesocolic hernia in the surgical literature . we present the case of rare type of congenital internal hernia and managed it successfully by the laparoscopy . a 49-year - old female was transferred to our emergency department with abdominal pain of several hours duration . pain showed colicky and aggravated pattern in the periumbilical area . abdominal x - rays showed slight distension of small bowels with air - fluid levels ( fig . 1 ) . ct scan revealed that dilated small bowel loops probably ileal level in left lower quadrant ( fig . 2 ) . a nasogastric tube was inserted and she was given a conservative treatment over the next 2 days , but we proposed a laparoscopic exploration because of no clinical improvement . figure 1:upright abdominal radiograph showing multiple air - fluid levels , suggestive of possible distal bowel obstruction . figure 2:contrast enhanced ct showing the transitional zone ( white arrow ) between dilated to collapsed loops in the left lower abdomen . upright abdominal radiograph showing multiple air - fluid levels , suggestive of possible distal bowel obstruction . contrast enhanced ct showing the transitional zone ( white arrow ) between dilated to collapsed loops in the left lower abdomen . two other 5-mm ports were placed for instruments in the right upper and lower abdomen . as tracing retrograde from the ileocecal junction , a loop of mid - ileum was incarcerated to 2-cm sized defect lateral to the sigmoid colon . first , trying the reduction of small bowel loop by atraumatic grasper gently , detachment of sigmoid lateral attachment was performed . incarcerated bowel was released as soon as we detached a just little ( fig . approximately 15 cm of small bowel had been incarcerated in the defect and initially appeared congested but its colour and peristalsis improved rapidly . the hernia defect did not involve the medial aspect of the peritoneum on the sigmoid mesocolon and was confirmed no full - thickness defect . the defect was disappeared and changed to broad space easily from dissection of peritoneal attachment . figure 3:after reducing the incarcerated ileum ( white arrowhead ) , the defect ( asterisk ) in the lateral leaf of the sigmoid mesocolon ( black arrow ) is seen . after reducing the incarcerated ileum ( white arrowhead ) , the defect ( asterisk ) in the lateral leaf of the sigmoid mesocolon ( black arrow ) these defects may be congenital , traumatic , postoperative , post - inflammatory or idiopathic . the autopsy incidence of internal hernias is 0.22% , most of them is asymptomatic and acquired . the herniated bowel may return to its normal location or be incarcerated , depending on the size of the defect and the length of the herniated bowel . sigmoid mesocolic hernia although uncommon , it is not extremely rare accounting for 5% of all internal hernias . ( i ) intersigmoid hernia : herniation into an intersigmoid fossa , situated at the attachment of the lateral aspect of the sigmoid mesocolon . this fossa is formed during fusion of the left peritoneal surface of the sigmoid mesentery with the parietal peritoneum of the posterior abdominal wall , the line of toldt . ( ii ) transmesosigmoid hernia : incarceration of intestinal loops through a full - thickness defect in the sigmoid mesocolon . ( iii ) intramesosigmoid hernia : a congenital , oval defect unrelated to the intersigmoid fossa is present in juxtaposition to the colon and involves only one leaf ( lateral more common ) of the sigmoid mesocolon and herniation occurs . a normal fusion fascia is present , and the right leaf is intact in this setting . no clear radiographic sign allows one to distinguish among the three types of intersigmoid hernias , and no precise radiologic differentiation is required because surgical exploration is mandatory . the clinical manifestations of internal hernia range from mild digestive symptoms to acute abdomen , depending on the severity of the obstruction and the presence of incarceration . ct scan is considered to suggest the diagnosis in a patient suspected of having intestinal obstruction . ct findings showed the presence of encapsulated fluid - filled and markedly distended bowel loops protruding toward left lower abdomen accompanied by fat and mesenteric vessels . however , these findings are not pathognomonic and only suggest the diagnosis . in patients presenting with small intestinal obstruction , the absence of an obvious external hernia , history of tuberculosis or of previous surgery should alert the clinician for the possibility of an internal herniation as the cause . if an internal herniation is suspected , the surgery should be prompt , as strangulation and necrosis of the hernial contents is likely to ensue if the surgery is delayed . traditionally , such a treatment is undertaken by open surgery in which the contents are reduced from the hernial defect , and resected if necrotic and the defect is closed . however , if no evidence of strangulation or necrosis , a laparoscopic approach is a useful method . in addition , we propose that there is always no necessity to close the hernia defect . if transmesocolic hernia was found , after reduction the hernia defect must be closed preventing recurrence . but as intramesocolic or intermesocolic hernia , detachment of peritoneal attachment for sigmoid mobilization is feasible and usually enough because there is no complete defect , and narrow hernia sac was changed to broad space which was free from incarceration . in conclusion , this case report shows the diagnostic as well as therapeutic roles of laparoscopy in patient with acute intestinal obstruction and this approach is feasible and valuable even in a rare pathology such as a sigmoid mesocolic hernia . we suggest not to repair any types of sigmoid mesocolic hernia but to manage more easily according to hernia types .

internal hernia is an unusual cause of small bowel obstruction and classified several types according to locations . sigmoid mesocolic hernia is an uncommon condition and among others intramesosigmoid hernia was rarely reported in the literature . we report the case of a 49-year - old female with a rare type of congenital internal hernia , through the mesosigmoid , causing small bowel obstruction . she suffered from obstructive symptoms but with no previous history of laparotomy . the diagnosis of internal hernia was suggested by computed tomography , but the type of internal hernia was confirmed by laparoscopic exploration . she underwent laparoscopic detachment of peritoneal attachment comprising hernia sac without defect repair . the postoperative course was uneventful and the patient is free from symptoms and recurrence . this report presents a case of intrasigmoid hernia managed successfully by the laparoscopic approach and shows another surgical technique according to hernia types .

mucormycosis or zygomycosis is a rare opportunistic , potentially lethal infection characterized by rapid progression and high mortality , which represents the third most common fungal infection after candidiasis and aspergillosis . these opportunistic pathogens are ubiquitous organisms , existing in the environment , soil , air , food , composite piles , animal excreta and play a pivotal role in the cycle of decomposition in the natural world . the usual human pathogens belong to genera absidia , mucor , rhizomucor , rhizopus and currently apophysomyces . unlike other fungal pathogens that target mainly immunocompromised hosts , these organisms infect a broader and more heterogeneous population . it is rarely reported in an apparently normal immunocompetent host which comprise only 4% of total affected individuals , but most frequently occurs in patients with an underlying illness such as diabetic mellitus , leukemia , lymphoma and in transplant patients undergoing immunosuppressive therapy . clinically , the most common clinical form of mucormycosis is rhino cerebral ( 4449% ) , followed by cutaneous ( 1016% ) , pulmonary ( 1011% ) , disseminated ( 611.6% ) and gastrointestinal ( 211% ) presentations . mucormycosis of the head and neck is divided into isolated nasal , rhino - orbital , rhino - orbito - cerebral mucormycosis ( rocm ) according to the involved sites , indicating the course of the disease . here we describe a case of invasive rocm to raise clinical awareness of this infection in an apparently normal individual and to emphasize the importance of early detection with clinical , neuroimaging , histopathological and culture findings . an 18-year - old male farmer was admitted in the government ear nose and throat ( ent ) hospital with a history of non healing ulcer on right side of the cheek involving right and left eye with signs of orbital invasion ( extensive proptosis , severe periorbital cellulitis and ulcer ) from 1.5 month . the patient was suffering from high fever , complete blindness , severe headache and seizures ; and he was non coherent and uncooperative . the lesion started as nonspecific sinusitis of 3 week 's duration and was treated for symptomatic relief in a local hospital . the pain and discomfort continued to get worse and he developed a unilateral swelling on the right side of the cheek which was edematous , erythematous followed by formation of a small nodule which ruptured and formed an ulcer within 3 days . the patient approached a local physician where he was put on antibiotics , anti - inflammatory drugs and was also referred to a dentist to rule out dental infections . the dental infection was ruled and he was asked to continue the prescribed medications , but there was no relief and the condition deteriorated with increased ocular discomfort , severe headaches , sloughing of the ulcer which extended rapidly and involving nose , both the orbits with gradual loss of vision in next 2 weeks . the patient was admitted to the hospital due to repeated seizures , altered sensorium , non - coherence and was uncooperative . clinical examination showed large irregular ulcer approximately 12 10 cm in size on the right side of the cheek , which extended from the right lower margin of the mandible to the medial and lateral canthus of the eye , involving half of the right side of the lips , exposing alveolar gingiva and teeth [ figure 1 ] . the submandibular and submental lymph nodes were palpable , enlarged , tender and firm . however , the primary cause was undetermined and broad spectrum antibiotic therapy was initiated that included intravenous cloxacillin 500 mg every 6h , cefuroxime 750 mg every 8h and metronidazole 500 mg every 8h along with anticonvulsant treatment for 1 week along with surgical debridement of the ulcer . the severity of the lesion prompted us to do a thorough clinical and radiological evaluation to rule out gangrenous stomatitis , chronic granulomatous disease and any malignancies . nonhealing ulcer over right side of the cheek involving right and left eye with signs of orbital invasion ( extensive proptosis , severe periorbital cellulitis and ulcer ) the complete blood picture and biochemical investigations showed a neutrophilic leukocytosis 12,000 cell / mm with left shift , differential leukocyte count of 76% neutrophils , 20% lymphocytes , 34% eosinophils , hemoglobin of 11 gm / dl , raised erythrocyte sedimentation rate ( esr ; 40 mm at the end of 1h ) , random blood sugar of 140 mg% , and fasting blood sugar of 80 mg% . the patient was human immunodeficiency virus ( hiv ) and hepatitis b surface antigen seronegative ; and the liver function and the renal function tests were within normal limits . the chest x - ray was clear and normal.computed tomography ( ct ) scan of paranasal sinuses and the brain showed right maxillary and ethmoidal sinusitis with deviation of the bony nasal septum to the left , mild erosion of bony nasal septum and bone destruction . widening of the optic nerve canal and the superior orbital fissure , probability of fungal etiology was also detected [ figure 2a and b ] . exploration of the ulcer and debridement of necrotic tissue were done under local anesthesia and sent for histopathology , culture analysis . histopathological examination of the debrided tissue showed elongated , broad , nonseptate hyphae , marked areas of necrosis with giant cells , thrombosis of vessels , diffused infiltration of lymphocytes , eosinophils and few plasma cells [ figure 2c - e ] . the grocott - gomori 's methanamine silver staining showed nonseptate , twisted , ribbon - like hyphae of zygomycetes [ figure 2f ] . rhino - orbito - cerebral zygomycosis was suspected and partial surgical debridement of ulcer and surrounding necrotic area was done . patient was put on intravenous liposomal amphotericin b 250 mg daily and itraconazole 200 mg twice daily for 10 days . the culture analysis on the sabouraud - chloramphenicol - gentamicin agar after 2 days at 30 and 37c grew a white cottony growth which covered the entire surface of the agar . the patient developed severe seizures , status epilepticus diminished reflexes and succumbed to death after 1 week of therapy . ( a and b ) computed tomography ( ct ) scan of paranasal sinuses and the brain showed right maxillary and ethmoidal sinusitis , deviation of bony nasal septum to left side with mild erosion of bony nasal septum , bony destruction ; and widening of the optic nerve canal and the superior orbital fissure . ( c - e ) histopathological examination of the debrided tissue showed elongated , broad , nonseptatehyphae , marked areas of necrosis with giant cells , thrombosis of vessels , diffused infiltration of lymphocytes , eosinophils and few plasma cells ( h&e stain , 100 ) . ( f ) the grocott gomori 's methanamine silver staining showed nonseptate , twisted , ribbon - like hyphae typical of zygomycetes ( grocott - gomori stain , 100 ) rocm refers to the entire spectrum of the disease , which usually starts in the sinonasal tissue ( limited sinonasal disease ) , progresses to the orbits ( limited rhino - orbital disease ) and finally affects central nervous system ( rhino cerebral disease ) . our patient had all the three classical stages of rocm which had developed gradually over a period of 1.5 month with nasal stuffiness , local pain and headaches . progression of the disease into orbital contents may be direct or due to vascular occlusion leading to preseptal and orbital cellulitis , chemosis , eyelid edema , severe proptosis , worsening opthalmoplegia , eventually blindness and ulcerations involving face indicating aggressive angioinvasion . necrotic eschars in nasal cavity , black turbinate and palatal ulcers were not appreciated . intracranial involvement might be from invasion by way of the superior orbital fissure , ophthalmic vessels , cribriform plate or is possible via a perineural route . more than one route might have been involved as the spread was extensive and of short duration , leading to seizures , status epilepticus , stroke with ultimate death in our case . it exhibits remarkable affinity for arteries and grows along the internal elastic lamina , causing thrombosis and infarction . rocm is suspected in patients with immunocompromised states but invasive fungal infections in immunocompetent / otherwise healthy patients are relatively rare . in immunocompetent patients , the nose and/or maxillary sinuses appear to be the predominant source of infection . there is substantial increase in cases of mucormycosis with no known risk factors . in the present case , the patient was a farmer , who might have been possibly exposed to soil particles with infectious agent . he had a history of chronic sinusitis probably allergic rhinitis , bacterial- or viral - induced sinusitis which was a nonspecific symptom to suspect any serious pathology . in recent studies , it is speculated that chronic sinusitis may be a predisposing factor which causes alteration of first - line barrier of upper airway sinonasal mucosa due to impairment of mucociliary clearance , loss of defense and reduction in molecules of epidermal differentiation complex necessary for maintenance of barrier function . it is likely that mucor sporangiospores are also capable of secreting several toxins or proteases , which may directly destroy endothelial cells in mucosal membranes with a widespread disease , thus invading the mucosal sinuses spreading along the vascular and neuronal structures or eroding through the walls of the sinus . it has been suggested , if sporangio spores are larger than 10 micron , they remain localized to upper airways and colonize . normal diagnostic tests are inconclusive and mucor can not be readily cultured from nasal secretions , cerebrospinal fluid ( csf ) and blood . diagnosis of rocm is classically dependent on direct morphologic identification of mycotic elements and from culture , but clinical findings and imaging also plays an important role in defining the extent of involvement and presence of intracranial disease . the ct and mri detect early vascular invasion and intracranial extent of the fungal infection . the ct features include opacification and bony destruction of the paranasal sinuses , orbital extension from the ethmoidal sinuses producing proptosis , chemosis and obliteration of the nasopharyngeal tissue planes . intracranial extension produces low absorption abnormalities , particularly in the anterior cranial fossa in frontal lobes with mass effect and contrast enhancement . even though culture remains a gold standard for diagnosis and species identification , recovery of fungi in culture was negative in many reports , especially due to aggressive processing of specimen , less fungal load and contamination of cultures . diagnosis is mainly based on suggestive clinical manifestations and morphologic finding of mucor hyphae in tissue specimen . the necrotic tissue must be well sampled to identify the fungal elements as density of fungal organisms is higher in such tissues . in the present case , histological examination of necrotic tissue revealed extensive areas of inflammation , necrosis , granulomas with multinucleated giant cells and presence of aseptate branching hyphae , which stained with periodic acid - schiff and gomori's - methanamine silver stains . the histopathological appearance showed predominantly granulomatous response than acute response . here , in our case , the colony morphology on sabouraud chloramphenicol gentamicin agar was a cottony , creamy - white growth filling up the entire agar plate . effective therapy requires prompt surgical intervention , systemic antifungal drug administration , and reversal of the underlying risk factors . a combination of radical surgical debridement and intravenous liposomal amphotericin b is the treatment of choice , but is limited by frequent side effects of the drug , most importantly the dose - limiting nephrotoxicity . fungi thrive in necrotic tissue , debridement is necessary and should be carried out well close to the bleeding periphery , as the drug may not be effectively distributed in thrombosed vessels . surgical debridement usually proceeds quickly because of an almost bloodless field and serial debridements are usually required . vacuum dressings are a good alternative to more labor - intensive and painful dressings.negative pressure dressings have been shown to improve wound healing by increasing tissue oxygenation via reduction of interstitial fluid and bacterial count in the wound . recent literature review has shown worldwide distribution of mucormycosis in immunocompetent patients , with india being the most affected country probably related to climate , socioeconomic state , scarce hygienic condition , and , last but not least , diagnostic delay . mortality rate is higher than 50% with incidence ranging from 62.5% in rhino cerebral form to 100% in disseminated form . its high morbidity and mortality rates are related to its capacity for rapid vascular invasions , with subsequent tissue necrosis and infarction . the survival rate depends on the multiple factors and early initiation of treatment and also depends on the fungal load , fungal hyphal diameter and granulomas with giant cell response . even initiation of the treatment within 24 h has not prevented the mortality rate which is 82% . the poor prognosis in our case was related to the advanced stage , delay in diagnosis since he was an apparently healthy immunocompetent individual . greater awareness , early understanding of clinical course and early suspicion when the disease is refractory with prompt management may improve the prognosis .

rhino - orbital - cerebral zygomycosis is a potentially lethal , opportunistic , fungal infection with protean manifestations , rapid progression , unpredictable course and high mortality . it is associated with angioinvasion and infarction , usually observed in diabetic ketoacidosis , immuno - compromised states and rarely reported in an apparently normal host . we present a case of an18-year - old patient with a chronic , painful , non healing ulcer with necrotic margins over the right side of the face which extended to both orbits involving eyes within a period of 1.5 month . later he developed severe headache , decreased vision , inability to speak , seizures and status epilepticus with fatal outcome . awareness of its occurrence in normal patients with prompt diagnosis and appropriate management may improve the outcome and decrease mortality .

tetanus is an infection caused by clostridium tetani , a bacterium that is found in the soil and which enters the body through skin wounds . after an incubation period of 7 - 10 days , the disease starts with focal symptoms , such as spasmodic laughter , trismus , and dysphagia , and progresses to systemic symptoms , including respiratory failure and opisthotonus . severely affected patients may suffer the paralysis of the respiratory muscles and autonomic disturbances that ultimately lead to death ( 1 ) . the tetanus vaccine has been available since 1953 ; the diphtheria - tetanus - pertussis ( dtp ) vaccine was introduced for children in 1968 as a routine vaccination that is required by vaccination law ( 2 ) . at present , approximately 100 cases of tetanus occur each year ; 94% of the patients are 40 years of age and 18% of the patients are 80 years of age ( 2 ) . a previous study showed that the mortality rate had decreased from 43% to 15% after the introduction of the intensive care unit ( icu ) ( 3 ) . in fact , the annual mortality rate in the past 10 years has been as low as 8% in japan ( 4 ) . however , little is known about the prognosis of elderly patients who survive severe tetanus . it is therefore important to form an appropriate discharge plan for tetanus patients who are treated in acute care hospitals . we therefore report three cases of tetanus in elderly patients who required mechanical ventilation and prolonged hospitalization . informed consent was obtained from each of the three patients for the publication of this case report and the use of the accompanying images . this report was reviewed and approved by the research ethics committee of the authors ' institution . a previously healthy 85-year - old male farmer presented to our otolaryngology department with swallowing difficulty and trismus without generalized muscle rigidity . the possibility of deep neck infection was excluded by laryngeal endoscopy and contrast - enhanced computed tomography . based on these findings he initially declined hospitalization and returned home ; however , he returned to our emergency department ( ed ) the next day due to the worsening of trismus . he was admitted to the icu and required endotracheal intubation due to the possibility that he may develop opisthotonus and respiratory failure . after 4 days , he was extubated because he did not develop systemic symptoms . however , he was immediately reintubated on the same day as a result of expectoration difficulties and dysphagia . a previously healthy 81-year - old male farmer was transferred to our ed by ambulance due to a 3-day history of progressively worsening trismus and swallowing difficulty ( fig . , he had sustained an abrasion on his left arm while using pruning clippers ( fig . a physical examination revealed rigidity of the jaw and left upper extremity and muscle spasms of the left upper arm . he was clinically diagnosed with tetanus and was admitted to the icu , where he required endotracheal intubation . the next day , a previously healthy 91-year - old man was transferred to our ed by ambulance because of new - onset speech difficulties , which he first noticed upon getting up in the morning . a physical examination revealed a puncture wound with redness and swelling on the dorsal side of the left hand , which had occurred 1 week previously while pruning a garden tree ( fig . he was clinically diagnosed with tetanus and was admitted to the icu , where he required endotracheal intubation . the clinical findings on admission in case 3 . a puncture wound from a tree branch with a small incision on the dorsal side of the left hand is shown . all of the patients received human tetanus immune globulin ( htig ) and tetanus toxoid . propofol or midazolam was administered for sedation to manage the patients ' muscle spasms and fentanyl was administered for pain relief ; muscle relaxants were not used . case 3 had persistent muscle spasms for 36 days and received magnesium sulfate for 3 days . wound debridement was performed for the two patients who had a clear source of infection ( fig . case 1 received penicillin g ( 4 million units , four times a day for 10 days ) ; case 2 received penicillin g ( 4 million units , four times a day for 7 days ) ; and case 3 received ampicillin / sulbactam ( 3 g , four times a day for 7 days ) . in all cases , tracheostomy was performed within 2 weeks of admission . in addition , enteral nutrition and heparin prophylaxis were administered as preventive measures against gastric ulcer and pressure sore formation , and physical therapy was provided . because of their prolonged critical illness , the patients experienced complications , including ventilator - associated pneumonia ( vap ) , catheter - related bloodstream infection , and deep vein thrombosis . spasms were triggered , leading to the elevation of systolic blood pressure to > 200 mmhg and a decrease in tidal volume . noradrenaline was also administered to treat his abnormally low blood pressure . weaning and liberation from mechanical ventilatory support were not feasible for this patient due to the weakness of his respiratory muscles . the weaning periods in cases 1 and 2 were 60 and 18 days , respectively ; weaning was not achieved in case 3 . all three patients were eventually transferred out of the icu . despite the fact that these patients had no underlying diseases and were independent in their activities of daily living ( adl ) before admission , prolonged hospitalization and rehabilitation case 2 was hospitalized for 38 days , then transferred to a care facility , from which he was discharged on day 59 . case 3 remained at our hospital for 151 days but died in another hospital on day 204 . a previously healthy 85-year - old male farmer presented to our otolaryngology department with swallowing difficulty and trismus without generalized muscle rigidity . the possibility of deep neck infection was excluded by laryngeal endoscopy and contrast - enhanced computed tomography . based on these findings he initially declined hospitalization and returned home ; however , he returned to our emergency department ( ed ) the next day due to the worsening of trismus . he was admitted to the icu and required endotracheal intubation due to the possibility that he may develop opisthotonus and respiratory failure . . however , he was immediately reintubated on the same day as a result of expectoration difficulties and dysphagia . a previously healthy 81-year - old male farmer was transferred to our ed by ambulance due to a 3-day history of progressively worsening trismus and swallowing difficulty ( fig . , he had sustained an abrasion on his left arm while using pruning clippers ( fig . a physical examination revealed rigidity of the jaw and left upper extremity and muscle spasms of the left upper arm . he was clinically diagnosed with tetanus and was admitted to the icu , where he required endotracheal intubation . the next day , a previously healthy 91-year - old man was transferred to our ed by ambulance because of new - onset speech difficulties , which he first noticed upon getting up in the morning . a physical examination revealed a puncture wound with redness and swelling on the dorsal side of the left hand , which had occurred 1 week previously while pruning a garden tree ( fig . he was clinically diagnosed with tetanus and was admitted to the icu , where he required endotracheal intubation . the clinical findings on admission in case 3 . a puncture wound from a tree branch with a small incision on the dorsal side of the left hand is shown . redness and swelling are visible around the site of injury . on admission , all of the patients received human tetanus immune globulin ( htig ) and tetanus toxoid . propofol or midazolam was administered for sedation to manage the patients ' muscle spasms and fentanyl was administered for pain relief ; muscle relaxants were not used . case 3 had persistent muscle spasms for 36 days and received magnesium sulfate for 3 days . wound debridement was performed for the two patients who had a clear source of infection ( fig . case 1 received penicillin g ( 4 million units , four times a day for 10 days ) ; case 2 received penicillin g ( 4 million units , four times a day for 7 days ) ; and case 3 received ampicillin / sulbactam ( 3 g , four times a day for 7 days ) . in all cases , in addition , enteral nutrition and heparin prophylaxis were administered as preventive measures against gastric ulcer and pressure sore formation , and physical therapy was provided . because of their prolonged critical illness , the patients experienced complications , including ventilator - associated pneumonia ( vap ) , catheter - related bloodstream infection , and deep vein thrombosis . spasms were triggered , leading to the elevation of systolic blood pressure to > 200 mmhg and a decrease in tidal volume . weaning and liberation from mechanical ventilatory support were not feasible for this patient due to the weakness of his respiratory muscles . the weaning periods in cases 1 and 2 were 60 and 18 days , respectively ; weaning was not achieved in case 3 . all three patients were eventually transferred out of the icu . despite the fact that these patients had no underlying diseases and were independent in their activities of daily living ( adl ) before admission , prolonged case 2 was hospitalized for 38 days , then transferred to a care facility , from which he was discharged on day 59 . case 3 remained at our hospital for 151 days but died in another hospital on day 204 . first , patients with severe tetanus requiring mechanical ventilation need prolonged mechanical ventilation ( pmv ) and hospitalization . second , sufficient vaccination is important for preventing tetanus in elderly individuals . in the present study , case 1 continued to suffer from dysphagia and vap , while cases 2 and 3 continued to suffer muscle spasms , which prolonged the period of bed rest and sedation . as a result , long - term rehabilitation was necessary due to the severe decline in the patients ' general condition after discharge from the icu . six cases of elderly patients ( 75 years of age ) with tetanus who required mechanical ventilation have been reported in japan ( table ) ( 5 - 9 ) . the continuous variables were presented as median [ interquartile range ( iqr ) ] . when combined with the three cases of the present study , the median weaning period , time to extubation and length of hospitalization ( in the acute care hospital ) were 31 days ( 18 - 41 days ) , 40 days ( 25 - 62 days ) , and 77 days ( 60 - 90 days ) respectively . one patient , who was not weaned from ventilatory support , was excluded from the analysis of the weaning period and the time until extubation . icu : intensive care unit , htig : human tetanus immune globulin , vap : ventilator - associated pneumonia , crbsi : catheter related bloodstream infection , dvt : deep vein thrombosis a study in the united states reported two cases of tetanus in patients of > 90 years of age ( 10 ) . similarly to our cases , these patients required mechanical ventilation for more than 3 weeks and spent more than 2 months in different medical facilities . the cost of hospitalization was more than 200,000 usd for each patient ( 10 ) . severe tetanus in older adults requires pmv for 1 month and hospitalization for 2 months . pmv is known to be associated with increased health care costs , morbidity , and mortality ( 11 ) . it is important for intensivists to collaborate with general physicians , physical therapists , social workers , and the family to achieve functional recovery and to plan for a smooth discharge from the acute care hospital . in japan , the overall annual incidence of tetanus was 0.98 cases / million in 2008 , which was approximately 10-fold of that in the united states ( 12,13 ) . furthermore , the incidence in the japanese individuals of 80 years of age was 3.6 cases / million ( 4 ) . we therefore wish to highlight the importance of preventing tetanus and its associated morbidities by achieving sufficient vaccination coverage in older adults . a worldwide study demonstrated the effectiveness of the vaccine by a decrease in the annual incidence of tetanus from approximately 110,000 cases in 1980 to around 9,600 cases in 2010 ( 14 ) . nevertheless , most japanese adults of 50 years of age have no history of vaccination , and their antibody levels remain at 30% ( 13 ) . we should engage in efforts to enlighten the population with regard to tetanus vaccination . we believed that tetanus toxoid and htig should have been administered immediately after the onset of injury to patients with a history of injury . because tetanus can re - occur even among patients with a history of the disease , tetanus patients should be vaccinated after treatment and discharge . in the present case report , one patient received a continuous intravenous infusion of magnesium sulfate to treat muscle spasms . a meta - analysis showed that magnesium sulfate did not reduce mortality and that its effects on the total duration of icu stay or hospital stay were unclear ( 14 ) . a randomized controlled study demonstrated that magnesium sulfate was effective in reducing the use of other drugs but that it did not reduce the need for mechanical ventilation ( 16 ) . further research is needed to determine the role of magnesium sulfate in the management of tetanus . in conclusion , although elderly patients with severe tetanus can be transferred out of the icu , they will probably require pmv and hospitalization for approximately 1 and 2 months , respectively , because of complications , including severe deconditioning . tetanus vaccination should therefore be promoted more aggressively among populations that are susceptible to the disease : tetanus vaccination should be included in the primary vaccination series of adults who have never been vaccinated and a booster should be administered every 10 years to those who have completed the primary series .

tetanus is a potentially fatal infection . approximately 100 cases are reported in japan each year ; however , little is known about its clinical course and outcomes in the current era of treatment . we herein report three cases of tetanus in elderly patients who survived after mechanical ventilation and intensive care . these patients , together with six other similar cases , had a median weaning period of 31 days and median length of stay of 77 days . in elderly patients , severe systemic forms of tetanus require prolonged mechanical ventilation and hospitalization . to improve prevention , tetanus vaccination should be promoted more aggressively among those who are susceptible to the disease .

the local institutional review board approved this retrospective study , and patients provided a written informed consent for the procedure . we def ined outpatient day - care management as a clinical process where the patients get a procedure on the day of admission and are subsequently get discharged on the same day for the diagnosis or on the following day for the neurointervention , which is generally performed under general anesthesia ( fig . we analyzed 412 uias in 345 patients who were referred to the neurointervention clinic of the asan medical center due to known cerebral aneurysms and underwent cerebral angiography or neurointervention during the recent four years between january 1 , 2011 and december 31 , 2014 . we excluded the patients who have aneurysms associated with other cerebrovascular diseases or patients with aneurysms in the head and neck or spine . we also assessed the results of cerebral angiography including serious complications which required additional management or emergency surgery and the process of the patients , and outcome . after the decision was made for patients with uias to undergo a cerebral angiography in the outpatient clinic , they underwent pre - admission study ( chest pa , electrocardiography ( ecg ) , blood test , urine analysis ) and attended the neuroangio - suite in the morning of the reserved day . oral intake ( breakfast ) was prohibited for about two hours before the procedure . after a short period of post - procedural observation ( 4 to 6h ) , the majority of patients who have been performed uncomplicated cerebral angiography were discharged on the same day . the angiography was performed via a transfemoral or transradial approach by an insertion of a 4f sheath . both the internal carotid arteriograms and the dominant or ipsilateral ( lesion side ) vertebral arteriogram were performed using a 4f angiocatheter . these angiographic procedures were identifical to what would have been done as an inpatient procedure . after the procedure , manual compression of the puncture site was applied using apad hemostasis device ( t & l , seoul , korea ) which was designed to promote bleeding control . the preparation before the procedure was the same as that for cerebral angiography except that general anesthesia was used . a 6 - 7f guiding catheter was introduced into the cervical distal of targeted internal carotid artery or vertebral artery . neuroform stent ( boston scientific corp , fremont , ca ) or enterprise stent ( codman neurovascular , miami , fl ) was used in patients who were performed stent - assisted coiling . the patients received clopidogrel 75 mg daily at least 4 days before the procedure and continued for 3 - 6 months , and aspirin 100 mg daily for a year . all endovascular procedures were performed with patients under systemic heparinization with a range of 200 - 250 seconds of activated clotting time . during the procedure , the patient 's vital signs were monitored by the arterial line via the radial artery . after the procedure , each patient was sent to the intensive care unit ( icu ) . from the icu all patients were discharged or transferred to another department if further management or procedure was required . we assessed the patient after angiography on whether there was any aneurysm corresponding to mra or cta . treatment options were discussed with the patients and their family with an explanation of the natural risk of the aneurysm . minor stroke was defined as a new , nondisabling neurologic deficit or as an increase in the national institutes of health stroke scale ( nihss ) by 3 ( points ) , but which completely resolved within 30 days . after the decision was made for patients with uias to undergo a cerebral angiography in the outpatient clinic , they underwent pre - admission study ( chest pa , electrocardiography ( ecg ) , blood test , urine analysis ) and attended the neuroangio - suite in the morning of the reserved day . oral intake ( breakfast ) was prohibited for about two hours before the procedure . after a short period of post - procedural observation ( 4 to 6h ) , the majority of patients who have been performed uncomplicated cerebral angiography were discharged on the same day . the angiography was performed via a transfemoral or transradial approach by an insertion of a 4f sheath . both the internal carotid arteriograms and the dominant or ipsilateral ( lesion side ) vertebral arteriogram were performed using a 4f angiocatheter . these angiographic procedures were identifical to what would have been done as an inpatient procedure . after the procedure , manual compression of the puncture site was applied using apad hemostasis device ( t & l , seoul , korea ) which was designed to promote bleeding control . the preparation before the procedure was the same as that for cerebral angiography except that general anesthesia was used . a 6 - 7f guiding catheter was introduced into the cervical distal of targeted internal carotid artery or vertebral artery . neuroform stent ( boston scientific corp , fremont , ca ) or enterprise stent ( codman neurovascular , miami , fl ) was used in patients who were performed stent - assisted coiling . the patients received clopidogrel 75 mg daily at least 4 days before the procedure and continued for 3 - 6 months , and aspirin 100 mg daily for a year . all endovascular procedures were performed with patients under systemic heparinization with a range of 200 - 250 seconds of activated clotting time . during the procedure , the patient 's vital signs were monitored by the arterial line via the radial artery . after the procedure , each patient was sent to the intensive care unit ( icu ) . from the icu all patients were discharged or transferred to another department if further management or procedure was required . we assessed the patient after angiography on whether there was any aneurysm corresponding to mra or cta . treatment options were discussed with the patients and their family with an explanation of the natural risk of the aneurysm . minor stroke was defined as a new , nondisabling neurologic deficit or as an increase in the national institutes of health stroke scale ( nihss ) by 3 ( points ) , but which completely resolved within 30 days . there were 403 aneurysms in 345 patients who underwent cerebral angiography and neurointervention at our institution between january 1 , 2011 and december 31 , 2014 . there were 141 ( 41% ) diagnostic catheter angiographies , 202 neurointerventional procedures ( 59% ) and 2 ( 0.6% ) neurointerventional procedures followed by operation . angiographic results showed a single aneurysm ( n=283 , 82% ) or multiple aneurysms ( n=62 , 18% ) . no aneurysm was found in 58 patients who were reported as having an aneurysm in mra or cta . among 345 patients with aneurysms , coiling was performed in 202 patients ( 59% ) , surgical clipping in 14 ( 4% ) , coiling followed by clipping in 2 ( 0.6% ) and cerebral angiography follow up in 127 ( 37% ) . of these aneurysms , the maximum diameter of 154 aneurysms was 4 mm , 166 aneurysms had diameters of 4 - 10 mm , 19 aneurysms had diameters greater than 10 mm ( table 1 ) . there were 3 giant thrombosed or fusiform aneurysms , 2 recurred aneurysms and 1 dissecting aneurysm whose sizes were not measurable . the mean hospital stay for neurointervention was 2.1 days . in the follow - up , there were recurrent aneurysms in 9 patients who underwent 2 procedures without further event . after neurointerventional procedures , there were 4 ( 2% ) adverse events including 3 minor and 1 major ischemic strokes . our study revealed that day - care management of uias resulted in 2% adverse events and 4.5% recurrence that required additional coil embolization without further event . outcome of outpatient neurointervention of uias in this study was comparable to other studies regarding endovascular treatment for inpatients with uias ( table 2 ) . the mean duration of hospital stay for neurointervention procedures for patients with uias was 2.1 days which were much shorter than those in a study performed by the national evidence - based healthcare collaborating agency ( 22 days for surgical clipping and 12 days for neurointerventional coiling ) . in one study of patient with ruptured and unruptured aneurysms , neurointerventional coiling , compared with surgical clipping , was associated a shorter length of hospitalization , but higher hospital cost . in another study , coiling compared to clipping was associated with a signif icantly shorter hospital stay and lower total hospital charges . in addition to reducing the hospitalization period and total hospital charges by using a neurointerventional procedure compared to surgery , our study demonstrated the possibility that day - care neurointerventional coiling can be used to treat uias . the advantage of day - care procedures was rapid admission process on an outpatient basis . the simplification of the admission process can be achieved by close communication in the outpatient clinics by admitting to an intermediary care unit in the angiosuite . after 6 hours of admission , patients who underwent uncomplicated cerebral angiography was be discharged on the same day . aneurysms considered as having relatively higher risks for rupture were scheduled after discussion with patients and their family for subsequent management . although in our study there were no reported significant adverse events after cerebral angiography and 4 strokes ( 2% ) after neurointerventional procedures , there was a higher complication rate as 25% in which some patients require further treatment . therefore , improvement of procedural outcome as well as management process might affect difference in adverse events even though study population was different among the studies . firstly , we did not perform a comparative study with surgical clipping for the same category of the patients even though outcome of endovascular therapy was known to be better . it could provide rapid patient flow in the hospital , shorten hospital stay and obtain better outcome , and is expected to reduce hospital costs furthermore , the availability of such outpatient management can contribute to meet higher standard of medical need of a large volume of patients with uias .

purposeday - care management of unruptured intracranial aneurysms can shorten hospital stay , reduce medical cost and improve outcome . we present the process , outcome and duration of hospital stay for the management of unruptured intracranial aneurysms via a neurointervention clinic in a single center during the past four years.materials and methodswe analyzed 403 patients who were referred to neurointervention clinic at asan medical center for aneurysm evaluation between january 1 , 2011 and december 31 , 2014 . there were 141 ( 41% ) diagnostic catheter angiographies , 202 ( 59% ) neurointerventional procedures and 2 ( 0.6% ) neurointerventional procedures followed by operation . we analyzed the process , outcome of angiography or neurointervention , and duration of hospital stay.resultsthere was no aneurysm in 58 patients who were reported as having an aneurysm in mra or cta ( 14 % ) . among 345 patients with aneurysm , there were 283 patients with a single aneurysm ( 82% ) and 62 patients with multiple aneurysms ( n=62 , 18% ) . aneurysm coiling was performed in 202 patients ( 59% ) , surgical clipping in 14 patients ( 4% ) , coiling followed by clipping in 2 patients ( 0.6% ) and no intervention was required in 127 patients ( 37% ) . the hospital stay for diagnostic angiography was less than 6 hours and the mean duration of hospital stay was 2.1 days for neurointervention . there were 4 procedure - related adverse events ( 2% ) including 3 minor and 1 major ischemic strokes.conclusionour study revealed that day - care management of unruptured intracranial aneurysms could be performed without an additional risk . it could enable rapid patient flow , shorten hospital stay and thus reduce hospital costs .

