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24,207 | 82,753 | tumors indicated that these undifferentiated cells were not derived from squamous cell carcinoma of the esophagus.\nApproximately 20 % of patients with ATC have a history of differentiated thyroid cancer [], and transformation from differentiated to anaplastic cancer was previously described in a patient who was followed up with serial biopsy []. Moreover, mutations in the p53 tumor suppression protein associated with late de-differentiating events in an anaplastic tumor rather than a | negative TTF-1 and thyroglobulin expression suggest that the tumor did not have typical patterns of either papillary or follicular thyroid carcinoma. The negative results for CK20 and CDX-2 suggested that the tumor did not likely originate from the gastrointestinal tract. Moreover, the findings of negative HMW-CK expression for both | 60-year-old man underwent total thyroidectomy with bilateral neck dissection in July 2004 for the treatment of well-differentiated papillary thyroid carcinoma (PTC) (Fig. ). The pathological classification was pT4a (esophagus), pN1a, M0, stage IVA. In September 2006, local recurrence to the neck (left of paratracheal sites) and distant metastasis to the femur were observed by positron emission tomography/computed tomography (PET/CT) with fluorodeoxyglucose (FDG). The patient rejected our proposed treatment regimen of resection at the local site recurrence and internal radiation therapy against the distant metastasis and was thus required to start specific substance of Maruyama (SSA). Thus, only external radiation therapy to both regions was administered as a palliative therapy. A trial of suppressive therapy |
4,796 | 91,829 | barium upper gastrointestinal (GI) study confirmed the diagnoses. An endoscopic dilatation was attempted without success.\nA few days later the patient underwent exploratory laparotomy, subtotal gastrectomy and resection of the first portion of the duodenum. No signs of peritoneal carcinomatosis were detected. On histopatological examination of the gastroduodenectomy, a poorly differentiated carcinoma composed of nests or single strands of atypic cells was identified in the duodenum (Figure ). Lymph nodes of greater and lesser curves did not show evidence of metastasis. The proximal and distal resection margins were tumor-free.\nImmunohistochemical stains were positive for cytokeratin (CK) 7 and | laparotomy, subtotal gastrectomy and resection of the first portion of the duodenum. No signs of peritoneal carcinomatosis were detected. On histopatological examination of the gastroduodenectomy, a poorly differentiated carcinoma composed | no family history of breast cancer or of other tumors; neither was there any sign of exposure to epidemiologic risk factors.\nHis relevant past history included an infiltrating ductal carcinoma of the left breast for which he underwent a left mastectomy with Halsted procedure in 2004. Prior to the mastectomy, assessment had included a chest X-ray, bone scan and an abdominal ultrasound, all of which were negative. His carcinoembryonic antigen (CEA) and CA 15-3 results were in the normal range. A review of the histology from his mastectomy specimen showed an infiltrating ductal carcinoma of the left |
15,391 | 57,595 | 2011. In 2013 she underwent induction of labour for poor glucose control at term, and finally gave birth by caesarean for failed induction of labour. The baby was born alive with a birthweight of 3.630 g. Afterwards she defaulted medical follow-up for six years due to financial and childcare issues. She did not have any fertility plan, but did not practice any contraception either.\nShe was unaware of her index pregnancy, as she had | a negative pregnancy test after three months of amenorrhea in mid 2018. She did | manoeuvres were applied to relieve the shoulders, but all failed. Posterior arm extraction was attempted, but the arm was too high and unreachable by the operator’s hand. The mother was already exhausted and could not get into an all fours position.\nFinally, an attempt to extract the posterior shoulder with posterior axillary sling method was performed (Video ). Firstly, two long ribbon gauzes were tied together (Fig. ). With its knot held by the operator’s right index and middle fingers, the ribbon |
16,211 | 37,636 | scan confirmed the submucosal lesion which originated from the muscularis propria, measured 4.9 × 4.4 cm, and was compromising the longitudinal, muscular layers of the stomach that showed enhancement after the use of iodinated contrast (). The exam showed no presence of hepatic metastasis or lymphadenopathy.\nWith preoperative diagnosis of gastric leiomyoma, the patient was subsequently referred for elective surgical procedure. During the laparotomy, it was found a tumor measuring about 5 cm at its widest | bleeding. Multiple regular biopsies were taken, and some histological features of smooth muscular tumor were identified. An abdominal CT | the patient was confused, pale, and with cyanosis of extremities, tachycardia, and 70 × 40 mmHg of blood pressure. Family members reported that she had been complaining of epigastric pain, nauseas, weakness, and five episodes of melena in the previous three days. On physical examination, the abdomen was soft, nondistended, without palpable masses but slightly painful to deep palpation in the epigastric region. The digital rectal examination |
9,356 | 109,306 | excised, and the aortic wall with the surrounding tissue was debrided and sent for culture. Retroperitoneal irrigation was performed using an antibiotic solution (rifampicin). Reperfusion was performed via in situ reconstruction of an aorto-right femoral bypass. For this reason, the right femoral vein was harvested in total length beyond the adductor hiatus (). However, the length of the harvested femoral vein was considered inadequate despite preoperative planning. Hence, a composite conduit consisting of a short segment of a silver-coated Dacron graft and his right femoral vein was created (). Considering the thrombosed left limb of the graft, sufficient collateral circulation of the left limb (ankle–brachial index of 0.6), | excised, and the aortic wall with the surrounding tissue was debrided and sent for culture. Retroperitoneal irrigation was performed using an antibiotic solution (rifampicin). Reperfusion was performed via in situ reconstruction of an aorto-right femoral bypass. For this reason, the right femoral vein was harvested in total length beyond the adductor hiatus (). However, the length of the harvested femoral vein was | lengths of both femoral veins were inadequate. Therefore, restoration of blood flow was accomplished using an in situ composite graft (). A short segment of a bifurcated silver-coated Dacron graft was proximally sutured to the infrarenal aorta, and the distal graft limbs were anastomosed to the vein conduits, which were eventually |
19,177 | 27,928 | patient, G3P2+0 presented to the emergency department on the 18th of October 2019 complaining of acute onset of lower abdominal pain associated with a history of amenorrhea for three months. She was unsure of the date of her last menstrual period and had no previous antenatal follow-up. She was medically free and her past obstetric history included a normal uncomplicated vaginal delivery, followed by a cesarean section which was performed four years back. She had no allergies and was not taking any medication or contraception. Upon presentation, she complained of generalized lower abdominal pain which was of a sudden onset, continuous, not radiating, and not relieved by oral analgesia. The pain was associated with nausea | onset of lower abdominal pain associated with a history of amenorrhea for three months. She was unsure of the date of her last menstrual period and had no previous antenatal follow-up. She was medically free and her past obstetric history included a normal uncomplicated vaginal delivery, followed by a cesarean section which was performed four years back. She had no allergies and was not taking any medication or contraception. Upon presentation, she complained of generalized lower abdominal pain which was of a sudden onset, continuous, not radiating, and not relieved by oral analgesia. The pain | 3.2 g/L, and her total white cell count was 7.5 g/L. Blood grouping and cross-matching of four blood units were immediately sent.\nThe possibility of a ruptured ectopic pregnancy was explained to the patient, and she consented to an emergency laparotomy with possible salpingectomy. During the laparotomy, a total of 4 liters of intra-abdominal blood was suctioned while blood transfusion was ongoing. A live 13-week fetus was found and removed from the pelvic |
24,626 | 53,018 | considered. Extensive investigation for delirium was suggested and, on day 8 of admission, the patient was transferred to medicine to be under the care of the hospitalist.\nComplete blood count, blood sugar, blood urea nitrogen, creatinine, electrolytes, troponin, liver function tests, thyroid stimulating hormone, rheumatoid factor, human immunodeficiency virus were all within normal limits or negative. Serum antinuclear antibodies (ANA), extractable nuclear antigen screen (ENA) and anti ribonucleoprotein (RNP) were positive. ANA positivity was characterized by a titre of 1:80 and a nucleolar pattern, raising suspicion for a possible systemic | of the hospitalist.\nComplete blood count, blood sugar, blood urea nitrogen, creatinine, electrolytes, troponin, liver function tests, thyroid stimulating hormone, rheumatoid factor, human immunodeficiency virus were all within normal limits or negative. Serum antinuclear antibodies (ANA), extractable nuclear antigen screen (ENA) and anti ribonucleoprotein (RNP) were positive. ANA | pain and migraines. She initially presented to a rural hospital emergency department with confusion and was diagnosed with substance-induced psychosis and discharged with an Ativan prescription. She returned within days via police and emergency medical services and was admitted to the county’s psychiatric observation unit at our hospital for paranoia, thought disorganization, irritability, and impulsivity.\nCommunication with her primary care provider, family and neurologist indicated a past medical history of multiple sclerosis (diagnosed three years prior), for which she has not been under treatment. She had |
40,224 | 66,363 | right hydronephrosis and right-sided pelvic lymphadenopathy. Transurethral resection of the bladder tumor (TURBT) was performed and pathologic examination showed a prominent inflammatory background with admixed high-grade undifferentiated tumor cells arranged in sheets with ill-defined cytoplasmic borders imparting a syncytial appearance diagnostic of the LEL variant of urothelial carcinoma (Fig ). Foci of urothelial carcinoma in situ were also noted involving the surface urothelium. Muscularis propria invasion was present.\nPatient was treated with four cycles of neoadjuvant chemotherapy of gemcitabine and cisplatin. Repeat CT two weeks after the last round of chemotherapy revealed smaller right-sided bladder mass (6.1 x 2.9 cm vs. 6.9 x 3.4 cm). Two months after the last round of chemotherapy, the patient underwent a radical cystectomy | tumor (TURBT) was performed and pathologic examination showed a prominent inflammatory background with admixed high-grade undifferentiated tumor cells arranged in sheets with ill-defined cytoplasmic borders imparting a syncytial appearance diagnostic of the LEL variant of urothelial carcinoma (Fig ). Foci of urothelial carcinoma in situ were also noted involving the surface urothelium. Muscularis propria invasion was present.\nPatient was treated with four cycles of neoadjuvant chemotherapy of gemcitabine and cisplatin. Repeat CT two weeks after the last round of chemotherapy revealed smaller right-sided | July 2015. The operation was complicated by extensive adhesions from previous appendectomy, hysterectomy, and hernia repair with ventral mesh placement necessitating small bowel resection.\nFinal pathology report showed three high-grade tumor foci in the bladder with the largest being high-grade urothelial carcinoma located in the right lateral wall measuring 2.8 cm, another tumor located in the posterior wall measuring 0.9 cm with areas of squamous differentiation, and the smallest tumor located at the dome measuring 0.6 cm with pathology consistent with LEL |
33,864 | 161,089 | were found to be blocking the anal canal, so the doctor could not use his little finger for a digital rectal examination (). The patient had diabetes mellitus and benign prostatic hypertrophy as underlying diseases, and denied having any surgical history than the two hemorrhoidectomies about 10 years earlier. From hematological assay, the white blood cell count was 13,960/µL (neutrophils, 80.9%), hemoglobin was 14.9 g/dL, platelet count was 224,000/µL, and high sensitivity C-reactive protein was 7.74 mg/dL (reference range, 0 to 0.5 mg/dL). The abdominal computed | mellitus and benign prostatic hypertrophy as underlying diseases, and denied having any surgical history than the two hemorrhoidectomies about 10 years earlier. From hematological assay, the white blood cell count was 13,960/µL (neutrophils, 80.9%), hemoglobin was 14.9 g/dL, platelet count was | size were found to be blocking the anal canal, so the doctor could not use his little finger for a digital rectal examination (). The patient had diabetes mellitus and benign prostatic hypertrophy as underlying diseases, and denied having any surgical history than the two hemorrhoidectomies about 10 years earlier. From hematological assay, the white blood cell count was 13,960/µL (neutrophils, 80.9%), hemoglobin was 14.9 g/dL, platelet count was 224,000/µL, and high sensitivity C-reactive protein was |