the case control study was conducted in metropolitan atlanta , georgia , usa , during march 2003february 2004 , among children with asthma who were > 2 years of age ( 10 ) . case - patients were defined as patients with asthma exacerbation ; controls were defined as patients with stable asthma . the definitions , epidemiologic and laboratory methods , and clinical description of patients are available from table 1 and the previously published report ( 10 ) . pcr ( rt - pcr ) targeting the 5-noncoding region ( ncr ) ( 10 ) . for further genetic characterization , hrv - positive samples were extracted from a previously unopened aliquot and amplified by using a nested rt - pcr that targeted the virus capsid protein 1 ( vp1 ) gene at positions 24322781 , based on hrv 1b ( genbank accession no . d00239 ) for species a and positions 25312799 , based on hrv 14 ( genbank accession no . nc_001490 ) for species b. we used sequencher 3.1.1 software ( gene codes , ann arbor , mi , usa ) for sequence assembly and editing . nucleotide and predicted amino acid sequences were aligned with previously published hrv vp1 sequences ( genbank accession nos . ay355180ay3552831 , ef186077 , ef077279 , ef077280 , ef582385ef582387 ) by using clustalw as implemented in bioedit ( version 7.0.5 ) ( www.mbio.ncsu.edu/bioedit/bioedit.html ) . phylogenetic trees were constructed by using the neighbor - joining algorithm implemented in paup * version 4.0.d10 ( 11 ) . partial vp1 sequences for the novel hrv strains were submitted to genbank ( accession nos . as reported previously ( 10 ) , hrvs were detected by a 5-noncoding region seminested rt - pcr in 53 ( 37% ) of 142 children with asthma , including 39 ( 60% ) of 65 case - patients and 14 ( 18% ) of 77 controls . of these , the hrvs from 29 ( 55% ) ( 24 [ 62% ] of the 39 hrv - positive case - patients and 5 [ 36% ] of the 14 hrv - positive controls ) were subsequently genotyped . vp1 sequences from the remaining 24 hrv - positive specimens could not be obtained because of low amplicon yield ( table 2 ) . specimens from patients with symptoms of acute viral respiratory infection ( table 1 ) were more likely than those from patients without viral symptoms to yield sufficient vp1 amplicon for genotyping ( percent genotyped 85% and 36% , respectively ; odds ratio [ or ] 9.1 ; 95% confidence interval [ ci ] 2.150.0 ; p<0.05 ) . * hrv , human rhinovirus ; case - patients , asthma patients with exacerbations ; controls , asthma patients without exacerbation . serotype designation based on > 90% vp1 amino acid sequence identity with respective prototype strains . genogroup c hrvs form a clade phylogenetically distict from species a and b hrvs . of the 29 hrvs successfully genotyped , species a accounted for 18 ( 62% ) strains , species b accounted for 3 ( 10% ) , whereas 8 ( 28% ) strains formed a phylogenetically distinct clade , which we provisionally named genogroup c ( table 2 , figure ) . of the 18 hrv - a strains , 17 showed close genetic relatedness ( 80.7%93.8% nucleotide and 89.6%98.8% predicted amino acid sequence identity ) to hrv prototype strains . one hrv - a strain ( ga23584 ) was highly divergent from the closest prototype , hrv80 ( 73.2% nucleotide and 73.0% amino acid sequence identity ) , which suggests that it could represent a distinct previously undescribed hrv . the 3 hrv - b strains were closely related to prototype strains ( 84.0%88.6% nucleotide and 89.7%93.4% predicted amino acid sequence identity ) . phylogenetic tree of partial virus capsid protein 1 ( vp1 ) amino acid sequences of human rhinoviruses ( hrvs ) identified in 29 hrv - positive pediatric asthma patients , march 2003february 2004 , atlanta , georgia , usa ( designated * ) , previously published sequences of strains qpm ( genbank accession no . the partial vp1 sequences of genogroup c strains were phylogenetically distinct from hrv species a and b and showed a substantial intragroup diversity ( figure ) . vp1 sequence identity of these viruses with the closest match within the same genogroup ranged from 68.4% to 74.6% for nucleotide and from 68.5% to 85.5% for amino acid sequences . these novel viruses were related to other recently described hrvs : hrv qpm detected in specimens from australia ( 4 ) , c024c026 detected in specimens from hong kong ( 6 ) , and nat001 and nat045 detected in specimens from california ( 8) ( figure ) . their identity scores compared with hrv qpm were 66.0%82.7% for nucleotide and 65.2%86.9% for amino acid sequences . one of the strains ( ga23592 ) was almost identical in partial vp1 sequence to c026 ( figure ) . the degree of genetic diversity among the genogroup c viruses far exceeded that between hrvs defined as distinct serotypes by classical serologic methods , which suggests that at least 7 of 8 of these viruses are antigenically distinct from each other rather than minor variants of the same serotype . the genogroup c hrv identity scores were substantially lower when compared with their closest matches from species a and b : 48.2%51.1% for nucleotide and 38.5%49.8% for amino acid sequences , and 35.9%42.8% for nucleotide and 29.3%35.8% for amino acid sequences , respectively . in our study , the association of asthma exacerbations with hrv infection appeared to be largely driven by the novel genogroup c , which was found exclusively in case - patients , and species a. the association was statistically significant for species a ( detected in 15 [ 23% ] of 65 case - patients vs. 3 [ 4% ] of 77 controls ; or 7.4 ; 95% ci 1.943.1 ; p<0.001 ) and for genogroup c ( detected in 8 [ 12% ] case - patients vs. 0 controls ; or undefined ; p<0.010 ) but not for infrequently identified species b ( detected in 1 [ 2% ] case - patient vs. 2 [ 3% ] controls , p>0.05 ) or for hrvs that could not be genotyped ( 15 [ 23% ] cases vs. 9 [ 12% ] controls ; p>0.05 ) . the distribution of hrvs between case - patients and controls still differed when the analysis was limited to the hrv - positive group ( p = 0.05 ) or to genotyped hrvs only ( p<0.05 ) . the results of the only other study that reported novel hrvs in asthma patients ( 2 of which , nat001 and nat045 , were related to genogroup c viruses in our study ) are difficult to interpret because that study of adults with cold symptoms showed an unexpected lack of association of hrvs with asthma exacerbation ( 8) . patients infected with genogroup c hrvs had lower forced expiratory volumes during the first second ( fev1 ) than did those infected with other hrvs ( median 58.5% vs. 93% ; p = 0.01 ) , but the distribution of demographic and other clinical variables did not differ significantly between the 2 groups . lower fev1 with genogroup c infection than with other hrvs suggests a potentially greater severity of asthma exacerbation in patients infected with these hrvs . when one considers the great variation among hrv serotypes in levels of sensitivity to candidate antiviral compounds ( 12,13 ) , genogroup - related differences in associated disease patterns have implications for clinical management of hrv infections in asthma patients and for development of antiviral drugs against hrvs . preliminary data suggest that hrv - qpm and related hrv - c strains from hong kong share certain vp1 sequence characteristics with hrvs that are resistant to a candidate antipicornavirus drug , pleconaril ( 4,6,13 ) . these data raise the possibility that these novel hrvs might also be resistant to this compound . the hrv - positive specimens from which vp1 gene sequences could not be obtained derived predominantly from patients without symptoms of acute respiratory viral illness . the absence of symptoms in hrv - infected persons likely reflects subclinical , asymptomatic infection , which is common for hrvs ( 14 ) , or hrv persistence after a recently resolved infection ( 15 ) , both of which are likely associated with lower viral loads ( as opposed to acute symptomatic infections ) , thus leading to lower detection rates in a vp1 assay that uses highly degenerate primers . in conclusion , we found a striking genetic diversity of hrvs among children with asthma and confirmed the existence and wide geographic distribution ( usa , australia , hong kong ) of hrvs distinct from both previously recognized hrv species , a and b. our finding supports the role of the novel hrvs as human pathogens . additional studies are needed to further explore clinical and public health implications of these findings .

to determine links between human rhinoviruses ( hrv ) and asthma , we used data from a case control study , march 2003february 2004 , among children with asthma . molecular characterization identified several likely new hrvs and showed that association with asthma exacerbations was largely driven by hrv - a and a phylogenetically distinct clade of 8 strains , genogroup c.

some investigators have reported an increased prevalence of si and as in patients with bd , but others have found a prevalence that does not differ from that of the general population . the case described here was first diagnosed as ankylosing spondylitis . at that time , he had had recurrent oral ulcer . several years later , painful scrotal ulcer and panuveitis that is a different clinical finding in as have been developed . seven years ago , he has had pain in right heel , buttocks and lower back . the pain and stiffness in lower lumbar region and buttock was worse in the early morning and was improved with activity . subsequently , painful swelling of the right knee developed . he was diagnosed to have as at the university medical center . he had been treated with indomethacin , low - dose methotrexate and sulfasalazine during three years . painful scrotal ulcer was occurred and painful swelling of right knee was developed again two years ago . physical examination revealed multiple aphthous ulcers on the buccal mucosa , papulopustular eruptions on the anterior chest , and scrotal ulcer . hematological and biochemical tests were as follows : wbc 9200/mm , hematocrit 40.1% , platelet 321000/mm , total protein 7.2 g / dl , albumin 4.4 g / dl , ast 26 iu / l , alt 35 iu / l , creatine kinase 76 iu / l . erythrocyte sedimentation rate was 30 mm / hr and c - reactive protein was negative . rheumatoid factor , antinuclear antibody and antineutrophil cytoplasmic antibody were negative . both hla - b27 and b51 antigens were positive . bilateral si ( right : grade 4 , left : grade 3 ) was noted on plain pelvis radiograph ( figure 1 ) and t2-weighted magnetic resonance imaging ( figure 2 ) . initially he was treated with indomethacin 50 mg / day , sulfasalazine 2g / day , methotrexate 7.5 mg / week and colchicine 1.2 mg / day . because of persisting , painful swelling of the right knee , methotrexate was increased to 15 mg / week , and intra - articular injection of triamcinolone acetonide 40 mg was done . while being treated , recurrent acute iritis with hypopyon , posterior uveitis and papillitis in both eyes ( figure 3 & 4 ) were developed . prednisolone 40 mg / day and cyclosporine 5 mg / kg / day were prescribed . the diagnosis of bd mainly depends upon the thorough history taking and clinical manifestations . the diagnosis of as is also based on the clinical findings and the radiographic si . our case fulfilled the diagnostic criteria of bd by the international study group for behcet s disease and modified new york criteria for as . although there are some reports for a coexisting bd and as , it is unclear whether that occurs incidentally or overlaps like other connective tissue diseases . some investigators report a high prevalence of si in patients with bd and therefore suggested that bd should be included in seronegative spondyloarthritides , whereas recent reports suggests no association between the two conditions . dilsen and co - workers reported the highest values , 33 ( 10% ) patients with as and 112 ( 34% ) with si in 331 turkish patients with bd . kahan et al . found as in 2 ( 6.2% ) of 32 patients with bd in france . in britain , caporn et al reported erosive si in 7 ( 50% ) of 14 patients with bd . however , other authors found no association between si or as and bd in japan , north america , iraq , britain and turkey . it remains unclear why there are differences in prevalence between as or si and bd . yazici and co - workers suggested that there was high observer variability in reading the anteroposterior radiographs of the sacroiliac joints . olivieri et al . suggested that computed tomography may reduce differences due to error in the radiological evaluation of the sacroiliac joints . so far , there are no reports about association of si or as in patients with bd in korea . the hla - b27-associated uveitis like as usually involves the anterior uveal track and follows a benign course . however , the uveitis in bd involves both anterior and posterior uveal tracts and causes the loss of sight in 25 % of patients . whereas most patients with as have hla - b27 antigen , the relationship between hla - b51 and bd appears to be in some racial populations . both hla - b27 and b51 ( b5 ) antigens were more frequent in patients with coexisting bd and as than in healthy controls . the eye involvement in our case was anterior uveitis , posterior uveitis and retinal papillitis that are similar to the features in bd . the problem has been mainly limited to whether the frequency of si and as is greater in bd . in order to define the relationship between as and bd , more reports and experience will be needed .

behcet s disease ( bd ) is a chronic inflammatory condition involving several organs , such as skin , mucous membrane , eye , joint , intestine , lung and central nervous system . ankylosing spondylitis ( as ) is a prototype of seronegative spondyloarthropathy , and a chronic systemic inflammatory disorder of the axial skeleton , mainly affecting the sacroiliac joint and spine . in the latter , systemic complications may develop in addition to joint involvement . the coexistence of bd and as has been rarely reported in the literature . the inclusion of bd among seronegative spondyloarthritides and whether sacroiliitis ( si ) develops in bd are still being debated . we describe a 28-year - old man who has fulfilled the diagnostic criteria for bd and as as well .

lipoid pneumonia ( lp ) is a rare inflammatory disease of the lung parenchyma caused by accumulation of fatty oily material in the alveoli . exogenous lipoid results from aspiration or inhalation of mineral , vegetable , or animal oil into the peripheral lung . children can aspirate large amounts of different oily materials , mineral oil being the most frequently encountered substance , and this happens especially when certain risk factors are present . the aspiration of fatty material elicits a pulmonary inflammatory reaction that produces non - specific clinical and radiologic findings , often similar to those of bacterial pneumonia and tuberculosis , complicating or delaying the diagnosis . thus , it is imperative to identify correctly this entity when there is a high degree of suspicion , through a thorough and focused noting of patient 's medical history and an accurate recognition of its radiologic manifestations . we present a case of acute lp in a 5-month - old infant due to accidental mineral oil aspiration , confirmed by analysis of bronchoalveolar lavage ( bal ) and focus on the radiologic findings showing evolution of parenchymal lesions over a follow - up period of 7 years . this was a case report of a 5-month - old male infant who was admitted as an emergency case to a secondary care hospital with acute onset of high - grade fever and respiratory distress . the chest x - ray showed bilateral extensive consolidation involving mainly the lower lobes of the lungs . he was placed on broad spectrum antibiotics and bronchodilatory inhalers , in response to which he showed no clinical improvement over a period of 2 days . therefore , and in view of his deteriorating clinical status , he was urgently transferred to our hospital for further management . upon arrival , the infant was in respiratory distress requiring 4 l / min of oxygen to keep his oxygen saturation above 90% . further examination of the infant revealed dysmorphic features such as low set ears , generalized muscular hypotony , and delayed psychomotor development . additional questions on patient history identified that at the age of 5-months the child had accidentally ingested paraffin oil administered by his 3-year - old brother . computed tomography ( ct ) scan [ figure 1a ] revealed extensive bilateral consolidations in the lower lobes . the bal aspirate was opalescent with a supernatant halo of fat and showed an increased number of macrophages . bal was sent for microbiological studies including gram staining , ziehl - neelsen staining , and bacterial and fungal cultures . the cytologic study showed numerous foamy macrophages with intracytoplasmic and extracellular droplets of fat with a positive histochemical confirmation of acute lp with oil red o stain . ( oil red o is a fat - soluble dye used for staining of lipids and triglycerides . ) total lavage was not performed as it was considered too risky in view of the critical status of the patient and the signs of hypoxia he demonstrated during the procedure . 5-month - old male infant aspirated large amounts of paraffin oil causing respiratory distress diagnosed later as due to lipoid pneumonia ( a ) chest computed tomography ( ct ) performed 1.5 month post - paraffin oil aspiration shows diffuse extensive airspace consolidations ( arrows ) in both lower lobes . ( b ) high - resolution chest ct taken 7 months after the incident shows persistent imaging findings ( arrows ) with minimal improvement . a corticosteroid therapy regimen was introduced which led to an improvement of his general condition . the infant remained in our hospital for a total of 5 months showing gradual clinical improvement . before discharge an additional bronchoscopy and bal was performed that showed a clear aspirate with no supernatant fat and fewer lipid - laden macrophages . further , an additional ct scan was performed which showed persistent findings with minimal improvement [ figure 1b ] . he underwent spirometry , which revealed a forced vital capacity ( fvc ) equal to 85% of predicted value , a forced expiratory volume in 1 s ( fev1 ) of 79% of predicted value . fev1/fvc ratio was 81% , which was within the normal range ( approximate range : 75 - 80% ) for healthy adults . the patient could not undergo further pulmonary function testing ( lung volume , diffusing capacity of lung for carbon monoxide ) . bal revealed far fewer lipid - laden macrophages , while the ct scan showed resolution of the consolidations , but evidence of residual interstitial findings [ figure 2 ] . follow - up high - resolution chest computed tomography taken 7-years after the episode of aspiration , shows bilateral thickening of the interlobular septa ( open arrow ) , streaky peripheral infiltrates ( arrows ) and areas of hyperinflation . lp is an uncommon pulmonary disorder that results from the accumulation of lipids in the alveoli . on the basis of the source of the lipid the exogenous type is due to aspiration of animal fat , vegetable or mineral oil and can be acute or chronic in presentation . acute exogenous lp is a type of pneumonitis associated with an incident of aspiration of a large amount of an oil - based product . most cases of exogenous lp result from aspiration of mineral oil , which is usually used for the treatment of refractory constipation . in early childhood , the factors that increase the risk of aspiration , in both the acute and chronic form , are commonly associated with underlying conditions , such as disruption of the normal physiologic function of the airway and the upper gastrointestinal tract , congenital disorders of the structure and function of the foregut , and impairment of neurologic or neuromuscular control of the process of breathing and/or swallowing . additional predisposing factors to lp in children are gastroesophageal reflux and forced ingestion of oily medication as practiced in a number of geographic areas . our patient showed features of developmental delay along with generalized muscular hypotony , which was hypothesized to have contributed to the aspiration of a large amount of material . acute exogenous lp in children , typically manifests clinically as an acute aspiration condition , which evolves into respiratory failure and , occasionally , death . in the report published by zanetti et al . , 17 children with lp having non - specific clinical presentation , showed air space consolidation on chest radiographs , which suggested bacterial pneumonia . the children showed no improvement with antibiotic therapy and were later investigated with high - resolution ct and bal . only at this stage the time period between the initial radiographs and diagnosis varied from 30 days to 45 days . such a delay was also observed in our case , partially attributed to the initial reluctance of the parents to mention the incident of accidental aspiration , afraid of being accused of lack of proper care of the baby . acute exogenous lp manifests radiologically within 30 min of the episode of aspiration or inhalation . pulmonary opacities can be seen in most patients within 24 h. chest x - ray shows parenchymal abnormalities that include areas of ground - glass opacity or consolidation , bilateral and segmental or lobar in distribution and predominantly involving the middle and lower lobes , similar to those seen in general aspiration pneumonia . high - resolution computed tomography is the imaging technique of choice for investigating lp and , in children , it must be performed with the lowest possible radiation . the principal ct imaging findings include alveolar consolidations , ground - glass opacities , nodular lesions , interlobular septal thickening , and intralobular interstitial thickening . the crazy - paving pattern , consistent with well - defined areas of ground - glass attenuation with superimposed septal thickening , has also been described as a characteristic feature of lp . in addition , exogenous lp may be diagnosed promptly when areas of fat attenuation are identified within a pulmonary air - space consolidation . pure mineral oil has a ct attenuation value of -132 hu and negative density values ( between -30 and -150 hu ) within the consolidation area . these findings , although non - specific , can suggest the diagnosis of lp . however , in some patients with lp , as in the present case , fat attenuation is not evident on ct images because the fat attenuation values are averaged with the surrounding inflammatory exudates so that the fat component becomes less conspicuous or obscure . according to most studies on pediatric patients , the radiologic manifestations of acute exogenous lp typically improve or resolve over time . sias et al . , evaluated 28 children with lp for 24 months and demonstrated normalization of ct scans in 18 of them right after treatment . in two patients scanned 12 months after treatment , a cystic lesion in the right lung and a discrete area of segmented atelectasia treatment abandonment occurred in 6 cases and no further ct follow - up was reported for the remaining children . sias et al . , also demonstrated the potential role of multiple bals in the treatment of lp , in a prospective study of 10 children with lp . in these cases , lp was secondary to mineral oil aspiration , and the delay between aspiration and treatment was 1 - 60 days . over a follow - up period of 6 months , complete radiologic resolution was demonstrated in 3 out of 6 patients who had a short interval between intake of mineral oil ( 1 - 4 days ) and treatment . in the remaining three cases , all four children with a longer time interval between aspiration of mineral oil and treatment had residual areas of consolidations on ct scans taken at 6-months , but no further follow - up was reported . in our case , the follow - up ct scan that was performed 7 years after the aspiration demonstrated architectural distortion associated with thickening of the interlobular septa . mineral oil ( a mixture of inert , long - chain , saturated hydrocarbons obtained from petroleum ) is emulsified and phagocytosed by alveolar macrophages , which , filled with oil , reach the interlobular septum through the lymphatic channels . subsequently , with the permanence of the oil , there is development of chronic interstitial inflammation , which can evolve into pulmonary fibrosis and decreased lung volume . in our case , there was no evidence of end - stage lung lesions and functional respiratory tests were normal . the imaging findings can be attributed to the large amount of aspirated oil , the delay in the correct diagnosis and the fact that the patient did not undergo any therapeutic bal , which has been shown to facilitate the removal of lipid - laden macrophages implicated in development of alveolar and interstitial fibrosis . to the best of our knowledge , this is the longest follow - up study of a pediatric patient with acute lp showing imaging features on ct and the only case reported where a single episode of fat aspiration that is associated with residual interstitial changes in the follow - up ct scan . we have described a case of acute exogenous lp induced by accidental aspiration of mineral oil for which the early imaging findings were consistent with published reports . long - term follow - up , however , revealed partial resolution with persistent interstitial lesions seen on ct scan . a finding that has not been reported in the pediatric population and merits consideration when interpreting imaging examinations of patients with a history of acute lp .

acute lipoid pneumonia ( lp ) in children is a rare disorder caused by the aspiration of oil - based substances and is difficult to diagnose due to non - specific clinical symptoms and radiological findings . we report the case of a 5-month - old male infant with acute lp caused by accidental aspiration of a large amount of mineral oil . we present the imaging findings in the computed tomography scans performed during his hospitalization and focus on the residual abnormalities seen on a scan performed 7-years after the incident . this , to the best of our knowledge , is the longest follow - up report of an acute exogenous lp patient and the only case that demonstrates non - resolving abnormalities in a pediatric patient after a single acute episode of mineral oil aspiration .

acdf is a commonly performed procedure for degenerative conditions of the cervical spine with a successful fusion rate of approximately 95% and with overall good to excellent results 1,2 . the majority of patients present with combined complaints of axial neck pain with associated upper extremity radicular or myelopathic symptoms . there is considerable controversy , however , regarding the role of acdf for neck pain without radiculopathy or myelopathy , and clinical outcome studies of acdf with validated outcome measures in this patient population are scarce . to analyze the clinical outcome in patients treated with acdf for axial neck pain in the absence of radiculopathy or myelopathy , especially with regard to changes in pain and function . study design : systematic review search : pubmed , cochrane collaboration database , and national guideline clearinghouse databases ; bibliographies of key articles dates searched : through march 2010 inclusion criteria : ( 1 ) axial neck pain only as primary indication for acdf , ( 2 ) failed conservative treatment exclusion criteria : ( 1 ) radiculopathy , ( 2 ) myelopathy , ( 3 ) arm pain , ( 4 ) severe trauma ( fracture , fracture - dislocation ) , ( 5 ) tumor / metastatic disease , ( 6 ) infection outcomes : pain visual analog scale ( vas ) , numerical rating scale ( nrs ) ; patient - reported function ( modified oswestry disability index , roland and morris disability index ) , patient satisfaction modified north american spine society outcome questionnaire , patient satisfaction index ; and complications analysis : descriptive statistics we found no studies comparing acdf with conservative treatment for axial neck pain without radiculopathy or myelopathy . however , three case series , all graded class of evidence iv , met our inclusion criteria and form the basis for this report ( fig 1 ) . further details on the class of evidence determination can be found in the web appendix at www.aospine.org/ebsj . overall , a total of 166 patients were included , with ages ranging from 21 to 76 years of age , and comprised of slightly more females than males . the majority of patients underwent 1 or 2-level fusion ( 84% , n = 140 ) followed by 3 or 4 level fusion ( 16% , n = 26 ) . all studies reported a mean improvement of over 50% at approximately 4-years follow - up , regardless of the number of levels fused . patient reported functional outcomes ( fig 3 ) overall mean functional scores improved significantly compared with preoperative scores at approximately 4 years after surgery . mean percent age improvement in odi ranged from 32.3% to 51.9% across the three studies 3,4,5 . for the rmdi , a mean improvement of over 50% was seen in all patients , including sub - group analyses of 1 to 2-level and 3-level fusion , in one study 4 . patient satisfaction and repeat surgery ( table 2 ) in two studies , 56% ( n = 49 ) and 79% ( n = 30 ) of patients reported that they were satisfied with the surgical outcome 4,5 . over 85% of patients in two studies said they would repeat the surgery 2,4 . in one study , pseudoarthrosis occurred in eight ( 9.2% ) patients and reoperation for screw removal in one ( 1% ) 4 . in another study , flow chart showing results of literature search north american spine society outcome questionnaire patient satisfaction index overall mean percent age improvement in pain scores at last follow - up across the three case seriesnrs = numerical rating scale ; vas = visual analog scale ; f / u = follow - up ; preop = preoperative overall mean percent age improvement in owestry disability index and roland and morris disability index function scores at last follow - up across the three case seriesodi = oswestry disability index ; rmdi = roland & morris disability index ; f / u = follow - up ; preop = preoperative a 43-year - old physically fit woman , with a history of tobacco abuse presented with a prolonged history of axial neck pain , recalcitrant to nonoperative treatments ( fig 4 ) . preoperative lateral x - rays showing degenerative disc disease at c47 , with mild kyphosis ( fig 5 ) . x - rays , ct , and mri revealed degenerative changes and mild anterolisthesis at c7t1 and pseudoarthroses at c45 and c67 ( figs 6,7,8a,8b ) . revision acdf resulted in approximately 75% resolution of her axial pain ( fig 9 ) . preoperative lateral x - ray showing degenerative disc disease at c47 , with mild kyphosis preoperative mid - sagittal mri showing degenerative disc disease at c47 lateral x - ray revealing degenerative changes and mild anterolisthesis at c7t1 and pseudoarthroses at c45 and c67 after index acdf mri revealing degenerative changes and mild anterolisthesis at c7t1 and pseudoarthroses at c45 and c67 after index acdf coronal reconstruction of ct revealing degenerative changes and mild antero - listhesis at c7t1 and pseudoarthroses at c45 and c67 after index acdf sagittal reconstruction of ct revealing degenerative changes and mild anterolisthesis at c7t1 and pseudoarthroses at c45 and c67 after index acdf six weeks postoperative lateral x - ray following revision acdf limitations of our sr : small number of studies available to address the issue , all with small sample sizes ( n = 38 , n = 41 , n = 87 ) . the proportion of patients who achieve a clinically meaningful improvement in pain and function > 30% is not reported . there is no reference made to restoration of physiologic sagittal cervical spine with fusion patients . selection of fusion levels and integrity of discs adjacent to the operated levels is insufficiently addressed . the role of provocative testing ( ie , injections , blocks , cervical discography ) was not addressed in this review and was not systematically used in the case series analyzed in this systematic review . there is no class of evidence i iii data regarding the success rate of surgical treatment for axial neck pain . the lack of data may reflect the reluctance of academic spine surgeons to operate on axial neck pain in the absence of neurological symptoms . surgery for the treatment of axial neck pain remains controversial and there is scant literature to guide treatment of any form operative and nonoperative . in two studies , 56% ( n = 49 ) and 79% ( n = 30 ) of patients reported that they were satisfied with the surgical outcome . a prospective randomized controlled study comparing surgical treatment to nonoperative measures , including aerobic exercise is needed , and due to the demonstrated relative therapeutic equipoise , appears ethically warranted . editorial staff perspective the subject of treatment for neck pain with anterior cervical discectomy and fusion and the methodology and findings of our authors evoked considerable debate among our reviewers . the inclusion of only three articles with a limited overall cohort was mentioned as a considerable limitation to the ability to conduct meaningful data analysis . of course the vast mainstay of the available scientific literature reflects the overwhelming clinical indication for an anterior cervical discectomy and fusion in the setting of a degenerative disc disease . as is apparent in this formal systematic review , the second biggest controversy revolved around a subject , which will become increasingly contentious in the future , of the degree of improvement as measured in clinically related health outcomes questionnaires . in the three studies that met the inclusion criteria of the authors , the objective percentage of improvement in neck pain was between 50% and 60% at 4 years ; the patient satisfaction was 56% and 79% in the two studies from which the data can be abstracted , and functional outcomes improved between 32% and 52% from baseline . the questions of level selection , restoration of normal sagittal alignment and actually achieving a solid fusion were felt to be considerable variables potentially affecting patient outcomes . furthermore , how long do these results last ? and the as yet unanswered question : does the presence of a rigidly fused level in the lower c - spine set an affected patient up for a cascade effect on other levels later on ? certainly acdf seems to have a positive treatment effect on patients who have failed nonoperative care for symptomatic cervical disc disease . the presented results do provide a justification of more formal study of this subject area .

study design : systematic reviewstudy rationale : anterior cervical discectomy and fusion ( acdf ) is a proven , effective treatment for relieving neck pain due to degenerative conditions of the cervical spine . since most patients also present with radiculopathy or myelopathy , little is known as to the effectiveness of acdf to relieve pain and improve function in patients without radicular or myelopathic symptoms.objective : to examine the clinical outcome in patients undergoing ( acdf ) for axial neck pain without radicular or myelopathic symptoms.methods : a systematic review was undertaken for articles published up to march 2010 . electronic databases and reference lists of key articles were searched to identify studies evaluating acdf for the treatment of axial neck pain only . radiculopathy and myelopathy , patients who suffered severe trauma , or with tumor / metastatic disease or infection were excluded . two independent reviewers assessed the strength of evidence using the grading of recommendations assessment , development and evaluation ( grade ) system , and disagreements were resolved by consensus.results : no comparative studies were identified . three case series met our inclusion criteria and were evaluated . all studies showed a mean improvement of pain of at least 50% approximately 4-years following surgery . functional outcomes improved between 32% and 52% from baseline . most patients reported satisfaction with surgery , 56% in one study and 79% in another . complications varied among studies ranging from 1% to 10% and included pseudoarthrosis ( 9% ) , nonunion and revision ( 3% ) and screw removal ( 1%).conclusion : there is low evidence suggesting that patients with axial neck pain without radicular or myelopathic symptoms may receive some improvement in pain and function following acdf . however , whether this benefit is greater than nontreatment or other treatments can not be determined with the present literature .

it has a peak incidence between 10 and 14 year of age and only 30% of all osteosarcomas occur in individuals aged > 40 . osteosarcoma is a rare disease , with an annual incidence rate of approximately 4.4 per 10 for people aged 024 years . several subtypes of osteosarcoma can be distinguished , of which conventional high - grade central , or intramedullary osteosarcoma , is by far the most common ( 75% of the cases ) . osteosarcoma is characterized by the production of osteoid matrix and is located mostly at the metaphysis of long bones . in addition to surgery patients receive intensive pre- and post - operative chemotherapy . although neo - adjuvant chemotherapy has markedly improved outcome , since its introduction in the 70ties survival has reached a plateau of about 6070% . therefore , new treatment options are needed . as osteosarcoma is a rare disease , international collaborations are essential for the conduction of clinical trials . the european and american osteosarcoma study group ( euramos ) , started its first trial in 2005 , in which 2260 patients from 326 centres across 17 countries were enrolled . this largest osteosarcoma study to date could be achieved by a committed collaboration between four well established study groups . however , due to the absence of consensus and regional differences in compound approval , a second study has not emerged yet , which is especially discouraging now this successful worldwide network has been established . to see how the quantity of osteosarcoma in vitro studies developed overtime , we set out to systematically identify all the drugs that have been tested on osteosarcoma cells in vitro in the past two decades . a pubmed search strategy was compiled which can be found in supplementary data 1 . to our surprise it struck our attention that the number of publications on treatment of osteosarcoma cell lines with various compounds has increased almost exponentially ( fig . after importing these pubmed hits in endnote x7 , we obtained an indication of how the amount of publications developed in china , the usa , india , australia , canada and europe ( defined as countries that are in the schengen area and/or the european union ) in the past few years by searching for these countries in the authors address box . the amount of publications from the usa showed a minor increase , from 45 in 1996 to 73 in 2015 , whereas the amount of publication from europe increased substantially from 35 in 1996 to 176 in 2015 . strikingly , the amount of publications from china rose from 1 to 359 , thereby mainly being responsible for the huge increase in publications observed in the last few years . china has been the leading country since 2012 , and 53% of the publications from 2015 involved chinese institutes ; this is a much higher proportion than reported for other research areas such as haematology research . we read all the abstracts of the hits of the past three years ( n=1755 ) , and categorized them based on non - osteosarcoma ( n=297 , many studies on other cancers metastasizing to the bone ) , no in vitro study ( n=179 ) , no drugs study ( n=596 , many studies performed sirna knockdown only ) and no inhibitory effect ( n=126 ) , leaving us with 560 studies from the last three years , a relatively large number when considering the rareness of this disease . interestingly , approximately 1/3 of the compounds could be classified as traditional medicine , of which over 80% was published by chinese authors . for example , we encountered several compounds such as evodiamine , a chemical extracted from the tetradium genus of plants , and crude extracts of rheum palmatum l. , the root of chinese rhubarb . remarkably , many studies were performed with only one cell line , either u-2 os or mg-63 . due to the high heterogeneity of osteosarcoma , studying a panel of cell lines instead of a single cell line is essential for eventual clinical applicability . u-2 os and mg-63 are both atcc cell lines established in 1964 and 1977 respectively . searching pubmed for u-2 os ( and u2os / u2-os / u-2-os ) and mg-63 ( and mg63 ) identified respectively 1449 and 2564 publications from 1996 to 2015 , while the combination only resulted in 163 pubmed hits . determining the amount of publications per year and per country for these cell lines as described above further demonstrated the almost exponential increase in publications with osteosarcoma cell lines attributable to studies from chinese institutes ( fig . 1b ) . to compare these results with another atcc sarcoma cell line with a comparable amount of total publications , we performed an identical search for ht-1080 ( fibrosarcoma ) , in which we did not see this trend ( fig . 1b ) , demonstrating that this is not a trend observed in all atcc sarcoma cell lines . u-2 os and mg-63 are ubiquitously applied also outside the osteosarcoma field for general cell biology studies because they are among the few human cell lines that are relatively susceptible to transfection . in addition , these cells grow rapidly facilitating experimental application but also boosting drug responsiveness . this probably explains why so many in vitro studies have been published for this relatively rare disease . there may be a jewel hidden in this avalanche of studies , but it is difficult to discern due to the huge quantity of papers using questionable designs . if in vitro studies are performed , researchers should always include a panel of cell lines to represent the tumour heterogeneity in osteosarcoma patients . as a researcher , it is impossible to keep track of all the research that is being published , which may lead to missing promising therapeutic targets . the publication of these relatively easy executable studies is obviously fed by the incentive of publish or perish , but it keeps scientists occupied with often irrelevant work , it usurps financial budgets and obscures relevant investigations . other major drivers of the enormous increase in research papers is the substantial increase in the number of academic journals . aggressive editor 's requests to submit manuscripts to new journals keep filling a scientist 's mailbox , which can be quite disturbing . this trend to prevail quantity over quality is occupying precious time from editors and reviewers . currently , the science citation index is used for medical career evaluation in the majority of large chinese hospitals , resulting in a huge pressure of chinese medical doctors to publish articles and an increase in number of publishing scientists , . therefore , it is essential that the evaluation system on research performance will be changed with the focus shifted from quantity to quality as was recently again advocated that bibliometrics are warping science . our analysis of in vitro osteosarcoma studies illustrates the effect of the increased publication pressure since the convenience of osteosarcoma cell lines renders them into low hanging fruit but results in studies with limited scientific value , which constrains solutions for this deadly disease that affects young patients .

osteosarcoma is a primary malignant bone tumour , for which no improvement in survival rate has been made since the nineteen seventies . we set out to systemically identify the in vitro studies performed in the past two decades describing potential future therapies . strikingly , we obtained a total of 5282 pubmed hits on this subject . the amount of publications has increased almost exponentially over the past few years . studies from chinese institutes are mainly responsible for this huge increase , accounting for 53% of the publications in 2015 . approximately 1/3 of all drugs described in the past three years could be classified as traditional medicine . furthermore , it struck our attention that even though in such studies multiple cell lines are essential to represent the heterogeneity in patients , many studies were performed with only one or two cell lines , i.e. u-2 os or mg-63 . these cells are fast growing , facilitating rapid experimental application but also boosting drug responsiveness . this probably explains why so many in vitro studies have been published for this relatively rare disease . furthermore , it illustrates the current publication pressure , especially in china .

paratesticular tumors are infrequent tumors that have a high incidence of malignancy ; they are either soft - tissue tumors or mesothelial neoplasms . paratesticular liposarcomas include all liposarcomas arising in the structures around the testis , including the lower end of the cord . it is felt to arise from the extra peritoneal fat that becomes continuous distally with the fatty tissue of the cord . they commonly present as painless , slowly growing masses that are usually diagnosed as being a lipoma or inguinal hernia . however , complete surgical resection offers the best chance of cure for these patients , and the established method for orchiectomy for testes / cord cancer is through an inguinal incision . a 65-year - old male patient presented with scrotal swelling of 2-year duration in both right and left hemiscrotum , which was gradually progressive in size and non - reducible . on examination , swelling was soft in consistency , testis was palpable posteriorly , and could not get above the swelling . intraoperative , a firm , well - defined tumor , about 20 14 5 cms on the left and 16 14 4 cms on the right side were found at the proximal spermatic cord [ figure 1 ] ; no hernia sac was noted at the inguinal canal . bilateral high inguinal orchiectomy was performed . the gross appearance of the specimen revealed a large , soft , well - circumscribed , multilobulated , fat - containing mass adhering to the spermatic cord and testis . the cut surface of the tumor [ figure 2 ] showed yellowish and myxoid areas , but without hemorrhage or necrosis . histopathological examination [ figures 3 and 4 ] showed sheets and nests of mature adipocytes , scattered atypical cells with hyper chromatic nuclei , and multivacuolated lipoblasts in between on a fibrous and myxoid background . he , however , refused further treatment because he did not have enough money to continue treatment . informed consent has been taken from the patient regarding the publication of the case report . gross specimen of the tumor mass measuring 20 14 5 cms on left and 16 14 4 cms on the right cut section of the specimen showing yellowish and myxoid areas microscopic examination of the mass revealed an encapsulated proliferation consisting of mature adipocytes accompanied by both spindle - shaped cells and multivacuolated lipoblasts microscopic photograph showing mature adipocytes , spindle - shaped cells with hyper chromatic nuclei within the stromal tissue and multivacuolated lipoblasts in between on a fibrous and myxoid background dreyfuss and lubash reported the first documented liposarcoma of the spermatic cord in a 54-year - old male in 1940 . liposarcomas are soft - tissue malignancies that are commonly found in the lower extremities and retroperitoneum . they are classified in four histology subtypes ( well differentiated , myxoid , pleomorphic , and dedifferentiated ) . paratesticular tumors have a high incidence of malignancy , which is estimated as 30% in the documented literature , mostly arising from the spermatic cord . most patients present with painless , slowly growing inguinal or scrotal masses , which are usually diagnosed as inguinal hernias or lipoma before surgical intervention . the majority of spermatic cord sarcomas begin their development just below the external inguinal ring and therefore , grows as a scrotal mass rather than as an inguinal mass . the homogenous fatty pattern of well - differentiated paratesticular liposarcomas being similar to lipomas or omentum in the hernia sac makes the differential diagnosis of a liposarcoma difficult through ultrasonograhic studies . hence , even though ultrasonography is the most helpful and commonly used diagnostic tool for differentiating cystic and solid lesions , an abdominal ct scan may be helpful . since they have the tendency for local recurrence after inadequate resection , complete resection , including high ligation of the spermatic cord , is indicated . an intralesional biopsy or surgery the role of adjuvant radiotherapy or chemotherapy remains controversial and is only limited in cases of metastatic tumors or in cases following incomplete resection . radiation therapy may be employed as an adjunct to surgical resection in an attempt to avoid local recurrence . the prognosis of paratesticular liposarcomas depends on the histological cell type , among well- differentiated , dedifferentiated pleomorphic , and myxoid / round cell types . the well - differentiated and myxoid / round cell types have a better prognosis , but they tend to have a high incidence of local recurrence . liposarcomas are the most radiosensitive of all sarcomas and in some cases remission has been achieved with radiotherapy alone . in conclusion , liposarcomas of the spermatic cord represent a rare type of tumors , which are often misdiagnosed preoperatively . being a rare disease and varied type of presentation , paratesticular liposarcoma should be considered as a possibility during the differential diagnosis of fat containing inguino - scrotal mass .

paratesticular liposarcomas are rare tumors and are often reported as isolated cases . patients usually present with a painless scrotal or inguinal mass , mimicking inguinal hernia . they refer to liposarcomas arising from the spermatic cord , testicular tunics , and epididymis . we report a case of bilateral scrotal swelling which was misdiagnosed as inguinal hernia . intraoperative diagnosis of testicular tumor was made . high inguinal orchiectomy was done . histopathological examination revealed it to be liposarcoma of the cord . to our knowledge , there is no reported case of bilateral paratesticular liposarcoma in english literature , hence we report this case .