7,859 | 63,792 | be swallowed. It was only when the sick child was referred by the general practitioner to the pediatrics department of our institute that the clinical presentation mimicking upper airway infection was considered to be caused by a probable hidden foreign body. Leading questions to his parents further strengthened the suspicion. A formal referral to the otolaryngology department was made.\nConsidering the localized nature of the infection and mild bulging of the soft palate, we conjectured that the symptoms were more corroborative of a hidden foreign body that could have possibly been lodged in the nasopharynx. At the same time, we were also | swallowing and pain in his throat, but there was no paroxysm of cough or dyspnea. Several attempts were made by his mother to take it out with her fingers, but without success. However, the symptoms ameliorated soon, and with the child feeding well, no further medical attention was sought and the cap was presumed to | cap was presumed to be swallowed. It was only when the sick child was referred by the general practitioner to the pediatrics department of our institute that the clinical presentation mimicking upper airway infection was considered to be caused by a probable hidden foreign body. Leading questions to his parents further strengthened the suspicion. A formal referral to the otolaryngology department was made.\nConsidering the localized nature of the infection and mild bulging of the soft palate, we conjectured that the symptoms were more corroborative of a hidden foreign body that could have possibly been lodged in the nasopharynx. At the same time, we were also preparing for rigid esophagoscopy as the child was not feeding well. |
17,443 | 148,524 | had undergone a left thyroidectomy to remove thyroid cancer. A chest radiograph revealed a collapse of the left lower lung, probably caused by a left main bronchial obstruction. A computed tomography (CT) scan of the lung revealed obstruction of the left main bronchus accompanied by a large endobronchial mass (). The next day, a bronchoscopy identified showed total obstruction of the left main bronchus, with evidence of active bleeding and the bronchoscopic findings suggested bronchogenic carcinoma (), and positronemission tomography | A computed tomography (CT) scan of the lung revealed obstruction of the left main bronchus accompanied by a large endobronchial mass (). The next day, a bronchoscopy | computed tomography (CT) scan of the lung revealed obstruction of the left main bronchus accompanied by a large endobronchial mass (). The next day, a bronchoscopy identified showed total obstruction of the left main bronchus, |
27,036 | 67,122 | was subjected to PCR amplification with DNA polymerase (PrimeSTAR GXL DNA Polymerase; Takara Bio Inc., Kusatsu, Japan) and primer sets.\nThe amplicons were subjected to conventional sequencing with Sanger sequencers (Applied Biosystems 3730/3130 DNA analyzers; Thermo Fisher Scientific, Waltham, MA, USA). The sequence data were processed with Gene Codes Sequencher Software (Takara Bio Inc.) and mapped to the human genome sequence (build GRCh37/hg19).\nGenetic analysis was performed to screen all coding exons and the exon–intron boundaries of the KCNQ1 gene (NCBI ref: NM_000218.2, NP_000209.2) with concurrent screening of other LQT causative genes (KCNH2, SCN5A, KCNE1, KCNE2, | KCNJ2, SCN4B, KCNJ5). We detected a novel homozygous nonsense variant, NM_000218.2:c.115G > T (p.Glu39X, in exon 1a), in the KCNQ1 gene of the proband, as well as a homozygous common variant (NM_000218.2:c.1343C > G, p.Pro448Arg) (Additional file : Table S1). Genetic screening of her mother (I-2) and children (III-1 and III-2) revealed that they were heterozygous for the nonsense variant (Fig. ). | of her pregnancy. She has congenital deafness, first experienced syncope at the age of 3, and was diagnosed with epilepsy. She was treated with anti-epilepsy medications; however, she subsequently experienced several instances of syncope. At the age of 13, she had a syncope event, and was suspected of having JLNS because of her congenital deafness and prolonged QT interval. Her syncope was diagnosed as an arrhythmic episode when she was aware of tachycardia and as epilepsy when she was |
26,431 | 149,212 | dystopia with ecchymosis, and subconjunctival hemorrhage was noted ( and B); intraocular pressure (IOP) was 30 mmHg. Lateral canthotomy and inferior cantholysis were performed by our oculoplasty colleague on emergency basis under local infiltration of a mixture of lignocaine 2% and adrenaline (1 in 20,000) and he found it difficult to control the bleed ing. He managed to reduce proptosis to 5 mm and IOP was 22 mmHg. Indirect ophthalmoscopy showed no evidence of intraocular or | canthotomy and inferior cantholysis were performed by our oculoplasty colleague on emergency basis under local infiltration of a mixture of lignocaine 2% and adrenaline (1 in 20,000) and he found it difficult to control the bleed ing. He managed to reduce proptosis to 5 mm and IOP was 22 mmHg. Indirect | over 2–3 hours daily, was started. Topical eye drop moxifloxacin 0.5% qid (four times a day) and eye drop prednisolone acetate 1% qid were started. Oral acetazolamide 250 mg qid and topical eye drop timolol 0.5% bid was given to control IOP. Frequent lubrication was given to prevent exposure keratopathy. Due to uncontrolled bleeding, coagulation abnormality was suspected and bleeding time–clotting time was determined immediately, which came to be normal. Proptosis worsened to 8 mm next day. A contrast-enhanced computed tomo graphy (CECT) scan showed inferolateral subperiosteal hematoma in the left eye (). He was posted for |
11,429 | 28,118 | 41–49%). His serum sodium was slightly low at 131 millimoles per liter (mmol/L) (reference range 136–145 mmol/L) with otherwise normal electrolytes and a normal serum creatinine. Glucose was 177 milligrams/dL (mg/dL) (reference range 70–99 mg/dL). His alanine aminotransferase and aspartate aminotransferase were elevated at 228 units (U/L) (reference range 5–55 U/L) and 125 U/L (reference range 5–40 U/L), respectively. Total bilirubin was elevated at 3.1 milligrams per deciliter (mg/dL) (reference range 0.2–1.2mg/dL), as well as direct bilirubin a 1.3 mg/dL (reference range 0.0–0.5 mg/dL). | icterus, or skin eruption.\nLaboratory evaluation was significant for a normal white blood cell count with thrombocytopenia (platelets 111 per microliter ]K/mcL] [reference range 135–371 K/mcL]) and anemia (hemoglobin nine grams per deciliter [g/dL] [reference range 14.0–18.1 g/dL], and hematocrit 25% (reference range | per microliter ]K/mcL] [reference range 135–371 K/mcL]) and anemia (hemoglobin nine grams per deciliter [g/dL] [reference range 14.0–18.1 g/dL], and hematocrit 25% (reference range 41–49%). His serum sodium was slightly low at 131 millimoles per liter (mmol/L) (reference range 136–145 mmol/L) with otherwise normal electrolytes and a normal serum creatinine. Glucose was 177 milligrams/dL (mg/dL) (reference range 70–99 mg/dL). His alanine aminotransferase and aspartate aminotransferase were elevated at 228 units (U/L) (reference range 5–55 U/L) and 125 U/L (reference range 5–40 U/L), respectively. Total bilirubin was elevated at 3.1 milligrams |