hereditary sensory neuropathies ( hsn ) are clinically and genetically heterogeneous disorders of autosomal dominant or autosomal recessive inheritance characterized by axonal atrophy and degeneration , predominantly affecting the sensory neurons [ 13 ] . hallmark features of the dominantly inherited variant subclassified as hsn type 1 ( hsn1 ) comprise severe distal sensory loss , painless injuries , skin ulcers and frequent bone infections that sometimes necessitate amputations of toes or feet [ 13 ] . variable distal muscle weakness and wasting and lancinating pain is also often observed . with disease progression the hands mutations in the serine - palmitoyltransferase , long chain base subunit 1 ( sptlc1 ) gene are the most frequent cause of hsn1 . sptlc1 encodes one of the three subunits of serine palmitoyltransferase ( spt ) , which catalyzes the first step in the de - novo synthesis of sphingolipids which is the condensation of l - serine and palmitoyl - coenzyme a. under certain conditions spt shows a shift from its canonical substrate l - serine to the alternative substrates l - alanine and glycine which leads to the formation of an atypical class of 1-deoxy - sphingolipids ( 1-deoxysl ) . pathologically elevated 1-deoxysls have been found in transgenic hsn1 mouse models and in hsn1 patients carrying different sptlc1 mutations but also in individuals with the metabolic syndrome and diabetes [ 68 ] . the 1-deoxysls show pronounced neurotoxic effects in vitro and may be disease causing in hsn1 but are possibly also involved in the pathology of the diabetic neuropathy . the observation that a high dose l - serine supplementation lowers plasma 1-deoxysl levels in hsn1 patients and in the transgenic mouse model has encouraged our hopes for a first treatment of this ulcero - mutilating disorder . this emphasizes the importance of an early and accurate genetic diagnosis of hsn1 patients . here we report a novel sptlc1 mutation in a female patient exhibiting an unusually severe and complicated phenotype . we show that mutations at the particular amino acid position serine 331 ( s331 ) are associated with a distinct syndromic phenotype in comparison to previously reported mutations in hsn1 . motor milestones during the first years were normal but height and weight always ranked low in percentile or they were even below the lower limit . at 4 years of age a strange gait , frequent falls and moderate hand tremor were noted . sensory disturbances were initially mild but progressed with disease . considerable pes cavus foot deformity necessitated triple arthrodesis at age 5 . subsequently , the diagnosis of hereditary motor and sensory neuropathy ( hmsn ) was made . disease progression was rapid and soon muscle weakness and wasting affected upper limbs , but also proximal limb and trunk muscles thus leading to severe scoliosis , respiratory problems and wheelchair dependence at age 14 . in addition , there was prominent growth retardation and delayed puberty whereas intellectual development was normal . at age 13 , there was general muscle hypotrophy and hypotonia with pronounced weakness in the distal muscles of the upper and lower limbs ( fig . 1 ) there were prominent sensory disturbances which were pronounced in the feet and affected all qualities except for the vibration sense which remained completely preserved . at the toes scars after burns due to reduced prominent pain and temperature sensation were evident ( fig . 1 , hypermobility of the joints , bilateral hand tremor and fasciculations , which were most prominent in the tongue , were observed ( fig . 1 ) . further evaluation included nerve conduction studies ( ncs ) , magnetic resonance imaging ( mri ) studies and molecular genetic testing which followed standard methods . whole exome sequencing was performed on a genome analyzer hiseq 2000 system ( illumina , san diego , ca . ) . nerve conduction velocities in the upper limbs were within the intermediate range ( median motor : 32 m / s , median sensory : 39 m / s , snap : 16.7 v ) and compound motor action potentials ( cmap : 2.5 mv , peak peak ) were reduced . there was no response for motor or sensory nerves in the lower limbs . based on these results the patient was initially classified as hmsn type ii . mri of the brain and spinal cord was normal at the age of 9 years . after exclusion of mutations in all common hmsn and sca ( spino - cerebellar ataxia ) genes , whole exome sequencing was carried out . thereby , a heterozygous missense change in sptlc1 ( c.992g- > t ; p.s331y ) was detected and confirmed by sanger re - sequencing . the parents were normal on neurological and on electrophysiological examination and this change was absent in both of them . also , no sequence variation at aa position s331 was found in 1969 individuals from our in - house exomes . subsequently , we measured the 1-deoxysl levels in the patients ' plasma which were found to be significantly elevated ( fig . 2a ) . increased 1-deoxysl formation was also confirmed in hek293 cells expressing the p.s331f and p.s331y mutant ( fig . to date , six disease causing mutations in sptlc1 ( p.c133w , p.c133y , p.c133r , p.v144d , p.s331f , p.a352v ) have been described . spltc1 mutations at positions p.c133 , p.c144 and p.a352 result in the typical hsn1 phenotype . in contrast , the p.s331f mutation , which was reported in two patients only , occurred de - novo and was associated with an extraordinary severe and complicated phenotype . one of these patients was initially diagnosed as early onset hmsn type ii due to muscle weakness and hypotrophy in addition to prominent sensory disturbances , bone fractures and osteomyelitis . notably , this patient also developed juvenile cataract at age of 9 years , complete retinal detachment at 10 and repetitive corneal ulceration and keratitis with poor corneal healing . an even more complex congenital phenotype with severe growth retardation , global amyotrophy , hypotonia , joint hyperlaxity , vocal cord paralysis , bilateral cataract , mild mental retardation , microcephaly and respiratory problems was described in the second patient . the pathogenicity of the p.s331f mutation was confirmed by functional studies : in vitro a reduction of spt activity was shown and in plasma samples of both patients increased levels of 1-deoxysls were detected . nevertheless , it remained uncertain whether these additional features were also related to the p.s331f mutation . the patient reported here carries a novel mutation in sptlc1 leading to a change of serine to tyrosine at aa position 331 which also results in a similar unusually severe and complicated phenotype . the core phenotype of the three patients described so far carrying an s331 sptlc1 mutation resembles early onset hmsn . the additional features highly enlarge the phenotype of hsn1 but are rather unique between the three patients ( table 1 ) thus proposing the existence of a distinct and severe syndrome associated with this particular mutation . since oral l - serine supplementation has been suggested to be a future treatment option , it will be most important to achieve a quick diagnosis by early screening of exon 11 of sptlc1 in patients exhibiting this distinct phenotype .

mutations in the serine palmitoyltransferase subunit 1 ( sptlc1 ) gene are the most common cause of hereditary sensory neuropathy type 1 ( hsn1 ) . here we report the clinical and molecular consequences of a particular mutation ( p.s331y ) in sptlc1 affecting a patient with severe , diffuse muscle wasting and hypotonia , prominent distal sensory disturbances , joint hypermobility , bilateral cataracts and considerable growth retardation . normal plasma sphingolipids were unchanged but 1-deoxy - sphingolipids were significantly elevated . in contrast to other hsn patients reported so far , our findings strongly indicate that mutations at amino acid position ser331 of the sptlc1 gene lead to a distinct syndrome .

central venous catheters ( cvcs ) are needed for monitoring patients in special conditions and as a route for parenteral nutrition . depending on the catheter type , cannulation is performed at different sites such as the jugular , subclavian , femoral , and brachial veins . complications associated with the cvcs are infection , failure to place the catheter , arterial puncture , improper catheter position , pneumothorax , hematoma , hemothorax , asystolic cardiac arrest of unknown etiology , and inferior vena cava ( ivc ) trauma . infection is the most common complication in subclavian vein route ; though arrhythmias and air embolism can occur . one of these extremely rare complications is intravascular loss of a guide wire , which is usually recognized immediately or sometimes with delay . here , we elucidate a case of retained guide wire during cannulation of the right external iliac vein , which was successfully treated with exploration of right iliac vessels . a 60-year - old woman presented to the emergency department with complaints of generalized abdominal pain , constipation , and fever . patient was hospitalized with primary diagnosis of intestinal obstruction . due to patient 's history of heart disease , the central venous catheterization was done for fluid resuscitation via the right internal jugular ( ij ) vein using the seldinger technique . the catheter was inserted by a 1-year surgical resident with no supervision by senior residents . the catheter tray was checked for the guide wire after the procedure which was missing . after the patient was stabilized , she underwent chest x - ray , plain abdominal radiography , and ultrasonography and the patient was admitted in surgical intensive care unit . the radiographs showed that the catheter had entered in the ivc via the right ij vein and then , had remained in the right iliac vein at the point of bifurcation into the internal and external iliac veins [ figures 1 and 2 ] . based on the consultation with the vascular surgeons and radiologists , the patient underwent exploration of right iliac vein . the method was successful and the retained guide wire was removed from right external iliac vein . chest x - ray showing guide wire of catheter had entered in the inferior vena cava ( ivc ) via the right internal jugular vein x - ray pelvis showing guide wire catheter had remained in the right iliac vein at the point of bifurcation into the internal and external iliac veins central venous catheterization has many complications such as infection , failure to place the catheter , arterial puncture , improper catheter position , pneumothorax , and hematoma . this study reports a case of retained guide wire and its treatment . in our case , the catheter was retained in the right iliac vein at the point of bifurcation . an important point in preventing this rare complication is that the guide wire should be held at least 18 cm distant from the vein . the diagnosis is very simple , which is often established incidentally during routine radiographic exams . the guide wire should be held at the tip at all times to prevent passage into or out of the vessel . predisposing factors for an intravascular placement of the guide wire include : inattentioninexperienced operator- either in method ( i.e. seldinger technique ) or actually central venous cannulationinadequate supervision of traineesovertired staff . inexperienced operator- either in method ( i.e. seldinger technique ) or actually central venous cannulation inadequate supervision of trainees the signs of guide wire loss include : the guide wire is missingresistance to injection via the distal lumenpoor venous backflow from the distal lumenguide wire is visible on a radiograph . the guide wire is missing resistance to injection via the distal lumen poor venous backflow from the distal lumen guide wire is visible on a radiograph . the most commonly reported guide wire related complications are listed and will be discussed below . cardiac dysrhythmiascardiac conduction abnormalitiesperforation of vessels or heart chamberkinking , looping , or knotting of wireentanglement of previously placed intravascular devicesbreakage of the distal tip of the guide wire with subsequent embolizationcomplete loss of guide wire within the vascular system . cardiac conduction abnormalities perforation of vessels or heart chamber kinking , looping , or knotting of wire entanglement of previously placed intravascular devices breakage of the distal tip of the guide wire with subsequent embolization complete loss of guide wire within the vascular system . cardiac dysrhythmias most often premature atrial or ventricular contractions are occasionally reported during subclavian or ij cvc insertion . the arrhythmias are typically short lived , resulting from the guide wire touching the endocardium , and resolve when the tip is pulled backa few centimeters . the most common cardiac conduction abnormalities seen during cvc placement are right bundle branch blocks , new left anterior and posterior fascicular blocks , and rarely asystole . the cause of these conduction problems , as described in the case of cardiac dysrhythmias , is also the overzealous advancement of the guide wire . the ease with which a right bundle branch block can be induced is probably related to the bundle branch 's superficial position in the right ventricular endocardium , just inferior to the tricuspid valve . however , in a patient with an underlying left bundle branch block , the induction of further conduction defects may lead to a life - threatening complete heart block requiring temporary pacing . the mentioned arrhythmias and conduction problems are essentially avoidable during central venous catheterization since placement should not involve entry into the heart by the guide wire or by the subsequently placed catheter . in clinical practice , it is often difficult to ascertain what caused the venous perforation ; the introducer needle , the guide wire , or the dilator . nevertheless , the literature reports cases of guide wire related perforation of the great vessels including the brachiocephalic and subclavian veins . this important complication occurs when excessive force is applied against resistance when introducing the guide wire , especially if the straight or angle tip wire , rather than j - tip style wire , is used . in most instances , bleeding from a small penetrating hole in a vein however , serious cases of hemothorax , including fatalities , due to the above complication have been reported . making a timely diagnosis in such cases requires maintaining a high index of suspicion when there is an unexplained drop in hemoglobin or the development of unilateral pleural effusion ipsilateral to a recently placed or attempted central venous catheterization . treatment of a serious perforation may necessitate the insertion of a chest tube or an emergent thoracotomy . perforation of the heart may occur at the time of catheter insertion or any time the catheter tip is placed within the heart chambers . there are at least two reported cases in the literature of heart perforation attributed to the guide wire itself . both of these complications occurred during the insertion of hd catheters : the first during a subclavian approach leading to a life - threatening cardiac tamponade and the second during an ij approach leading to a fatal tamponade . cardiac tamponade usually results from perforation of the right atrium , or less frequently , the right ventricle . tamponade has also been reported after superior vena cava ( svc ) perforation within the pericardium . the possibility of tamponade should be considered when a patient collapses during , or shortly after placement of a cvc . other diagnoses to consider in that scenario include tension pneumothorax and air embolism . an emergent chest x - ray or bedside echocardiogram followed by pericardiocentesis can be life - saving in such situations . another occasional guide wire complication is kinking or looping of the wire itself . applying force to thread a guide wire through the introducer needle despite significant resistance kinking can also result if the dilator is forced in a direction that diverges from the original path of the wire . if a clinician does not recognize this scenario there is potential for cutting through the vein with possible fatal complications . this type of complication can be avoided by intermittently moving the wire gently in and out as the dilator is being advanced through the subcutaneous tissue . it is almost exclusively described following the subclavian approach which may be due to the curved path the vein takes as it loops over the first rib to descend into the svc . this complication should be suspected when the guide wire can not be pulled out after successful catheter insertion . in this situation , no force should be used to pull the catheter and wire out , and an immediate x - ray should be ordered . once the diagnosis is established , interventional radiology should be consulted , and sometimes surgical intervention is necessary . entanglement of a guide wire with an existing intravascular apparatus is another reported complication of cvc placement . special attention is needed in patients with ivc filters since there have been numerous reports of entrapment of guide wires in these filters . it results from over advancement of the guide wire leading to hooking of the j - tip to the filter . this complication should be suspected when the guide wire can not be retrieved after catheter placement in a patient with an ivc filter already deployed . in such circumstances , no excessive force should be used to free the wire since this could lead to filter dislodgment and cava perforation . x - ray or examination under fluoroscopy should be ordered promptly followed by interventional radiology consultation once the diagnosis is made . shearing and breakage of the wire usually results from pulling the wire back through the needle after it has passed the bevel . hence , if a guide wire fails to pass freely from the introducer needle into the vessel , the careful retraction of the wire through the needle is an option , but it is much safer to withdraw the wire and needle as a single unit . the inadvertent intravascular insertion of the entire guide wire , as in our case , is a completely avoidable complication . although the loss of a complete guide wire might cause arrhythmias , vascular damage , and thrombosis ; it is usually asymptomatic and is often incidentally found on a routine x - ray done up to several months after the procedure . holding on to the proximal tip of the wire at all times is fundamental in preventing this mistake . if this complication happens , use of interventional radiology techniques is the preferred method for retrieval and removal . guide wire fragment , or entire guide wire should be possible to be removed in most cases . during the intervention the patient should be heparinized . usually , the foreign body ( e.g. guide wire ) is caught by a gooseneck snare passed via the femoral vein using radiographic control . the use of endovascular forceps or a dormier basket increases the risk of endovascular trauma . if the foreign body is captured , it is usually necessary to remove it along with the vascular sheath . if the vascular sheath is twice the size of the lost catheter or the lost guide wire may be possible to withdraw the foreign body through it . if heparinization is contraindicated , extraction should be attempted by careful surgical exploration . during central venous catheterization , guide wire - related complications are uncommon and essentially preventable . the following precautions should be taken : inspect the wire for defects before insertionconsider a guide wire to be a delicate and fragile instrumentwhen resistance to insertion is met , remove and inspect the wire for damage , reposition the introducer so that no resistance to its passage is feltparticular caution should be used when attempting central catheter placement in patients who are predisposed to thrombosis or have had repeated catheterizations of a particular vesselif multiple manipulations are needed , reinspect the wire and replace it if necessarypass catheter over wire into the veinmake sure that the wire is visible at the proximal end , before the catheter is advancedthe catheter should be railroaded over the guide wire into the vein , holding the wire , and not pushing catheter and wire together into the veinalways inspect the wire for complete removal at the end of the procedurehold onto the wire at all times until removal from the vessel . inspect the wire for defects before insertion consider a guide wire to be a delicate and fragile instrument when resistance to insertion is met , remove and inspect the wire for damage , reposition the introducer so that no resistance to its passage is felt particular caution should be used when attempting central catheter placement in patients who are predisposed to thrombosis or have had repeated catheterizations of a particular vessel if multiple manipulations are needed , reinspect the wire and replace it if necessary pass catheter over wire into the vein make sure that the wire is visible at the proximal end , before the catheter is advanced the catheter should be railroaded over the guide wire into the vein , holding the wire , and not pushing catheter and wire together into the vein always inspect the wire for complete removal at the end of the procedure hold onto the wire at all times until removal from the vessel .

catheterization of central veins is a routine technique which is widely used in emergency department and medical intensive care units . seldinger 's technique is widely used to place central venous and arterial catheters and is generally considered safe . the technique does have multiple potential risks . guide wire - related complications are rare but potentially serious . we describe a case of a lost guide wire during central venous catheter ( cvc ) insertion followed by a review of the literature of this topic . measures which can be taken to prevent such complications are explained in detail as well as recommended steps to remedy errors should they occur .

glucose transport protein type 1 ( glut1 ) delivers glucose to the brain from bloodstream and is therefore crucial for an adequate energy provision . glut1 deficiency syndrome , inducing a chronic brain energy failure , is caused by mutations of the solute carrier family 2 ( facilitated glucose transporter ) member 1 ( slc2a1 ) gene , located on the chromosome 1p34.2 . the classic phenotype of glut1 deficiency syndrome is characterized by : mild to severe motor delay and mental retardation ; infantile - onset epilepsy ; head growth deceleration , possibly resulting in acquired microcephaly ; movement disorders ( ataxia , dystonia , spasticity ) ; and non - epileptic paroxysmal events ( intermittent ataxia , periodic confusion , recurrent headaches ) . reported features of epilepsy in this condition are heterogeneous ; generalized tonic - clonic and absence seizures prevail . lumbar puncture shows hypoglycorrhachia , with a reduced cerebrospinal fluid / blood glucose ratio in most patients . the ketogenic diet has proved to markedly improve epilepsy , movement disorders and head growth , while the cognitive effects are less pronounced . the patient 's family history was positive for : a not better specified psychiatric disorder and somnambulism in the mother ; epilepsy and mental retardation , in a paternal uncle and a paternal cousin , respectively . he was an only child , born at the 36 week of gestation by caesarean section due to hypertensive gestosis , after a two - placenta twin pregnancy , with the intrauterine death of the other fetus . apgar index was 7 ( 1 ) and 8 ( 5 ) ; birth weight was 3040 grams . cyanosis and jaundice at the birth were reported ; jaundice was treated by phototherapy and exsanguinotransfusion . at the age of 4 years 1 month , eeg tracing during wakefulness , performed due to the psychomotor retardation , was normal . from the age of about 4 years he has suffered from headache several times monthly , sometimes associated with nausea and vomiting , treated with paracetamol . at the age of about 6 years , he started to present , especially in the morning , short but frequent ( even several times a day ) episodes of loss of consciousness , eye closure , inconstant eyelid myoclonia . the events could occur isolated or close together resulting in falling asleep but showing amelioration on awakening . the drowsiness associated with the long clusters of these events was a major problem in his everyday life , especially at school . neurological examination showed only a mild , aspecific incoordination ; head circumference corresponded to the fiftieth percentile . neuropsychological evaluation showed a mild mental retardation ( wechsler scale ) , stable during the follow - up , with a significant prevalence of verbal intelligence quotient ( iq ) versus performance iq ; an aspecific learning disorder was evident . eeg revealed diffuse paroxysmal abnormalities and several brief absence seizures have been recorded [ figures 1 and 2 ] . high - resolution kariotype and search for fragile x syndrome were normal , as well as a metabolic screening including creatine kinase , lactic acid at baseline and after exercise , thyroid hormones , tests for celiac disease , ammonia , serum and urinary aminoacids , and urinary oligosaccharides . absence seizures were drug resistant to ethosuximide , levetiracetam , lamotrigine , and valproate , with only transient improvements after beginning a drug . after antiepileptic therapy start , we found episodic , mild postural and tremor - like action dyskinesias in the arms . at the age of 15 years , mainly due to the drug - resistant absence seizures , we performed the molecular analysis of the slc2a1 gene . the polymerase chain reaction sequencing of all exons revealed a nucleotide deletion in heterozygosity , c.1336_1338del , causing the loss of one amino acid ( isoleucine : p.ile446del ) . we chose not to give the lumbar puncture to avoid causing the patient excessive discomfort . a ketogenic diet was started and we noted a fast , marked clinical improvement . the boy became more responsive and active , while absence seizures and headache frequency decreased . however , patient 's compliance with the prescribed dietary regimen was so poor that after 1 year we decided to stop the diet . only a few days after the discontinuation , the boy showed clinical worsening , which made him willing to resume the diet . eeg recording , at the age of 14 years , showing diffuse bilateral and frontal dominant spike and wave discharges during wakefulness : open eyes on the left , closed eyes on the right eeg recording , at the age of 14 years , showing diffuse bilateral spikes and waves during hyperpnea , once associated ( see arrows ) with a brief absence seizure a constant supply of glucose is the most important source of energy for the brain . therefore , glut1 deficiency syndrome could be considered as a brain energy failure prototype . during last years also the three following clinical pictures have been described : ( a ) carbohydrate - responsive phenotype , characterized by clinical worsening ( motor and mental performance , seizures ) with fasting and improvement with carbohydrate intake ; ( b ) movement disorder without epilepsy , characterized by ataxia , dystonia , spasticity , mild delay of motor and mental development , normal or decelerated head growth ; ( c ) paroxysmal exertion - induced dyskinesias ( dystonia , choreoathetosis , ballism ) and epilepsy . the case we have described shows an atypical phenotype of glut1 deficiency syndrome . no movement disorders were present ( except for slight tremor after antiepileptic therapy start , probably a side effect of antiepileptic drugs ) , nor decrease of head circumference has been detected . the phenotype of our patient does not fully fit in any of the clinical pictures described so far in association with glut1 deficiency . in 2010 , leen et al . reported 10 cases with the so - called late - onset classical phenotype , but only in one of them movement disorders were absent and the reported features of seizures were different compared to those of our patient . it is true that epilepsy with the absence seizures is among those most frequently described in glut1 deficiency syndrome , but more often it has an early onset ( before the age of 4 ) , while in the forms with later onset , as in our patient , the combination of drug - resistant absence seizures ( without other types of seizures ) and mental retardation , present in the case we have reported , has not been described . considering the findings of our patient 's eeg ( initially normal , then clearly pathological ) , our data confirm what pong et al . stated , namely that in the same individual , affected by this disorder , eeg picture could change over time . our case report suggests that , in the lack of a better definition of the possible phenotypes associated with glut1 deficiency , there is a risk of underestimating the actual occurrence of the disease . especially because of the atypical phenotypes , this fact has important implications also for the treatment , because a ketogenic diet , that should begin as soon as possible , could significantly improve the quality of life of these patients , while classic antiepileptic drugs usually fail . in fact , a high - fat diet leads to the production of ketone bodies bypassing the glut1 deficiency and providing an alternative source of energy to the brain . incidentally , we emphasize that the exact pathogenetic mechanism of the formation of cataracts , also present in our patient , is currently unknown . in conclusion , it is recommended to consider this diagnostic hypothesis in any case with an unexplained neurological disorder , also when , as in our case , a main clinical feature consists of drug - resistant seizures associated with a global developmental delay , even in the lack of a movement disorder , according to klepper suggestions .

the glucose transport protein type 1 ( glut1 ) deficit causes a chronic brain energy failure . the classic phenotype of glut1 deficiency syndrome is characterized by : mild to severe motor delay and mental retardation ; infantile - onset epilepsy ; head growth deceleration ; movement disorders ( ataxia , dystonia , spasticity ) ; and non - epileptic paroxysmal events ( intermittent ataxia , periodic confusion , recurrent headaches ) . during last years the classic phenotype of this syndrome , as originally reported , has expanded . we report the atypical phenotype of a boy with glut1 deficiency syndrome , characterized by mild mental retardation and drug - resistant absence seizures with onset at the age of 6 years , without movement disorders nor decrease of head circumference . a prompt diagnosis of this disorder is mandatory since the ketogenic diet might represent an effective treatment .

all subjects were evaluated during a 2010 family forum in chicago , as part of our monogenic diabetes registry ( http://monogenicdiabetes.uchicago.edu ) ( 11 ) . all parents provided informed written consent as approved by the university of chicago institutional review board . the beery - buktenica developmental test of visual - motor integration ( vmi ) presents drawings of geometric forms in order of increasing difficulty to be copied with paper and pencil for subjects > 2 years of age . the vmi is often administered to evaluate visual - motor and visual - perceptual deficits . it has a coefficient of 0.82 , and its validity has been established ( 1214 ) . nonparametric analysis was performed using the kruskal - wallis anova test ( with value h ) for group comparisons , as well as spearman correlations . all subjects were evaluated during a 2010 family forum in chicago , as part of our monogenic diabetes registry ( http://monogenicdiabetes.uchicago.edu ) ( 11 ) . all parents provided informed written consent as approved by the university of chicago institutional review board . the beery - buktenica developmental test of visual - motor integration ( vmi ) presents drawings of geometric forms in order of increasing difficulty to be copied with paper and pencil for subjects > 2 years of age . the vmi is often administered to evaluate visual - motor and visual - perceptual deficits . it has a coefficient of 0.82 , and its validity has been established ( 1214 ) . nonparametric analysis was performed using the kruskal - wallis anova test ( with value h ) for group comparisons , as well as spearman correlations . eight subjects had the r201h mutation characterized by isolated diabetes without neurodevelopmental concerns , eight had v59 m or v59a ( v59m / a ) mutations associated with the intermediate dend syndrome , and three had mutations that have an inconsistently reported neurodevelopmental phenotype ( one each with r201c , y330c , and e322k ) ( table 1 ) . overall , no group differences were found in age ( kruskal - wallis anova group comparison h [ 2 , n = 19 ] = 1.9 ; p = 0.39 ) , sex distribution ( = 0.79 ; p = 0.68 ) , age of diabetes diagnosis ( h [ 2 , n = 19 ] = 2.1 ; p = 0.35 ) , or age of treatment initiation ( h [ 2 , n = 19 ] = 2.2 ; p = 0.33 ) among the three groups . clinical characteristics and results of beery - buktenica vmi testing in patients with monogenic neonatal diabetes caused by r201h ( n = 8) , v59 m or v59a ( n = 8) , or other ( n = 3 ) mutations in kcnj11 the three groups differed significantly ( h [ 2 , n = 19 ] = 12.78787 ; p = 0.0017 ) from each other in graphomotor constructional abilities necessary for accurate copying of the vmi geometric figures ( table 1 and supplementary fig . namely , in children with r201h , scores fell within the normal range ( median = 107 , lower quartile = 93 , and upper quartile = 118.5 ) , whereas children with v59m / a scored low to very low ( median = 49 , lower quartile = 49 , upper quartile = 74.5 ) , and scores of children with other mutations were intermediate ( median = 89 , lower quartile = 65 , and upper quartile = 91 ) . age at treatment initiation was significantly inversely correlated with vmi scores only in the v59m / a group ( spearman correlation = 0.79 , p < 0.05 ) ( supplementary table 1 ) . all three children with v59m / a who had transitioned to sulfonylureas before their first birthday had standard scores > 70 , whereas the five children whose treatment started later scored < 50 ( greater than three sds below the mean ) . to our knowledge , our study represents the largest cohort of rare kcnj11 neonatal diabetic patients undergoing an identical neurodevelopmental assessment at one time . using a well - validated , age - standardized measure , we show that those with intermediate dend - associated v59m / a mutations have significant impairment of eye - hand coordination , whereas those with the r201h mutation not associated with neurodevelopmental concerns performed in the normal range . early treatment with sulfonylureas was associated with better vmi scores in the v59m / a group ; however , this observation must be confirmed in larger numbers of patients with more comprehensive longitudinal assessments . why mutations such as r201h do not cause a similar level of impairment as seen in v59m / a is uncertain , especially since the diabetes caused by these mutations appears to be equivalent . given that a few of the r201h and other mutation case subjects exhibited low normal scores , it may be that the vmi is not sensitive enough to quantify mild subclinical difficulty . other factors could contribute to the neurodevelopmental concerns in these patients , including diabetic ketoacidosis at diagnosis during a very young age critical for brain development , as well as longer - term metabolic control characterized by prolonged hyperglycemia and sometimes frequent episodes of severe hypoglycemia , which has been associated with a spectrum of visual - spatial , memory , attention , and executive dysfunctions ( 15 ) . the current study and previous reports of improved cognitive and motor symptoms after the change in treatment suggest the benefit of sulfonylurea blockade of activated glucose - responsive channels that have an unknown function in the brain ( 810 ) . this implies that sulfonylureas cross the blood - brain barrier ; however , the degree to which they do may be a critically important factor and warrants further study . the three v59m / a subjects who started sulfonylurea therapy before 1 year of age had better vmi scores than the five subjects who did not ; however , it remains to be determined whether there is a definitive critical age for treatment . this finding raises hope for prevention of at least some of the neurodevelopmental disability in those who start sulfonylureas at an early age . this bolsters consideration of an empirical trial of sulfonylureas in newly diagnosed neonatal diabetic patients before results of genetic testing are available , given that atp - sensitive potassium channel mutations cause almost 50% of cases . however , the risk / benefit of sulfonylureas should be carefully considered and should in no way supplant mandatory genetic testing . notably , vmi scores in the three v59m / a children treated early were still low and developmental challenges are likely to persist , as is also likely in rare severe dend cases not assessed in this study . efforts should include comprehensive specialty assessment and support of optimal progress and continued collection of data on greater numbers of patients tracking long - term neurodevelopmental outcome . in this regard

objectiveto assess performance on an age - standardized neuromotor coordination task among sulfonylurea - treated kcnj11-related neonatal diabetic patients.research design and methodsnineteen children carrying kcnj11 mutations associated with isolated diabetes ( r201h ; n = 8) , diabetes with neurodevelopmental impairment ( v59 m or v59a [ v59m / a ] ; n = 8) , or diabetes not consistently associated with neurodevelopmental disability ( y330c , e322k , or r201c ; n = 3 ) were studied using the age - standardized beery - buktenica developmental test of visual - motor integration ( vmi).resultsalthough r201h subjects tested in the normal range ( median standard score = 107 ) , children with v59m / a mutations had significantly lower than expected vmi standard scores ( median = 49 ) . the scores for all three groups were significantly different from each other ( p = 0.0017 ) . the age of sulfonylurea initiation was inversely correlated with vmi scores in the v59m / a group ( p < 0.05).conclusionsneurodevelopmental disability in kcnj11-related diabetes includes visuomotor problems that may be ameliorated by early sulfonylurea treatment . comprehensive longitudinal assessment on larger samples will be imperative .

streptococcus pneumoniae ( spn ) may cause a wide spectrum of diseases ranging from otitis and pneumonia to invasive forms such as meningitis or sepsis . among pneumococcal diseases , pneumonia has the higher clinical burden in terms of morbidity , mortality and hospitalization rate , with heavy implications for worldwide health systems . in particular , higher incidence and mortality rates of pneumococcal community - acquired pneumonia ( cap ) cases , with related costs , are registered among elderly . incidence values vary among different countries and surveys , but generally mortality rate increases with age and comorbidities . in the future , this will lead to an inevitable increase of hospitalizations , with an economic burden that should not be underestimated . therefore , pneumococcal vaccination is extensively recommended for subjects aged 65 y and for those aged 5064 y at high risk ( hr ) for specific health conditions , such as diabetes , cardiovascular diseases , nephropathies , hypertension and chronic obstructive pulmonary disease ( copd ) . in italy , the ministry of health recommends the use of conjugated 13-valent vaccine ( pcv13 ) for children aged < 2 y , while the immunization with 23-valent polysaccharide vaccine ( ppv23 ) is recommended for adults aged 65 y and for hr subjects aged 2 y. however , the levels of immunization coverage among adults are so far insufficient , and probably this depends on the doubts about polysaccharide vaccine efficacy . in fact , clinical studies showed that this formulation is unable to induce an adequate and durable immune response , especially in hr individuals and against non - invasive pneumococcal diseases . the 13-valent conjugate vaccine , recently indicated for the immunization of all the ages , has showed adequate safety and immunogenicity levels and seems to induce a durable protection against pneumococcal diseases , both invasive and not . several studies suggest that immunological properties of pcv are higher than those of ppv23 , while safety and tolerability are comparable . this study aimed to realize an economic evaluation about the immunization with pcv13 in the adult population in campania region , south italy . for this purpose we performed , considering a period of 5 y , a budget impact analysis ( bia ) and a cost - effectiveness analysis which considered 2 immunization targeted cohorts . figure 1 shows the pneumococcal cap cases expected in the first group ( hr subjects aged 5079 ) with and without vaccination . figure 1 . expected cases with and without vaccination in the first targeted group ( hr subjects aged 5079 ) . costs needed for the vaccination of the first targeted cohort in 5 y of follow - up are reported in table 1 . the total costs per year with or without immunization of the first cohort are reported in table 2 . during the first year , the implementation of the vaccination program requires more than 2-fold the resources needed for the treatment of pneumococcal cap cases expected without vaccination . the bia for the base case scenario confirms the great initial expense and the following savings , up to 29 005 660 after 5 y ( table 3 ) . table 4 considers savings and avoided cases achievable in 5 y with vaccination . for the first targeted group , total pneumococcal cap cases expected with a vaccination program were assumed to be 509 , while those expected without vaccination were estimated to be 4083 ( with a reduction of 3574 cases ) . therefore , the final savings per pneumococcal cap case is equal to 8116 , what relationship between avoided costs and avoided cases . the sensitivity analysis was performed by varying the effectiveness of the vaccine ( + /10% ) : estimated savings after 5 y could be 34 662 134 in the first case , and 23 402 745 in the worst scenario ( data not shown ) . as for the second targeted group ( hr subjects aged 5064 plus 65 y - old subjects ) , expected cases with and without vaccination in the second targeted group ( hr individuals aged 5064 + those aged 65 y ) . table 5 shows vaccination costs in 5 y. the costs per year with or without immunization of the second cohort are reported in table 6 . in this case also , at the first year the costs with vaccination seem to be higher than those for the treatment of pneumococcal cap cases in the second scenario ; however , even from the second year it s possible to observe notable savings . * bia showed at the end of the follow - up achievable savings equal to 10 006 017 ( table 7 ) . the number of expected cases ( 2694 ) among the second targeted cohort without vaccination could be reduced by vaccination to 337 . with this strategy , sensitivity analysis showed savings equal to 10 879 772 when considering a 10% increase in the effectiveness of the vaccine and equal to 9 132 263 with a 10% decrease ( data not shown ) . the new paradigm of evidence based medicine for decision - making has widely grown in recent years , making available to public health care policies and to professionals and managers as well tools to assess the clinical and welfare rationality of public choices . the evidence - based health care approach currently support most of the control activities and decision - makers choices , thus becoming a real asset in all health care organization levels : national first , and then regional . this study represents an example of how these indicators could be useful to manage and control diseases with a high burden . although pneumococcal diseases are assumed to be not always correctly identified and/or notified , they represent one of the main cause of morbidity and mortality . in order to reduce their burden , and the great number of risk factors for pneumococcal diseases and their interactions highlight the importance of immunoprophylaxis . therefore , contrarily to other analyses , focused on age - based vaccination strategies , this study considered some risk groups as targeted cohorts for adult vaccination . the inclusion of these groups followed indications of the italian ministry of health , which suggests the consideration of risk conditions for pneumococcal immunization in adults . multimorbidity patterns were difficult to apprise , due to the absence of appropriate data collection systems ; this would produce artificial estimates and information far from adhering to reality . the economic evaluation of pneumococcal vaccine for adult groups represents an essential instrument to support health policies . in fact , due to the cost restriction , stakeholders should know the value for money of a new immunization strategy , but also its budget impact as in the short as in the long period . as described above , this impact comes from the difference between cost of vaccination program and savings achievable through the vaccine - related reduction of cases . the pharmacoeconomics evaluation performed in this study showed that both hypothesized immunization strategies could produce savings . results showed that the vaccination of hr subjects of 5079 y could allow about 28 million euro of savings . however , this strategy requires a high investment in a short period . on the contrary it has to be noted that the present analysis did not consider the serotype coverage , which could be considered a limitation of the procedure . however , the analysis considered only direct costs using the perspective of the national health service . therefore , the conservative nature of this evaluation disregards further implications that could be advantageous for the local health system . moreover , the analysis takes into account only the pneumococcal pneumonia cases and does not include the other vaccine - preventable pneumococcal diseases , and it referred only to hospitalized cases however , the impact of vaccination may be wider , both clinically and economically , if non - hospitalized pneumococcal pneumonia cases are included . furthermore , the infection in high - risk subjects is likely more severe than considered and , consequently , the economic impact of vaccination is more extensive . lastly , vaccination advantages do not interest only immunized subjects but also the community , due to the herd immunity effects . also regarding this aspect , the present analysis is conservative , because further savings deriving from the increase of targeted cohorts were not considered . in the health care system , policy - makers choices basically depend on 2 elements which are concatenated together . on the one hand , there are the financial resources available ; on the other , the epidemiological context of reference that will decree the priorities on the allocation of resources . findings of this study support the vaccination for hr adults , as recommended by ema . our findings could help to choice between the 2 proposed hypotheses , in order to better address economical resources . this economic evaluation was developed to analyze for a 5-y period the impact of an adult pneumococcal vaccination program in the campania region . the model considered 2 vaccination strategies : at first , the group of hr subjects aged 5079 ( about 1 million of individuals in the region ) , and later hr individuals aged 5064 , together with all those aged 65 y ( about 400 000 subjects ) . hr subjects were considered those with chronic diseases such as diabetes , hypertension , nephropathies , copd and cardiovascular diseases . the analyses were performed on the resident population in campania on january 1 , 2009 , as reported by the national institute for statistics ( istituto nazionale di statistica , istat ) , without considering sex and origin . on the base of the average national coverage for the last influenza immunization program in italy in the elderly , vaccination coverage of the targeted cohorts the clinical outcome of the analysis were hospitalized pneumococcal cap cases in adult population ( 5079 y ) . data were obtained from the hospital discharge forms ( scheda di dimissione ospedaliera , sdo ) of respiratory departments which participate to the training regional network . during the years 20102011 , 18 965 cap cases were reported on these sdos . assuming that the overall rate of cap due to spn is about 40% , the number of pneumococcal cap per year among reported cases was estimated to be 3793 . on the basis of previous studies , the vaccine efficacy against pneumococcal pneumonia was assumed to be 87.5% , then this value was used to calculate the number of avoided cases for each vaccination strategy . expected cases were corrected for the global mortality rate , as obtained from 2010 istat data . the economic model was based on the difference between the costs sustained with ( vaccine plus treatment for expected cases ) and without ( only expected cases ) a vaccination program . as regard the first vaccination strategy , all the subjects at risk aged 5079 y were considered for immunization at first year ; since the second year only 50 y old were included in the vaccination program . as for the second strategy , individuals at risk aged 5064 y and those aged 65 y were considered for immunization at first year , while 50 y old and 65 y old were included for subsequent years . the cost of the vaccine was 42.5 euro per dose ; the cost of a cap case due to spn was assumed to be the average of costs for complicated and non - complicated pneumonia cases , equal to 3809 . costs were updated to a rate of 3% . to test the strength of results , a sensitivity analysis was applied by considering a + / 10% variation in the vaccine efficacy .

pneumococcal pneumonia has a high clinical burden in terms of morbidity , mortality and hospitalization rate , with heavy implications for worldwide health systems . in particular , higher incidence and mortality rates of community - acquired pneumonia ( cap ) cases , with related costs , are registered among elderly . this study aimed to an economic evaluation about the immunization with pcv13 in the adult population in campania region , south italy . for this purpose we performed , considering a period of 5 y , a budget impact analysis ( bia ) and a cost - effectiveness analysis which considered 2 scenarios of immunization compared with lack of immunization for 2 targeted cohorts : first , the high risk subjects aged 5079 y , and second the high risk individuals aged 5064 y , together with all those aged 65 y. regarding the first group , the decrease of pneumonia could give savings equal to 29 005 660 , while the immunization of the second cohort could allow savings equal to 10 006 017.the economic evaluation of pneumococcal vaccine for adult groups represents an essential instrument to support health policies . this study showed that both hypothesized immunization strategies could produce savings . obtained results support the use of pneumococcal conjugate vaccine for adults . this strategy could represent a sustainable and savings - producer health policy .

according to the american cancer society , more than 178,000 women are affected by breast cancer every year ; international statistics reports estimated 1,152,161 new cases annually . this form of the disease is the leading killer of women between 40 and 55 years old and is the second leading cause of death overall in women . due to this , screening techniques allowing early detection and diagnosis have been studied in order to increase the chances of survival using less aggressive treatment [ 2 , 3 ] . among the screening techniques currently available , mammography is the most often used , considered as the gold standard to breast tumor detection . however , this procedure is less effective when investigating dense breasts due to relatively high false negative rates . moreover , the number of unnecessary biopsies is very large and can lead to changes in the parenchyma making it difficult to read subsequent mammographic images . in recent years , ultrasonography has proven a valuable technique used as an adjunct to conventional mammography for the detection and classification of breast lesions . this procedure has been used to obtain additional diagnostic information , in order to reduce the number of unnecessary biopsies and assist with more accuracy the diagnosis of simple cysts ( around 96100% of efficacy when both of these techniques are used together ) . an additional advantage of ultrasound is that it does not use ionizing radiation and therefore is useful especially for younger patients who tend to have dense breasts . the detection of abnormalities in medical images is a procedure prone to errors , even for qualified radiologists , due to the subjectivity in defining boundaries , overlap between benign and malignant characteristics , and the presence of artifacts that may confuse the diagnosis . in order to increase diagnostic accuracy and minimize such errors , computational tools have been developed to provide a second opinion for the specialist and assist in early detection of breast cancer . in this context , this work aims to develop a tool to aid the diagnosis based on the automatic detection of lesions in ultrasound images and the consequent classification of such finding as clinically suspicious ( malignant ) or not ( benign ) considering an analysis of their morphological characteristics . the database used in this research consisted of two distinct sets of breast ultrasound images . the first corresponds to images from breast phantoms and the second from conventional clinical examinations . the phantom images were acquired from tests performed by the group of innovation in medical instrumentation and ultrasound ( giimus ) from university of so paulo , brazil . the phantoms used in this research were bb-1 model ( breast biopsy phantom , ats laboratories ) and models previously developed by vieira et al . . all the phantoms were made of an acoustically tissue mimicking material and have a shape similar to the breast of an adult woman . all these phantoms were submitted to ultrasound beams from a ge logic - book xp portable device , operating in the frequency range of 110 mhz . a total of 144 phantom images in b - mode were acquired as those illustrated in figure 2 . two medical centers of imaging diagnosis at so carlos , sp , brazil , provided clinical ultrasound images . four devices were used in the process of obtaining these images , siemens g50 , medison x8 , toshiba nemio 30 , and general electric logiq p5 , considering a broadband linear transducer of 7.510 mhz frequency range . figure 3 shows some examples of b - mode ultrasound images acquired with such different equipment . for each image , an experienced radiologist performed the analysis in order to detect lesions with suspicious appearance and then selected the regions of interest ( rois ) . therefore , such a procedure resulted in 173 rois corresponding to actual clinical ultrasound images and 144 from phantoms images . in order to remove noise and to smooth the image components , rois have been preprocessed by a wiener filter , followed by the contrast enhancement ( image equalization ) and median filter . based on the variability in segmentation techniques , the efficacy was evaluated taking into account some techniques applied in order to highlight the lesion : active contour , region growing , fuzzy c - means , k - means , and som neural network [ 18 , 19 ] . a postprocessing technique was then applied aiming to improve the segmentation quality since many pixels were verified to be disconnected from the actual lesion after the use of some of the techniques mentioned above . as a consequence , this effect has produced a more spiculated and noisier appearance than the nodule actually had . therefore , artifacts disconnected from the object of interest were eliminated and the internal valleys have joined the region . feature extraction in digital images is a critical step for identifying objects . in most cases , the use of more than one measure is required in order to decide to which class the pattern belongs . the most common is to extract from each sample several measures and then represent them through a vector , which will serve as an input to the classifier . in general , thus , based on the shape of the lesion as previously reported , 24 morphological features were extracted from each one . however , due to the large number of features considered , gaussian distribution curves were used regarding this features set optimization , so that it could accurately describe the identified object . in this procedure , each descriptor is normalized and gaussian curves are generated based on the distribution of values presented for each class ( or just two for this work 's purposes ) . the most important is the level of curves intersection : the smaller its occurrence , the higher the probability of such feature representing such a category . furthermore , the distribution range of the values in the abscissa axis must be checked in order to determine the optimum distance between the classes . multilayer perceptron ( mlp ) neural network is a tool frequently used in differentiating between benign and malignant lesions . its topology consists of sensory units which include the input layer , one or more hidden layers ( also known as intermediary ) , and an output layer . a supervised learning algorithm analyzes , through comparative actions between inputs and the desired output , the training data and produces an inferred function , which can be used for mapping new examples . an optimal scenario will allow for the algorithm to correctly determine the class labels for unknown instances . after performing comparisons in the learning method ( the backpropagation ) , the synaptic weights are adjusted continuously reaching for convergence . in this step , the discrepancy between the responses produced by the network and the desired signal is evaluated . the network adjusts the values of the synaptic weights and this process is finished only when the error assumes an acceptable value . this procedure was performed through random partitioning of the dataset into two subsets : training and test . the training was accomplished only in phantom images due to the low number of malignant cases in actual clinical exams . thus , 144 rois from phantoms images were used for classification , 72 corresponding to benign and 72 to malignant images . from these 144 images , the first computational test was performed on a set of 80 rois from phantom images and 50 from actual clinic ones . after the roi selection , the following preprocessing techniques were applied : wiener filter , equalization , and median filter . figures 5 and 6 show some examples of this preprocessing effect on phantom and clinical images . in the second step , some segmentation techniques ( as those previously mentioned in section 3 ) were applied in order to precisely delineate the lesions with smooth and regular edges . however , it was necessary to apply opening and closing morphological operators after segmentation to smooth the segmented lesion edge . manual segmentation provided by an experienced radiologist as well as some examples of the effects of segmentation techniques application and postprocessing on phantom images can be seen in figure 7 . in order to confirm the validation of these procedures also to actual clinical images , some corresponding results are shown in figure 8 . due to the visual subjectivity in evaluation to find the most accurate detector , measures were determined to quantify the distance between the edge automatically defined and that manually delineated by an experienced radiologist . hence , ten measures were evaluated , according to the descriptions in [ 2426 ] . the calculated values for the phantoms images dataset are shown in table 1 while table 2 reports those values but they were calculated for the actual breast images dataset . based on these data , the advantage of segmentation by active contours and by the som neural network can be noted in comparison to the others . in addition , when comparing both methods with the delimitation by the radiologist , they reported greater accuracy and low error rates . thus , both detectors were tested individually to gather the best classification results with phantoms as well as actual clinical images . the first step was the extraction of 24 morphological features only for the 144 phantoms images ( 72 corresponding to benign signals and 72 to malignant ones ) . then , the most relevant features were selected by means of gaussian distribution curves . among the 24 curves produced , those not evidencing appropriate visual results , that is , those with fully or partially overlapping areas , were discarded . just 8 gaussian distributions provided good partition for both the active contour segmentation and som , as shown in table 3 . each of the 8 selected features by the gaussian distribution curves was individually introduced to mlp , but the results achieved were not significant . the amount of neurons in the single hidden layer varied from 1 to 9 , and the learning rate was constantly adjusted between 0.1 and 0.9 . during this step , the topology that achieved the best result for each detector is described in table 4 . the accuracy rate in classification when the lesion was segmented by som was 94.2% and it was 95.6% when the lesion was segmented by active contour . figure 9 illustrates the respective gaussian distribution curves used for determining each descriptor selected by their overlapping analysis . after completing the classification procedure , we obtained the values of true positive ( tp ) , false positive ( fp ) , false negative ( fn ) , and true negative ( tn ) , as shown in table 5 . in figure 10 , roc curves regarding the classification of phantom images with mlp are shown as for segmentation by som network ( a ) as well as by active contour ( b ) . the values calculated for the areas under the curve ( auc ) are displayed in their respective graphics . the performance of this classifier was compared to others previously described by correlate literature with similar purposes . table 6 shows the data previously presented by each one of those studies in comparison to our results mainly in terms of accuracy , sensitivity , and specificity rates . both classification proposals , with the contour segmented by som ( case 1 ) and active contour ( case 2 ) , have yielded high sensitivity and specificity in breast lesions classification , similar to the works considered in table 6 . the same accuracy was achieved for both cases and it was higher than all the results presented by such works . in our study , the sensitivity was higher in case 1 , while the specificity was higher in case 2 . additionally , it is important to stress that in our study the training and validation procedures were performed with phantom images , due to the small set of clinical images corresponding to the class malignant . these phantom images had structures of interest with a relatively regular shape and in some cases they were easily segmented . this aided in achieving high accuracy in both cases ( for benign and for malignant simulated structures ) . in order to evaluate whether the classifier is able to generalize and reach similar results when applied to actual clinical images , tests with the second dataset were performed , taking into account the fact that it was trained with phantom images which have slightly different intrinsic characteristics . with this purpose , an experienced radiologist determined 173 rois which were automatically segmented by both techniques ( i.e. , active contour and som ) . then , measures of solidity , area ratio , and form factor were extracted from each roi . finally , these data were used by the neural network classifier with the topological configuration providing the best result for each detector ( shown in table 4 ) . the high fp rates are largely related to morphological differences between phantom images and actual ones , mainly the simulated structures in the phantoms under test with more rounded shapes . as a consequence , even with these morphological differences between the types of images , the classifier achieved good data generalization , reaching 100% of sensitivity and 78% of specificity when using segmentation by som . in the classification after segmentation by active contour , the sensitivity rate decreased significantly ( only 63% ) though specificity was almost the same : 79% . this difference is evident when the area under the curve is calculated ; corresponding results are shown in figure 12 . the overlap of benign and malignant characteristics in interpreting ultrasound images turns the process subjective and tends to complicate the diagnosis of breast lesions . for this reason , cad schemes have emerged to improve the analysis of the radiologist by means of computerized characterization . some flaws however often arise in many cad schemes when evaluating images from breast ultrasound acquisitions mainly due to speckle noise influence on the lesions boundaries definition . testing five detectors techniques and measuring how close they were relative to the ground truth , only the som network and the active contour yielded significant accuracy rates . a differential of active contour technique is not requiring the preprocessing and the use of morphological operators to smooth edges . nevertheless , this final smoothing caused some changes in lesion limits , influencing the classification step . moreover , its algorithmic complexity requires many numerical operations and iterations until convergence of data has been reached . consequently , this leads to a high computational cost , making the processing relatively slow : about 30 seconds for each roi . the segmentation by som network on the other hand produced smoother contours and faster outcome results allowing a better understanding of the morphological differences between benign and malignant lesions . based on such a result , the classification by mlp was performed for both detectors . after extensive tests and topological changes , the classification taking breast phantom images with detection by active contour was more than 95% accurate , a rate higher than that for detection by som network ( 94.24% ) . however , the index of the classification with detection by active contour decreased significantly when applied to actual clinical images , which has registered an accuracy of 77.5% . therefore , the detection using the neural som network allowed better accuracy and data generalization when new images were introduced to the classifier . another important feature to be stressed is the contribution that breast phantoms ultrasound images have made to this investigation , since they constituted a manageable dataset with known materials and morphological characteristics . furthermore , as large variations related to the simulated lesion morphology can be provided , the dataset becomes useful for the network training before the tests with actual us images , especially with the new guidelines and recommendations for clinical use of ultrasound elastography . the system described here has an intuitive and easy interface , providing fast and accurate responses to the specialist . the tool is fully automated but allows , if necessary , user intervention to improve the segmentation process , due to manual change in the maximum and minimum parameters in the training . it is considered that the system has produced good results , acting as an important tool for the aid in diagnosis in breast ultrasound .

this research presents a methodology for the automatic detection and characterization of breast sonographic findings . we performed the tests in ultrasound images obtained from breast phantoms made of tissue mimicking material . when the results were considerable , we applied the same techniques to clinical examinations . the process was started employing preprocessing ( wiener filter , equalization , and median filter ) to minimize noise . then , five segmentation techniques were investigated to determine the most concise representation of the lesion contour , enabling us to consider the neural network som as the most relevant . after the delimitation of the object , the most expressive features were defined to the morphological description of the finding , generating the input data to the neural multilayer perceptron ( mlp ) classifier . the accuracy achieved during training with simulated images was 94.2% , producing an auc of 0.92 . to evaluating the data generalization , the classification was performed with a group of unknown images to the system , both to simulators and to clinical trials , resulting in an accuracy of 90% and 81% , respectively . the proposed classifier proved to be an important tool for the diagnosis in breast ultrasound .

two years ago , i analyzed the journal metrics of the korean journal of urology ( kju ) . at that time , i manually calculated the 2012 journal citation reports ( jcr ) impact factor ranking from the web of science , which corresponded to the upper 84.9% . the hirsch index ( h - index ) from the web of science was 8 . that retrospective study was conducted to determine if the strategy of changing the language of the kju to exclusively english in 2010 was successful from the point of view of journal metrics . here , i would like to verify how much progress has been made in journal metrics since the last citation analysis of kju . the results of the present analysis will provide the journal with direction for recruiting high - quality submissions and will provide basic data for the future planning of journal promotion . this was a cross - sectional descriptive bibliometric study . in this follow - up study , the following journal metrics were analyzed in february 2015 : total citations , impact factor , and h - index . the number of different countries of the authors publishing in kju was compared between 2012 and 2014 . the proportion of funded papers and the countries of the editorial board members were added in the present analysis . the number of total articles and citable articles in kju from 2012 to 2014 is presented in fig total citations in the web of science were 332 in 2012 , 439 in 2013 , and 578 in 2014 . impact factors from 2012 to 2014 were 0.770 , 0.824 , and 0.751 , respectively . the 2013 impact factor corresponds to the upper 81.8% in the urology and nephrology category if compared with the 2013 jcr . the score for the 2014 impact factor may be higher if it is checked again in april 2015 , when more journal data are inputted for 2014 web of science journals . of the 15 most frequently cited articles , 12 were original research articles and 3 were review articles . the authors in kju were from 16 different countries in 2012 and from 21 different countries in 2014 . the proportion of original articles that were funded was 0.8% in 2012 , 0.9% in 2013 , 7.1% in 2014 , and 43.8% in the january and february issues of 2015 . editorial board members were from 7 countries in 2012 ( australia , austria , china , japan , korea , taiwan , and united states ) and from 15 countries in 2014 ( australia , austria , canada , china , hong kong , india , indonesia , italy , japan , korea , malaysia , singapore , taiwan , turkey , united kingdom , and united states ) . new scopes added in 2014 were genomics / stem cells in urology , urological oncology , laparoscopy / robotics , and new technology / lasers in urology . because the journal metrics from komci ( korean medical citation index ) and sjr ( scimago journal & country rank ) are easily found and interpretable , i did not add those results . since kju has not been indexed in the web of science through february 2015 , it is necessary to analyze the metrics manually calculated from the web of science . over the past 2 years the 2013 impact factor , which corresponded to the upper 81.8% of jcr ranking , was a meaningful increase . the increase in the h - index from 8 to 11 over 2 years is also astonishing progress , although the h - index usually increases every year because it is a cumulative value . interestingly , the publication types of the 15 articles frequently cited equal to or greater than 11 times were original articles ( 12 ) and review articles ( 3 ) . in other journals , the publication type of highly cited articles tends to be review article . for example , of 13 highly cited articles in diabetes & metabolism journal , 10 articles were review articles . of seven highly cited articles in clinical and experimental reproductive medicine , five articles were review articles . this discrepancy may arise from the fact that the original articles in kju focused on emerging fields such as laparoendoscopy . the increase in the number of countries of the authors from 16 to 21 reflects that the kju is already an internationally well - known journal . , there may be at least 40% funded articles among the original ones , because the proportion of funded articles in the january and february issues was 43.8% . it is believed that funded articles have already passed one level of peer review in order to acquire research funds . it is the editors ' task to recruit funded research results as much as possible and review them . the number of countries of the editors increased in 2014 to more than two times the number in 2012 . diversity in editors ' countries is believed to contribute to diversity in authors ' countries . new scopes in 2014 such as genomics / stem cell , uro - oncology , and robotic surgery will be prominent characteristics of the kju that will allow it to compete with other international journals . there was a comparable 2-year follow - up study of journal metrics for the korean journal of internal medicine from 2011 to 2013 . for that journal , the impact factor increased from 0.623 to 1.252 and the h - index increased from 14 to 15 . from these data , it can be seen that a rapid increase in the h - index is difficult as the value increases . the increase in the kju h - index from 8 to 11 was possible because of an h - index below 10 in 2012 . in korea , journal metrics are of concern to editors because these are among the important selection criteria for international citation databases . especially , a new journal title likes to know the journal 's position in the journal markets through journal metrics . this remarkable progress in kju journal metrics has been accelerated since the journal 's inclusion in pubmed central ( pmc)/pubmed from april 2010 . this inclusion was possible after the change to english language only from the january issue of 2010 . the production of pmc extensible markup language ( xml ) , now also called journal article tag suite ( jats ) xml , of an english - language journal is a basic requirement to be a pmc journal . in korea , the production of jats xml is possible through several publishing companies or information technology companies . increased citation usually originates not from open access itself but also from the journal platform . since pmc / pubmed is the most important platform for medical literature searches , all editors of korean medical journals published in english tried to add their journals to this platform and succeeded in increasing their journals ' impact factors enough to be indexed in the international databases . furthermore , being indexed in medline in july 2014 has given the kju a greater chance of being cited owing to the addition of mesh ( medical subject headings ) to kju articles in pubmed . the editor of kju has immediately and continuously adopted recent information technology introduced for scholarly journals , such as doi ( digital object identifier ) , crossmark , fundref , qr ( quick response ) code , orcid ( open researchers and contributors i d ) , video clips , mobile web , social networking services , and youtube . such efforts are the most powerful tool for disseminating invaluable information in the internet age beside the journal platform . introduction of tdm ( text and data mining ) in the near future will also enhance the citation of kju . the promotion of the journal metrics for the kju over the past 2 years was possible as a result of the editor 's and editorial board members ' enthusiasm , sacrifice , and devotion to kju . two years after the first report on journal metrics of kju , remarkable progress has been made in total citations , impact factor , and the h - index manually calculated from the web of science . introduction of new scopes such as genomics / stem cells , robotics , and uro - oncology will be a mainstay for journal development .

purposein april 2013 , the journal metrics of the korean journal of urology ( kju ) were reported . that report showed tremendous improvement from the point of view of journal metrics . two years later , the same metrics were reanalyzed to determine the present position of the kju among the international journals in the web of science.materials and methodsi analyzed journal metrics of the kju such as impact factor , total citations , and h - index by use of the same methods as in the previous report.resultstotal citations in the web of science were 332 in 2012 , 439 in 2013 , and 578 in 2014 . manually calculated impact factors from 2012 to 2014 were 0.770 , 0.824 , and 0.751 , respectively . there was an increase in the h - index from 8 in 2012 to 11 in february 2015 . editorial board members were from 15 countries in 2014 . authors of kju articles were from 21 countries in 2014.conclusionsduring 2 years , remarkable progress was made in kju 's citation indicators and in the diversity of the authors ' and editorial board members ' countries .

. they may occur as solitary or multiple lesions . in case of multiple lesions numerous small papules and/or large dome - shaped nodules are present on the scalp like a turban , hence the name turban tumor . scattered nodules are present occasionally on the face and in rare instances on the extremities . we report a 38-year - old male patient who had multiple cylindromas on the anterior region of the scalp . a 38-year - old male patient presented with a long - standing history of multiple non - tender scalp swellings from 2.5 to 3.5 cm in diameter , with progressive growth over the past one year . clinical examination revealed multiple nodular lesions coalesced on the anterior region of the scalp , which was solid and movable from the underlying surface . excisional biopsy was planned under general anesthesia followed by primary closure [ figures 3 and 4 ] . the excised specimen was sent for histopathological examination , which showed lobules of epithelial cells arranged in a jigsaw or mosaic pattern . each lobule shows a peripheral lining by dark basaloid cells and an inner larger and paler zone of cells , which was suggestive of dermal cylindroma [ figure 5 ] . follow - up was done regularly for one year and there were no signs of recurrence [ figure 6 ] . preoperative frontal view of the patient showing multiple swellings on the anterior scalp preoperative superior view of the patient showing multiple swellings on the anterior scalp intraoperative view after surgical excision of multiple swellings excised specimen showing multiple swellings with a glistening , smooth , faintly lobulated surface . note the cut section of the tumor showing solid mass inside histopathology showing lobules of epithelial cells arranged in a jigsaw or mosaic pattern . each lobule shows a peripheral lining by dark basaloid cells and an inner larger and paler zone of cells which was suggestive of dermal cylindroma postoperative frontal view of the patient after one week it has been reported to follow x - ray epilation of the scalp . in cases with solitary lesion , there is no family history association . the tumors are frequently multiple , smooth , firm , pink to red in color and often somewhat pedunculated the tumors may be almost hairless when pedunculated , but the smaller lesions form dermal nodules with little loss of hair over them . a proportion of lesions occur on the face and neck , in less than 10% of cases they are situated on the trunk and limbs . while phenotypic features differ between cylindromas and spiradenomas , recent studies have shown immunohistological and cytomorphological overlap , with both tumors exhibiting apocrine , eccrine , secretory , and ductal features . cylindromas are most likely a very primitive sweat gland tumor differentiating toward either the eccrine or apocrine line . the cause of sporadic , solitary cylindromas is largely unknown ; however , genetic studies of sporadic cylindromas show loss of heterozygosity at and around the cyld locus in a substantial number of cases , suggesting that this gene also plays a role in the development of sporadic tumors . familial cylindromatosus is inherited in an autosomal dominant fashion , and the responsible gene , cyld , is located on band 16 q 12 - 13 . the lesion is composed of numerous oval and polygonal nests molded into a jigsaw - like pattern . masses of epithelial cells are surrounded and penetrated by a hyaline sheath closely resembling a basement membrane . this sheath separates the tumor from the dermal mesenchyme , yet does not interfere with tumor growth and proliferation . cylindromas , on the other hand , demonstrate a large number of prominent dendritic cells that most likely represent langerhans cells that permeate the tumor . used carbon dioxide laser to treat facial trichoepitheliomas in twp patients , with good results . multiple cylindromas usually require extensive plastic surgery that may be obviated by progressively excising a group of nodules in multiple procedures . follow - up care of patients with multiple cylindromas is recommended because of the tendency for new lesions to develop and to prevent the risk of malignant degeneration .

dermal cylindroma is a benign neoplasm of the eccrine sweat glands , which presents in the head and neck area in majority of cases . in its most florid presentation , the entire scalp can be involved , leading to the descriptive label turban tumor . they most commonly occur on the head and neck as solitary or multiple tumors . solitary cylindromas occur sporadically and typically are not inherited . multiple tumors are observed in an autosomal dominantly inherited manner . when nodules enlarge and coalesce on the scalp , they form the distinctive turban tumor feature . we present a case of multiple form of dermal cylindroma , occupying the anterior scalp in a 38-year - old male patient .

insomnia , which is difficulty with falling asleep , is more common among aged people . it was found that insomnia occurs in one - third of the general population leading to daytime sleepiness and mental disturbances . it has very serious impacts on individuals health and psychological status which leads to anxiety , depression and poor performance1 . studies have shown that insomnia is also more common among college students and can result in stress , depression and reduced academic performance2,3,4,5,6 . sleep disorders are one of the public health issues that need attention for prevention and early detection , as they are one of the causes of work absenteeism9 . insomnia is defined by the presence of an individual s report of difficulty with sleep10 . subjective assessments includes self- reporting scales like the pittsburgh sleep quality index ( psqi ) , the insomnia severity index ( isi ) , the women s health initiative insomnia rating scale , the basic nordic sleep questionnaire , and the daily sleep log and anxiety index ( stai ) . the insomnia severity index is a valid , reliable and easy to administer tool11 . although pharmacological treatments are effective , they can cause adverse effects such as increased risk of falls , drowsiness , dizziness , cognitive impairment , somnolence , nausea , vomiting and motor vehicle crashes . non pharmacological managements of insomnia include bright light therapy , stimulus control therapy , sleep restriction therapy , sleep hygiene education , cognitive therapy , relaxation therapy , paradoxical intention , and multi- component therapy12 . it has also been found that there is an association between regular exercise or physical activity and the prevalence rate of insomnia13 . most studies have focused on management of clinical insomnia among the middle- aged and elderly , but the aim of our present study was to assess the level of insomnia among female college students , and to determine the association between their physical activity and the insomnia severity index . after obtaining ethical committee approval multiple events were planned at the college of applied medical sciences , king saud university , riyadh , to invite female graduate students to take part in this study . activities like posters , face book events , broadcasts , and lectures were undertaken to motivate the students to participate in the walking program . one hundred and five volunteers as a sample of convenience were included and screened for the inclusion criteria . subjects who had a history of fracture or surgery to the back , pelvis , or lower limb , any contraindications to increased walking , current complaints or conditions affecting their ability to walk , pregnancy or cardiopulmonary disorders were excluded . subjects with insomnia based on the icsd-2 definition , which consists of frequent awakening and difficulty with falling asleep again , difficulty with falling asleep , waking too early , secondary day time impairment due to nighttime sleeplessness were included14 . , medical , socioeconomic and academic details were collected and the isi questionnaire and daily physical log were distributed . in the second stage , a seven- meter distance was taped on the floor to measure stride length , which was calculated by asking subjects to take 10 steps forward , 5 steps with each foot at their natural stride bringing the feet together with the last step . the stride length was calculated by dividing the distance covered by 10 . after recording stride length values , each subject was given a pedometer ( omron model hj-152 ) in the final stage . subjects were instructed to wear the pedometer at the level of the anterior superior iliac spine ( asis ) and also to fill in the daily physical activity log . out of the 105 volunteers , 33 were excluded , and there were 10 dropouts during the 3-week motivation program , leaving finally 62 volunteers who successfully completed the study . the insomnia severity index ( isi ) it is comprised of seven questions which are scored on a likert scale ranging from 0 to 4 . the scores range from 0 to 28 : 0 to 7 , no clinically significant insomnia ; 8 to 14 , sub- threshold insomnia ; 15 to 21 , clinical insomnia ( moderate ) ; 22 to 28 , clinical insomnia ( severe ) . the isi is a valid , reliable , and easy to administer questionnaire both as a screening tool and a measurement tool11 . pedometers are small devices that can be worn at the waist or ankle , and are capable of counting the number of steps taken15 . the participants were given an omron ( model hj-152 ) pedometer , and they recorded their total daily steps for three weeks . out of 105 volunteers , 80 subjects met the inclusion criteria , but only 62 could completed the study . prevalence of insomnia : 50% of the subjects had no clinically significant insomnia ( ncsi ) , 42% had sub- threshold insomnia ( sti ) , and 8% had moderate clinical insomnia ( mci ) . physical activity log : the number of steps taken per day was recorded for 3 weeks . this encouraged the subjects to take as many steps as they could to improve their physical activity ( table 1table 1 . the results show that physical activity increased from the first to the third week . association between insomnia and sleep problems : pearson correlation analysis revealed a significant correlation between sleep problem and the insomnia severity index after the motivation program ( r= 0.353 , p 0.01 ) ( table 2table 2 . relationship between isi and sleep problemcorrelationssleep probleminsomnia severityindex beforeinsomnia severityindex aftersleep problempearson correlation10.4 ( * * ) 0.3 ( * * ) sig . ( 2-tailed).0.00.0n787265insomnia severityindex beforepearson correlation0.4 ( * * ) 10.7 ( * * ) sig . ( 2-tailed)0.0.0.0n727264insomnia severityindex afterpearson correlation0.3 ( * * ) 0.7 ( * * ) 1sig . association between the number of coffee cups drunk and insomnia : pearson correlation analysis of the insomnia severity index before and after the motivation program with the number of coffee cups drunk per day showed a positive correlation with a value of r=0.178 and ( p=0.149 ) which was not statistically significant . association between physical activity and insomnia : physical activity measured as the number of steps taken correlated with the isi values showing a moderately negative correlation , with values of r= 0.396 at week 1 , and r= 0.378 at week 3 ( table 3table 3 . association between physical activity and isincorrelationpair 1pa 1 & isi720.3pair 2pa 3 & isi660.3pa- physical activity in weeks 1 and 3 . this is the first study conducted among saudi female college students to have determined the association between their physical activity and insomnia . the results show that 50% had ncsi ( no clinically significant insomnia ) , 42% had sub- threshold insomnia and 8% had moderate clinical insomnia . the average number of steps taken increased from the first week to the third week . we found a mild negative correlation between physical activity and the insomnia severity index . this is consistent with earlier findings that exercise has a beneficial effect on sleep problems especially insomnia16 . sleep regulates mood and affects learning , memory , concentration and recall , because it is one of the most important processes in a creature s life . on the other hand , poor sleep quality has adverse effects on learning , memory , and awareness adversely affecting work performance , especially among students . students need to show a high level of performance , which may not be achieved with sleep disturbances , because higher mental functions would be affected , leading to unhappiness , irritability , tiredness , depression and decreased level of performance . in 1998 , sherrill et al . associated the level of physical activity and sleep disorders in the middle aged to elderly with obstructive lung airway disease . they reported that women have sleep disturbance and participate in exercise programs more than men , whereas men did regular vigorous activity , and walking at a brisk pace approximately 4.8 to 6.4 km / h . the effect of exercise on sleep is observed when it exceeds 1 hour in duration , and appears to be related to alteration of sleep architecture , e.g. frequency , duration , daytime sleep , quality etc13 . this is consistent with the results of our study that higher physical activity has beneficial effects on sleep quality . researchers conducted a study of patients with end- stage renal disease in saudi arabia . they found that insomnia is common in dialysis patients and was significantly associated with other sleep disorders17 . previous studies also showed that sleep deprivation , and psychological stress are more common among medical students in other countries18,19,20 . moderate intensity aerobic exercise reduced pre - sleep anxiety and improved the sleep of middle - aged and older patients with chronic primary insomnia22 , 23 . previous studies have shown a strong relation between subjective assessment and objective assessment using polysomnography or actigraphy24 , 25 . the insomnia severity index ( isi ) is considered a clinically reliable and valid tool in insomnia treatment research26 . pedometers are considered the most valid and reliable tools for measuring physical activity27,28,29,30 . our present study included a small sample size , and had only a 3-week motivational program for increasing the number of steps taken per day . physical activity was observed to be highest in the second week , and it gradually reduced in the third week . we recommend further research with a longer duration motivation program in a larger group to establish a stronger relationship between physical activity and insomnia .

[ purpose ] insomnia is quite common and it can affect the quality of life of an individual . students undergo stress due to various academic demands leading to sleeplessness and daytime sleepiness . this study was conducted to investigate the association between physical activity and insomnia among female saudi students . [ subjects ] 62 female students with a mean age of 21 1.5 years took part in a motivational program to increase the number of steps taken per day for three weeks . [ methods ] after obtaining subject s informed consent all the subjects were assessed for insomnia using the insomnia severity index ( isi ) , they were then given pedometers to calculate the number of steps they took per day . a physical activity log was kept for three weeks . pre- and post -intervention isi scores were calculated and correlated with the 3-week physical activity log . [ results ] 50% of the subjects had no clinically significant insomnia ( ncsi ) , 42% had sub threshold ( sti ) , and 8% had moderate clinical ( mci ) insomnia . there was a moderate negative correlation between physical activity and isi scores after the 3-week motivation program . [ conclusion ] prevalence of insomnia was common among female saudi students and increase in physical activity appears to improve the sleep pattern .

synovial cysts with neurologic symptoms are common in the lumbar spine , but rare in the cervical spine . most cervical synovial cysts are found incidentally , but may cause cervical radiculopathy or myelopathy due to compression of the spinal cord or nerve roots . a review of the literature revealed only 31 cases of synovial cysts of the cervical spine ; in most of these cases , the cysts had a non - traumatic origin10 ) . only two cases were associated with major trauma presenting as myelopathy1,8 ) . here , we present a patient who presented with acute paraparesis after manual stretching due to a cervical synovial cyst , and we discuss the clinical aspects of this disease . although a cervical synovial cyst is often associated with degeneration of facet joints , clinicians should be aware that cervical synovial cysts can cause acute neurologic presentations . a 67-year - old man with a 10-year history of lower back pain presented with abrupt onset gait disturbance and paresthesia in his lower limbs after manual stretching 3 days prior . on admission , neurological evaluation revealed weakness of both legs ( hip flexion : g4/5 , knee extension : g4/5 , foot plantarflexion and dorsiflexion : g4/5 ) , and the patient showed diminished touch sensation with increased sensitivity to pain below the level of the t12 dermatome . on deep tendon reflex examination , the patient 's right patellar tendon reflex was diminished ; the other reflexes were increased . we performed magnetic resonance imaging ( mri ) of his whole spine to accurately assess spinal cord lesion . cervical mri identified a 1 cm diameter extradural cystic lesion in the spinal canal with cord compression at the left c7-t1 level ( fig . 1 ) . we performed a left partial laminectomy of c7 and t1 using a posterior approach and completely removed the cystic mass under the intraoperative neurophysiologic monitoring . histological examination of the resected mass showed fibrous tissue fragments with amorphous materials and granulation tissue , consistent with a synovial cyst ( fig . synovial cysts of the spinal column arise from the lining of defective facet joints or those with degenerated articulations5 ) . synovial cysts usually occur in patients aged 50 - 60 years and there is no gender bias2,6,8 ) . most cases are asymptomatic and are detected incidentally , but may cause pain , radiculopathy , or myelopathy . however , this condition is very rare ; only 31 previous studies have reported an association between a cervical synovial cyst and neurologic changes10 ) . a review of literature revealed that 10 of these cysts occurred at the upper cervical level ( peri - odontoid process , c1-c2 articulations related to rheumatoid arthritis , only one case in c3-c4 ) and 21 cases in c6-c7 or c7-t1 facet joints . most cases presented with acute or progressive myelopathy induced by a non - traumatic origin . only two cases of a cervical synovial cyst presenting as myelopathy associated with trauma have been described . one patient developed spastic paraplegia after spine fracture1 ) , while the other case of posttraumatic myelopathy was related to cyst enlargement due to intra - cystic acute hemorrhage8 ) . in the case presented here , there was no acute formation of a synovial cyst or hematoma by microscopic examination and no evidence of a fracture . 3 ) first , synovial cysts may grow due to motion resulting in a mass effect over time . in these cases , neurologic deterioration could develop progressively . as was reported previously8 ) , secondary changes of the cyst , such as intra - cystic hematoma after trauma , presence of a calcified cystic wall , or an inflammatory response can induce neurologic changes7 ) . third , regardless of changes in cyst size , patients with degenerative static synovial cysts may undergo direct trauma or hyperextension resulting in spinal cord or nerve root damage . in our patient , acute myelopathy resulted from pressure to his posterior neck applied by a massage therapist ; he reported that he felt as if an electric shock flowed from his thoracic to his lower extremities . at that moment , his degenerative cervical synovial cyst seemed to give rise to direct spinal cord injury . even in the absence of a traumatic event , a synovial cyst may aggravate spinal cord ischemia resulting from direct static compression . in the past , cervical myelography was performed to diagnose a cervical synovial cyst1,8 ) . nowadays , t2-weighted mr and ct scanning allow excellent visualization of cystic lesions with high signal and confirmation of proximity to the spinal cord or nerve root10,11 ) . other extradural spine tumors in the posterior column , including meningiomas , perineural cysts , dermoid cysts , lymphoma , abscess and metastases , should be considered in the differential diagnosis2,9 ) . recently , it was reported that facet arthrography allowed preoperative determination of the continuity between the extradural lesion and the facet joint , leading to confirmation of a synovial cyst11 ) . the prognosis of a symptomatic cervical synovial cyst varies ; some patients recover after surgical removal of the cyst , while others experience spontaneous resolution without surgery3,6 ) . in lumbar synovial cysts , ct - guided percutaneous needle aspiration or corticosteroid injection have been attempted as non - surgical treatments , but these approaches have not been used to treat cervical synovial cyst7 ) . in cervical synovial cysts , a percutaneous needle procedure may worsen the patient 's neurologic state if the cyst ruptures . hence , surgical excision is generally accepted as the treatment of choice for cervical synovial cysts , as it results in early neurological improvement and there have been no reports of the recurrence of a cervical synovial cyst after surgical excision . we described a case of acute myelopathy caused by a cervical synovial cyst that was treated successfully by surgical excision . although a cervical synovial cyst is often associated with degenerative facet joints , clinicians should be aware that cervical synovial cysts can cause acute neurologic symptoms .

synovial cysts of the cervical spine , although they occur infrequently , may cause acute radiculopathy or myelopathy . here , we report a case of a cervical synovial cyst presenting as acute myelopathy after manual stretching . a 68-year - old man presented with gait disturbance , decreased touch senses , and increased sensitivity to pain below t12 level . these symptoms developed after manual stretching 3 days prior . computed tomography scanning and magnetic resonance imaging revealed a 1-cm , small multilocular cystic lesion in the spinal canal with cord compression at the c7-t1 level . we performed a left partial laminectomy of c7 and t1 using a posterior approach and completely removed the cystic mass . histological examination of the resected mass revealed fibrous tissue fragments with amorphous materials and granulation tissue compatible with a synovial cyst . the patient 's symptoms resolved after surgery . we describe a case of acute myelopathy caused by a cervical synovial cyst that was treated by surgical excision . although cervical synovial cysts are often associated with degenerative facet joints , clinicians should be aware of the possibility that these cysts can cause acute neurologic symptoms .

a pleural loose body , which is also known as a ' pleural mouse ' , ' pleural fibrin body ' , or ' thoracolithiasis ' , is a rare benign condition . there have been several case reports of this benign condition , in which most of the loose bodies were calcified and up to 1.5 cm in size ( 123 ) . we report a pleural loose body found incidentally that was unusually large and non - calcified , mimicking a pedunculated pleural tumor on imaging studies . this case report was approved by our institutional review board and the patient 's informed consent was waived . a 58-year - old woman presented with a mass found incidentally on a chest radiograph . the posteroanterior chest radiograph showed a well - defined mass with a smooth margin in the right paratracheal area ( fig . precontrast computed tomography ( ct ) showed a 4 cm mass in the subcarinal area ( fig . 1b , c ) , but on the postcontrast ct obtained 2 minutes later , the mass was observed in the right paravertebral area ( fig . the attenuation value of the mass was 42 - 44 hounsfield units on precontrast ct , and the mass did not show contrast enhancement . in a follow - up posteroanterior chest radiograph , the mass had migrated to the subcarinal area ( fig . the impression based on the imaging studies was a pedunculated solitary fibrous tumor of the pleura , and the differential diagnosis included a benign neurogenic tumor . cystic mass types , such as the bronchogenic cyst , were not included in the differential diagnosis due to the mass ' mobile nature . a 3 4 cm " soap - like " white hard mass was found floating freely in the pleural cavity . the mass did not have a stalk connecting it to the parietal pleura ( fig . histopathologically , the mass consisted of hypocellular hyalinized collagen and the surface of the tumor showed some scattered chronic inflammatory cells and the characteristic " basket - weave " configuration of laminated hypocellular mature collagen ( fig . there have been a few case reports and case series , mainly from japan , which variably describe this condition as an ' intrapleural loose body ' , ' pleural fibrin body ' , or ' thoracolithiasis ' ( 123456 ) . the pleural loose body is rarely symptomatic and there are no age or sex predilections . most of the cases were found incidentally on imaging studies or at autopsy , although there have been a few case reports in which the mass developed after a thoracotomy or traumatic pneumothorax ( 56 ) . the size usually ranges from 5 - 15 mm ( 123 ) and it may or may not be calcified . the largest reported example was a 5 cm calcified mass ( 7 ) . in our case , the loose body was a 4 cm non - calcified fibrin body , which is the largest reported non - calcified loose body . although this mass was found around the carina , they tend to be located in the dependent portion of the thorax around the diaphragm . the mobile nature on sequential imaging studies is the most characteristic finding of a pleural loose body . ( 3 ) demonstrated the continuous migration of 11 calcified loose bodies on multiple sequential cts . our case also showed spontaneous shifting in every sequential imaging study , even in the 2 minute interval between the pre- and postcontrast cts . in a retrospective review of our case , another important diagnostic clue differentiating it from soft tissue tumors was the absence of contrast enhancement , although some benign tumors , such as benign neurogenic tumors , can show little contrast enhancement . they consist of an outer wall of fibrous tissue and a variable central core which is usually fatty tissue with or without necrosis ( 8) . calcification may or may not be present . in our case , the entire mass consisted of hyalinized collagen without a fatty core . in cases with a fatty core , magnetic resonance imaging can help with the differential diagnosis , since the fatty core shows high signal intensity on both t1- and t2-weighted images ( 9 ) . ( 3 ) proposed epipericardial fat necrosis as a possible mechanism for loose bodies with a fatty core , in which twisted , torn epipericardial fat undergoes aseptic fat necrosis and then may drop into the intrapleural space , resulting in a mobile loose body . for loose bodies not containing a fatty core , such as in our case , loose bodies have occurred after a thoracotomy ( 5 ) or traumatic pneumothorax ( 6 ) in which an exudative pleural effusion or hemothorax occurs , we postulated that a fibrin clot might form during resolution of the effusion or hemothorax . although our patient did not have a history of chest - related problems , she might have once suffered from self - limited pleurisy because tuberculous pleurisy is endemic in our country . a small calcified nodule migrating freely in the pleural cavity is virtually pathognomonic for thoracolithiasis , although a loose body with no or little calcification might be misdiagnosed as a benign neoplasm and resected with unnecessary surgery . some loose bodies have been reported to grow at follow - up ( 710 ) . our case was also misdiagnosed pre - surgically as a benign pedunculated solitary fibrous tumor of the pleura because of its non - calcified nature , mobility , and location between the lung and pleura , although the absence of contrast enhancement on ct did not favor a neoplastic condition . pre- and postcontrast ct may play an important role in the differential diagnosis and prevention of unnecessary surgery . in a mass abutting the pleura or mediastinum , the combination of mobility and no contrast enhancement is an important clue to diagnosing a pleural loose body . in patients with these imaging findings

we present a rare case of a pleural loose body , thought to be a pedunculated pleural tumor , found incidentally in a 58-year - old female . computed tomography showed a non - enhancing mass , which migrated along the mediastinum and paravertebral area . thoracoscopic surgery revealed a 4 cm , soap - like mass that was found to be a fibrin body consisting of hyalinized collagen histopathologically . mobility and the lack of contrast enhancement of a pleural mass are important clues to diagnosing this benign condition .