18,745 | 161,003 | the left side of the mouth. Other electrodes were placed by the electrophysiological monitoring team to monitor cranial nerves 7 and 8 as well as sensory evoked potentials (SEP's) and motor evoked potentials (MEP's) and correct positioning confirmed. The patient was placed in left lateral decubitus position, park bench with right-side-up, and the head was turned to the left to facilitate retrosigmoid craniotomy. A lumbar drain was placed for brain relaxation. Brain tumor resection was performed with no apparent complications. Histopathology revealed meningioma with atypia.\nPost-operatively, she was neurologically stable and no injury to the tongue was noted on extubation. However several hours after extubation she developed | that neither the laryngeal mask airway (LMA), nor the electrodes shifted during the procedure and a gauze bite block was placed between the incisors and molar teeth on | A 34-year-old female presented for neurosurgical evaluation with complaints of decreased left hearing and left facial numbness for the past year and a half. For the past several weeks, she noticed new difficulty with her balance.\nShe underwent audiometric testing, which revealed complete sensorineural hearing loss on the left. In addition to her left hearing loss, she had left face numbness within V1 and V2 sensory distribution. The rest of her exam was normal.\nMagnetic resonance imaging revealed a large extra-axial mass of the left cerebellopontine angle that extended to the cavernous sinus and a second lesion in the left frontal |
29,474 | 56,972 | the program Image J released from National Institute of Health, USA. The reference range of type III/I collagen ratio has been determined by measuring this ratio in samples collected from healthy subjects over a period of 3 years. This analysis showed delayed electrophoretic mobility of type III collagen (Figure ). A decreased amount of α1(III) chain, as confirmed by the densitometric scan of the fluorogram, was also detected.\nIn the hypothesis that the electrophoretic abnormalities were due to post-transcriptional modifications of the | of type III/I collagen ratio has been determined by measuring this ratio in samples collected from healthy subjects over a period of 3 years. This analysis showed delayed electrophoretic mobility of type III | program Image J released from National Institute of Health, USA. The reference range of type III/I collagen ratio has been determined by measuring this ratio in samples collected from healthy subjects over a period of 3 years. This analysis showed delayed electrophoretic mobility of type III collagen (Figure ). A decreased amount of α1(III) chain, as confirmed by the densitometric scan of the fluorogram, was also detected.\nIn the hypothesis that the electrophoretic abnormalities were due to post-transcriptional modifications of the mRNA we analyzed the mutation through “Human Splicing Finder” (Figure ), which predicted the creation of a cryptic donor splice site (CCCGTTGGA).\nThe employment of this cryptic site may |
43,764 | 88,106 | tomography (CT) scan in 2014, with a disease-free result.\nAt admission he showed the result of the fecal occult blood test he took at home, which was positive. Blood tests were performed, revealing the known anemia (hemoglobin 7.7 g/dL) and an increase in C-reactive protein (33.9 mg/L). His carcinoembryonic antigen and CA 19.9 were both not beyond the normal values (respectively, 3.6 ng/mL and <0.8 UI/mL). He was then transfused with two blood units because of his low hemoglobin level. An abdominal examination revealed a tender abdominal mass in his right iliac fossa. He did not complain of pain or nausea and he did | radiotherapy, but developed a degenerative encephalopathy with cognitive impairment. After 2 years, in good clinical condition, he decided autonomously not to continue the follow-up. He underwent his last abdominal computed | with melena and anemia. He had a history of left RCC with metastasis in both adrenal glands and his brain. He underwent left nephrectomy and ipsilateral adrenalectomy in 1999. A histopathologic examination revealed a pT1bN0 clear cell RCC with a metastatic lesion in his ipsilateral adrenal gland. In 2004 |
42,201 | 15,164 | stiffness, we referred her to the physiotherapist to improve the range of motion (ROM) in both hips. Four months later, the ROM was acceptable (Table ).\nA computed tomography (CT) scan revealed a central acetabular bony prominence posterior to the triradiate cartilage that measured around 1.5 cm in width at its base and had an 8-mm long tooth-like end projecting into the joint. The femoral head was dislocated | was treated with closed reduction under anesthesia and immobilized in a hip spica for another 2 months. Upon removal of the cast, the right hip had dislocated again, and there was stiffness in both hips.\nAt the age of 20 months, the patient was referred to our hospital with severe stiffness of both hips and a dislocated right hip (Fig. ). Because of the | We secured the position of the cement ball in the acetabulum with multiple non-absorbable sutures to ensure the healing of the acetabular surface (Fig. ).\nA hip spica cast was applied for 2 months to allow the acetabular bone to heal and to allow fibrocartilage to cover the bone so that the smoothened surface was ready to accommodate the head of the femur.\nEight weeks later, we removed the spacer and explored the acetabulum intraoperatively. We found that it was healed completely and covered with fibrocartilage of an optimal depth and congruency to accommodate the |
39,959 | 33,886 | after the collision with a bus on the 5th of May and we were able to capture him on the 11th of May). When captured, the animal weighed 110 kg and seemed to have a fracture of the left humerus. This bear was transferred to the same veterinary team and a non-reducible comminuted fracture of the left humerus was confirmed radiographically (Fig. a). Blood examinations revealed increased white blood cells, AST, and C-reactive protein. On the 17th of May (12 days after the accident), preoperative | we were able to capture him on the 11th of May). When captured, the animal weighed 110 kg and seemed to have a fracture of the left humerus. This bear was transferred to the same veterinary team and a non-reducible | ± 2.1 km, 36.9 km2, 170.6 km2, and 40.5 km2, respectively (Table ). Additionally, those in autumn 2018 were 1.9 ± 1.7 km, 106.7 km2, 215.8 km2, and 59.2 km2, respectively (Table ), and bear-02 hibernated from the 27th of December 2018 until the 3rd of March 2019. During hibernation, we visited at its |
24,221 | 11,493 | nonweight-bearing precautions immediately postoperatively. Range of motion was initiated on postoperative day one. Weight-bearing was advanced to as tolerated on postoperative day one. Jogging was initiated at three months. She completed postoperative rehabilitation without issue and returned to her desired level of activity by six months. Maximum KT-2000 testing at 6 months was 8 mm on the right and 9 mm on the left. Biodex testing at | advanced to as tolerated on postoperative day one. Jogging was initiated at three months. She completed postoperative rehabilitation without issue and returned to her desired | arts twisting injury to her left knee. Continued pain and mechanical symptoms despite activity rest and conservative measures prompted an MRI study by her primary care physician and subsequent referral to our care based on the imaging findings of an ACL tear. The patient reported persistent instability and locking of her knee occurring with all activities and had failed trials of bracing, NSAIDs, and icing. She was unable to return to sport or her desired level of activity, and she desired |