a 61-year - old patient attended a consultation in a urology clinic due to complaints associated with the lower urinary tract . digital rectal examination ( dre ) revealed a slightly enlarged non - painful prostate gland with normal density and smooth contours . prostate - specific antigen ( psa ) level was 2.1 ng / ml . a urine test revealed 1015 red blood cells / hpf . the patient reported polyuria during the day and nocturia as well as persistent urgency with a normal urine stream . in an abdominal ultrasound scan no abnormalities were found in the upper urinary tract . due to the lack of effects of solifenacin therapy histopathological examination of samples from the tumor revealed : urothelial carcinoma high - grade pt1 , total resection of the lesion . in addition , carcinoma in situ was diagnosed in samples taken from the posterior wall of the urinary bladder . the patient was scheduled for intravesical immunotherapy . due to the size of the primary lesion ( 5 mm ) and the radicality of the original resection no repeated transurethral electroresection of the tumor of the bladder ( re - turt ) bacillus calmette - gurin ( bcg ) vaccine therapy was started 5 weeks after transurethral resection of the tumor ( turt ) . the vaccine was an attenuated strain of mycobacterium bovis ( onco bcg 100 formulation , biofarm , lublin , poland , containing at least 300 million live , attenuated mycobacteria of the brazilian moreau substrain dissolved in saline in 1 ampoule of 100 mg ) . after the first 2 doses the patient reported increases in body temperature of up to 37.5c as well as urgency episodes . after 6 weeks from the completion of the induction course cystoscopy and urine cytology were performed and no abnormalities were found . during a follow - up visit in a urology clinic dre revealed a very hard non - painful left prostatic lobe with an uneven surface , which was suspected of neoplastic hyperplasia . in line with the european association of urology guidelines , the patient was scheduled for a core biopsy of the prostate based on rectal examination results , despite a low psa level ( 2.1 ng / ml in the pre - operative period ) . in the group of patients with psa in the range of 2.13 ng / ml the risk of prostate cancer diagnosis is 23.9% ( european association of urology guidelines ) . twelve samples in total were collected under local anesthesia , including heterogeneously hypoechoic foci located in the peripheral zone on the left side . histopathological examination revealed multifocal low - grade prostatic intraepithelial neoplasia ( lg - pin ) in the right lobe of the prostate , while prostatitis chronica granulomatosa cum necrosi coagulativa telarum was found in samples from the right lobe , indicating a serious suspicion of tuberculosis origin of the lesions . the patient received consultation in a tuberculosis clinic ; however , no indications were found for anti - tuberculosis treatment . eight months after turt cystoscopy , dre and trus were conducted and samples were taken from lesions with suspected cancer relapse . rectal examination after 2 months from the biopsy revealed a non - painful , very hard left lobe of the prostate with an uneven surface . trus conducted in a reference center revealed an enlarged prostate of 45.6 ml in volume . the peripheral zone on the left , the apex of the prostate in the midline and the area of the membranous urethra on the left were hypoechoic ( fig . 1 , 2 , 3 , 4 , 5 ) . fine hyperechoic foci with the largest one characterized by reverberations ( probably gas ) were found ( fig . hypoechoic lesion ( 22 mm 20 mm ) located in the peripheral zone on the left corresponds with a hard nodule transrectal ultrasound of the prostate . bulky hypoechoic lesion originating from the peripheral zone of the left prostatic lobe transrectal ultrasound of the prostate . color doppler examination demonstrating blood flow within the suspicious lesion transrectal ultrasound of the prostate . hypoechoic lesion reaching beyond the midline part of the prostate transrectal ultrasound of the prostate . hypoechoic lesion in grayscale is heterogeneously hard in elastography mode transrectal ultrasound of the prostate . reverberation bands found within the nodule in line with the european association of urology guidelines , due to the presence of a high - grade neoplasm in the original turt the patient underwent cystoscopy every 3 months . liquid - based urine cytology was also regularly performed due to the original diagnosis of carcinoma in situ . in histopathological examination of samples taken during flexible cystoscopy low - grade intraurothelial neoplasia was found in a 1-millimeter sample taken from the neck / left wall and posterior wall . a relatively intense chronic inflammatory infiltration with epitheloid cell granuloma was observed in a sample from a polypous mucosa of the prostatic urethra . in rectal examination performed 9 months after turt the prostate was very hard on the left side . transrectal ultrasound scan revealed a peripheral zone on the left side filled with hypoechoic foci with signs of extraprostatic infiltration ( fig . 7 , 8) . a core biopsy of the prostate was conducted under neurovascular bundle block . three samples each were taken bilaterally from the base and four samples each were taken bilaterally from the apex ( fig . extraprostatic infiltration at the prostatic apex on the left side transrectal ultrasound of the prostate . biopsy of the suspicious lesion infiltrating periprostatic fatty tissue the histopathological report stated the following : inflammatione chronica partim granulomatosa et cum necrose focali in samples from the base of the left lobe . inflammatione chronica partim granulomatosa et cum necrose focali in the apex of the left lobe necrosis ( upper left ) and two multinucleated langhans - type giant cells ( arrows ) are visible during a follow - up visit in a clinic 14 months after turt rectal examination revealed a very hard , non - painful left lobe of the prostate . bcg therapy is currently the most effective immunotherapy method used for the treatment of non - muscle - invasive transitional cell carcinoma of the bladder . due to the common use of this type of therapy urologists are aware of the most frequent adverse reactions occurring during the therapy , both local and systemic ones . granulomatous prostatitis of tuberculosis origin is an exceptionally rare complication of intravesical therapy . in approximately 40% of cases symptomatic , mycobacterial prostatitis , which requires a 3-month antimycobacterial drug therapy , may be accompanied by symptoms of irritation in the lower urinary tract , pain in the perineum , episodes of hematuria towards the end of micturition , sterile purulent discharge from the urethra and compromised fertility . histopathological assessment of samples taken from the prostate is recommended if elevated psa levels persist for more than 3 months . however , no algorithm of optimal treatment has been determined for the cases in which granulomatous prostatitis with little or no symptoms is diagnosed . the patient was referred for a core biopsy of the prostate due to a justified suspicion of concomitant bladder and prostate cancer . in the early follow - up period the presence of a hard or even very hard , non - painful lesion was determined already after an induction course of bcg , while no signs of prostatitis were observed . gray - scale , doppler and elastography ultrasound scans showed a hypoechoic lesion with irregular contours , distinct blood flow and significantly increased density , which did not lose sonographic signs of malignant hyperplasia and even seemed to infiltrate the extraprostatic area despite the discontinuation of the intravesical therapy . an atypical finding for a prostate ultrasound image were fine hyperechoic foci with reverberation bands dispersed in the hypoechoic lesion , which could have corresponded to necrotic foci found in biopsy specimens . unfortunately , transrectal ultrasound imaging does not offer sufficient ability to differentiate between hypoechoic lesions of inflammatory and/or neoplastic nature . although rectal examination performed before the instillations demonstrated only enlargement of the prostate that suggested benign , adenomatous hyperplasia , unfortunately , a transrectal ultrasound scan was not performed at the time which could have been the point of reference for images of the prostate obtained after induction bcg therapy . therefore , in our opinion , not only thorough physical examination , but also imaging of the prostate is justified in patients referred for intravesical therapy , since it allows for comparison of the condition of the prostate with the image from before the therapy .

intravesical immunotherapy with attenuated strains of mycobacterium bovis is a widely used therapeutic option in patients with non - muscle - invasive transitional cell carcinoma of the bladder . a rare complication of intravesical therapy with the bacillus calmette - gurin vaccine is granulomatous prostatitis , which due to increasing levels of prostate - specific antigen and abnormalities found in transrectal examination of the prostate may suggest concomitant prostate cancer . a case of extensive granulomatous prostatitis in a 61-year - old patient which occurred after the first course of a well - tolerated bacillus calmette - gurin therapy is presented . due to abnormalities found in rectal examination and an abnormal transrectal ultrasound image of the prostate with extensive infiltration mimicking neoplastic hyperplasia a core biopsy of the prostate was performed . histopathological examination revealed inflammatory infiltration sites of tuberculosis origin .

hepatitis e virus ( hev ) is a nonenveloped , single stranded rna virus which belongs to the hepeviridae family . hev is a causative agent for acute hepatitis in one - third of the world 's population and fulminant hepatitis in pregnant women . the virion is relatively resistant to environmental conditions and remains infectious even in rough situation such as sewage . therefore the major route of hev transmission is the ingestion of the fecal contaminated water ; however , hev can be spread zoonotically and by blood transfusion especially in industrialized countries . although there is an inclusive debate on the parental route of transmission , available evidence seems to prove the ability of the virus to cause congenital infections . hev infection is a significant public health concern especially in developing countries , where large outbreaks as a result of poor sanitation and lack of sewage infrastructures have been reported . there is also a growing support for the claims that seroprevalence of hev infection in industrialized countries is increasing . patients with chronic liver disease , travelers to endemic areas , and people working with animals like pigs , cows , sheep , and goats are at high risk of hev infection [ 5 , 810 ] . pregnant women infected in third semester develop fulminant hepatic failure particularly in the endemic areas of hev infection [ 11 , 12 ] . iran is an endemic country for hepatitis e infection [ 7 , 13 ] , but hev prevalence has not been determined among general population in all parts of this country . most conducted studies in iran have reported the hev prevalence in specific groups and studies on hev prevalence in general populations are limited . hev prevalence information in general population can be a better indicator of the public health and hygiene . ahvaz is a large city in the south - west of iran with a population of about 1.18 million inhabitants that consists of two ethnic groups : arab and farsi . ahvaz is located in the banks of the karun river , which is the main river in this area . no data is available so far on the prevalence of hev among general population of ahvaz city ; therefore this study was conducted to determine the prevalence of hev among adults in south - west of iran . this cross - sectional study was approved by the ethical committee of ahvaz jundishapur university of medical science with research project number 91112 . to estimate the prevalence of anti - hev igg and igm antibodies in the general population of ahvaz city , 510 blood samples from the adult population of ahvaz city were collected randomly using the multistage cluster sampling method from february to july 2014 . ahvaz is a large city in the south - west of iran that consists of 8 districts and has 94 public health centers . in the first stage , 4 public health centers were selected randomly from each district . in the next stage , the family registry code was used to randomly select 16 households within each public health center . from each family , one subject the trained interviewers visited the subjects in their homes and completed a questionnaire containing information of age , gender , and race / ethnicity for each individual . the subjects who refused to participate in the study were replaced with the next random participants . the serum samples were tested in duplicate for anti - hev igg and igm antibodies by using dia.pro hev ab elisa kit and hev igm elisa kit ( dia.pro , italy ) according to the manufacturer 's instructions . statistical analyses were performed using spss 17 package program ( spss inc . , chicago , il , usa ) and p values of less than 0.05 were considered statistically significant . data were analyzed and compared by descriptive statistics and chi - square test or fisher 's exact test . out of 510 study subjects , 206 ( 40.4% ) were male and 304 ( 59.6% ) were female . the average age of participants was varying from 18 to 81 years while the mean age sd was 45.89 14.63 years . the subjects were classified into six age groups : 1830 , 3140 , 4150 , 5160 , 6170 , and over 71 years . 70 ( 13.7% ) subjects were between 18 and 30 years old , while 135 ( 26.5% ) were between 31 and 40 years old , 135 ( 26.5% ) were between 41 and 50 years old , 80 ( 15.7% ) were between 51 and 60 years old , 55 ( 10.8% ) were between 61 and 70 years old , and 35 ( 6.9% ) were older than 71 years . based on race / ethnicity , 53.7% ( 274 ) of cases were arab and 46.3% ( 236 ) were farsi . of the 510 subjects , 235 ( 46.1% ) are shown to be positive for anti - hev igg antibody by dia.pro hev ab elisa kit , while 275 ( 53.9% ) were negative . with regard to gender and race , 86/206 ( 41.7% ) in the male group and 149/304 ( 49% ) in the female group were positive for anti - hev igg antibodies . 134/274 ( 48.9% ) in the arab group and 101/236 ( 42.8% ) in the farsi group are shown to be positive for anti - hev igg antibody . however , the seroprevalence was higher among arab and female groups ; hev seropositivity was not statistically associated with gender ( p = 0.106 ) and race ( p = 0.168 ) . meanwhile , there was statistical difference in anti - hev igg seroprevalence rate between the subjects grouped according to age ( p < 0.001 ) , so that seroprevalence of hev increased with age from 14.3% ( 10/70 ) in subjects aged 1830 years to 71.4% ( 25/35 ) in persons over 71 years old , with a peak among 6170 year - olds ( 90.9% , 50/55 ) . the highest rate of anti - hev seroprevalence was seen in subjects aged 6170 years ( table 1 ) . when we evaluated anti - hev igm antibody seroprevalence rate in the gender and race groups , no significant differences were observed between the subjects regarding gender ( 1% in females and 1.9% in males , p = 0.448 ) and race ( 2.2% in arab and 0.4% in farsi , p = 0.130 ) . however , with regard to age , 4/70 ( 5.7% ) in the age group 1830 years and 3/135 ( 2.2% ) in the age group 3140 years were positive for anti - hev igm antibodies . there was a significant difference between the age groups regarding hev seropositivity ( p = 0.012 ) . the highest rate of anti - hev seroprevalence was observed in subjects aged 1830 years ( table 2 ) . overall , 7 blood samples ( 1.4% ) are shown to be positive for hev - specific - igm antibodies , while 503 samples ( 98.6% ) were negative . hepatitis e infection is a worldwide public health concern , which causes large outbreaks of acute hepatitis in developing countries especially asia , middle east , and africa and also sporadic cases of the infection in developed countries such as south america and europe . although hev is mainly transmitted via the fecal - oral route especially contaminated water in endemic areas , transmission via the blood transfusion has also been suggested according to the high prevalence of anti - hev igg among blood donors [ 4 , 13 , 14 ] . epidemiological studies in different parts of the world show the wide variation in hev prevalence patterns , though the hev seroprevalence rates are higher among less developed countries . high prevalence rates are often reported from south asia , egypt in the middle east , and the far east except japan , and low rates are often found in europe and the americas . iran is an endemic country for hepatitis e infection [ 7 , 13 ] , since hev seroprevalence in general population is above 5% . ataei et al . in 2005 reported hev seroprevalence rate of 3.8% among general population in isfahan province , iran . assarehzadegan et al . in 2005 reported hev prevalence rate of 11.5% among blood donors in khuzestan province . study , hev prevalence was 9.3% in general population of tehran . in another study by nazer et al . , the prevalence of hev was reported to be 7.8% in khorramabad city in 2009 . regarding hev prevalence among the general population of other countries , the overall hev prevalence rate was reported to be 22.5% among general population in bangladesh by labrique et al . , about 3.20% in french blood donors by boutrouille et al . , 13% in the general population in england by ijaz et al . , 1.9% in the general population in netherlands , and 5.3% in the general population of japan . in the present study we investigated the hev seroprevalence among adult population in ahvaz city and found that anti - hev igg and igm seroprevalence were 46.1% and 1.4% , respectively . the result of the current study is considerably higher than that reported among adults in other parts of iran : 9.3% in nahavand , 8.1% in isfahan , 7.8% in western iran , 7.3% in sari , and 7.915% in tehran ; it is also higher than that reported among adult population of some other countries : 3.9% in united kingdom , 16.8% in germany , 7.3% in spain , about 20% in korea , 23% in thailand , 3942% in usa , and 5.9% in turkey ; however , it is lower than that reported among rural population older than four years in egypt ( 5178% ) [ 16 , 34 ] , pregnant women in nile delta , egypt ( 84% ) [ 16 , 35 ] , general population older than 11 years in central malaysia ( 5067% ) , tribes population ( 50100% ) and adult population ( 1677% ) in andaman islands , india , and homeless children in cochabamba city , bolivia ( 66% ) . however , a part of this difference may be due to differences in the used elisa detection kits , the time of sampling , and the demographics and size of studied population . overall , our results compared with the previous studies from iran indicate that the geographic distribution of hev infection is different even within a specific country , which most likely reflects different levels of exposure to infection over time due to different living conditions in different regions and fecal - oral transmission of hev . in the current study , the hev seroprevalence rate significantly increased with age from 14.3% in people aged below 31 years to 90.9% in persons aged 6170 years . improvement of public health and hygiene results in decreased exposure to the virus over time . however , exposure to hev increases with age . this is consistent with most studies which reported a significant association between age and higher anti - hev positive values , since the prevalence of the disease increases with age [ 26 , 29 , 31 , 36 ] . similarly high seroprevalence was found among adult population older than 60 years in china ( 7080% ) , adult population older than 80 years in bangladesh ( 67% ) , and adult population older than 80 years in hong kong ( 5260% ) . similar to the results of previous studies [ 5 , 13 , 17 , 29 , 37 ] , our results show that the presence of anti - hev igg and igm antibodies is not associated with gender ; also we did not find any association between race / ethnicity and hev seropositivity . our data showed that the anti - hev igg prevalence rate among adult population in ahvaz is 46.1% , the highest rate reported in different parts of iran . the implication is that ahvaz city is a highly endemic area for hev and the main route of hev transmission in this city is most likely karun river . evidence for this claim is that the drinking water source of the city is supplied from karun river and this river is commonly used for swimming , fishing , and other household needs by inhabitants . since the major transmission route of hev is most often the fecal contaminated drinking water and also this virus is relatively resistant to environmental conditions and remains infectious in sewage , the river can be considered as the water source for hev infection . however more studies are required to confirm this hypothesis . therefore , type e hepatitis is more common among adult population of ahvaz city compared with other parts of iran and this finding should be considered in the differential diagnosis of hepatitis infections and also prediction of possible outbreaks . in conclusion , high anti - hev igg seroprevalence of 46.1% was observed among the adults population living in ahvaz city of iran . determination of hev prevalence in different regions can be used for the purpose of hev epidemiology by developing a prevalence map on the base of hev geographical distribution . in addition to epidemiological purposes , hev prevalence information is important in evaluating the public health and hygiene and in identifying the major route of hev transmission in iran .

background . knowledge regarding prevalence of hev in general population can be an indicator of the public health and hygiene . therefore , this study was conducted to evaluate the prevalence of hev among adults in south - west of iran . methods . blood samples were taken from 510 participants , 206 ( 40.4% ) males and 304 ( 59.6% ) females from february to july 2014 . detection of anti - hev igg and igm antibodies was carried out by elisa test . results . the overall anti - hev igg and igm prevalence rates were 46.1% and 1.4% , respectively . anti - hev igg and igm seropositivity were not statistically associated with gender and race / ethnicity . meanwhile , there were significant differences between the age groups regarding hev igg and igm seropositivity . hev igg seroprevalence increased with age from 14.3% in subjects aged 1830 years to 71.4% in persons over 71 years old , and considerably individuals aged 61 to 70 years had the highest hev prevalence ( 90.9% ) . also , 5.7% in the age group 1830 years and 2.2% in the age group 3140 years were positive for anti - hev igm antibodies and the highest rate was observed in subjects aged 1830 years . conclusion . in conclusion , high hev igg seroprevalence of 46.1% was observed among adults in south - west of iran .

colorectal cancer ( crc ) with invasion limited to the lamina propria ( lp ) is defined as intramucosal carcinoma . the current consensus is that intramucosal crc should not metastasize because colonic lp lacks lymphatics . tis in the tumor , node , metastasis ( tnm ) staging system , and endoscopic resection is regarded as adequate treatment . however , recent reports have described local recurrence with distant metastasis after surgical resection for poorly differentiated intramucosal rectal cancer . data regarding metastasis in intramucosal tumors are still lacking , and the metastatic potential of intramucosal crc remains unclear . herein , we report two rare cases of local recurrence with distant metastasis in patients who previously underwent endoscopic submucosal dissection ( esd ) for intramucosal crcs . a 67-year - old woman underwent esd for a 5.6-cm mixed - nodular type laterally spreading tumor ( lst ) in the rectum ( fig . the specimen was fixed in 10% formalin , paraffin - embedded , and evaluated after being cut into 2-mm - thick slices . the histology showed a well - differentiated adenocarcinoma confined to the lp without lymphovascular invasion and with clear resection margins ( fig . abdomino - pelvic computed tomography ( ct ) did not show any lymph node or distant metastasis . ct showed a perirectal mass , enlarged perirectal lymph nodes , and multiple lung nodules . the pathological findings of the previous esd site lesion revealed a poorly differentiated adenocarcinoma under normal colonic crypts ( fig . this undermining invasion pattern without surrounding mucosal change suggested that the recurrent lesion represented in situ recurrence rather than de novo cancer . 1f , inset ) showed a poorly differentiated adenocarcinoma that was positive for cytokeratin 20 and negative for cytokeratin 7 on immunohistochemistry , suggesting pulmonary metastasis of enteric type adenocarcinoma . following these findings , the entire original esd specimen was re - examined after slicing the paraffin - embedded blocks to check for the presence of missed submucosal invasive foci smaller than 2 mm , the routine slice thickness for histologic review of an esd specimen at our center . at low magnification , higher magnification of the least differentiated area showed solid and cribriform architecture and multiple foci of the invasive front , consisting of small , infiltrative tumor glands ( fig . however , neither submucosal invasion nor lymphovascular invasion was identified , even with cd34 and d2 - 40 immunostaining . a 62-year - old woman underwent en bloc esd for a 6-cm , mixed - nodular lst in the ascending colon ( fig . the histological examination showed a laterally spreading adenoma with a small fraction of moderately differentiated adenocarcinoma component ( fig . 2c , dashed line ) . at higher magnification , the invasive tumor cells formed large , irregularly shaped tubules and had occasional goblet cells , and the surrounding stroma was desmoplastic ( fig . the adenocarcinoma component was confined to the lp without lymphovascular invasion . as expected in the endoscopic findings ( fig . 2b , arrowheads ) , the resection margins showed severe cautery artifact and low - grade dysplasia involved the resection margins . colonoscopy showed an ulcerofungating mass encircling the lumen at the previous esd site ( fig . the colectomy specimen showed a large subserosal tumor with atypical ulcer , which was characterized by the absence of surrounding hyperplastic mucosa and multiple foci of intervening non - neoplastic mucosal islands . microscopically , the colectomy specimen showed an undermining invasion pattern , in which total tumor volume was disproportionately larger than that expected from the size of the mucosal lesion . furthermore , surrounding mucosa and mucosal islands in the ulcer base did not show any preneoplastic changes ( fig . at higher magnification , the cytomorphology of the resected tumor was similar to that of the invasive component of the previous esd specimen ( fig . the pathological findings of the hepatic segmentectomy specimen showed findings similar to those of the colon specimen , suggesting hepatic metastasis from the colon cancer . similar to case 1 , the entire esd specimen was reviewed again with additional sections of the paraffin - embedded blocks and with cd34 and d2 - 40 immunostaining . we concluded this case was a recurrence of colon cancer with hepatic metastasis in a patient who previously underwent esd for intramucosal colon cancer , because the second colon lesion developed precisely at the previous esd scar site during a 34-month follow - up period , and the pathologic finding showed an undermining invasion pattern without surrounding preneoplastic mucosal change . a 67-year - old woman underwent esd for a 5.6-cm mixed - nodular type laterally spreading tumor ( lst ) in the rectum ( fig . the specimen was fixed in 10% formalin , paraffin - embedded , and evaluated after being cut into 2-mm - thick slices . the histology showed a well - differentiated adenocarcinoma confined to the lp without lymphovascular invasion and with clear resection margins ( fig . abdomino - pelvic computed tomography ( ct ) did not show any lymph node or distant metastasis . ct showed a perirectal mass , enlarged perirectal lymph nodes , and multiple lung nodules . the pathological findings of the previous esd site lesion revealed a poorly differentiated adenocarcinoma under normal colonic crypts ( fig . this undermining invasion pattern without surrounding mucosal change suggested that the recurrent lesion represented in situ recurrence rather than de novo cancer . 1f , inset ) showed a poorly differentiated adenocarcinoma that was positive for cytokeratin 20 and negative for cytokeratin 7 on immunohistochemistry , suggesting pulmonary metastasis of enteric type adenocarcinoma . following these findings , the entire original esd specimen was re - examined after slicing the paraffin - embedded blocks to check for the presence of missed submucosal invasive foci smaller than 2 mm , the routine slice thickness for histologic review of an esd specimen at our center . at low magnification , higher magnification of the least differentiated area showed solid and cribriform architecture and multiple foci of the invasive front , consisting of small , infiltrative tumor glands ( fig . however , neither submucosal invasion nor lymphovascular invasion was identified , even with cd34 and d2 - 40 immunostaining . a 62-year - old woman underwent en bloc esd for a 6-cm , mixed - nodular lst in the ascending colon ( fig . the histological examination showed a laterally spreading adenoma with a small fraction of moderately differentiated adenocarcinoma component ( fig . 2c , dashed line ) . at higher magnification , the invasive tumor cells formed large , irregularly shaped tubules and had occasional goblet cells , and the surrounding stroma was desmoplastic ( fig . the adenocarcinoma component was confined to the lp without lymphovascular invasion . as expected in the endoscopic findings ( fig . 2b , arrowheads ) , the resection margins showed severe cautery artifact and low - grade dysplasia involved the resection margins . colonoscopy showed an ulcerofungating mass encircling the lumen at the previous esd site ( fig . the colectomy specimen showed a large subserosal tumor with atypical ulcer , which was characterized by the absence of surrounding hyperplastic mucosa and multiple foci of intervening non - neoplastic mucosal islands . microscopically , the colectomy specimen showed an undermining invasion pattern , in which total tumor volume was disproportionately larger than that expected from the size of the mucosal lesion . furthermore , surrounding mucosa and mucosal islands in the ulcer base did not show any preneoplastic changes ( fig . at higher magnification , the cytomorphology of the resected tumor was similar to that of the invasive component of the previous esd specimen ( fig . the pathological findings of the hepatic segmentectomy specimen showed findings similar to those of the colon specimen , suggesting hepatic metastasis from the colon cancer . similar to case 1 , the entire esd specimen was reviewed again with additional sections of the paraffin - embedded blocks and with cd34 and d2 - 40 immunostaining . we concluded this case was a recurrence of colon cancer with hepatic metastasis in a patient who previously underwent esd for intramucosal colon cancer , because the second colon lesion developed precisely at the previous esd scar site during a 34-month follow - up period , and the pathologic finding showed an undermining invasion pattern without surrounding preneoplastic mucosal change . generally , it is thought that intramucosal crc does not carry the risk of metastasis , and thus , endoscopic procedures such as esd or endoscopic mucosal resection , are accepted as curative modalities for intramucosal crc . nation - based survival data for the revised staging system in the seventh edition of the american joint committee on cancer also showed that a small proportion of tis colon cancers have lymph node metastasis . table 1 shows the characteristics of intramucosal crcs with metastasis at diagnosis or recurrent intramucosal crcs during follow - up in previous studies . interestingly , two of five cases had two synchronous intramucosal crcs as primary lesions , and the other three cases had huge intramucosal crcs as primary lesions . one previously reported case had focal signet ring cell features , and case 1 in the present report showed a focal least - differentiated area , although the metastatic potential of these focal poorly differentiated features is uncertain . therefore , metastasis from intramucosal colorectal adenocarcinoma may be theoretically impossible , but may not be a never - happened event . we present two cases with unusual features of local recurrence with distant metastasis in patients who previously underwent en bloc esd for intramucosal crc . however , in these cases , second lesions developed precisely at the esd scar sites in a relatively short - term period . in addition , an undermining invasion pattern without overlying mucosal change strongly suggested recurrence of the previous intramucosal crcs . the second lesions in both cases showed pathological findings similar to the least - differentiated component of previous esd specimens . moreover , the cancers at the previous esd sites showed an undermining invasion pattern , in which most tumor cells were observed underneath non - neoplastic mucosa without any preneoplastic changes . although a previous report suggested that focal lymphatic tumor invasion at the base of the mucosa might be a possible route for metastasis in intramucosal crc , no lymphatic tumor invasion was identified in our present cases . according to a meta - analysis moreover , a recent study revealed that tumor cells can be exfoliated into the intestinal lumen during colorectal esd , although little is known about the clinical significance of exfoliated tumor cells related to endoscopic procedures . interestingly , a case report suggested that colorectal adenocarcinoma cells might be implanted into the artificial ulcer after endoscopic resection . as esd for our primary lesions needed prolonged time , neoplastic cells shed from the tumor surface during the procedure might be implanted on the exposed submucosal layer or directly into the damaged lymphatics of the artificial ulcer . in case 2 , which showed lateral margin involvement by adenoma and severe cautery artifact , the remaining neoplastic cells at the margins might be the source of recurrence , although the progression to invasive cancer was extraordinarily fast . the presence of missed unfavorable histologic findings such as focal deep submucosal invasive cancer , even after meticulous histologic reexamination , might be another mechanism of recurrence . the presence of an extremely rare , but still unknown subtype of intramucosal crc can not be excluded . in conclusion , we report two rare cases of local recurrence with distant metastasis in patients who previously underwent successful esd for intramucosal crc . regardless of the mechanism , the rare possibility of recurrence may be considered during surveillance after en bloc esd of huge intramucosal crcs . the appropriate surveillance interval after esd of huge intramucosal crcs is still uncertain , as most postpolypectomy surveillance guidelines are based on the data retrieved from non - esd - related studies [ 14 - 16 ] . given that both local and distant recurrences were identified at 17 , 30 , and 34 months after esd in our cases and in previous reports , yearly surveillance for 3 years with colonoscopy and/or ct might be acceptable if a rare but possible recurrence is a concern after esd of huge intramucosal crcs . however , additional data should be accumulated to suggest a reasonable surveillance strategy after endoscopic treatment of huge intramucosal crcs .

intramucosal colorectal cancer ( crc ) is thought not to metastasize because the colonic lamina propria lacks lymphatics . only a few recent case reports have suggested lymph node metastasis from intramucosal crc , but there is no clear evidence supporting the metastatic potential of intramucosal crc . hence , endoscopic resection is regarded as curative treatment for intramucosal crc . this report describes two cases of unusual local recurrence with distant metastasis in patients who had previously undergone successful endoscopic submucosal dissection for intramucosal crc . the recurrent colorectal lesions developed at the site of the previous endoscopic submucosal dissection scars in a relatively short - term period , and the pathologic findings showed an undermining invasion pattern without surrounding mucosal change . based on the clinical course and pathological findings , we concluded that the second colorectal lesions were recurrences rather than de novo cancers .

situs solitus represents the normal position of heart and viscera relative to midline , and situs inversus indicates mirror - image location of the viscera relative to situs solitus.1 ) situs ambiguous ( sa ) is defined as an abnormality which can be considered to be present when the thoracic and abdominal organs are not clearly lateralized.2 ) sa is typically associated with complex cardiovascular malformations . thus sa is usually categorized either as splenic morphology - polysplenia ( bilateral left - sidedness , usually with multiple spleens , left isomerism , namely , polysplenia syndrome ) or as asplenia ( bilateral right - sidedness , with absence of spleen , right isomerism , namely , asplenia syndrome).2 ) sa with polysplenia ( sap ) is considerably rarely found in adults because of its high mortality rate with severe anormalies.3 ) however , patients with minor cardiac deformities can survive to adulthood.1 ) we report 2 cases of incidentally detected sap . a 42-year - old male was admitted for radiofrequency ablation of atrial fibrillation ( af ) . he was diagnosed as af 4 years ago and took anti - arrhythmic agent , beta blocker and anticoagulant . he had left side weakness due to cerebral infarction of right middle cerebral artery territory 3 years ago . his heart sound was irregular , but nothing particular was revealed on other physical and laboratory examinations . double the shadow of thoracic aorta and widening state of superior mediastinum were shown in chest x - ray , but there were no other remarkable matters ( fig . initial electrocardiogram showed af with moderate ventricular response ( average 60 - 80 beats / min ) . it seemed that hepatic vein was connected to right atrium through inferior vena cava ( ivc ) as usual . we checked coronary multidirectional computed tomography ( mdct ) to identify the anatomical variations of the patient 's coronary vessels and heart before the ablation procedure . multiple and round soft tissue densities were detected around the spleen , which were enhanced at the same degree of the spleen . ivc was located at the left side of aorta , and the hepatic segment of ivc was absent ( fig . 2b - d ) . by means of venography of ivc through right femoral vein , the interruption of the thoracic ivc with hemiazygos continuation along with aortic arch was confirmed ( fig . a 52-year - old female was presented with a history of intermittent fever for a month . she had been dddr - type pacemaker insertion state for last 8 months due to sick sinus syndrome . her chest x - ray showed no significant lesions , except gastric air detected under the right side of diaphragm and hepatic shadow in the left side abnormally ( fig . the left - sided ivc was crossed the aorta at the level of diaphragm and drained into right atrium ( fig . she was referred us for an echocardiographic examination to find any evidence of infection in her heart . echocardiogram revealed that large multiple mobile vegetations which were attached on the right ventricular pacemaker lead . the vegetations were prolapsed through the tricuspid valve , and the largest diameter of them was 20 mm . after 4 weeks of antibiotics therapy , there was no longer pathogen growth in blood culture . a 42-year - old male was admitted for radiofrequency ablation of atrial fibrillation ( af ) . he was diagnosed as af 4 years ago and took anti - arrhythmic agent , beta blocker and anticoagulant . he had left side weakness due to cerebral infarction of right middle cerebral artery territory 3 years ago . his heart sound was irregular , but nothing particular was revealed on other physical and laboratory examinations . double the shadow of thoracic aorta and widening state of superior mediastinum were shown in chest x - ray , but there were no other remarkable matters ( fig . initial electrocardiogram showed af with moderate ventricular response ( average 60 - 80 beats / min ) . it seemed that hepatic vein was connected to right atrium through inferior vena cava ( ivc ) as usual . we checked coronary multidirectional computed tomography ( mdct ) to identify the anatomical variations of the patient 's coronary vessels and heart before the ablation procedure . multiple and round soft tissue densities were detected around the spleen , which were enhanced at the same degree of the spleen . ivc was located at the left side of aorta , and the hepatic segment of ivc was absent ( fig . 2b - d ) . by means of venography of ivc through right femoral vein , the interruption of the thoracic ivc with hemiazygos continuation along with aortic arch was confirmed ( fig . a 52-year - old female was presented with a history of intermittent fever for a month . she had been dddr - type pacemaker insertion state for last 8 months due to sick sinus syndrome . her chest x - ray showed no significant lesions , except gastric air detected under the right side of diaphragm and hepatic shadow in the left side abnormally ( fig . the left - sided ivc was crossed the aorta at the level of diaphragm and drained into right atrium ( fig . she was referred us for an echocardiographic examination to find any evidence of infection in her heart . echocardiogram revealed that large multiple mobile vegetations which were attached on the right ventricular pacemaker lead . the vegetations were prolapsed through the tricuspid valve , and the largest diameter of them was 20 mm . after 4 weeks of antibiotics therapy , there was no longer pathogen growth in blood culture . however gatrad et al.5 ) obtained 1/24,000 affected in an english population and 1/2,700 in a highly inbred asian population . the overall prognosis of children with sa had fatally poor prognosis in their early age , which result from the degree of congenital heart diseases.6 ) sap have congenital heart disease in 50 - 100% of cases.1 ) in a study of the spectrum of cardiac abnormalities in the 170 fetes with sap , complete atrio - ventricular septal defect ( 68% ) , complete heart block ( 38% ) , double outlet right ventricle ( 23% ) , right ventricular outflow tract obstruction ( 21% ) and total anomalous pulmonary vein ( 5% ) drainage were detected , and only 58% of 170 survived.7 ) therefore , the case reports of sa in middle aged adults are extremely rare . the abnormal arrangement of the abdominal organs was present up to 50% in a review of 146 autopsied cases of sap.1 ) but , such cases without congenital cardiac defects in sap was also rarely reported previously . there were 5 case reports of adults ' sap in korea from 1997 to 2010 . these cases were different from one another in their compositions of organ arrangement and the mean age of these cases was 25.5 years . three cases had congenital disease , noncompaction of the ventricular myocardium,8 ) coarctation of aorta with bicuspid aortic valve9 ) and intraluminal duodenal diverticulum,10 ) which were too minor to be detected until adulthood . in 2 cases , they were incidentally detected while respectively evaluating dyspnea due to congestive heart failure with atrial fibrillation11 ) and constiptation.12 ) among venous malformation , the congenital interruption of the ivc is usually found in about 80% of patients sap.13 ) the most typical ivc interruption is complete absence of the hepatic segment of the ivc with azygos continuation.14 ) among the 5 korean adults mentioned above , the ivc interruption was presented in 4 cases , ivc was drained to hemiazygous vein in just one case.8 - 11 ) venous malformations in sap can be accompanied by various types which have usually no functional problems . but they do in some special circumstances as the 2 followings . in first case , a patient was found to be interrupted ivc while inserting catheter into right femoral vein for radiofrequency ablation of atrio - venticular nodal reentrant tachycardia , only to give the procedure up.15 ) secondly , a pacemaker was failed to be inserted in general approach because of persistent left superior vena cava which can be accompanied by sap.16 ) consequently , the congenital abnormality does not always cause symptoms or medical problems in adults . however , these anatomical misarrangements can cause confusion in diagnosis and can bring problems during invasive procedure . therefore , careful analysis of systemic anomalies is necessary to be done in medical approaching , especially for all patients expected surgical or medical interventions.14 )

situs ambiguous is rare congenital anomaly in adults . in 2 adult patients who admitted for different cardiac problems , situs ambiguous with polysplenia was detected . a 42-year - old male admitted for radio frequent catheter ablation of atrial fibrillation , and he had left - sided inferior vena cava ( ivc ) , hepatic segment of ivc interruption with hemiazygos continuation , multiple spleens and intestinal malrotation . and in a 52-year - old female case who was hospitalized due to infective endocarditis after implanting pacemaker for sick sinus syndrome , multiple spleens , left - sided stomach , bilateral liver with midline gallbladder , and left - sided ivc were found . those findings were consistent with situs ambiguous with polysplenia , but their features were distinctive .

a 46-year - old caucasian man presented with a 10-year history of mild gait ataxia and undirected vertigo after fast head movements . he had a past medical history of resection of a thyroid adenoma and also for benign polyposis of the sigmoid colon . at the age of 41 years physical inspection revealed megalocephaly , congenital facial asymmetry and left thenar aplasia . at the latest presentation , the neurological examination showed minimal intention tremor , gait ataxia without visual compensation , an undirected imbalance on romberg 's test and bradydiadochokinesia . with approval of the local ethic committee and with the patient 's informed written consent , mri examinations of the brain were performed on a 1.5 t scanner ( avanto , siemens medical solutions , erlangen , germany ) in combination with using a vendor supplied 12-channel receive - only head coil and then mri examinations of the brain were done on a 7 t scanner ( magnetom 7 t , siemens medical solutions , erlangen , germany ) in combination with an 8-channel transmit - and - receive head coil ( rapid biomed , wuerzburg , germany ) . the gradient - echo and turbo spin echo sequences were performed to obtain the axial proton density ( pd ) , t2 , t2 and susceptibility weighted images ( swi ) , which were optimized for each field strength ( table 1 ) . in addition , proton ( h ) mr spectroscopy ( mrs ) was performed at 1.5 t . the spectroscopic data was acquired from the patient 's cerebellar lesion using a single - voxel , point - resolved technique ( te = 135 ms ; tr = 1500 ms ) . the resulting prominent resonances representing choline ( cho ) , creatine ( cr ) and n - acetylaspartate ( naa ) within the lesion were compared to the mirror image voxels on the white matter of the normal contralateral hemisphere . spectral post - processing was performed using the software provided by the mri system manufacturer ( siemens syngo , vb 15 , siemens medical solutions , erlangen , germany ) . for 11 years , repeated 1.5 t mri examinations revealed a slowly growing , non - enhancing tumor mass in the left cerebellar hemisphere with preservation of the gyral pattern . thus , the present study was done without administration of contrast media . on mri at 1.5 t and 7 t , the posterior fossa tumor ( 493432 mm in size ) appeared mainly hyperintense on the t2-weighted images ( fig . 1a ) and iso - hypointense on the proton density images ( not shown ) . the characteristic striated pattern of the lesion was best displayed on the t2-weighted images at both field strengths ( fig . the tumor caused descensus of the cerebellar tonsils , but any obstructive supratentorial hydrocephalus was absent . due to their high sensitivity for paramagnetic substances like deoxyhemoglobin , the swi and t2 weighted images revealed thin veins running deep between the thickened folia of the cerebellar lesion in great detail ( fig . the 7 t swi minimal intensity projection ( mip ) images depicted thin vessel branches as small as 250 m , whereas the 1.5 t swi mip images could only resolve larger vessels to a size of 450 m . compared to the 1.5 t swi images ( fig . 1c ) the medial displacement and compression of the dentate nucleus by the tumor were much better registered on 7 t swi images ( fig . the h - mrs at 1.5 t demonstrated a reduction in naa and a prominent lactate peak . contrary to other previous reports , the cho , cr and the resulting cho / cr ratio were slightly elevated in the lesion and the myoinositol ( mi ) levels were not changed ( 3 , 4 ) . thus far , neurosurgical therapy and histopathological examination have not been performed because the lesion exerted only mild compression of the iv ventricle without any hydrocephalus . a dna analysis revealed a heterozygous mutation in exon 5 of the pten gene ( chromosome 10 q23 ) , and this supported the diagnosis of ldd ( c. 388c > t ; p. arg130x ) . for 11 years , repeated 1.5 t mri examinations revealed a slowly growing , non - enhancing tumor mass in the left cerebellar hemisphere with preservation of the gyral pattern . thus , the present study was done without administration of contrast media . on mri at 1.5 t and 7 t , the posterior fossa tumor ( 493432 mm in size ) appeared mainly hyperintense on the t2-weighted images ( fig . 1a ) and iso - hypointense on the proton density images ( not shown ) . the characteristic striated pattern of the lesion was best displayed on the t2-weighted images at both field strengths ( fig . the tumor caused descensus of the cerebellar tonsils , but any obstructive supratentorial hydrocephalus was absent . due to their high sensitivity for paramagnetic substances like deoxyhemoglobin , the swi and t2 weighted images revealed thin veins running deep between the thickened folia of the cerebellar lesion in great detail ( fig . images depicted thin vessel branches as small as 250 m , whereas the 1.5 t swi mip images could only resolve larger vessels to a size of 450 m . compared to the 1.5 t swi images ( fig . 1c ) the medial displacement and compression of the dentate nucleus by the tumor were much better registered on 7 t swi images ( fig . the h - mrs at 1.5 t demonstrated a reduction in naa and a prominent lactate peak . contrary to other previous reports , the cho , cr and the resulting cho / cr ratio were slightly elevated in the lesion and the myoinositol ( mi ) levels were not changed ( 3 , 4 ) . thus far , neurosurgical therapy and histopathological examination have not been performed because the lesion exerted only mild compression of the iv ventricle without any hydrocephalus . a dna analysis revealed a heterozygous mutation in exon 5 of the pten gene ( chromosome 10 q23 ) , and this supported the diagnosis of ldd ( c. 388c > t ; p. arg130x ) . lhermitte - duclos disease or dysplastic cerebellar gangliocytoma is a slowly enlarging mass within the cerebellar cortex , and patients with this malady present with headaches , occlusive hydrocephalus , cranial nerve palsies , gait ataxia and other symptoms of cerebellar dysfunction ( 1 ) . beside some pediatric cases , the majority of patients are diagnosed in the third or fourth decade of life without a gender predilection . histopathologically , ldd is characterized by regional enlargement of the cerebellar stratum granulosum , an absence of the purkinje cell layer and progressive hypertrophy of the granular cell neurons with increased myelination of their axons in the expanded molecular layer ( 5 ) . mri has proven to be the best imaging modality for revealing the characteristic appearance of ldd , and mri often enables physicians to make the diagnosis of ldd even without histopathological confirmation ( 3 , 4 , 6 - 10 ) . the striated pattern of ldd is a result of the close apposition of the thickened cerebellar folia that are lacking their secondary arborization . a non - enhancing , unilateral cerebellar mass in a middle - aged patient , which is characterized by a ' tiger - striped ' pattern of hyperintensity on the t2-weighted mr images and this respects the cerebellar margins , is typical of ldd ( 8) . to the best of our knowledge , this is the first reported case of ldd that has been examined by 7 t mri ultrahigh field mri systems ( 7 t ) with their increased signal - to - noise ratio ( snr ) and higher sensitivity to susceptibility contrast . these systems are currently being tested for clinical applications and they allow for imaging anatomical structures with thinner sections , larger matrices and reduced acquisition times . however , the clinical challenges associated with 7 t mri include higher specific absorption rates ( sar ) , non - uniformity of the transmitted radiofrequency field , non - homogeneity of the static magnetic field , increased susceptibility artifacts and potential physiological side - effects . moving from 1.5 t to 7 t mri , the t2 is shortened and the susceptibility contrast of paramagnetic substances ( e.g. deoxyhemoglobin , neuromelanin , iron ) is significantly amplified , which enables a superior illustration of the venous vasculature and cerebellar nuclei . 1.5 t swi was found to be helpful for detecting deep running veins around the thickened folia of ldd ( 3 ) . 7 t swi can demonstrate in greater detail veins that are even smaller than the voxel size , due to the associated paramagnetic effect , than the corresponding 1.5 t images ( fig . 1c - f ) because the sensitivity of mri scanners for paramagnetic substances increases in proportion to the applied magnetic field . the deoxyhemoglobin in these veins helps to resolve the outer most layer of the ldd , which consists of the outer molecular layer , the leptomeninges and the associated abnormal vessels . ( 3 ) and kulkantrakorn et al . ( 7 ) reported good correlation of this mri pattern with the histological specimen . beside the characteristic striated pattern on the t2-weighted images , these abnormal veins surrounding the thickened folia on the swi images seem to be another unique feature of ldd . beside the preoperative identification of ldd , the higher resolution of 7 t swi their anatomical relation is of clinical importance for planning surgical procedures because lesions affecting the cerebellar nuclei are associated with more severe symptoms than are cortical lesions . h - mrs demonstrated a prominent lactate peak , suggesting increased glycolysis and the high metabolism of this ldd lesion ( 4 , 9 ) . decreased levels of cho , cr , naa and mi and the chr / cr are normally found on the side affected by the ldd ( 9 ) . the slightly increased cho levels in our patient suggested increased demyelination and membrane turnover , whereas the decreased cho levels in the lesion suggested a non - neoplastic etiology of this lesion ( 4 , 9 ) . making the preoperative diagnosis of ldd via mri obviates the need for biopsy and this allows surgeons to plan an appropriate therapy , which consists of decompression of the posterior fossa by total surgical resection . tumor resection has not yet been performed in our patient due to the mild clinical symptoms . in conclusion , as seen on mri , a non - enhancing , ' tigers striped ' cerebellar lesion with unilateral hemispheric expansion and preservation of the gyral pattern should be considered specific for ldd and these findings often allow making the preoperative diagnosis . 7 t mri more precisely reveals the known morphology and microstructure of this tumor entity than can 1.5 t mri . especially , 7 t swi enables the identification of the outermost layer of ldd due to its inherent venous vasculature , and 7 t swi better displays the iron containing dentate nuclei . hence , 7 t mri is expected to become a valuable tool for studying the cerebral microvascularity and tumor angiogenesis not only for ldd , but also for other resectable brain tumors .

lhermitte - duclos disease ( ldd ; dysplastic cerebellar gangliocytoma ) is a rare hamartomatous lesion of the cerebellar cortex and this was first described in 1920 . ldd is considered to be part of the autosomal - dominant phacomatosis and cancer syndrome cowden disease ( cs ) . we examined the brain of a 46-year - old man , who displayed the manifestations of cs , with 7 tesla ( t ) and 1.5 t mri and 1.5 t mr spectroscopy ( 1h - mrs ) . we discuss the possible benefits of employing ultrahigh - field mri for making the diagnosis of this rare lesion .

glaucoma drainage implants ( gdi ) are a useful modality in the management of intractable glaucoma cases . late exposure of the implant tube through the overlying conjunctiva is a known complication of the surgical procedure . untreated tube exposure seems to be a risk factor for endophthalmitis.1 gedde et al . recommended prophylactic surgical revision with patch graft in all cases of tube exposure.1 we describe the novel use of fibrin sealant for the surgical revision of tube exposure . a 42-year - old male had retinal detachment repair with placement of an episcleral encircling band in right eye . an ahmed glaucoma valve ( agv ; model fp7 , new world medical , rancho cucamonga , la ) was placed to treat his intractable secondary open - angle glaucoma . the plate of the agv was placed above the encircling band in the supero - temporal quadrant and the donor scleral patch graft covering the limbal portion of the tube was sutured with non - absorbable sutures to the underlying sclera . the scleral patch graft overlying the agv tube had retracted posteriorly by about 3 mm . the dashed line outlines the scleral patch graft , ( b ) schematic demonstrating layering of scleral and conjunctival grafts during revision surgery . the arrow heads denote sticking of lateral edges of the conjunctival auto - graft to the edges of the reflected conjunctiva and the underlying episcleral surface , ( c ) slit - lamp photograph at 4-month post - revision surgery shows well - integrated patch grafts we performed revision surgery of the exposed tube under peribulbar anesthesia . the conjunctiva was incised in a parallel fashion on either side of the exposed tube . a lateral flap of the conjunctiva was undermined in the episcleral plane on either side of the exposed tube . a 5 3-mm human donor scleral patch graft was stuck on the episcleral bed over the exposed segment of the tube using fibrin sealant ( tisseel kit ; baxter ag , vienna , austria ) . adequate care was taken to avoid capture of the conjunctiva under the scleral patch graft to reduce the chances of epithelial entrapment and epithelial inclusion cyst formation.2 a 7 4-mm - free conjunctival autograft was obtained from the inferior fornix and was stuck over the scleral patch graft . the lateral edges of the conjunctival graft were stuck to the edges of the conjunctival flap as well as to the episcleral surface beyond the scleral graft using the fibrin sealant [ figure 1b ] . amniotic membrane was fixed with the fibrin sealant to cover the denuded conjunctival surface in the inferior fornix . the grafts were well integrated and iop was in the target range at the 4-month post - revision follow - up visit [ figure 1c ] . tube exposure occurs in patients with drainage devices despite the use of patch grafts that are covered with the patient 's conjunctiva . an inflammatory and/or immune mediated melting of the patch graft and mechanical breakdown of the overlying conjunctiva appears to be a prominent mechanism.3 in our case , the scleral patch graft , though intact , was retracted posteriorly . conjunctival scarring and retraction following agv implantation above the pre - existing episcleral encircling element may be responsible for retraction of the scleral patch graft , and thereby , might have predisposed to exposure of the tube . the surgical repair of exposed tube involves replacing a patch and covering this patch by conjunctiva . a graft of collagenous human tissue is necessary as conjunctiva does not reliably remain closed over immediately underlying synthetic material e.g. silicone as in this case.2 in a study comparing donor sclera , pericardium , and dura as materials for gdi tube coverage , no material was found to be associated with a reduced rate of tube exposure.4 we chose human donor sclera as it is readily available and most affordable . some methods to cover the patch by conjunctiva include conjunctival advancement,3 vascularized flap5 or grafting . our patient had limited mobility of the superior conjunctiva and either conjunctival advancement , or vascularized conjunctival flap was not possible . buccal mucous membrane graft6 and amniotic membrane transplantation7 have been described as conjunctival substitutes to cover exposed gdi tubes . moreover , the suture material may act as a source of inflammation and localized tissue melt . this was reported to be the cause of failure of repaired tube exposure.7 on the other hand , fibrin sealant has been shown to be safe and effective suture substitute for conjunctival and scleral wound closure in glaucoma surgery8 and for placement of a human donor scleral patch graft covering the sub - conjunctival portion of agv tube.910 in addition to saving suturing time , the fibrin sealant did allow sticking of the conjunctival graft to the edges of the conjunctiva on either side as well as to the underlying episcleral surface beyond the extent of the revision scleral patch graft in our case . since our patient was relatively young and had a thick tenon 's capsule , the adhesion was expected to be strong . the intention of this surgical modification was to gain maximum possible blood supply to the grafted conjunctiva . in our opinion , this novel use of the fibrin sealant and the technique used help in better integration of the patch grafts in the revision of an often difficult problem of exposed agv tube .

tube exposure is a known complication of ahmed glaucoma valve ( agv ) implantation . repair of the exposed tube is not easy . a 42-year - old monocular aphakic male had undergone retinal detachment repair with placement of an episcleral - encircling band followed by implantation of agv . he presented to the clinic on routine review with exposure of the shunt tube . the complication was managed by placing scleral and conjunctival grafts over the exposed tube using a fibrin adhesive ( tisseel kit ; baxter ag , vienna , austria ) . the novel use of the fibrin sealant in the repair of agv tube exposure was for better graft - integration .

hyper - immunoglobulin m syndrome ( higm ) is a rare heterogeneous group of disorders , 70% of which are due to cd40-ligand deficiency . these patients are susceptible to recurrent sinopulmonary infections and opportunistic infections , especially pneumocystis jiroveci pneumonia . bronchiectasis is characterized by abnormal dilated thick - walled bronchi that are inflamed and colonized by bacteria . after excluding cystic fibrosis , tuberculosis and congenital lung abnormalities on searching the literature for the youngest and only case of higm with bronchiectasis , we could found data of a 7-year - old girl published by montella et al . to the best of our knowledge , the case described here is the youngest case of higm-1 presenting with bronchiectasis and , possibly , pj pneumonia . a 5-year - old boy , born of consanguineous ( 4 degree ) marriage , presented with complaints of productive cough and right ear discharge since 1 year , fever and respiratory distress for 25 days and oral thrush since 20 days . he had a history of five admissions in various hospitals for pneumonia since the age of 1 year . he also had a history of repeated diarrhea ( six to seven episodes every year ) since the age of 6 months . antitubercular therapy was given on an empirical basis at the age of 2.5 years , without any significant improvement . two of his elder male siblings died because of recurrent pneumonia and diarrhea at the age of 2 years and 8 years . onset of recurrent pneumonia and diarrhea in both the siblings was at about 8 months of age . on examination , his heart rate was 120/min , respiratory rate was 66/min , spo2 was 91% ( on room air ) and grade 2 clubbing was present . right side maxillary area tenderness and right ear discharge ( yellowish - green ) were also noted . his blood counts revealed total leukocyte count -27,000/cc ( p75 ) and the platelet counts and erythrocyte sedimentation rate were normal . arterial blood gas revealed ph -7.32 , pco2 -53.1 mmhg , pao2 -60 mmhg and hco3 -26.9 liver function test , renal function tests and coagulation profile were normal . the serum lactate dehydrogenase level ( ldh ) was raised . on bronchoscopy , the right bronchial tree showed collapse of some sub - segmental bronchi and proximal bronchiectasis . high serum igm level and no detectable serum levels of igg and iga [ table 1 ] suggested higm syndrome . his whole blood flow cytometry revealed reduced expression of cd40l ( cd154 ) on activated t lymphocytes after stimulation [ table 1 ] thus confirming the diagnosis of higm-1 . chest roentgenogram performed 1 month before the admission and at the time of admission showed persistent opacity in the right middle zone . high - resolution computed tomography ( hrct ) of the chest demonstrated bronchiectatic changes in the right lower lobe , right middle lobe , left lower lobe and lingular lobe [ figure 1a and b ] . ( a ) areas of ground - glass haze and nodular air space lesions in a branching pattern ( tree in bud ) in the right lower lobe , dilated and thickened bronchi in the left lower lobe , lingular lobe and right middle lobe . ( b ) ground - glass haze in the right lung with air space lesions in the right lower lobe the patient presented with severe respiratory distress , for which he was put on mechanical ventilation . intravenous ( iv ) ceftriaxone and cloxacillin were started in addition to nebulizations with 3% saline and chest physiotherapy . on the basis of culture sensitivity ( pseudomonas growth ) iv liposomal amphotericin b and co - trimoxazole was given in view of probable invasive candidiasis and pj pneumonia , respectively . he did respond to the treatment well , and was discharged in satisfactory condition and is in regular follow - up . he is getting oral co - trimoxazole prophylaxis , ivig therapy ( 600 mg / kg ever 4 weeks ) , salbutamol and budesonide inhalation with mdi and spacer and 3% saline nebulization followed by chest physiotherapy at home . x - linked higm syndrome results due to defects in class switch recombination caused by mutations in the cd40 ligand and nuclear factor kb essential modifier ( nemo ) . t cell functions are also affected in both cd40l and nemo deficiency , which explains the associated opportunistic infections . nemo gene defect was ruled out in our case due to the absence of ectodermal dysplasia , mycobacterial infection , osteopetrosis and lymphedema . higm-1 usually presents around 6 - 9 months of age ( when maternal antibodies decrease below the protective level ) with recurrent sinopulmonary bacterial infections , opportunistic infections and recurrent diarrhea . management of bronchiectasis includes antibiotics , bronchodilators , inhaled steroids , mucolytics and chest physiotherapy , along with treatment of underlying disorder . the goal of therapy is to mobilize secretions and to reduce the infectious and inflammatory load , thereby preventing progression of airway destruction . pj pneumonia is being reported as the presenting feature in about 40% of higm-1 patents . festic et al . reported elevated ldh in 29 of 30 patients with non - hiv pj pneumonia . the classic presentation of pcp is a bilateral interstitial pattern , which may be characterized as finely granular , reticular or ground - glass opacities . in the described patient , there was markedly elevated serum ldh level with ground - glass haze on contrast - enhanced computed tomography of the chest [ figure 1a and b ] , suggesting interstitial pneumonitis and hypoxemia suggesting possibility of pj pneumonia . however ; we could not recover pj trophozoites and cysts in the bronchoalveolar lavage , which may be explained by the fact that bal ( bronchoalveolar lavage ) could only be performed after initial stabilization of the patient and co - trimoxazole was started empirically on the basis of raised ldh level with pneumonia and hypoxemia . appropriate treatment of infections and regular ivig therapy ( every 3 - 4 weeks ) is considered the mainstay of therapy . boiled drinking water to prevent cryptosporidium infection and co - trimoxazole prophylaxis to prevent pj pneumonia should be given . the only curative treatment currently available for higm-1 is allogeneic hematopoietic cell transplantation ( hct ) . early diagnosis and appropriate management of recurrent / persistent pneumonia in cases of higm-1syndrome may prevent development of bronchiectasis , a serious complication that limits the success of bone marrow transplantation , a definite cure of higm-1 syndrome .

the x - linked hyper - immunoglobulin m syndrome ( higm-1 ) is a rare genetic disorder characterized by elevated serum igm levels and low to undetectable levels of serum igg , iga and ige . these patients characteristically present with recurrent sinopulmonary infections and recurrent diarrhea . they also have high susceptibility for pneumocystis jiroveci ( pj ) pneumonia . herein , we report a case of hgm-1 in a 5-year - old boy who presented with bronchiectasis and , possibly , pj pneumonia . the diagnosis was established on the basis of clinical features , immune profile , whole blood flow cytometry and history of two male sibling 's death due to recurrent pneumonia and diarrhea .

the sample population included 18 to 45 year old subjects living in tabriz , north - west of iran in 2009 . a sample size of 400 subjects was estimated prior to the study according to the cochrane formula considering p as 0.04 , d as 0.02 , and as 0.05 . a two stage cluster sampling method with a probability postal codes were extracted by the cooperation of the east azerbaijan provincial health center ( department ) providing an annually updated sampling framework . at the first clustering stage , a presumed 200 households were selected followed by equal sized samples according to gender at the second stage . then , the researchers evaluated one male and one female subject in each of the selected households through conner s adult adhd rating scale ( self- report ) . in non - cooperating cases , the subjects with adhd index higher than 70 in the self - report questionnaire of conner s adult adhd rating scale were initially evaluated for childhood adhd symptoms ; and if positive , the adhd portion of k - sads questionnaire about childhood was fulfilled ; and if certified by one more family member knowing about his / her childhood , the subject was selected . then , the psychiatric interview was performed for all selected individuals according to the dsm - iv - tr criteria and wender utah ; and those who had definite symptoms were diagnosed to have adult adhd . the participants included 400 population subjects ( 200 men and 200 women ) with an age range of 18 to 45 years living in urban tabriz , north - west of iran in 2009 . the inclusion criteria were defined as follows : an age range of 18 - 45 , lack of severe mental and somatic disability , willingness and consent to participate in the study . conner s adult adhd rating scale was used for screening the purpose followed by a clinical diagnosis made through psychiatry interview based on dsm - iv . the conners adult adhd rating scale ( caars ) has widely been used to screen and follow up patients ; and its validity and reliability are shown to be in accordance with dsm - iv . it has multiple indices including attention deficit index ( subscale a ) , hyperactivity - impulsivity index ( subscale b ) , adhd total symptoms index ( subscale c ) and adhd index ( subscale d ) . subscale c is the sum of a and b subscales . in the original reference manual of the caars , it is clarified that which questions belong to specified subscales ; and with adding the scores of each subscale questions , scores of each subscale was determined . this questionnaire had been translated to persian by clinical psychiatry research center ( cprc ) in tabriz and validated by amiri et al . the reliability and feasibility of the persian version of this diagnostic instrument were already determined as fair to good for most diagnostic categories ( kappa > 0.6 ) . and has just recently been used by the authors referring also to the previous studies with an overall internal consistency of the conner s adult adhd rating scale by cronbach s alpha being equal to 0.83 ( 14 ) . in this study , the internal consistency of the scale was also assessed as a measure of reliability by cronbaches being equal to 0.83 . the descriptive statistics including frequency , relative frequency , means and standard deviations were used to depict the current situation of adult adhd and describe the demographic status of the understudy population . chi - square and fisher s exact tests were used to determine the association of demographic categorical variables and occurrence of adult adhd . independent t - test was used to compare the numeric scale variables such as age of smoking initiation in the two groups ( adult adhd and normal population ) . this study was approved by the regional committee of ethics in tabriz university of medical sciences . the study protocol was approved and publicly defended as a thesis project for a degree of specialty in psychiatry in tabriz university of medical sciences . the participants included 400 population subjects ( 200 men and 200 women ) with an age range of 18 to 45 years living in urban tabriz , north - west of iran in 2009 . the inclusion criteria were defined as follows : an age range of 18 - 45 , lack of severe mental and somatic disability , willingness and consent to participate in the study . conner s adult adhd rating scale was used for screening the purpose followed by a clinical diagnosis made through psychiatry interview based on dsm - iv . the conners adult adhd rating scale ( caars ) has widely been used to screen and follow up patients ; and its validity and reliability are shown to be in accordance with dsm - iv . it has multiple indices including attention deficit index ( subscale a ) , hyperactivity - impulsivity index ( subscale b ) , adhd total symptoms index ( subscale c ) and adhd index ( subscale d ) . subscale c is the sum of a and b subscales . in the original reference manual of the caars , it is clarified that which questions belong to specified subscales ; and with adding the scores of each subscale questions , scores of each subscale was determined . this questionnaire had been translated to persian by clinical psychiatry research center ( cprc ) in tabriz and validated by amiri et al . the reliability and feasibility of the persian version of this diagnostic instrument were already determined as fair to good for most diagnostic categories ( kappa > 0.6 ) . and has just recently been used by the authors referring also to the previous studies with an overall internal consistency of the conner s adult adhd rating scale by cronbach s alpha being equal to 0.83 ( 14 ) . in this study , the internal consistency of the scale was also assessed as a measure of reliability by cronbaches being equal to 0.83 . the descriptive statistics including frequency , relative frequency , means and standard deviations were used to depict the current situation of adult adhd and describe the demographic status of the understudy population . chi - square and fisher s exact tests were used to determine the association of demographic categorical variables and occurrence of adult adhd . independent t - test was used to compare the numeric scale variables such as age of smoking initiation in the two groups ( adult adhd and normal population ) . this study was approved by the regional committee of ethics in tabriz university of medical sciences . the study protocol was approved and publicly defended as a thesis project for a degree of specialty in psychiatry in tabriz university of medical sciences . twenty - two among 400 selected subjects ( 5.5% ) had adhd index higher than 70 points including six females ( 27.3% ) and 16 males ( 72.7% ) . the interview showed that 15 subjects ( 3.8% ) had adult adhd according to the dsm - iv - tr criteria and wender utah . the mean age was 33.40 7.67 and 32.19 7.74 in adult adhd and normal subjects . the adult adhd prevalence in the general population according to the age strata was six ( 3.2% ) in 18 - 30-year - old subjects , seven ( 5% ) in 31 - 40-year - old subjects , and two ( 2.7% ) in 41 - 45-year - old subjects . also , the prevalence of adult adhd was 5.5% ( 11 subjects ) in men and 2% ( four subjects ) in women . according to the results obtained from fisher exact test , the sex ratio was not different between those with and without adult adhd ( table 1 ) . also , according to the results obtained from chi - square test , the frequency distribution of age , marital status , birth order , educational level and occupational status were not different between subjects with and without adult adhd ( table 1 ) . the frequency distribution of history of psychiatric treatment , alcohol drinking , and smoking did not differ between subjects with and without adult adhd according to fisher exact test ( table 2 ) . according to table 3 , the results of the t - test test showed that the mean age of smoking initiation did not differ between the subjects with and without adult adhd . this study which was conducted to determine the prevalence of adult adhd in tabriz showed that 3.8% among 400 participants aged 18 to 45 years had adhd which was determined according to dsm - iv - tr criteria and wender utah . this prevalence is similar to that of western countries . in the national comorbidity survey replication , 4.4% of 3199 subjects aged 18 to 44 years met the dsm - iv criteria for adhd ( 8) . in another report , the prevalence rate of 3.4% was reported among 18 to 44 year old subjects ( 13 ) . also , in a study conducted on outpatients with non - psychotic psychiatric illnesses , the prevalence of adhd was 16.8% and it was 5.3% among healthy participant ( 15 ) . in a study conducted in hungary among 3529 adults aged 18 to 60 years , adult adhd was more common in men and in adults younger than 40 years of age . the prevalence was 2.3% in males and 0.91% in females ; 2.02% in the < or = 40 year old group and 0.70% in the > 40 year old group based on dsm - iv diagnostic criteria ( 16 ) . similar prevalence of adult adhd in western countries and iran demonstrates the weak effect of sociocultural factors in this disorder . in a study it was showed that the heritability of adhd in adults is estimated around 30% in men and women . all familial transmission is explained by genetic inheritance ; there is no support for the hypothesis that cultural transmission from parents to offspring is important ( 17 ) . this prevalence rate of adult adhd requires designing and managing general health . in different studies , the prevalence of adhd in boys has been reported to be more than girls ( 18 , 19 , 20 ) . nonetheless , as the results of our study indicate , gender has a weak impact on adult adhd as well as non - significant prevalence in men ( 5.5% vs. 2% percent ) . however , some studies have reported higher prevalence among men ( 8 , 13 ) . according to our findings , the prevalence of adult adhd was not different in the age strata , which is similar to the reports of some other studies ( 1 , 9 ) and opposite to some others ( 13 ) . one study had reported higher prevalence of adhd in lower ages ( 11 ) . in some studies , the prevalence of adult adhd was not reported to differ according to marital status ( 1 , 13 ) as in our study ( 1 , 13 ) , but some others have reported significantly higher prevalence among divorced or previously married patients ( 7 , 8 , 21 ) . another study showed a higher prevalence of adult adhd in widowed / divorced/ separated and single patients ( 11 ) . however , due to the effect of adult adhd on intimate relationships leading to less stability and higher divorce rate , the judgment about the effect of this disorder on marital status may need longer follow ups . the lack of association between adult adhd and educational level was similar to some studies ( 1 , 9 ) and opposite to some others showing higher prevalence of adult adhd in illiterate subjects or those with low literacy ( 11 , 13 and 21 ) . employment status was not associated with the prevalence of adult adhd , but in previous studies unemployed subjects have had higher prevalence of adult adhd ( 8 , 11 , 21 ) . also , a study on workers has shown lower prevalence of adult adhd among expert workers ( 1 ) . previous studies did not evaluate the association of adult adhd and birth order ; the results obtained in our study showed no association in this aspect . this may be explained by the fact that when a person enters adulthood and integrates with the public , the effect of birth order will be diminished despite its initial effect on personality development in childhood . however , in previous studies , patients with adult adhd seeked treatment less than the normal adults ( 8 , 13 ) , but in our study the number of psychiatrist visits was similar between normal and adult adhd subjects . this may be due to different factors such as poor insight , psychiatric disorders stigma , or lack of access to treatment . however , the findings of this study highlighted the importance of increasing our knowledge about the general population . also , it is suggested that the contributing factors for lack of treatment seeking among adult adhd patients be evaluated in the future studies . another part of our study showed the self - report of alcohol use and smoking and revealed that the mean age of smoking initiation was not different between the subjects with and without adult adhd . this finding is the opposite of those findings reported by previous studies about smoking ( 22 ) and alcohol use ( 23 , 24 ) , which showed the substance abuse as the outcome and comorbidity of adhd . with respect to the association of smoking and substance use with adult adhd , it may be noted that this is a type of self - administration treatment for adhd ( 25 , 26 ) . in our study , few normal and adult adhd subjects were reported to use alcohol , and this may be due to the fact that alcohol use is illegal and stigmatic in iran . since the self - report of alcohol and substance use in islamic countries , would bias the results and regarding small sample size and type of questions , it may not be judged . however , in our study , the sample size was calculated to be 400 , but the 3.8% prevalence rate of adult adhd is required to be replicated with a larger sample population to increase the reliability of the correlational analysis . limitations : the main limitation of this study was its moderate sample size allowing for 2% precision . however , the results are yielding considering it to be among the first prevalence studies conducted in iran about adult adhd . the prevalence of adult adhd in tabriz ( with one million and three - hundred thousand population ) residents aged 18 to 45 years was 3.8% ( 5.5% in men and 2% in women ) according to dsm - iv - tr criteria and wender utah . the prevalence of adhd was not associated with age , marital status , birth order , educational level , career status , alcohol use and smoking . however , other studies have reported the effect of psychosocial factors on the prevalence of adult adhd ( 8 , 11 , 21 ) , but it was not observed in our study . our findings about the contributions of adult adhd were important in some aspects ; these findings may be due to iranian sociocultural effect , and also research factors such as inclusion criteria and sample size . performing complementary studies about the contributors of adult adhd and psychiatric comorbidities in iran and the other middle east countries would result in more definite recognition of psychosocial contributors of adult adhd . considering the high prevalence of adhd in adults and the importance of on time diagnosis and treatment of this disorder , further studies are needed to determine the definite prevalence in the whole country . since many patients are hidden cases receiving no treatment and may develop side effects of the disease in their life , providing information for the public and exclusive training for the professionals are needed in this field . more special trainings for general practitioners to diagnose and refer the patients for treatment would decrease the under - treatment cases . furthermore , early prognosis and treatment of patients may decrease burden of disease , such as costs due to accidents , substance abuse , career and education leave and other problems .

objectiveattention deficit hyperactivity disorder in adults ( adult adhd ) is gaining more attention nowadays . nevertheless , very few studies have addressed this issue in iran . the present study was conducted to determine the prevalence of adult adhd in tabriz , north - west of iran.methodsfour hundred urban inhabitants of tabriz- with an age range of 18 to 45 years were selected through the probability proportional to size cluster sampling in 2009 . the screening was performed by conner s adult adhd rating scale , and the definite diagnosis of adult adhd was performed via clinical interview according to dsm - iv - tr and wender utah criteria.resultsthe prevalence of adult adhd was estimated to be 3.8% . men when compared with women were more likely to have adhd ( 5.5 % in men versus 2 % in women ) . marital status , birth order , educational level and occupational status showed no significant association with adult adhd . history of psychiatric treatment , alcohol drinking and smoking had similar relative frequency in subjects with and without adult adhd.conclusionthe prevalence of adult adhd in this region of iran seems to be substantially higher than expected or treated . this would require more attention to be drawn by health sector managers in order to improve the knowledge of the general population and the knowledge of the health care professionals about the disorder .

a total of 917 stool specimens were collected from infants and children with acute gastroenteritis in dhaka children s hospital , bangladesh , during october 2004 to september 2005 . fecal specimens were diluted with distilled water to 10% suspensions and clarified by centrifugation at 10,000 g for 10 min . the supernatant was collected and viral genomes were extracted from fecal specimens by using the qiaamp viral rna mini kit ( qiagen , hilden , germany ) . using reverse transcription pcr ( rt - pcr ) with specific primers , as previously reported ( 6 ) , resulted in the identification of diarrheal viruses , including group a , b , and c rotaviruses and adenovirus . rav - positive samples were then subjected to g and p genotyping by nested pcr with previously published primers ( 79).the rav isolate for which the g and p types could not be determined by rt - pcr method was subjected to nucleotide sequence analysis of pcr products positive for vp7 and vp4 genes with the bigdye terminator cycle sequencing kit and abi prism 3100 genetic analyzer ( applied biosystems inc . , foster city , ca , usa ) . their vp7 and vp4 nucleotide sequences were compared as well as those of reference rotavirus strains available in genbank by using blast ( http://blast.ncbi.nlm.nih,gov/blast.cgi ) . phylogenetic and molecular evolutionary analyses were conducted by using mega version 3.2 software ( 10 ) . the sequences of vp4 and vp7 genes of rotaviruses detected in this study had been submitted to genbank under accession nos . eu855813eu855822 and eu855823eu855830 , respectively . among diarrhea - causing viruses detected , rav was the most prevalent ( 33.5% ) , followed by adenoviruses ( 1.9% ) . most of the patients in this study were 1 to 24 months of age ; rav infection was most commonly detected in patients 6 to 23 months of age . gender distribution of patients with rav - positive samples was 56% male and 44% female . we could not initially determine g type for 10 rav and p type for 8 rav isolates , even though their vp7 and vp4 genes were successfully amplified by rt - pcr . g1 strains analyzed in this study belonged to the asian cluster and were most closely related to dhaka-02 , dhaka-03 , and thai-1602 strains , which had high identities at the nucleotide level with each other ( 99%100% ) . eight rotavirus p sequences in this study belonged to 1 distinct lineage , lineage p - ii , but made a novel sublineage , sublineage p - iib , which had a high nucleotide sequence identity of 100% within lineage p - ii ( figure 1 ) . these untypeable rotavirus p strains contained 23 point mutations at the vp4 primer - binding site . phylogenetic analysis of the nucleotide sequences of the vp7 and vp4 genes of untypeable group a rotavirus strains ( rav ) from bangladesh . a ) neighbor - joining phylogenetic tree based on nucleotide sequences of the vp7 encoding genes for untypeable rav strains . b ) neighbor - joining phylogenetic tree based on nucleotide sequences of the vp4 encoding genes for untypeable rav strains . reference strains of rav g1 and p strains were selected from dna database of japan / genbank under the accession number indicated in boldface . reference rav strains used in this study and their accession numbers are as follows : rav p strains : bp785/00/hungary ( aj605315 ) , va70/usa ( aj540229 ) , wa/ usa ( l34161 ) , hochi / japan ( ab039943 ) , odelia / japan ( ab039942 ) , mw670/malawi ( aj302146 ) , op530/malawi ( aj302152 ) , ai-75/japan ( ab008285 ) , mw258/malawi ( aj302143 ) , op511/malawi ( aj302151 ) , ch927b / china ( ab008273 ) , mo / japan ( ab008278 ) , kagawa/90 - 513/japan ( ab039944 ) , op601/malawi ( aj302153 ) , cu132p8/thailand ( dq235955 ) , dk v98 - 893/denmark ( ay509908 ) , dk v00- 2138/denmark ( ay509910 ) , s8/porcine / brazil ( af052449 ) , cu90p8/thailand ( dq235978 ) , tf101/taiwan ( af183870 ) , hun9/hungary ( aj605320 ) , wh-1194/china ( ay856445 ) , dhaka25 - 02 ( dq146652 ) , cu90p8 ( dq235978 ) , 2vp4n ( dq675009 ) , cau 164 ( eu679398 ) and wh-624/china ( ay856444 ) ; rav g1 strains : dhaka9 - 03 ( dq482715 ) , cu122g1 ( dq236053 ) , pa5/03 ( dq377596 ) , kh210 ( ab303218 ) , 7014/jp ( ef079064 ) , rotavirus g1 isolate 5.1(dq672628 ) , mvd9906 ( af480278 ) , 7265/jp ( ef079066 ) , 7124/jp(ef079069 ) , 7108/jp ( ef079068 ) , jp421 ( d16326 ) , fin-408 ( z80303 ) , pa2/04 ( dq377598 ) , fin-429 ( z80312 ) , au007 ( ab081799 ) , g192b ( af043678 ) , dc03 ( af183859 ) , oh-64 ( u26387 ) , pa3c ( dq377566 ) , pa32 ( dq377574 ) , thai-1604 ( dq512981 ) , dhaka8 - 02 ( ay631049 ) , thai-804 ( dq512979 ) , mvd9816 ( af480293 ) ch631 ( af183857 ) , china-45 ( u26371 ) , russia-1407 ( s83903 ) , pa8/01 ( dq377592 ) , pa19/01 ( dq377593 ) . rav was detected all year round , but 2 peaks in infections occurred : 1 peak apparently lasted 4 months ( october 2004 through january 2005 ) and another peak lasted 3 months ( june 2005 through august 2005 ) ( figure 2 ) . five different g types , g1g4 and g9 , were detected during the study period . of these , g2 was the most common ( 43.3% ) followed by g4 ( 19.5% ) , g9 ( 13.7% ) , g1 ( 12.7% ) , and g3 ( 2.6% ) . mixed infections between > 1 g genotypes were identified in 4% of the specimens ( table ) . genotype g2 was detected in every month with a relatively high incidence rate . among 307 rav - positive samples , 280 samples were p typed successfully , and p was the most predominant genotype ( 53.2% ) , followed by p ( 42.9% ) and mixed infections between different p genotypes ( 5.0% ) . g2p combination was the most predominant genotype ( 39% ) , followed by g4p ( 18.2% ) , g9p ( 13% ) , g1p ( 11.8% ) , and g3p ( 2.9% ) . seasonal pattern of group a rotavirus infection in infants and children with acute gastroenteritis in dhaka , bangladesh , october 2004september 2005 . this result was consistent with the previous findings on rotavirus epidemiology in bangladesh in which its prevalence was 29% ( 11,12 ) . the winter rotavirus peak is usually observed worldwide , but the monsoon peak is not common in settings with temperate climates . why there was we identified most of the globally common rotavirus types ( g1 , g2 , g4 , and g9 ) in our study . even though g3 is one of the most prevalent rotavirus types worldwide , the g3 strain has not been detected in bangladesh since 1993 ( 13 ) . however , we found that 4% of the rotavirus types identified in this study were g3 . results of rotavirus diversity from this study were compared with results of previous studies in bangladesh ( 13 ) , and we found that g2 was a predominant rotavirus strain among infants and children in dhaka , bangladesh . rotavirus g4 genotype was the most common genotype in dhaka from 1992 through 1997 but became a less common rotavirus strain over time ; g9 was the leading genotype followed by g2 , g4 , and g1 in dhaka ( 12,14 ) . the prevalence of g9 strains was nearly the same in our study , but g2 strains showed a dramatic increase . from 20012004 , the most common rotavirus genotype was p ( 76% ) ; non - p strains constituted 20% . we found that the 4 most common strains globally , g1p , g2p , g3p , and g4 , were found in 83.9% of cases . the g1p strains , less common in 2001 , became the predominant strains in the following years , but decreased again in 200506 . rotaviruses show great genomic diversity , and several studies in different regions of bangladesh have identified types not targeted by candidate rotavirus vaccines ( 11,14 ) . the frequent genomic reassortment among different rotavirus types was accelerated by mixed infection and generated huge genomic diversity ( 13 ) . rav has been associated with gastroenteritis outbreaks in infants and children < 5 years of age . however , less is known of the age distribution of rotavirus infection in bangladesh . in this study , infections were most commonly detected in children < 2 years of age . common clinical symptoms of rav - infected patients were dehydration ( 84% ) , vomiting ( 69% ) , abdominal pain ( 52% ) , and fever ( 31% ) , which are in agreement with previous published reports ( 15 ) . number of loose stools per day was increased , with most patients ( 76% ) having loose stools 35 times per day . our study is limited because we could not conduct other tests such as enzyme immunoassay or polyacrylamide gel electrophoresis to confirm rotavirus illness . the incidence of rotavirus gastroenteritis identified by rt - pcr could be an overestimate because healthy controls tested by rt - pcr had a 5%10% general incidence of rotavirus .