14,513 | 132,934 | had neither fever nor features of meningitis, raised intracranial pressure, or peritonitis. His clinical examination revealed that there were multiple infected ulcers around the VPS catheter in the chest area. VPS catheter proximal to the chamber was also seen protruding out for few centimeters from the chest wound []. On palpation of the VPS catheter, the part of the shunt from the cranial to the upper chest | was missing. Abdominal examination revealed two healed abdominal scars in the right hypochondrium [], and the rest of the abdominal examination | wall around the implanted VPS catheter for 5 days []. At the age of 3 years, a right-sided, medium pressure, whole-length VPS (Chhabra slit n spring hydrocephalus shunt system) was implanted for hydrocephalus following tubercular meningitis. Five years, 8 months following VPS implantation, he was admitted with vague abdominal pain for 2 weeks, and malfunctioning of peritoneal part of the VPS catheter was detected. He was managed well with exteriorization of peritoneal part of the VPS catheter and followed by delayed revision of peritoneal part of the VPS catheter. Ten months following revision of the peritoneal catheter, he was |
43,733 | 159,571 | wanted a permanent replacement of her missing teeth. Clinical examination [], diagnostic impressions, face-bow transfers, bite registrations, photographs, radiographs, and a thorough history were obtained from the patient. A severe maxillary anterior ridge deficiency was noticed. To evaluate the bone width, ridge mapping was performed. Computed tomography (CT) scan of the edentulous area [] was taken to accurately measure the available bone. The available bone dimensions were found to be as follows:\nBone height at Tooth #11 = 16 mm\nBone height at Tooth #21 = | was performed. Computed tomography (CT) scan of the edentulous area [] was taken to accurately measure the available bone. The available bone dimensions were found to be as follows:\nBone height at Tooth #11 = 16 mm\nBone height | to prevent nosocomial infection and anti-inflammatory agent ibuprofen 400 mg two times daily, for a period of five days. The use of 0.2% chlorhexidine mouth rinse two times a day was instituted for two weeks. Suture removal was done after 10 days. Post operative follow-up the next day, after 10 days, and three months showed uneventful healing at both the surgical sites. A removable partial denture was given to the patient provisionally. Significant improvement in the ridge width was noticed at six months []. All the initial examination procedures were repeated post operatively to aid in the final prosthetic plan. On re-examination, the available bone dimensions were as follows:\nBone |
28,305 | 58,235 | increased uptake in the left perihilar region with a maximum standardized uptake value of 3.5 (Figure ).\nThere was no evidence of distant metastatic disease. Subsequently, he underwent a repeat flexible bronchoscopy with endobronchial ultrasound-guided and transbronchial needle aspiration of the right upper lobe mass and level four and seven lymph nodes, which demonstrated atypical cells, with no evidence of malignancy. He was then referred to surgical oncology and underwent a mediastinoscopy with biopsy of the lymph node, which demonstrated poorly differentiated carcinoma with extensive necrosis. Furthermore, immunohistochemistry was consistent with adenocarcinoma of the lung (Figures , ), with a PD-L1 Tumor Proportion Score of 80%. A repeat CT | referred to surgical oncology and underwent a mediastinoscopy with biopsy of the lymph node, which demonstrated poorly differentiated carcinoma with extensive necrosis. Furthermore, immunohistochemistry was consistent with adenocarcinoma of the lung (Figures , ), with a PD-L1 Tumor Proportion Score of 80%. A | was started on 2 L of oxygen via a nasal cannula. His blood pressure was 87/55 mmHg. Laboratory workup was normal except for lactic acid of 3.9 mmol/L. CT chest pulmonary artery embolism was negative for the pulmonary embolism but showed significant interval disease progression with increased right upper lobe lung mass (Figure ).\nThe patient was medically managed with broad-spectrum antibiotics, furosemide, and Solu-Medrol 40 mg twice daily. The patient continued |
40,694 | 28,339 | and catheters were placed in the coronary sinus (CS) and anterolateral RA (proximal catheter in the high lateral RA, with distal electrodes inferior toward the floor of the RA along the low lateral wall), | and catheters were placed in the coronary sinus (CS) and anterolateral | have required access to the LA and was not deemed necessary and was not performed to avoid unnecessary procedural risk to the patient.\nEntrainment was performed adjacent to the posterior RA channel (, with a PPI of 370 ms that was identical to the TCL. Pacing from the ablation catheter at a high output of 15 mA was also performed to exclude the possibility of ablation of the phrenic nerve. Ablation in this area slowed and terminated the tachycardia, which could not be induced at the end of the procedure.\nIn addition, importantly, while attempting to check the line of block at the CTI by pacing |
18,888 | 175,772 | cervical os with no sign of invasion to adjacent tissue. According to the International Federation of Gynecology and Obstetrics (FIGO) staging system, the tumor was vaginal cancer staged as I, and a fluorodeoxyglucose positron emission tomography/CT revealed no metastases to the lymph nodes or other organs. Although the diagnosis of this case was vaginal cancer, the main tumor was located in the uterine cervix because of the | no sign of invasion to adjacent tissue. According to the International Federation of Gynecology and Obstetrics (FIGO) staging system, the tumor was vaginal cancer staged as I, and a fluorodeoxyglucose positron emission tomography/CT revealed no metastases to the lymph nodes or other | was inserted into the lumen of each of the four plastic BT needles, and X-ray imaging was performed. The patient was then transferred to the CT room. CT was performed with 2-mm slices, confirming that the BT sources had been inserted around the lesion (Fig. ). At our facility, HDR ISBT is administered using a 60Co remote afterloading system (RALS) (MultiSource; Eckert & Ziegler BEBIG). Thus, these CT scans were uploaded to the RALS treatment planning system (HDR plus; Eckert & Ziegler BEBIG). According to the guidelines established by the Groupe Europeen de Curietherapie and European Society for Radiotherapy and Oncology [, ], the gross tumor volume (GTV) and organs at risk (OARs) (i.e., |