to determine g and p genotypes , we performed nested pcr on 307 rotavirus specimens collected in dhaka , bangladesh , during 20042005 . g2 ( 43.3% ) was detected at the highest frequency , followed by g4 ( 19.5% ) , g9 ( 13.7% ) , g1 ( 12.7% ) , and g3 ( 2.6% ) . p[8 ] was the most predominant genotype ( 53.2% ) , followed by p[4 ] ( 42.9% ) .

transcutaneous electrical nerve stimulation ( tens ) is widely used in western and developed countries to relieve a wide range of painful conditions , including non - malignant acute and chronic pain and pain resulting from cancer and its treatment [ 13 ] . tens can be self administered by patients following simple training and because there is no potential for toxicity , patients can titrate the dosage on an as - needed basis . during tens pulsed electrical currents are generated by a small battery operated tens device that can be kept in the pocket or attached to the user 's belt . currents from the tens device are delivered through the skin by two self - adhering electrode pads ( figure 1 ) . a standard tens device . maximal pain relief is achieved when tens generates a strong non - painful electrical sensation beneath the electrodes . pain relief is usually rapid in onset and stops shortly after tens is turned off . for this reason patients are encouraged to deliver tens for as long as needed , which may be for hours at a time and throughout the day . , tens devices can be purchased without prescription , although this is not the case in some european countries . tens devices , including electrode leads , pads and battery , retail for approximately 30gbp although bulk buying can markedly reduce cost . interestingly , tens does not appear to be widely available for patient use in developing countries . in this review the basic science behind tens will be discussed , the evidence of its effectiveness in specific clinical conditions will be provided and a case for its use in pain management in developing countries will be made . the ancient egyptians are usually acknowledged as the first people who used electrogenic fish to apply electricity for pain relief . yet , the first documented use of this kind of pain relief is of a roman physician in 46 ad . in 1786 , luigi galvani , an italian doctor , demonstrated that the leg of a frog contained electricity . this observation and other advancements in generating electricity lead to a resurgence in the use of electricity to treat different illnesses and relieve pain . however , increased use of pharmacological agents to manage pain resulted in the decline of the electrotherapy at the end of the 19th century . in 1965 , ronald melzack from mcgill university in montreal canada and patrick wall from university college london uk , published their seminal paper which proposed a gating mechanism in the central nervous system to regulate the flow of nerve signals from peripheral nerves en - route to the brain . according to this gate - control theory of pain , activity in large diameter low threshold mechanoreceptive ( touch - related ) nerve fibers could inhibit the transmission of action potentials from small diameter higher threshold nociceptive ( pain - related ) fibers through pre and post synaptic inhibition in the dorsal horn of spinal cord . because nociceptive fibers ( a - delta and c - fibers ) have a higher threshold of activation than mechanoreceptive fibers ( a - beta fibers ) melzack and wall proposed that it would be possible to selectively stimulate mechanoreceptive fibers by titrating the amplitude of electrical currents delivered across the surface of the skin ( ie tens ) . this would prevent signals from nociceptive fibers from reaching higher centres of the brain , thus reducing pain ( figure 2 ) . diagrammatic representation of the principle of conventional tens . by selectively activating a - beta fibers , tens shuts the pain gate on a - delta and c fibers preventing pain - related signals reaching the brain . in addition to interrupting nociceptive signals , at spinal cord dorsal horn , we now know that tens analgesia also involves a descending inhibitory mechanism that could be partially prevented by spinalization . activity in nerve fibers descending from the brain can also block onward transmission of peripheral nerve signals within the spinal cord . humans utilise this mechanism whenever they mentally distract themselves to not feel pain despite the presence of tissue damage ( figure 2 ) evidence gathered from animal studies suggested that low frequency tens effects may be due to release of endogenous opioids . this explains why analgesia may persist for hours after electrical stimulation has stopped because endorphins have long lasting effects in the central nervous system . the released opioids may generate their analgesic action at peripheral , spinal and supraspinal sites [ 7 , 8 ] . however , other neurochemicals have been implicated in tens analgesia including gaba , acetylcholine , 5-ht , noradrenaline and adenosine . in health care the term tens refers to the delivery of currents using a standard tens device ( table 1 ) . however , there are a variety of devices that deliver electrical currents through the skin but have technical output characteristics that differ from a standard tens device . we have previously described these as tens - like devices and include trancutaneous spinal electroanalgesia , interferential therapy , microcurrent stimulation and pain gone pens ( see [ 3 , 14 , 15 ] for a review of these devices ) . low - intensity pulsed currents are administered at high - frequencies ( between 10200 pulses per second , pps ) at the site of pain . the user experiences a strong , non - painful tens sensation often described as tingling or pleasant electrical paraesthesiae. physiologically , conventional tens activates large diameter non - noxious afferents which has been shown to close the pain gate at spinal segments related to the pain . another technique , which is used less often is acupuncture - like tens ( al - tens ) using high - intensity and low - frequency ( less than 10pps , usually 2pps ) administered over muscles , acupuncture and trigger points . the purpose of al - tens is to activate small diameter afferents which has been shown to close the pain gate using extra - segmental mechanisms . tens can also be used as a counter - irritant , termed intense tens , using high - intensity and high - frequency currents ( table 2 , figure 3 ) . the user can control the amplitude ( intensity ) , duration ( width ) , frequency ( rate ) and pattern ( mode ) of the pulsed electrical currents . in western clinical practice tens has been shown to have a role in pain management . there are many systematic reviews on tens although evidence is often inconclusive because of shortcomings in rct methodology . early systematic reviews suggested that tens was of limited benefit as a stand alone pain therapy for acute pain . judged there to be no benefit of tens for postoperative pain because 15 of 17 rcts found no differences in pain relief between active and placebo tens . re - assessed the evidence and concluded that tens reduced post - operative analgesic consumption if tens was applied using adequate tens technique . systematic reviews have also concluded that there was no evidence for tens producing beneficial analgesic effects during childbirth [ 19 , 20 ] and insufficient evidence to determine the effectiveness of tens in reducing pain associated with primary dysmenorrhoea . rcts suggest that tens is effective for acute orofacial pain , painful dental procedures , fractured ribs and acute lower back pain ( for review see . previously , systematic reviews suggested that tens may be of benefit for chronic pain but definitive conclusions were hindered by shortcomings in rct methodology [ 23 , 24 ] . reviews on rheumatoid arthritis of the hand , whiplash and mechanical neck disorders , chronic low back pain , poststroke shoulder pain and chronic recurrent headache were inconclusive . in contrast , systematic reviews have demonstrated tens efficacy for knee osteoarthritis and chronic musculoskeletal pain . rcts have also demonstrated effects for a range of other chronic pain conditions including localized muscle pain , post - herpetic neuralgia , trigeminal neuralgia , phantom limb and stump pain and diabetic neuropathies ( for review see . a recent cochrane review by robb et al . concluded that there is insufficient available evidence to determine the effectiveness of tens in treating cancer - related pain [ 32 , 33 ] . the international association for the study of pain ( iasp ) speculate that the prevalence of most types of pain may be much higher in developing countries than in developed countries , although epidemiological evidence is lacking . it is known that there is a higher incidence of pain conditions associated with epidemics such as hiv / aids in the developing world . an iasp developing countries task force , which included africa and the middle east reported that pain management in the general population was inadequate , although there was considerable variations between regions . limited resources , ignorance by health care professionals and a lack of pain specialists were contributing factors . this has impacted significantly on pharmacological therapy with many drugs commonly used in the developed world being unavailable to the general public because of the weak economy and limited purchasing power of citizens . in addition , drugs even when available may be fake , adulterated , passed their expiry date or perished due to inadequate storage . the cost of a tens device is 30gbp , although devices are available for less than 15gbp if bought in bulk . once purchased a tens device will not perish or deteriorate and devices in the developed world are used for many decades without the need for further servicing or repair . often clinics purchase tens devices in bulk and loan them to patients for short and long term use , on the proviso that the patient returns the device to the clinic when it is no longer needed . manufacturers recommend that individual pads have longevity of one month on daily use , although patients often use them for far greater lengths of time , especially if they take care to store them carefully . electrode costs can be reduced by using carbon rubber electrodes which are smeared with electrode gel and attached to the skin with micropore tape , rather than using self adhering electrodes . in general , tens has no known drug interactions and so can be used in combination with pharmacotherapy to reduce medication , medication - related side effects and medication costs . tens has very few side effects with no incidents of serious or adverse events reported in the literature . tens has a rapid onset of action , unlike medication , and there is no potential for toxicity or overdose . clearly , there is a case to use tens for pain management in the developing world . however , research is needed to determine the feasibility of tens use in developing countries . perhaps health promotion authorities should alert the public and heath care practitioners to the role of tens as an important aid in the fight against pain .

transcutaneous electrical nerve stimulation ( tens ) refers to the delivery of electrical currents through the skin to activate peripheral nerves . the technique is widely used in developed countries to relieve a wide range of acute and chronic pain conditions , including pain resulting from cancer and its treatment . there are many systematic reviews on tens although evidence is often inconclusive because of shortcomings in randomised control trials methodology . in this overview the basic science behind tens will be discussed , the evidence of its effectiveness in specific clinical conditions analysed and a case for its use in pain management in developing countries will be made .

impressions play a vital role in the success of prosthesis because a prosthesis can be no more accurate than the impression from which it has been made . one of the most critical factors in the production of an accurate impression is the use of an appropriate impression material . there is a continuous effort to improve materials used to achieve dimensional stability , precision and fine tissue details . the dimensional stability and surface detail obtained with elastomeric impression materials has made them the material of choice for recording impressions that require a high degree of accuracy . it is also necessary for the impression materials to allow easy flow of the stone as is being poured . silicone impression materials , however are recognized as having poor surface wettability.1 clinically , the topical use of a surface wetting agent has been demonstrated to improve wettability and significantly reduce the number of voids in dental casts poured in silicone impressions.2 the impressions are contaminated with saliva , plaque and sometimes blood , all of which may carry pathogenic micro - organisms . mere washing of the impression as it is practiced does not clear away all the micro - organisms.3 these contaminated impressions may cause cross - infection from the patient to operator or dental assistant or laboratory technician.4 hence , it is necessary that the disinfection of dental impressions be adopted as a mandatory procedure in dental practice . in trying to achieve the goal of disinfection for the protection of the dental team , it is absolutely necessary that accuracy and surface details of impressions , not be compromised . moreover currently available impression materials were never originally designed to undergo disinfection or sterilization and it is quite conceivable that available disinfecting solutions may adversely affect the impressions.5 commonly used disinfecting agents like glutaraldehyde and sodium hypochlorite may alter the surface characteristics of impression materials , which may lead to dimensional changes in the impressions , along with changes in surface tension and wettability of the impression material . thus , the need arises to critically evaluate how these disinfecting solutions could affect the physical properties of elastomeric impression materials in order to ensure efficient , ethical and a consistent modern day prosthodontic practice . hence , this study was designed to evaluate the effect of two commercially available chemical disinfectants namely sodium hypochlorite and glutaraldehyde and a surface wetting agent on the physical property of three high precision elastomeric impression materials , viz . the study was conducted : to determine the contact angle and the wettability of various elastomeric impression materials before and after immersion disinfectionto determine the contact angle and the wettability of various elastomeric impression materials before and after treatment with a surface wetting agent . to determine the contact angle and the wettability of various elastomeric impression materials before and after immersion disinfection to determine the contact angle and the wettability of various elastomeric impression materials before and after treatment with a surface wetting agent . for the purpose of this study , three different types of elastomeric impression materials commonly used in prosthodontic practice were selected . addition silicone impression material : express stdputty and light body syringeable ( 3 m espe dental products u.s.a . ) condensation silicone impression material : zetaplusputty and light body ( zhermack italy ) polyether impression material : impregum fhydrophilic medium consistency ( 3 m espe dental products u.s.a . ) addition silicone impression material : express stdputty and light body syringeable ( 3 m espe dental products u.s.a . ) putty and light body syringeable ( 3 m espe dental products u.s.a . ) condensation silicone impression material : zetaplusputty and light body ( zhermack italy ) putty and light body ( zhermack italy ) polyether impression material : impregum fhydrophilic medium consistency ( 3 m espe dental products u.s.a . ) hydrophilic medium consistency ( 3 m espe dental products u.s.a . ) the glutaraldehyde and sodium hypochloride solutions were employed to disinfect the impressions made with the above mentioned elastomeric impression materials . true blue surface wetting agent was selected . glutaril2% glutaraldehyde ( glaxo india ltd.)sodium hypochlorite sodium u.s.p.4 - 6% sodium hypochlorite ( snow chem industries , mumbai)true bluesurface wetting agent ( georg taub products , u.s.a . ) 2% glutaraldehyde ( glaxo india ltd . ) sodium hypochlorite sodium u.s.p . 4 - 6% sodium hypochlorite ( snow chem industries , mumbai ) surface wetting agent ( georg taub products , u.s.a . ) aluminum model die , glass slide.gbx contact angle analyzer to measure advancing and receding contact angle . three different types of elastomeric impression materials were selected as representative of the materials currently used . specimens 20 mm 10 mm 2 mm were prepared by compressing the elastomeric material in a mold and glass slide . the test conditions were as follows : drysurface wetting agent ( spray twice)2% glutaraldehyde ( 10 min immersion)2% glutaraldehyde ( 10 min immersion ) and surface wetting agent4% sodium hypochlorite ( 10 min immersion)4% sodium hypochlorite ( 10 min immersion ) and surface wetting agent . surface wetting agent ( spray twice ) 2% glutaraldehyde ( 10 min immersion ) 2% glutaraldehyde ( 10 min immersion ) and surface wetting agent 4% sodium hypochlorite ( 10 min immersion ) 4% sodium hypochlorite ( 10 min immersion ) and surface wetting agent . care was taken not to permit contamination of the surfaces . a contact angle analyzer linked to a compatible computer as used to measure the advancing and receding contact angles . used , the material was suspended in an electro balance while the wetting medium scans along at a constant speed via a computer - controlled stage . the meniscus at the interface is characterized by the dynamic contact angle ( ) . both the advancing and receding contact angles are measured as the stage moves up ( the specimen ) and then down . a simple equation relates the cosine of the contact angle ( ) to the magnitude of the wetting force recorded by the balance , the surface tension of the liquid , and the wetted perimeter of the solid specimen : v = surface tension ( dyne / cm ) three different types of elastomeric impression materials were selected as representative of the materials currently used . specimens 20 mm 10 mm 2 mm were prepared by compressing the elastomeric material in a mold and glass slide . the test conditions were as follows : drysurface wetting agent ( spray twice)2% glutaraldehyde ( 10 min immersion)2% glutaraldehyde ( 10 min immersion ) and surface wetting agent4% sodium hypochlorite ( 10 min immersion)4% sodium hypochlorite ( 10 min immersion ) and surface wetting agent . surface wetting agent ( spray twice ) 2% glutaraldehyde ( 10 min immersion ) 2% glutaraldehyde ( 10 min immersion ) and surface wetting agent 4% sodium hypochlorite ( 10 min immersion ) 4% sodium hypochlorite ( 10 min immersion ) and surface wetting agent . a contact angle analyzer linked to a compatible computer as used to measure the advancing and receding contact angles . used , the material was suspended in an electro balance while the wetting medium scans along at a constant speed via a computer - controlled stage . the meniscus at the interface is characterized by the dynamic contact angle ( ) . both the advancing and receding contact angles are measured as the stage moves up ( the specimen ) and then down . the difference between these two contact angles a simple equation relates the cosine of the contact angle ( ) to the magnitude of the wetting force recorded by the balance , the surface tension of the liquid , and the wetted perimeter of the solid specimen : v = surface tension ( dyne / cm ) contact angle of express 3 m , zetaplus and impregum f ( addition silicone , condensation silicone and polyether respectively ) were evaluated after 10 min immersion disinfection in one of the two disinfectants namely sodium hypochlorite and glutaraldehyde and also after treatment with surface wetting agent . for the evaluation of contact angle of impression materials , gbx contact angle analyzer instrument was used . the contact angle measurements were conducted using each sample and each test solution only once before discarding . the results of this study have been presented in tables 1 - 5 with their standard deviations . comparison of advancing contact angle between three elestomeric impression materials ( dry sample ) : control group . impressions play a vital role in the success of a prosthesis because a prosthesis can be no more accurate than the impression from which it has been made . the impressions are contaminated with saliva , plaque and sometimes blood all of which may carry pathogenic microorganisms . these contaminated impressions may cause cross - infection from the patient to operator or dental assistant . this study was designed to evaluate the wettability of the three commercially available elastomeric impression materials viz . addition silicone ( express 3 m ) , condensation silicone ( zetaplus ) and polyether ( impregum f ) after immersion disinfection in two commercially available chemical disinfectants , 2% glutaraldehyde ( glutaril ) , and 4% sodium hypochlorite for 10 min and after spraying with surface wetting agent ( true blue ) . wettability was assessed by measuring the contact angle of elastomeric impression materials with the help of gbx contact angle analyzer.the data collected was tabulated and subjected to statistical analysis.considering the results of the study , following conclusions can be drawn . the polyether impression material was the most hydrophilic of all the materials , followed by hydrophilic addition silicone . condensation silicone was least hydrophilic of the three materials.all the three elastomeric impression materials showed improvement in the wettability when a topical surfactant was used.the short term disinfection of the three elastomeric impression materials does not affect the wettability of these impression materials.the treatment with a topical surface wetting agent after short term disinfection resulted in an improvement in the wettability of the impression materials . thus it is recommended that elastomeric impression materials be treated with a surface wetting agent after disinfection to obtain accurate and void free casts and dies.thus the evaluated impression materials could be safely disinfected with any of the given chemical disinfectants for a short duration of 10 min , without compromising wettability . from the results , it was observed that none of the disinfectants affect the physical properties of the impression materials beyond the acceptable limits.furthermore , it was observed that treatment with a surface wetting agent improved the wettability of elastomeric impression materials.however , statistically significant differences were found in the wettability of the three types of impression materials used.it should be kept in mind that the current in vitro study has certain limitations . further long term in vivo studies with respect to these impression materials and disinfectants are suggested to enhance the conclusion obtained from the current study . wettability was assessed by measuring the contact angle of elastomeric impression materials with the help of gbx contact angle analyzer . the data collected was tabulated and subjected to statistical analysis . considering the results of the study , following conclusions can be drawn . the polyether impression material was the most hydrophilic of all the materials , followed by hydrophilic addition silicone . condensation silicone was least hydrophilic of the three materials.all the three elastomeric impression materials showed improvement in the wettability when a topical surfactant was used.the short term disinfection of the three elastomeric impression materials does not affect the wettability of these impression materials.the treatment with a topical surface wetting agent after short term disinfection resulted in an improvement in the wettability of the impression materials . thus it is recommended that elastomeric impression materials be treated with a surface wetting agent after disinfection to obtain accurate and void free casts and dies.thus the evaluated impression materials could be safely disinfected with any of the given chemical disinfectants for a short duration of 10 min , without compromising wettability . the polyether impression material was the most hydrophilic of all the materials , followed by hydrophilic addition silicone . all the three elastomeric impression materials showed improvement in the wettability when a topical surfactant was used . the short term disinfection of the three elastomeric impression materials does not affect the wettability of these impression materials . the treatment with a topical surface wetting agent after short term disinfection resulted in an improvement in the wettability of the impression materials . thus it is recommended that elastomeric impression materials be treated with a surface wetting agent after disinfection to obtain accurate and void free casts and dies . thus the evaluated impression materials could be safely disinfected with any of the given chemical disinfectants for a short duration of 10 min , without compromising wettability . from the results , it was observed that none of the disinfectants affect the physical properties of the impression materials beyond the acceptable limits . furthermore , it was observed that treatment with a surface wetting agent improved the wettability of elastomeric impression materials . however , statistically significant differences were found in the wettability of the three types of impression materials used . it should be kept in mind that the current in vitro study has certain limitations . further long term in vivo studies with respect to these impression materials and disinfectants are suggested to enhance the conclusion obtained from the current study .

background : this study was carried out to evaluate the effect of two commercially available chemical disinfectants namely sodium hypochlorite and glutaraldehyde and a surface wetting agent on the wettability of three high precision elastomeric impression materials , addition silicone , condensation silicone and polyether.materials and methods : three different types of elastomeric impression materials commonly used in prosthodontic practice were selected . the glutaraldehyde and sodium hypochloride solutions were employed to disinfect the impressions made with the above - mentioned elastomeric impression materials.true blue surface wetting agent was selected.gbx contact angle analyzer was used to measure advancing and receding contact angle.results:the results of this study have demonstrated that the polyether impression material was the most hydrophilic of all the materials , followed by hydrophilic addition silicone . condensation silicone was least hydrophilic . all materials showed improvement in the wettability when a topical surfactant was used.conclusion:the short term disinfection of the three elastomeric impression materials does not affect the wettability of these impression materials .

in the diabetes prevention program ( dpp ) , women with prediabetes and prior gestational diabetes mellitus ( gdm ) were 71% more likely to develop diabetes compared with women without prior gdm and one or more previous live births . interestingly , intensive lifestyle intervention ( ils ) was equally effective at preventing progression to diabetes in both groups of women compared with placebo ( 53 vs. 49% risk reduction ) , whereas metformin was more effective in women with a history of gdm ( 50 vs. 14% risk reduction ) ( 1 ) . individual genetic risk scores ( grs ) , developed from a composite of single nucleotide polymorphisms ( snps ) at loci associated with type 2 diabetes , predicted progression to diabetes among dpp participants ( 2 ) . here , we compared -cell function between gdm and non - gdm women in the dpp and examined the utility of this grs and its individual risk alleles in predicting progression to diabetes and response to intervention in women with or without prior gdm . the dpp trial design and baseline characteristics have been described in detail previously ( 3,4 ) . in brief , across 27 u.s . clinical centers , 3,234 participants aged 25 years with impaired glucose tolerance , elevated fasting glucose ( 95125 mg / dl ) , and bmi 24 kg / m were randomized to placebo , metformin , or ils . primary study end point was development of diabetes . at the time of enrollment , all women completed a questionnaire regarding gravidity , parity , and gdm history . among 1,416 women with one or more live births and without gdm and 350 with a history of gdm , a subset ( n = 1,102 without gdm ; n = 281 with gdm ) underwent genotyping . a grs for each participant was calculated using the 34 loci by weighting each risk allele by its effect size ( -estimate ) on diabetes risk and summing these values , with a theoretical range of 068 ( 2 ) . similar numbers of gdm and non - gdm women who underwent genotyping were assigned to placebo , metformin , or ils ( table 1 ) . insulinogenic index calculated from the 75-g , 2-h oral glucose tolerance test [ log(insulin/glucose)(0 - 30 min ) ] ( 5 ) was used as a measure of -cell function in general linear models at baseline and at 1 year to determine differences between gdm and non - gdm women . independent variables included gdm status , race / ethnicity , age at randomization , parity , and intervention ( at 1 year only ) . -cell function [ insulinogenic index : log(insulin/glucose)(030 min ) ] at 1 year , after adjustment for baseline -cell function , race / ethnicity , age at randomization , and parity logistic regression was used to evaluate the association between grs and baseline history of gdm adjusted for ethnicity , age , and parity . we examined the grs , treatment interventions , and history of gdm in cox regression models as independent variables predicting diabetes incidence . next , ancova was used to assess the effect of dpp treatments , grs , and history of gdm on -cell function adjusted for concomitant insulin sensitivity , as measured by the oral disposition index ( dio ) ( 2,6 ) at 1 year . in contrast to the insulinogenic index , dio captures -cell function adjusted for insulin sensitivity and therefore takes into account physiological compensation ( 2,6 ) . individual effects of snps were tested in similar ancova models using snp as an additive term . genotype , treatment , and gdm three - way and two - way interaction tests were performed for all models testing postrandomization outcomes . analyses were also performed after adjustment for waist circumference , which was a significant predictor of development of diabetes in the dpp cohort ( 2 ) . similar numbers of gdm and non - gdm women who underwent genotyping were assigned to placebo , metformin , or ils ( table 1 ) . insulinogenic index calculated from the 75-g , 2-h oral glucose tolerance test [ log(insulin/glucose)(0 - 30 min ) ] ( 5 ) was used as a measure of -cell function in general linear models at baseline and at 1 year to determine differences between gdm and non - gdm women . independent variables included gdm status , race / ethnicity , age at randomization , parity , and intervention ( at 1 year only ) . -cell function [ insulinogenic index : log(insulin/glucose)(030 min ) ] at 1 year , after adjustment for baseline -cell function , race / ethnicity , age at randomization , and parity logistic regression was used to evaluate the association between grs and baseline history of gdm adjusted for ethnicity , age , and parity . we examined the grs , treatment interventions , and history of gdm in cox regression models as independent variables predicting diabetes incidence . next , ancova was used to assess the effect of dpp treatments , grs , and history of gdm on -cell function adjusted for concomitant insulin sensitivity , as measured by the oral disposition index ( dio ) ( 2,6 ) at 1 year . in contrast to the insulinogenic index , dio captures -cell function adjusted for insulin sensitivity and therefore takes into account physiological compensation ( 2,6 ) individual effects of snps were tested in similar ancova models using snp as an additive term . genotype , treatment , and gdm three - way and two - way interaction tests were performed for all models testing postrandomization outcomes . analyses were also performed after adjustment for waist circumference , which was a significant predictor of development of diabetes in the dpp cohort ( 2 ) . at baseline , -cell function ( insulinogenic index ) was decreased in gdm ( mean 4.19 [ 95% ci 4.104.29 ] ) versus non - gdm ( mean 4.35 [ 4.304.40 ] ) women ( p < 0.01 ) . at 1 year , there was a significant interaction between treatment group and gdm status ( p = 0.02 ) ; therefore , analysis was stratified by gdm status and treatment group . after adjustments , 1-year insulinogenic index was also lower in gdm compared with non - gdm women ( p < 0.01 ) ( table 1 ) . adjusted for ethnicity and age , the grs was positively associated with gdm history ( odds ratio 1.05 [ 95% ci 1.001.08 ] , p = 0.04 ) , such that for every one unit increase in the grs , the odds of gdm increased by 5% . this association was unaffected by additional adjustment for parity ( 1.04 [ 1.001.08 ] , p = 0.04 ) ; however , it was no longer significant after adjustment for waist circumference ( 1.04 [ 1.001.08 ] , p = 0.07 ) . there was no difference in the hazard ratios ( hrs ) for the grs predicting progression to diabetes in women with gdm compared with women without gdm after adjustment for ethnicity , age , and treatment arm ( p = 0.09 ) . because -cell function as measured by insulinogenic index was lower in gdm than in non - gdm women , we next examined the relationship of individual snps within the grs with -cell function after adjustment for concomitant insulin sensitivity , as measured by dio . four of the 34 snps comprising the grs are primarily associated with insulin resistance ( klf14 , rs972283 ; pparg , rs1801282 ; irs1 , rs7578326 ; gckr , rs780094 ) ( 7 ) and thus were excluded from this analysis in order to isolate any genetic component of -cell function in gdm women . after adjusting for ethnicity , age , and parity , none of the remaining 30 snps comprising the grs independently associated with dio in women with gdm compared with women without gdm . we found that among parous women in the dpp , -cell function defined by insulinogenic index was reduced in women with a history of gdm compared with women without prior gdm . this is consistent with the reduced insulin - to - glucose ratio previously reported in gdm women in this cohort ( 1 ) . further , a grs calculated using snps strongly associated with type 2 diabetes was higher in women with gdm compared with women without gdm ; thus , grs is positively associated with prior gdm in dpp women . this association remained significant after adjustment for age , ethnicity , and parity , consistent with epidemiological data demonstrating that increasing parity or gravidity do not alter future diabetes risk in women with ( 8) or without ( 9 ) previous gdm who have been pregnant . on the other hand , these data suggest the grs is not associated with progression to diabetes in high - risk women either with or without a gdm history , in any of the study arms . this is of interest because a prior analysis from the dpp showed that risk reduction for progression to diabetes in response to metformin was greater among women with gdm compared with women without gdm ( 1 ) , leading us to hypothesize that genetic variability may play a role . our data showed that grs predicted the presence of gdm but not progression to diabetes among affected women . that said , the hr for the grs predicting progression to diabetes in this small cohort of female dpp participants with prior gdm ( hr 1.04 [ 95% ci 1.001.08 ] ) is similar to the significant hr for the grs predicting progression to diabetes among the entire dpp cohort with genetic information ( 1.02 [ 1.021.03 ] ) ( 2 ) , indicating that analysis of a larger population of prediabetic women with prior gdm may strengthen the relationship between this grs and diabetes progression . limitations of our study include small sample size and a relatively long diabetes - free interval ( mean 12 years ) since the index pregnancy among women with gdm at enrollment . this suggests the dpp excluded gdm women with the highest risk for diabetes progression , possibly diminishing differences in grs between women with and without gdm . accordingly , grs comprising 34 diabetes - associated loci is higher in women with prediabetes and histories of gdm compared with women with prediabetes without gdm and one or more prior live births . this grs does not , however , differentiate diabetes risk or response to treatment with metformin or ils between high - risk women with and without gdm .

objectivethe diabetes prevention program ( dpp ) trial investigated rates of progression to diabetes among adults with prediabetes randomized to treatment with placebo , metformin , or intensive lifestyle intervention . among women in the dpp , diabetes risk reduction with metformin was greater in women with prior gestational diabetes mellitus ( gdm ) compared with women without gdm but with one or more previous live births.research design and methodswe asked if genetic variability could account for these differences by comparing -cell function and genetic risk scores ( grs ) , calculated from 34 diabetes - associated loci , between women with and without histories of gdm.results-cell function was reduced in women with gdm . the grs was positively associated with a history of gdm ; however , the grs did not predict progression to diabetes or modulate response to intervention.conclusionsthese data suggest that a diabetes - associated grs is associated with development of gdm and may characterize women at risk for development of diabetes due to -cell dysfunction .

the calcifying epithelial odontogenic tumor ( ceot ) was first introduced into scientific literature almost 50 years ago by dr . classified it as a benign odontogenic tumor , which is exclusively epithelial in its tissue of origin . the differential diagnosis for ceot should include adenomatoid odontogenic tumor ( aot ) , calcifying odontogenic cyst ( coc ) , ameloblastic fibro odentoma ( afo ) , odontoma . a 50-year - old male reported to the oral and maxillofacial surgery opd with a swelling in left body of mandible measuring 8 10 cms extending from tooth nos . the swelling was tender and had progressively increased over a period of two years leading to facial asymmetry . orthopantomograph [ figure 1 ] revealed a mixed radiolucent - radiopaque lesion , which was multilocular with coarse trabeculae and scattered foci of calcification extending from left lower canine to first molar region with a radio opaque mass representing embedded premolar . the provisional clinical diagnosis of ossifying fibroma , calcifying epithelial odontogenic tumor , ameloblastoma and odontogenic myxoma was made . histopathology findings revealed a neoplasm composed of cells arranged as sheets and anastomosing small and large islands . the neoplastic cells have well defined cell borders , abundant eosinophilic cytoplasm and hyperchromatic mildly pleomorphic nuclei , few bizarre nuclei were seen , however no abnormal mitosis was seen . normal mature lamellar bony trabeculae were seen between tumor islands interspersed with large areas of haemorrhage . the eosinophilic material was confirmed as amyloid upon special staining , diagnosing the lesion to be ceot . orthopantamograph revealing large osteolytic lesion a presurgical computed tomography ( ct ) scan [ figure 2 ] was obtained to ascertain the boundaries of the neoplasm . it [ figure 3 ] revealed an osteolytic lesion with foci of calcifications . in view of the extensive involvement , resection of the involved portion of the mandible and reconstruction with an ao unilock the mandible was exposed via an extraoral approach and resection of the left hemimandible from 32 to 37 with safe clinical margins was performed and defect was bridged by 2.4 mm unilock reconstruction plate [ figure 4 ] . resected specimen [ figure 5 ] was dark brown to grey in color surface measuring 7.55.54 cms . specimen was submitted for histopathological examination where it was confirmed as ceot . a 3d computed tomography ( ct ) image of the lesion ct scan depicting the large involvement of body of mandible orthopantamograph revealing reconstructing plate bridging the segmental defect neville and colleagues , in their textbook of oral and maxillofacial pathology , assert that the lesion is a distinct entity and probably represents less than 1% of all odontogenic neoplasms . there are differences of opinion within the oral and maxillofacial pathology community regarding degree of differentiation of the odontogenic epithelium which forms the basis for tumor pathogenesis . some authors suggest that the epithelial cells of the pindborg tumor are reminiscent of the sequestered cells in the stratum intermedium layer of the enamel organ.[35 ] this idea is based on the morphological similarity of the tumor cells to the normal cells of stratum intermedium and a high activity of alkaline phosphatase and adenosine triphosphate . it has been suggested that amyloid deposition within pindborg tumor is an immunologic response to these stratum intermedium cells . others insist that it arises from remnants of the primitive dental lamina found in the initial stage of odontogenesis , and these epithelial rests are the more likely true progenitor cell . ceot occurs most commonly between 20 to 60 years of age with mean around 40 years . in 113 cases reviewed by franklin and pindborg , patients ranged from 8 to 92 years of age with mean at 40 years . in 2004 , cicconetti and colleagues reported that tumor more frequently affects adults in the age range of 40 to 60 years with peak incidence in the 5 decade with an equal sex distribution . ninety - four percent of the lesions are central and intraosseous and 6% are extraosseous . intraosseous ceot shows a maxilla - to - mandible site ratio of 1:2 and is mainly located in the premolar / molar region . ceot may lead to tooth tipping , rotation , migration , and/or mobility secondary to root resorption . alternatively it may present symptomatically as a slow - growing , painless , expansile , bony swelling with cortical bone resorption and finally perforation , as was seen in the case reported . in the initial stage , it is totally radiolucent , simulating a dentigerous cyst because of its relation with impacted tooth . small intratumoral calcification starts appearing in the second phase , which is characteristic but not diagnostic . the final stages are associated with osseous destruction and the tumoral calcification giving it a honeycomb appearance . quite similarly the radiographic finding in our case showed a loculated / trabeculated honeycomb mixed radiolucent radiopaque finding . the diagnosis of ceot is also based on histopathological examination revealing polyhedral neoplastic cells , which have abundant eosinophilic finely granular cytoplasm with nuclear pleomorphism and prominent nucleoli . an extracellular eosinophilic homogenous material staining like amyloid is characteristic of this tumor with concentric calcific deposits called liesigany ring . numerous surgical treatment modalities have been suggested , and the treatment plan is dependent on multiple factors such as size and location of neoplasm , general condition of patient and operator skill . small , intrabony mandibular lesions with well - defined borders are treated by simple enucleation or curettage followed by judicious removal of a thin layer of bone adjacent to the tumor . large tumors require aggressive approach by segmental resection , hemimandibulectomy and hemimaxillectomy , which causes bone discontinuity requiring reconstruction procedures such as grafting or distraction osteogenesis . patient reported here underwent hemimandibulectomy and there has been no recurrence on 6 month follow - up . numerous surgical treatment modalities have been suggested , and the treatment plan is dependent on multiple factors such as size and location of neoplasm , general condition of patient and operator skill . small , intrabony mandibular lesions with well - defined borders are treated by simple enucleation or curettage followed by judicious removal of a thin layer of bone adjacent to the tumor . large tumors require aggressive approach by segmental resection , hemimandibulectomy and hemimaxillectomy , which causes bone discontinuity requiring reconstruction procedures such as grafting or distraction osteogenesis . patient reported here underwent hemimandibulectomy and there has been no recurrence on 6 month follow - up .

the calcifying epithelial odontogenic tumor ( ceot ) is a rare entity and represents less than 1% of all odontogenic tumors . dr . j j pindborg ( 1958 ) first described four cases of this unusual lesion ; subsequently shafer et al coined the term pindborg tumor . this lesion is a locally aggressive benign odontogenic neoplasm arising from epithelial tissue . it occurs most commonly in 4th-5th-6th decade of life and bears no gender predilection . a case of ceot in a 50-year - old male arising in the left body region is described .

clinical presentation of gas under the diaphragm and acute abdomen can be due to rupture of viscus , perforated peptic ulcer disease and rarely spontaneous . a 38 year old woman presented in accident and emergency ward with a history of acute abdominal pain . she gave a history of dyspepsia , symptoms of gastritis in the past and was treated with omeperazole . she was seen by surgeons who advised for an erect chest x - ray which showed gas under the diaphragm implying the diagnosis of perforated peptic ulcer disease . erect chest x - ray highlighting the presence of subphrenic gas she was seen b they gynaecology team in view of history and acute abdomen . a detailed history was elicited and patient reported having had sexual intercourse earlier on the same day and denied the pain following it . her vital signs were stable and abdominal examination revealed diffuse vague tenderness , no sign of distension or guarding and vaginal examination was difficult and no abnormalities detected . in view of the clinical symptoms and radiological findings patient was taken for emergency laparatomy . there was no perforation of viscus but there was a defect noted in the vaginal vault . gas under the diaphragm can be due to like perforation in stomach , duodenum due to peptic ulcer disease , in jejunum or illeum by inflammatory bowel disease or cancer can lead to pneumoperitoneum . this can present as an acute symptom.(1 ) 10% of cases diagnosed on pneumoperitoneum are not due to perforation of an air containing viscus but due to sexual activity , peritonitis , gas forming bacteria and some rare causes like iucd . first case of pneumoperitoneum due to post coital perforation after abdominal hysterectomy has been reported in 1980.acute abdomen may or may not be the symptom ( 2,3 ) . vaginal evisceration may or may not be a presenting symptom.(3,4 ) in our patient the acute symptoms and x - ray findings lead for an early laparatomy . this condition could have been managed conservatively if the pain has not been severe . the vault repair can be corrected laparoscopic or vaginally and a major laparatomy could be avoided embarrassment and modesty often prevent patients form talking about sexual activity . clinical examination during acute pain , particularly vaginal examination , is more painful for patients . the condition is rare but gynaecologist and surgeons should be aware of the situation and appropriate team work is essential to deal with the rare situations .

gas under the diaphragm can be due to like perforation in stomach , duodenum due to peptic ulcer disease , in jejunum or illeum by inflammatory bowel disease or cancer can lead to pneumoperitoneum . we present a rare cause of pneumoperitoneum following abdominal hysterectomy .

diabetes mellitus is recognized as a group of heterogeneous disorders , with common elements of hyperglycemia and glucose intolerance due to insulin deficiency , impaired effectiveness of insulin action , or both . the prevalence of type 2 diabetes increases with age , is increasing worldwide , and its economic impact currently accounts for a significant portion of health care expenditure.1 injection of long - acting insulin is a common therapeutic approach for patients with type 2 diabetes that is poorly controlled with multiple oral regimens.2 unfortunately , although insulin use as the mainstay of treatment for diabetes has resulted in favorable treatment outcomes , poor adherence / compliance continues to be a problem because of fear of insulin or fear of injection , and this can be associated with poor glycemic control , clinical complications , psychological comorbidity , poor general well being and health status , and increased mortality risk in patients with diabetes.3 last but not least , use of insulin is very often considered to be the point of no return in medical intervention for diabetes . these observations suggest a need for implementation of new therapeutic strategies to delay the need for insulin as far as possible . berberine , an isoquinoline alkaloid of the protoberberine type and found in an array of plants , has been used in indian and chinese medicine for many decades . it is present in hydrastis canadensis ( goldenseal ) , coptis chinensis ( coptis or goldenthread ) , berberis aquifolium ( the oregon grape ) , berberis vulgaris ( barberry ) , and berberis aristata ( tree turmeric ) . berberine and extracts of berberine have demonstrated significant antimicrobial activity against a variety of organisms , including bacteria , viruses , fungi , protozoans , helminths , and chlamydia . the predominant clinical uses of berberine , at least in the recent past , have included bacterial diarrhea and intestinal parasite infections.4 more recently , clinical research on berberine has revealed novel pharmacological properties and multiple therapeutic applications , mainly concerning hypercholesterolemia and diabetes.5 with regard to the lipid profile , berberine upregulates low - density lipoprotein receptor expression independent of sterol regulatory element - binding proteins , but dependent on extracellular signal - regulated kinases and c - jun n - terminal kinase activation , leading to reductions in total cholesterol and low - density lipoprotein cholesterol of about 30% and 25% , respectively . this upmodulation occurs via a post - transcriptional mechanism that stabilizes mrna and enables berberine to act as a cholesterol - lowering drug via a mechanism of action different from that of the statins.6 in addition to its cholesterol - lowering properties , berberine reduces triglycerides by about 35% . these effects on the lipid profile have been observed in both animals and humans.6,7 berberine also has an important additive effect in the presence of statins.8 this is likely due to the ability of berberine to downmodulate proprotein convertase subtilisin / kexin type 9 , a protein which reduces the cholesterol - lowering properties of statins.9 this effect of berberine could be relevant when treating patients with suboptimal control of hypercholesterolemia despite receiving high doses of statins . due to this additive effect , it is quite common to find nutritional supplements containing berberine10 along with a natural source of lovastatin ( ie , monascus purpureus).11 however , these products do not take into consideration the poor standardization of the raw materials12 and the risk to consumers due to the possible presence of mycotoxic contaminants like citrinin.13 berberine has also been shown to be effective in the treatment of diabetes , in which it significantly decreases glycosylated hemoglobin ( hba1c ) , fasting blood glucose , and postprandial blood glucose . in this respect , berberine has an effect similar to that of metformin,14 even if it likely acts via a mechanism different from that of metformin.15 berberine regulates glucose metabolism via multiple mechanisms of action . it enhances glucose uptake by upmodulation of glucose transporter type 4 , activates 5-amp - activated protein kinase as a consequence of inhibition of mitochondrial function , suppresses adipogenesis by inhibition of peroxisome proliferator - activated receptor gamma and c - enhancer - binding protein alpha function , and decreases intestinal glucose absorption by inhibition of alpha - glucosidase . 16 however , despite these functions , berberine has poor oral bioavailability.17 in humans , this appears to be due to a p - glycoprotein - mediated gut extrusion process18 and substantial excretion in bile.19 p - glycoprotein seems to decrease the amount of berberine able to cross enterocytes by about 90%,20 suggesting that inhibition of p - glycoprotein could potentially improve its oral poor bioavailability . among the potential p - glycoprotein inhibitors , silymarin from silybum marianum could be a good candidate due to its very poor oral bioavailability and its good safety profile.21 therefore , we investigated the activity of a combination of berberine and silymarin when added to oral hypoglycemic regimens for patients with suboptimal glycemic control . our aim was to evaluate the impact of this approach on body mass index , hyperglycemia , hypercholesterolemia , triglyceride levels , and liver enzymes in patients with type 2 diabetes . the study was performed in routine clinical practice in accordance with international guidelines and in line with the principles outlined in the declaration of helsinki , so approval from the local ethics board was not required . this study was carried out in a single center in italy where it is not mandatory to obtain ethical approval when performing experiments involving nutraceutical products . twenty - two of the 26 patients completed the study , with four dropouts as a result of gastrointestinal discomfort and/or other side effects . the main inclusion criteria were stable ( for at least 6 months ) but suboptimal glycemic control ( hba1c 7.5%9.5% ) , body mass index > 22 kg / m , age 2575 years , and a negative pregnancy test for female patients . all patients had suboptimal glycemic control despite use of the following drugs , unchanged at least in the last 3 months : metformin ( n = 20 ) , incretins ( n = 4 ) , sulfonylureas ( n = 14 ) , glitazones ( n = 3 ) , and insulin ( n = 5 ) . as regards the lipid profile , 12 patients were receiving statins , 1 was receiving a fibrate whereas 5 , previously under treatment with statins , had interrupted the therapy due to unwanted effects , mainly myalgia . exclusion criteria were moderate to severe liver dysfunction ( serum alanine aminotransferase > 120 iu / l and aspartate aminotransferase > 80 iu / l ) , abnormal renal function ( serum creatinine > 115 mol / l ) , severe heart failure ( new york heart association class iii or greater ) , history of acute diabetic complications , including diabetic ketoacidosis or hyperosmolar hyperglycemic nonketotic coma , psychiatric disease , severe infection , pregnancy or planning for pregnancy , and fasting plasma glucose 200 mg / dl . all patients received addon nutraceutical therapy , ie , berberol ( pharmextracta , pontenure , italy ) , an oral tablet containing 588 mg of b. aristata extract titered as 85% berberine and 105 mg of s. marianum extract titered as > 60% flavonolignans . the product , in agreement with the italian legislation ( law number 169/2004 ) had been notified to the minister of health in 2010 ( e10 40753y ) and registered as a food supplement , with both its actives ( standardized extracts of b. aristata and s. marianum ) belonging to the list of botanicals approved as nutraceuticals and its excipients all being food grade . the patients took two tablets per day on an empty stomach in the late evening for the 90-day duration of the study . berberol was manufactured by siit ( trezzano s / n , milan , italy ) . the two actives , ie , b. aristata extract and s. marianum extract , were provided , respectively , by siit and indena , both located in milano , italy . the statistical analysis was performed using spss 12.0 for windows ( spss inc , chicago , il ) . statistical differences between baseline and different time points were analyzed using the nonparametric paired t - test . the statistical analysis was performed using spss 12.0 for windows ( spss inc , chicago , il ) . statistical differences between baseline and different time points were analyzed using the nonparametric paired t - test . berberol containing extracts of b. aristata and s. marianum extract , dosed at two tablets daily for 90 days , was demonstrated to be a valid addon treatment option for patients with type 2 diabetes and suboptimal glycemic control . as shown in table 2 , a significant reduction was observed in hba1c , basal insulin , total cholesterol , low - density lipoprotein cholesterol , triglycerides , homa - r ( homeostatic model assessment for insulin resistance , calculated as glucose insulin/405 , where glucose is expressed as mg / dl and insulin as u / ml ) , and alanine transaminase . there were no significant changes in high - density lipoprotein cholesterol , fasting glucose , body mass index , weight , or waist circumference . four of the 26 patients diagnosed with type 2 diabetes and suboptimal glycemic control who enrolled in this study dropped out , leaving data for the 22 patients who completed the study . we investigated the clinical effects of oral treatment using a nutraceutical combination of b. aristata extract ( containing 85% berberine ) and s. marianum extract . the latter ingredient is included with the aim of enhancing the oral bioavailability of berberine , mostly by reducing p - glycoprotein activity in the gut . to be eligible for entry into this study , patients had to have had suboptimal glycemic control ( hba1c 7.5%9.5% ) unchanged for at least 3 months despite at least 6 months of treatment with a multidrug regimen . according to the international guidelines , hba1c values in this range are linked with an increased risk of developing microvascular and macrovascular complications , and all possible medical effort should be made to reduce hba1c below 7%.22 use of injectable insulin should be delayed as long as possible using oral insulin - saving drug cocktails . the basis for using such cocktails , precisely established on the basis of the metabolic features of a patient , have to be considered carefully , not only because of the very poor patient compliance with insulin injections , but also because delaying insulin therapy should spare endogenous insulin and avoid pancreatic exhaustion.23 in patients with suboptimal glycemic control , we observed an hba1c reduction of about 0.85% after 3 months of treatment with berberol , which was maintained after 6 months of treatment ( data not shown ) . such a percentage reduction is comparable with that normally obtained in patients treated with acarbose , dipeptidyl peptidase-4 inhibitors ( sitagliptin , vildagliptin , saxagliptin ) , or glitazones , used alone or adjunctive to metformin , to achieve optimal glycemic control . we did not modify any drug or treatment protocol established before starting treatment with berberol in any of the 22 patients who completed the study . at the same time , no modifications in terms of food intake or lifestyle were suggested or adopted before or during the trial , and this is reflected by the minimal changes in body weight and waist circumference . a possible mechanism of action of berberol could be its ability to increase insulin sensitivity , as shown by the reduction in homa - r . another possible mechanism of action could be linked to the acarbose - like action observed by some clinicians.24 this hypothesis should explain some of the gastrointestinal side effects observed , and could explain why four patients dropped out of the trial . we observed a relevant reduction in total cholesterol , low - density lipoprotein cholesterol , and triglycerides in our patients , all of whom had a cholesterol value within normal range or were on treatment with statins . this result , already observed by many clinicians , is likely due to the hypocholesterolemic activity of berberine and to an additive effect of berberine when combined with statin therapy . similar observations have been made in animals and in humans , and berberine has been shown to reduce liver necrosis both in nonalcoholic steatosis and in steatosis due to hepatitis c infection.25 however , these observations need to be confirmed by studies specifically designed to demonstrate a protective effect of berberine on the liver . berberol is a nutraceutical combination of highly standardized herbal extracts of b. aristata and s. marianum titered , respectively , as 85% berberine and > 60% flavanolignans . berberol seems to have positive effects in patients with type 2 diabetes and suboptimal glycemic control when given orally in addition to a conventional regimen ( ie , metformin , dipeptidyl peptidase-4 inhibitors , glitazones , acarbose or insulin , alone or as multidrug therapy ) . berberol seems to improve the cholesterol - lowering properties of statins , and has a positive effect on liver enzymes . treatment seems to be safe and tolerated at the doses tested , with minimal unwanted effects , which resolve on cessation of treatment without any further consequences . the results of our pilot study performed in 26 patients need confirmation by larger trials and with better definition of the diabetic patients enrolled . allowing for these limitations , berberol can still be considered as a potential oral nutraceutical suitable for use in addition to conventional therapy for type 2 diabetes , with the aim of ameliorating suboptimal glycemic control as a strategy for postponing the use of injectable insulin .

backgroundsuboptimal glycemic control is a common situation in diabetes , regardless of the wide range of drugs available to reach glycemic targets . basic research in diabetes is endeavoring to identify new actives working as insulin savers , use of which could delay the introduction of injectable insulin or reduce the insulin dose needed . commonly available as a nutraceutical , berberine is a potential candidate.methods and resultsbecause its low oral bioavailability can be overcome by p - glycoprotein inhibitors like herbal polyphenols , we have tested the nutraceutical combination of berberis aristata extract and silybum marianum extract ( berberol ) in type 2 diabetes in terms of its additive effect when combined with a conventional oral regimen for patients with suboptimal glycemic control . after 90 days of treatment , the nutraceutical association had a positive effect on glycemic and lipid parameters , significantly reducing glycosylated hemoglobin , basal insulin , homeostatic model assessment of insulin resistance , total and low - density lipoprotein cholesterol , and triglycerides . a relevant effect was also observed in terms of liver function by measuring aspartate transaminase and alanine transaminase . the product had a good safety profile , with distinctive gastrointestinal side effects likely due to its acarbose - like action.conclusionalthough further studies should be carried out to confirm our data , berberol could be considered a good candidate as an adjunctive treatment option in diabetes , especially in patients with suboptimal glycemic control .

the search for an ideal restoration led to the introduction of composite resins by bowen in 1962 and its continuous evolution since then to this present day . a variety of composites , including conventional , microfilled , hybrid , flowable , packable , nanofilled have been introduced till date . though they have become the material of choice for anterior restorations , they were found lacking in strength to suit the requirements of a posterior restorative material . various modifications in chemical structure and composition have been tried to overcome this issue . with the intention of extending the use of microfilled composite for posterior restoration along with anterior restorations , the proportional composition of the monomer mixture , i.e. , the portion of comparatively large copolymers was lowered while the portion of microfillers was slightly raised by manufacturers . also , a rheology modifier in the form of an organically modified compound silicate was added to the material . currently , most composite resins have their common basis in the radical polymerization of methacrylates . mozner and salz ( 2001 ) have reported that vinyl cyclopropane derivatives are also able to copolymerize with common methacrylate - based resins . the reaction involves the cationic ring opening of spiro ortho carbonates especially in combination with epoxy monomers . silorane ( 3 m espe ) , a low shrinkage tooth - colored restorative material , as claimed by the manufacturer , has been recently introduced in the market . silorane was so named to indicate a hybrid compound of siloxane and oxirane functional moieties . studies in the past have shown this material to be superior to conventional methacrylate - based composites . dye penetration tests have proved silorane - based composites to show significantly less microleakage at both the resin - enamel and resin - cementum interface . solid state light emitting diodes ( led ) have been used for curing composites since 1995 . these lamps offer high - energy performance , have a longer life span of more than 10,000 hours and undergo little degradation over time . also , they consume little power and can be battery - operated . the degree of cure of resin composites influences its mechanical properties , solubility , dimensional stability , color change and biocompatibility . depth of cure and microhardness testing have been reliably and widely used to assess the relative degree of cure of resins , and thus the efficiency of light sources . the knoop microhardness test has been shown to be one of the best indirect methods for testing the hardness of resin composite . the present in vitro study was carried out to compare the surface hardness and depth of cure achieved in methacrylate - based and silorane posterior composite resin on curing with led curing unit . teflon moulds with inner diameter of 8 mm and thickness of 2 mm were prepared . moulds were placed on mylar strips placed on a glass slab and were filled with composite using bulk insertion technique . in all , 20 samples were prepared using silorane - based filtek p-90 posterior composite a3 shade ( 3 m espe st . paul , mn , usa ) and 20 samples were prepared using methacrylate - based heliomolar hb posterior composite , a3 shade ( ivoclar vivadent ag , schaan , germany ) . a mylar strip was placed on the upper surface and the material was flattened with a glass slide . after the removal of the excess material the glass slide was removed , leaving the mylar strip . led curing light ( rotex , india ) , with a light intensity of 1000 mw / cm and a tip diameter of 8 mm was used to cure the samples for a period of 40 seconds with the tip kept at a distance of 1 mm . the intensity of the light curing unit was checked by an external hand - held radiometer before curing each specimen . descriptive statistics and comparative analysis of top and bottom surface hardness values by bonferroni test the specimens were then removed from the molds , and polished and measured using digital vernier calipers . all samples were stored dry at room temperature in light - proof containers for 24 hours . knoop hardness testing was performed using a 50-gram load and a dwell time of 15 seconds . for each sample , the mean hardness values for the top and bottom surfaces were noted and percentage depth of cure was calculated using the following formula : the data was statistically analyzed using a two - way anova test , bonferroni test and student t - test . all the data collected was tabulated and statistically analyzed using spss ( statistical package for social science ) 14.0 software . results showed greater surface hardness for the silorane - based group ( group i ) than the methacrylate - based group ( group ii ) with a p value of 0.000 ( highly statistically significant ) on both the top and bottom surfaces . table 2 shows the comparison of top and bottom values in each group and the comparison of depth of cure . the difference in top and bottom surface hardness was statistically significant in both the groups . however , the difference in mean depth of cure was not statistically significant between silorane- and methacrylate - based groups . siloranes , a new class of ring - opening monomers , were synthesized to overcome the problems related to polymerization shrinkage . obtained from the reaction of oxirane and siloxane molecules , the volumetric shrinkage of a silorane - based composite was determined to be 0.99 vol . this resin is considered to have combined the two key advantages of the individual components : low polymerization shrinkage due to oxirane monomers and increased hydrophobicity due to the presence of siloxane species in its composition . apart from the predominant radical polymerization initiation in conventional methacrylate resin - based composites ( rbcs ) , the silorane composite polymerizes by a cationic process , which is insensitive to oxygen . the silorane - based composite revealed decreased water sorption , solubility and associated diffusion coefficient compared with conventional methacrylate rbcs . nanjundasetty et al . , have shown superior marginal integrity both below and above the cej with siloranes compared to methacrylate - based composites . the present study showed that greater hardness and depth of cure values were achieved in silorane - based posterior composite samples than with methacrylate - based posterior composite samples when cured with led light . customized teflon moulds were used , as the material does not stick to the mold and can be easily demolded after polymerization . as bulk insertion technique was adopted in this study and a maximum of 2 mm is acceptable , the thickness of the samples was standardized to 2 mm . the international organization for standardization ( iso ) has standardized the specifications for light curing units to have a minimum intensity of 300 mw / cm in 400 - 515 nm wavelength bandwidth at the curing light tip . these criteria set by the iso were fulfilled by the led curing unit used in this study . light cured composites polymerize both during and after visible light activation , known as light and dark reactions , respectively . in all composites , the samples were stored in dark light - proof boxes after curing in this study in order to prevent further curing due to exposure to light after the stipulated curing cycle . the hardness of the composite is directly related to the degree of polymerization , and thus a good indicator of the degree of conversion of composite resins and a valuable parameter to estimate the mechanical properties . dewald and ferracane have stated that knoop hardness correlates well with the degree of conversion . also , it minimizes the effect of elastic recovery , is a relatively simple technique and shows reliability of obtained result , hence it was the method chosen in this study . composite hardness is influenced by several factors , such as organic matrix composition , type and amount of filler particles , and degree of conversion . the organic matrix of filtek p-90 is composed mainly of silorane resin and inorganic particles , quartz and yttrium fluoride . in contrast , the organic matrix of heliomolar is composed mainly of bis - gma , udma and 1,10- decandiol dimethacrylate , and a combination of inorganic particles silicon dioxide , ytterbium trifluoride and copolymers . several studies have suggested that microfilled composites are more difficult to cure because the small filler particles cause light to scatter , thus decreasing the effectiveness of the curing light . on the other hand , silorane - based composites have cationic polymerization reaction , which is characterized by continuous ring opening expansion initiated at the time of curing and promoted further cross - linking and hardening of the entire resin matrix . within limitations of the study , higher top and bottom hardness values were achieved in silorane - based posterior composites as compared to methacrylate - based posterior composites , though both attained similar percentage depth of cure .

aim : this in vitro study was carried out to compare the effect of led light curing system on polymerization and hardness of silorane - based and methacrylate - based posterior composite resin.materials and methods : a total of 40 samples , 20 of silorane - based composite filtek p-90 and 20 of methacrylate - based composite heliomolar hb measuring 2 mm thickness and 8 mm diameter were prepared using teflon molds and cured using led curing light . the samples were polished and tested in knoop hardness tester using a 50-gram load and dwell time of 15 seconds on top and bottom surfaces . the percentage depth of cure was calculated , and statistical analysis was performed using two - way anova test and student t- test.results:higher statistically significant values were seen for both the top and bottom surface hardness in silorane - based resins than methacrylate - based resins on led light curing.conclusion:greater depth of cure was achieved in silorane - based posterior composite than in methacrylate - based posterior composite resins with a statistically significant difference .

a 76-year - old female presented to the emergency department with the main complaint of 7 days of dyspnea and 1 day of dysarthria and dizziness . auscultation findings showed an irregular heart beat with a diastolic rumbling murmur in the apical region and crackles in both lower lung fields . transthoracic echocardiography showed a moderate degree of aortic regurgitation with left ventricular ( lv ) ejection fraction of 70.8% and a 1.631.31-cm complex , echogenic , round , mass - like lesion attached to the left atrial side of the interatrial septum . transesophageal echocardiography revealed the same mass finding with prominent spontaneous echo contrast in the left atrium and decreased emptying velocity of the left atrial appendage ( fig . 2 ) . the diagnostic coronary angiogram revealed a round , movable mass lesion in the left atrium with feeding arteries originating from the conus branch and atrioventricular nodal artery of the right coronary artery and no significant stenosis in either coronary artery ( fig . 3 ) . the patient was transferred to cardiac surgery and underwent removal of the mass and a maze operation . macroscopic findings were compatible with myxoma , and the microscopic findings revealed an acid mucopolysaccharide - rich stroma composed of a myxoid matrix and polygonal cells with scant eosinophilic cytoplasm scattered throughout the matrix ( fig . 4 ) . after surgery , the atrial fibrillation was abolished and an electrocardiogram showed a normal sinus rhythm . follow - up transthoracic echocardiography was performed after surgery and no remnant mass was observed in the left atrium ( fig . , the patient is admitted to outpatient department regularly and has taken aspirin and angiotensin receptor blocker steadily without specific problems . the presence of possible tumor vessels originating from coronary arteries may be helpful in the decision on an operative strategy for cardiac myxoma . about 52% of cardiac myxoma is visualized by coronary angiograms according to previous reports , but catheterization of the chamber from which the tumor arises carries the risk of tumor embolization .

a 76-year - old female present to the emergency department with dysarthria , dizziness , dyspnea . the patient had hypertension and atrial fibrillation . brain mri revealed right cerebellar infarction . transthoracic echocardiography showed a large round mass in the left atrium . transesophageal echocardiography showed large complex echogenic round mass lesion attached on left atrial side of interatrial septum . coronary angiogram revealed round movable mass lesion in left atrium with feeding arteries originated from right coronary artery . she underwent removal of mass and maze operation , and pathologic finding was compatible with myxoma .

blood samples were collected during postmortem examination of 313 red deer and 211 roe deer shot during the 2010 and 2011 hunting seasons . the 524 samples were randomly collected during october december from 35 hunting estates in 4 of the 5 provinces in southern belgium ( figure 1 ) . the animals sex ; age ; body condition ; and macroscopic aspects of hooves , mucosae , and internal organs were recorded . igg against the recombinant nucleoprotein of the emerging sbv was detected by using an elisa kit ( i d screen schmallenberg virus indirect , version 1 ; id.vet innovative diagnostics , montpellier , france ) . results are expressed as percentages of the reference signal yielded by the positive control serum ; serologic status is defined as negative ( < 60% ) , doubtful ( 60%70% ) , or positive ( > 70% ) . neutralizing antibodies against sbv were sought as described ( 3 ) in subsets of roe deer serum ( igg - negative and igg - positive according to elisa ) , and a linear relationship between percentages and reciprocal neutralizing titers was found . in addition , necropsies were performed on 22 fetuses and 5 newborn red deer fawns ; brain samples were tested for sbv genomic rna and cellular -actin transcripts by reverse transcription quantitative pcr ( 3 ) . contingency tables were analyzed by using analysis to detect associations between seroconversion and species , sex , age , sampling location , and sampling date . location of 4 provinces in southeast belgium ( shaded ) where 524 wild cervids ( 313 red deer and 211 roe deer ) were killed during hunting seasons 2010 and 2011 and sampled . seroprevelance for schmallenberg virus is shown for each of the 225 deer killed in 2011 . all 299 serum samples collected during the fall of 2010 were negative for igg against sbv . however , among the 225 samples from deer killed in 2011 , seroprevalence was 43.1% ( 95% ci 36.6%49.6% ) . no significant association was found between species and seroconversion : 40.5% ( 95% ci 31.6%49.5% ) among red deer and 45.9% ( 95% ci 36.5%55.2% ) among roe deer ; p = 0.42 . acquired immunity against sbv was thus already high , suggesting that sbv had quickly spread since its emergence 250 km northeast during late summer 2011 . a significant association between month of sampling and seroconversion was detected for both deer species ( p = 0.0016 and 0.0083 for red and roe deer , respectively ) . seroprevalence increased during weeks 4050 of 2011 : for red deer , 20.0% ( 95% ci 8.3%31.7% ) in october , 52.6% ( 95% ci 36.8%68.5% ) in november , and 54.6% ( 95% ci 37.6%71.5% ) in december and for roe deer , 34.0% ( 95% ci 20.5%47.6% ) in october , 49.1% ( 95% ci 35.6%62.5% ) in november , and 88.9% ( 95% ci 68.4%100% ) in december , thus suggesting that the virus had circulated in the areas sampled until at least mid - november ( figure 2 ) . frequency distribution of the results yielded by indirect elisa for detecting igg targeting recombinant nucleoprotein of emerging schmallenberg virus in serum samples collected from 116 red deer and 109 roe deer in southeast belgium during the fall of 2011 . results are expressed as percentages of the reference signal yielded by the positive control serum . serologic status is defined as negative ( < 60% ) , doubtful ( 60%70% ) , or positive ( > 70% ) . this late circulation of virus might be surprising because biting midges of the genus culicoides , which reportedly transmit sbv ( 4 ) , are not usually active during cold months . however , during fall 2011 , temperatures in the region were substantially higher than normal ( 5 ) and thus compatible with persistent wild - ruminant exposure to biting midges until mid - december . no association was found between seroconversion and sex of the deer ( p = 0.71 and 0.85 for red and roe deer , respectively ) , age ( p = 0.99 and 0.24 ) , and location of sampling ( p = 0.47 and 0.23 ) . these results suggest a similar level of exposure to infected vectors and a similar degree of susceptibility to infection among all animals in the study area ( 13,058 km ) . in most animals that had been found dead , gross lesions were consistent with trauma ( e.g. , fractures , hematomas , hemoperitoneum / thorax , ruptured spleen ) suggestive of impact against a vehicle . no fetus or newborn showed morphologic alterations of the neck , trunk , or limbs suggestive of arthrogryposis . no macroscopic abnormalities were seen in the cerebral cortex , cerebellum , and spinal cord . all -actin positive samples of these 27 fetuses and newborns remained negative for sbv rna . sbv infects wild cervid populations , and infected insect vectors were homogeneously distributed over southern belgium in the fall of 2011 . emergence probably took place in 2011 . however , because seroprevalence was already 20% in red deer and 34% in roe deer during october and because our results show that the proportion of the infected population increased exponentially during october december , we suggest that the virus began circulating months earlier than the currently believed august / september ( 3 ) . we recently showed that among the fetuses of pregnant cows that were infected after the establishment of the first placentome , 28% were infected and that an arthrogryposis / hydranencephaly syndrome follows if transplacental virus transmission occurs before fetuses are immunocompetent ( 6 ) . for this study , no feedback from forest rangers , no macroscopic observations , and no pcr results suggested transplacental contamination . however , aborted fetuses and stillborn and distorted nonviable newborn fawns are almost impossible to collect in the wild ( quickly eaten by scavengers ) , and the absence of sbv - specific genetic material or morphologic alterations at necropsy are not evidence of noninfection . therefore , no objective facts confirm or refute transplacental transfer . because the virus can infect the fetus only after the first placentome has developed and because roe deer embryos remain in diapause until january ( 7 ) , it is unlikely that sbv has contaminated many roe deer fetuses . because 90% of roe deer were already sbv positive in mid - december and because circulating antibodies prevent transplacental passage of the closest phylogenetic relatives of the virus ( 8) , we suggest that roe deer fetuses were probably not infected . on the contrary , red deer mate in september , and the first functional placentome is established by the end of october ( 9 ) ; thus , 80% of pregnant red deer were exposed to the emerging virus when placental transfer was possible . furthermore , 35% of pregnant red deer were infected in november and december , i.e. , after establishment of the first placentome and before the fetus was immunocompetent . by extrapolating the rate of transplacental infection among cattle ( 6 ) , we determined that 28% of these pregnancies resulted in contamination of the fetus , i.e. , 10% , of expected pregnancies . because unrestricted replication of simbu - like viruses occurs in the central nervous system of immunologically incompetent ruminant fetuses ( 1 ) , which can lead to a typical arthrogryposis / hydranencephaly syndrome , a 10% loss among fawns can be expected in 2012 . in the same geographic area , 5 years apart , 2 arboviruses have emerged : bluetongue virus serotype 8 ( btv-8 ) during the summer of 2006 and sbv during the summer of 2011 . for each virus , culicoides spp . midges function as vectors and infect sheep , goats , cattle , and red deer . although most ( > 50% ) red deer seroconverted against btv-8 , only a few ( < 3% ) roe deer sampled in the same places and at the same time were btv-8-positive ( 10 ) , which sharply contrasts with the sbv seroconversion rates reported here . this finding invalidates the assumption that less exposure of roe deer to infected midge bites explains the almost complete absence of seroconversion against btv-8 in this species .

schmallenberg virus was detected in cattle and sheep in northwestern europe in 2011 . to determine whether wild ruminants are also susceptible , we measured antibody seroprevalence in cervids ( roe deer and red deer ) in belgium in 2010 and 2011 . findings indicated rapid spread among these deer since virus emergence 250 km away .

extrarenal calyces are rare anomalies of the upper urinary tract . only 20 cases were reported so far in the literature . the rarity of this anomaly and the complexity of possible associated anomalies often makes the preoperative diagnosis difficult . they are known to be associated with other anomalies , including bifid kidney and renal dysplasia . to the best of our knowledge , only 3 cases have been reported in the literature wherein , it was associated with pelviureteric junction obstruction ( pujo).[24 ] when associated , management options depend on the renal function and presenting symptoms . herein , we are reporting a case where routine preoperative imaging did not throw any light on the diagnosis and was an intraoperative surprise . a 9-year - old male child presented to us with complaints of pain in the left flank for 1 month . an ultrasound of the abdomen showed severe hydronephrosis of the left kidney with a parenchymal thickness of 2 mm with upper ureteric dilation . a radionuclide scan showed a poorly functioning left kidney with a split renal function of 7% with obstructed curves . an ante grade dye study was done , which showed significant stasis in the hydronephrotic kidney and the ureter was not visualized . intraoperatively , a large dilated kidney with papery thin cortex was found with 5 pseudopodia - like projections ( extrarenal calyces ) arising from it and connected to the pelvis ; pujo was noted . the rest of the ureter appeared normal . in view of the complex nature of the lesion and poorly functioning kidney , a right nephroureterectomy was performed [ figure 1 ] . the presence of extrarenal calyces is a very rare anomaly of the upper urinary tract that was first described in 1925 . a few cases were reported in the literature and the exact etiology of this condition is unclear . it has been hypothesized that the anomaly could be due to a disparity resulting from slow development of the metanephric tissue or to a relatively rapid development of the ureteric bud . a kidney with extrarenal calyces is usually associated with other anomalies , such as bifid kidney , renal ectopia , horseshoe kidney , and renal dysplasia . it might be an incidental finding diagnosed at autopsy or may present with complications , such as hydronephrosis secondary to associated pujo , as in our case . because the incidence of this anomaly is quite low and the clinical presentation is very similar to classic pujo , a high degree of suspicion should be kept , especially when preoperative radiologic findings are not classical and show distorted calyceal appearance on preoperative imaging studies . this would safeguard against inadvertent injury of the calyces when operating on a well - functioning kidney . but , when they are associated with complications , such as pujo , as in our case , the management is not standardized . ( 2006 ) mentioned the successful management of pujo associated with extrarenal calyces in a pelvic kidney using transperitoneal laparoscopic reconstruction . the management options may include the following : ( 1 ) to do a classic pyeloplasty and follow the patient , risking failure of pyeloplasty and recurrent urinary tract infection ( uti ) ( as was done in the previous case ) ; ( 2 ) to resect the pelvis and do a ureterocalicostomy with fusion of the calyces ( again associated with extensive dissection and suturing ) ; or ( 3 ) to go ahead with a single - stage nephroureterectomy , thereby preventing the child from further recurrent uti . the management strategies are controversial and should be decided on individual merits and surgeon competence . however , in kidneys with well - preserved function , a renal sparing procedure is worth attempting .

extrarenal calyces are one of the rare renal anomalies associated with the collecting system . their association with renal ectopia or horse shoe kidney is known . but , here in , we are reporting an intraoperative surprise , where extrarenal calyces were associated with pelviureteric junction obstruction and routine preoperative imaging did not show any light on the diagnosis .

quinupristin / dalfopristin ( synercid ) , a combination of two different streptogramins antibiotics , has a bactericidal effect by inhibiting the bacterial protein synthesis of ribosome . it is currently used in infections caused by vancomycin - resistant enterococcus faecium ( vref ) , when no other active antibacterial agent is available . the known adverse effects of quinupristin / dalfopristin are peripheral vasculitis , arthralgia , myalgia , nausea , diarrhea , vomiting and skin papules . sweet s syndrome , or acute febrile neutrophilic dermatosis , is characterized by painful skin papules , and plaques , fever and peripheral blood leukocytosis , with dermal neutrophilic infiltration on a skin biopsy . drug - induced sweet s syndrome has a temporal relationship between the drug ingestion and clinical presentation , or a temporally - related recurrence after oral rechallenge , with temporally - related resolution of the lesions following drug withdrawal or on treatment with systemic corticosteroids . the authors , having encountered a patient , who was the first to our knowledge , developed sweet s syndrome after administration of quinupristin / dalfopristin , herein report on the case with a review of the english literature relating to the other adverse effects of the drug and the clinical features of the syndrome . a 63-year - old woman , with end stage renal disease , receiving hemodialysis three times a week , was hospitalized for acute subdural hemorrhage . on the 30th day following her admission , she had a high fever of 39c and complained of costovertebral angle ( cva ) tenderness on physical examination . vref was isolated in a urine culture , but with blood cultures yielding no growth of microorganism . the patient was treated with quinupristin / dalfopristin ( synercid , 7.5 mg / kg , intravenously , through a central venous catheter , every 8 hours ) . on the 1st day of the quinupristin / dalfopristin treatment , her body temperature was normalized and the cva tenderness subsided , but she complained of nausea , vomiting , and myalgia . on the 2nd day of treatment with the drug , she complained of severe myalgia , arthralgia and general weakness , and presented tender erythematous 2 cm - sized papules on the palms of her hands ( figure 1a ) . on the 3rd day of treatment the skin papules , which started on the palm , spread to the face , chest and neck , and progressed to maculopapular plaques or pustules ( figure 1b ) . the white blood cell count was 20,600 cells / mm ( neutrophils , 84% ) , the hemoglobin was 7.0 g / dl , the platelet count was 209,000 cells / mm , but her liver enzymes were within normal limits . a punch biopsy of a skin lesion on her palm was performed , which showed intra- and sub - corneal pustular formation , with epidermal leukocytosis ( figure 2 ) . there was no evidence of vasculitis , necrosis or infections caused by bacteria , fungus or mycobacteria , in the biopsy specimen . she had received no other drugs that could have caused the drug - induced sweet s syndrome . the quinupristin / dalfopristin treatment was stopped , after which , the severity of these side effects were rapidly relieved , and the pain from the skin lesions subsided without analgesics . in 1964 , sweet described a new disease , in eight female patients , which was characterized by the acute onset of fever , leukocytosis , and tender skin plaques infiltrated by neutrophils : he named the disorder acute febrile neutrophilic dermatosis . in as many as 50 percent of patients , sweet s syndrome is associated with a variety of underlying diseases : malignancy , bacterial and viral infections , drugs ( furosemide , hydralazine , oral contraceptives , minocycline , nitrofurantoin , trimethoprim - sulfamethoxazole and granulocyte - stimulating factor , autoimmune and collagen vascular diseases ( rheumatoid arthritis , systemic lupus erythematosus , mixed connective tissue disease , hashimoto thyroiditis , sjogren s syndrome ) , inflammatory bowel disease ( chron s disease , ulcerative colitis ) and pregnancy . the pathogenesis of sweet s syndrome is still unknown , but it is currently thought that cytokine dysregulation , a type 3-hypersensitivity reaction or a t cell - dependent cellular immune reaction is involved . diagnostic criteria have been proposed for sweet s syndrome , with a patient having to meet two major and two minor criteria for the diagnosis to be confirmed . one major criterion is the abrupt onset of typical cutaneous lesions , with the other being a histopathology compatible with sweet s syndrome . there are four minor criteria antecedent fever or infection ; accompanying fever , arthralgia , conjunctivitis , or underlying malignancy ; leukocytosis and good response to systemic corticosteriods , but no response to antibiotics . the cutaneous lesions are characterized by tender or painful erythematous or violaceous plaques or nodules . they are most often found on the face , neck and upper extremities , especially on the dorsum of the hands , but they can occur anywhere . the diagnostic histopathologic feature of sweet s syndrome is nodular and dense perivascular neutrophilic infiltration , with no evidence of vasculitis . drug - induced sweet s syndrome is found to be resolved promptly , without recurrences , on discontinuation of medication , or with systemic steroid therapy . in patients with drug - induced sweet s syndrome , it is difficult to definitively determine whether the cause of the dermatosis is drug - induced , or related to an underlying condition . two useful criteria for establishing a diagnosis of drug - induced sweet s syndrome are a temporal relationship between the drug administration and the clinical presentation , and between drug withdrawal and resolution of the disease . quinupristin / dalfopristin is a novel parenteral antimicrobial agent , consisting of two different semisynthetic , water - soluble , streptogramins antibiotics , quinupristin ( 30% ) and dalfopristin ( 70% ) . they are synergistic , and usually bactericidal against gram - positive , selected gram - negative and some anaerobic organisms , and is an effective therapy for serious infections due to vref . it has a unique mechanism of action that involves bacterial cell entry , by diffusion of the drug to the bacterial ribosome , followed by the formation of stable dalfopristin - ribosome - quinupristin complexes . consequently , this combination of the two components may prevent the appearance of strains resistant to either of the components arthralgia , without objective signs of articulopathy , and myalgia are the most commonly reported adverse events , and the leading causes of treatment discontinuation . gastrointestinal adverse events ( nausea , vomiting , and diarrhea ) and skin rash have also been documented . all theses side - effects are reversible on discontinuing the drug , and its overall tolerability is good . patients receiving at least one intravenous infusion of quinupristin / dalfopristin have been known to experience local venous intolerability ( pain , burning , inflammation , and thrombophlebitis ) . laboratory findings of the adverse events are the increases in alkaline phosphatase , aminotransferases and -glutamine transferase , as well as decreases in sodium , hemoglobin , haematocrit , platelet count and red blood cell count the drug is primarily excreted by the liver ( 75% ) , with a small portion of the unchanged ( 1519% ) form eliminated by the kidneys . a recent study indicates that no formal dosage reduction would appear necessary in patients with severe chronic renal impairment or hepatic dysfunction , although there is a tendency for slower clearance of unchanged dalfopristin and active quinupristin derivatives . however , the effect of a dose reduction or an increase in the dosing interval , on the pharmacokinetics of quinupristin/ dalfopristin in these patients requires further study , so no recommendations can be made at this time . our patient , who received quinupristin / dalfopristin treatment , initially presented with arthralgia , myalgia , nausea , vomiting and fever , with maculopapular plaques that progressed to pustules . after discontinuation of the drug , the systemic adverse events were quickly resolved , and the cutaneous lesions cleared within 7 days . the patient receive no systemic corticosteroids . although unproved , it is not inconceivable that in this patient the quinupristin / dalfopristin was involved in the clinical and histological reactions . the drug has never been implicated in the literature as a causative agent of sweet s syndrome before . additional studies are warranted to determine the mechanism of sweet s syndrome associated with the drug .

quinupristin / dalfopristin is a new combination of streptogramin antibiotics designed specifically to treat clinically significant infections due to vancomycin - resistant enterococcus faecium . sweet s syndrome is characterized by painful skin plaques , which is associated with dermal neutrophilic infiltration , fever and peripheral blood leukocytosis . drug - induced sweet s syndrome has a temporal relationship between drug ingestion , clinical presentation and the temporally - related resolution of lesions following drug withdrawal or on treatment with systemic corticosteroids . a 63-year - old woman received quinupristin / dalfopristin for acute pyelonephritis developed fever , arthralgia , vomiting , and painful erythematous skin plaques . a skin biopsy showed neutrophilic dermatosis , and there was rapid resolution of the symptoms and cutaneous lesions after discontinuation of quinupristin / dalfopristin , consistent with drug - induced sweet s syndrome . to date , there has been no reported case of sweet s syndrome associated with the use of quinupristin / dalfopristin .