28,416 | 70,461 | Laboratory data showed anemia, normal platelet and leucocyte counts with elevated lactate dehydrogenase (LDH), aspartate aminotransferase (AST) and C-reactive protein (CRP). Serum alpha-1-fetoprotein and human chorionic gonadotropin were normal while carbohydrate antigen 125 was increased. Urine analysis and renal function were within normal limits. Serum immunoglobulin levels were within normal limits, without evidence of monoclonal gammopathy and serology | (LDH), aspartate aminotransferase (AST) and C-reactive protein (CRP). Serum alpha-1-fetoprotein and human chorionic gonadotropin were normal while carbohydrate antigen 125 was increased. Urine analysis and renal function were within normal limits. Serum | with enlarged ipsilateral axillary lymph nodes, along with generalized abdominal lymphadenopathy, an enlarged spleen with diffuse multiple nodal masses and a complex right pelvic tumor mass with amorphous calcification similar to tooth formation. Based on the MSCT scan, a tentative diagnosis of an immature teratoma was made. The patient proceeded to surgery for a unilateral right salpingo-oophorectomy, lymphadenectomy, splenectomy, omentectomy and right breast lumpectomy. Intraoperative peritoneal washing revealed a poorly differentiated malignant tumor on cytology.\nOn macroscopic examination, the right ovary was replaced by a |
36,561 | 196,501 | to the start of surgery.\nThe surgery commenced and was progressing unremarkably. Prior to opening of the dura, 20 mL of CSF was drained over 15 minutes per neurosurgeon request. After dural opening and during dissection of the aneurysm, the surgeon requested the lumbar drain to | a total of 80 grams was administered. The neurosurgeon placed an 80 cm closed-tip, barium impregnated lumbar drainage catheter with a 0.7 mm inner diameter (Medtronic USA, REF 46419) at the L3-4 level prior | remifentanil boluses aimed at treating light anesthesia as well as a bolus of 7.5 mg labetalol. At the time of the hypertensive event, the propofol, remifentanil, and Sevoflurane dosing had been stable and unchanged for over an hour. There was also no change in the level of surgical stimulation at this time as the dura had been incised and the neurosurgeons were using the operative microscope to expose the aneurysm. After the aneurysm was successfully clipped, the lumbar drain was closed and the surgery was completed without further episodes |
42,308 | 21,177 | is discharged from the upper fistula bag. Therefore, after the third hospitalization, the patient gained two routes for feeding, oral and jejunal. This boosted her energy and also reduced exposure to antigens in the remaining vulnerable intestine. This time, she finally received IFX as her treatment option. On March 30, 2017, the patient's former fistula completely healed (Fig. B).\nTwo years later, on March 20, 2018, the patient came back to receive the stoma closure surgery. Her physicians and surgeons were surprised to see that she weighted 44 kg this time (Fig. C). We performed the operation on April 2, 2018, and | surgeons were surprised to see that she weighted 44 kg this time (Fig. C). We performed the operation | discharged.\nOn May 31, 2016, the patient was admitted again because of a fistula rupture. At great risk, our gastrointestinal surgeon completed an operation consisting of small intestinal stoma closure, enterocolic anastomosis, enterostomy, jejunal nutrition tube implantation, and intestinal adhesion lysis on June 6, 2016. Because of her fistula rupture, the surgeons had to perform the small intestinal stoma closure, and they made a new small intestinal stoma (Fig. A). The jejunal nutrition tube provides another access for nutrition intake |
9,007 | 111,331 | and other genes associated with early-onset dementia and revealed a heterogeneous variant in DNAJC5 NM_025219:exon3:c.C188T:p.A63V (chr20:62560745 [hg19]), a gene commonly associated with ceroid lipofuscinosis (neuronal, 4, parry type). The variant was identified using exome sequencing where paired end sequence reads were converted to FASTQ | a heterogeneous variant in DNAJC5 NM_025219:exon3:c.C188T:p.A63V (chr20:62560745 [hg19]), a gene commonly associated with ceroid lipofuscinosis (neuronal, | right occipital lobe infarct with an acute to subacute left anterior thalamic lacunar infarct, which were new compared to prior scan. Given that his infarcts were in multiple territories, an echocardiogram was done which ruled out thrombus. He was diagnosed with early vascular dementia and continued on medical therapy for aggressive risk factor modification. He was discharged home to the care of his mother-in-law and fiancé for approximately 5 months. However, due to difficulties in taking care of him by his fiancé and mother-in-law, he was referred for a third admission to better define his condition and needs while the court assigned a conservator for him as |
2,551 | 168,531 | an acute porphyria. The first attack in January 2013 led to a diagnosis of appendicitis. Because the symptoms worsened following the surgery an emergency laparoscopic exploration was done. But the exploration revealed no cause to explain the worsening symptoms. The second attack was managed as sinus tachycardia and he was started on beta adrenergic blockers. The third attack which was associated with a fever was conservatively managed for a questionable renal colic. Forth attack was complicated with transient hyponatremia and transiently high serum creatinine levels. These complications were | emergency laparoscopic exploration was done. But the exploration revealed no cause to explain the worsening symptoms. The second attack was managed as sinus tachycardia and he was started on beta adrenergic blockers. The third attack which was associated with a fever was conservatively managed for a questionable renal colic. Forth attack was complicated with transient | centile; 142–258) with LDL fraction of 225 mg/dL (5th to 95th centile; 78–185). Serum ferritin level was 646 ng/mL (20–250). Arterial blood gas analysis was suggestive of a metabolic acidosis. Echocardiogram showed evidence of left ventricular hypertrophy. There were no significant radiological findings in abdominal |
6,620 | 68,744 | previous incision, was reconducted. We found a lower lobe abscess with destruction and gangrene of the right lower lobe. The esophagus was normal and without any signs of inflammation. We carried out just decortication and a lobectomy. The postoperative period was uneventful. Fever subsided on the day after surgery; meanwhile the drain was removed 5 days after surgery and she was | on imipenem and was taken back to the operating room on the fifth day of admission because of the persistence of sepsis despite broad spectrum antibiotics. A thoracotomy, through the | hemodynamic condition of the child and our working environment did not permit for a longer procedure. We thus choose to be conservative. A nasogastric tube was |
6,150 | 110,492 | 19-G needle; however, the highly viscous nature of the pus precluded aspiration. The patient was advised to continue taking oral antibiotics.\nThe patient presented to the emergency department a few days later with ongoing discharge from her left breast. Examination revealed an open wound in the left breast with a hard, non-mobile, tender lesion palpable underneath. The wound contained central necrosis with surrounding purulent discharge and accompanying erythema extending to the nipple. Peau d’orange changes were also present | viscous nature of the pus precluded aspiration. The patient was advised to continue taking oral antibiotics.\nThe patient presented to the emergency department a few days later with ongoing discharge from her left breast. Examination revealed an open wound in the left breast with a hard, non-mobile, tender lesion palpable underneath. | at 13.0 × 109/L and her C-reactive protein was 123 mg/L. Her blood sugar level on presentation was elevated to 25.2 mmol/L.\nA repeat US was conducted with no drainable collection noted. The underlying mass at the 10 o’clock position with edematous changes in the surrounding subcutaneous tissue was again noted. The patient was admitted under the general surgical team and commenced on intravenous trimethoprim and sulphamethoxazole.\nA magnetic resonance imaging (MRI) was performed to aid in operative planning. The MRI revealed no evidence of malignancy or adenopathy in the right breast. The left breast contained a large collection, measuring100 × 40 × 60 mm. The MRI features were in keeping with a large |
14,592 | 78,914 | and plantar flexion (5/5 MRC) with reduced toe flexion and extension (3/5 MRC). A tourniquet was immediately applied to her right upper thigh for approximately 30 minutes prior to a CT angiogram, which excluded an arterial injury (). This was then reinflated for approximately 30 minutes prior to surgery.\nShe was brought to the operating room within three hours of her injury and underwent irrigation and debridement of her right thigh and left iliac crest as well as temporary fixation of her femur fracture | with a 4.5 mm compression plate (). It was felt that this would provide the fastest stabilization of her femur fracture given her hemodynamic instability. | toe extension or flexion (0/5 MRC). She had persistent global sensory loss in the calf and foot.\nAfter fasciotomy, a Doppler ultrasound demonstrated an occlusive DVT in her right femoral vein at the level of the venous repair. She was started on heparin until an IVC filter was inserted. At 72 hours after fasciotomy, she had conversion of the temporary medial femoral plate to a locked intramedullary nail (), as well as repeat irrigation and debridement of her traumatic wound, and split-thickness skin grafts (STSG) for the traumatic wound and fasciotomy incisions. |
12,559 | 44,304 | HFS and anemia, and then re-started at a dosage of 150 mg thrice daily. At the end of June, contrast-enhanced CT scan showed size reduction of the major lesion to 75 mm × 72 mm with hypodense necrotic areas (, C and D), the persistence of three subcentimetric lesions, and the complete disappearance of the other four lesions. Capecitabine was continued and, after a further dose reduction to 150 mg twice daily due to a transient reappareance of grade 2 HFS which | lesions, and the complete disappearance of the other four lesions. Capecitabine was continued and, after a further | showed HCC (Edmondson grade II). Due to the detection on Doppler US of a high flow arteroportal fistula within the major HCC lesion, she underwent percutaneous transcatheter endovascular embolization. Control endoscopy showed grade I-II esophageal varices. Since the patient was considered not eligible for endovascular treatment of HCC, but had a good liver function (Child-Pugh class A), treatment with sorafenib was started in December 2011. Alpha-fetoprotein (AFP) serum levels were 19 ng/ml (< 7 ng/ml).\nThree months later, treatment was stopped due to CT evidence of disease progression. The major lesion had increased to 90 mm × 87 mm, with persistent high vascularization, and involved the corresponding segmentary portal vessel (, A |
24,504 | 108,273 | patient was allowed knee mobilization exercise for both knees. The patient was monitored with clinical and radiological assessment at 6, 12, and 24 weeks. At 6 months, the patient was able to mobilize with stick support once there were clear radiologic signs of fracture consolidation. Follow-up scanogram (), radiographs of femur (, ), tibia (, ), and patella | exercises and assisted passive range of movements exercises for the right knee and ankle from the 1st week onward. Three weeks after surgery, the patient was allowed walker support walking and rehabilitation of the left knee in a brace support continued. At 6 weeks, the | right lower limb injury.\nThe patient was stabilized and on the 2nd day of injury, the patient underwent surgical reduction and fixation of distal femur fracture with distal femoral locking plate (AO Synthes) through the lateral approach and diaphyseal tibial fracture fixation with narrow locking plate (AO Synthes). Primary autologous iliac ipsilateral bone grafting to augment the healing at both fracture segments done. The left knee patellar fracture was managed conservatively in a long knee brace immobilization. Immediate post-operative period was uneventful |
29,859 | 154,591 | socket was then thoroughly debrided and curetted to eliminate all the visible granulation and infected tissues []. Consequently, a restrained peripheral intrasocket ostectomy of the alveolar bone was performed using bone scoop to ascertain absolute eradication of all infected soft and hard tissues with special attention to the periapical region. The surgical site was vigorously irrigated with a sterile solution. Sequential implant drilling was done for the site to receive a 4.2x10-mm length implant***. Implant was placed with a torque wrench with adequate primary stability. The implant had a large buccal fenestration of 5 mm []. The void was filled with bone graft [] and GTR collagen | of the alveolar bone was performed using bone scoop to ascertain absolute eradication of all infected soft and hard tissues with special attention to the periapical region. The surgical site was vigorously | the option of extraction followed by implant placement. Pros and cons of the procedure were explained to the patient and informed consent was obtained. Preoperative evaluation included study of diagnostic casts, photographs, periapical radiograph and CT for assessment of implant size, position of implant and anatomical landmarks.\nAfter administration of local anesthesia [2% Lignocaine 1:80000 adrenaline], a crestal incision was placed in the edentulous 34 region; vertical relieving incision was placed in relation to 33. A full-thickness mucoperiosteal flap was elevated and reflected. Implant site was marked with round bur. A 2-mm pilot drill osteotomy was done to the depth of 3 mm. On encountering an obstruction on |
40,316 | 102,910 | of the injured elbow joint, once at the first hospital, and then in our emergency room. According to the Mayo classification, the olecranon fracture was diagnosed as type IIIB. Sixteen days after the initial trauma, the anterior trans-olecranon fracture dislocation of the right elbow joint was treated by open reduction and internal fixation by applying a pre-contoured olecranon plate (Zimmer, Warsaw, IN, USA) using the posterior approach incised along the triceps, followed by application of a long arm splint ().\nAfter surgery, the elbow was immobilized in a long arm splint at 90 degrees of | at the first hospital, and then in our emergency room. According to the Mayo classification, the olecranon fracture was diagnosed as type IIIB. Sixteen days after the initial trauma, the anterior trans-olecranon fracture dislocation of the right elbow joint was treated by open reduction and internal fixation by applying a pre-contoured olecranon plate (Zimmer, Warsaw, IN, USA) using | After 6 months maturation of the heterotopic mass, surgical excision was carried out using the posterior approach through the previous incision scar. Skin, subcutaneous tissue, and deep fascia were incised in line with the skin incision. The ulnar nerve was identified and retracted. The extent of the mass was exposed adequately and was excised completely from the distal humerus and ulna (). Intraoperative elbow range of motion flexion 0 to 140 degree was checked.\nPostoperative radiographs showed no trace of HO (). One day after the operation, a 1-time dose |
20,614 | 121,044 | with the last recorded blood sugar being 116 mg/dL. Upon discharge, it was decided to discontinue all diabetes medications due to the fact his most recent hemoglobin A1c was measured to be 5.7%. The patient had multiple co-morbidities and limited life expectancy because of them, and the | patient’s urinalysis, microbial cultures, and other markers of infection were all negative upon admission. His blood sugars the last 4 days of admission ranged from 75 to 131 mg/dL, | case describes a 77-year-old, African American male with a past medical history of diabetes mellitus type II, combined systolic and diastolic congestive heart failure (CHF) with biventricular implanted cardioverter defibrillator, atrial fibrillation, hypertension, chronic kidney disease stage II, and hypothyroidism. On day 18 prior to admission, his primary care physician changed his oral hypoglycemic therapy from metformin 1000 mg daily to glimepiride 1 mg daily. The patient was also stated to be on insulin detemir 40 units every morning and 10 units every evening during this time, but pharmacy records do not indicate this medication ever being dispensed. On day 11 prior to admission, he received a prescription for a 14-day course of linezolid 600 mg twice daily for |
20,208 | 134,904 | also inspected exhaustively. However, the missing piece was nowhere to be found. The patient remained hemodynamically stable through the entire case. At this point, the procedure was concluded, and the patient was sent to obtain computed tomography (CT) scan of the chest, abdomen, and pelvis to look for the retained IVC filer leg.\nThe imaging of the | nowhere to be found. The patient remained hemodynamically stable through the entire case. At this point, the procedure was concluded, and the patient was sent to obtain computed tomography (CT) scan of the chest, | structure in the region of the tricuspid valve []. This was highly suspicious for the fractured strut of the IVC filter. Two-dimensional transthoracic echocardiography was obtained, which showed no changes compared to prior studies in the past.\nThe decision was made to retrieve the IVC filter strut under fluoroscopic guidance. Because of the possibility of tricuspid valve/heart injury and the need for sternotomy, general anesthesia was planned. Two large bore peripheral IVs (18G on each hand) were placed. Preinduction arterial line was placed in the left radial artery. The Standard American Society of Anesthesiologists monitors with five-lead electrocardiography were used throughout the procedure. After IV induction of anesthesia, the trachea was intubated with a 7.0 |
27,991 | 64,441 | diagnosed 30 years previously and was complicated with chronic ischemic heart disease, as demonstrated by total occlusion of the left anterior descending artery on coronary angiography. The occlusion was treated with a percutaneous coronary intervention 3 years previously. The above medications were maintained during the admission period. A complete blood cell count revealed a leukocyte count of 14,800 cells/μL, a hemoglobin level of 9.8 g/dL, and a platelet count of 452,000 cells/μL. Liver function tests, prothrombin time, activated partial thromboplastin time, serum electrolytes, sodium levels, and creatinine levels were within normal | angiography. The occlusion was treated with a percutaneous coronary intervention 3 years previously. The above medications were maintained during the admission period. A complete blood cell count revealed a leukocyte count of 14,800 cells/μL, a hemoglobin level of 9.8 g/dL, and a platelet | intravenous administration of dexmedetomidine (0.3 μg/kg/h) was initiated following a bolus administration (0.5 μg/kg). After confirmation of the sensory blockade using a pinch test on the dermatomes corresponding to the femoral and sciatic nerves (23 minutes after the end of local anesthetic injection for each block), the surgery for the left below-knee amputation began following blood exsanguination with an Esmarch bandage from the whole left lower extremity, with subsequent inflation |
34,856 | 32,868 | of genetic diseases and dysmorphism. She had received antibiotic therapy for 1 day before readmission at the local hospital. Laboratory examination showed that the white blood cell (WBC) count was 5.94 × 109/L, and the percentage of neutrophils was 81.8%. Blood culture showed positive for Staphylococcus aureus. The electrocardiograph showed frequently occurring ventricular premature beat, and ultrasonic cardiogram (UCG) showed a spherical cystic echo (82 × 76 mm) at the anterolateral aspect of the ascending aorta (). Then an emergent computed tomography angiography (CTA) was done which revealed an abnormal | had received antibiotic therapy for 1 day before readmission at the local hospital. Laboratory examination showed that the white blood cell (WBC) count was 5.94 × 109/L, and the percentage of neutrophils was 81.8%. Blood culture showed positive for Staphylococcus aureus. The electrocardiograph showed frequently occurring ventricular premature beat, and ultrasonic cardiogram | to implement brain local mild hypothermia therapy. After the patient was placed in a head-down position, we incised the pseudo-aneurysm rapidly and found an ostium (8 × 9 mm in diameter) in the anterior wall of ascending aorta where the purse-string suture was made during the previous surgery. Cardioplegia solution (St. Thomas solution, 30 ml/kg) was infused directly via the coronary ostia to achieve cardiac arrest. A piece of appropriate size of aneurysmal wall was harvested and soaked in iodophor for 2 min then overlaid |
26,250 | 50,549 | or dizziness were noted. There is no family history of rheumatoid arthritis, felty syndrome, or recurrent infections. There is no history of previous or current alcohol, smoking, or recreational drug use. The patient was not sexually active. Physical examination revealed the patient was febrile at 101.5 °F, tachycardic at 117 beats per minute with normal rhythm, intact distal pulses, normal breath sounds bilaterally with no wheezing, bilateral tympanic membrane injection without effusion, pharyngeal erythema, lower lip ulcers, abdominal tenderness, hepatomegaly, splenomegaly, and no active synovitis but decreased range of motion of right wrist. Pertinent laboratory tests showed white blood cell count of 3.50 | × 103/μL with absolute neutrophil of 25 cells/mm3, and platelet count of 286 × 103/μL. Hemoglobin was 7.6 g/dL, hematocrit of 32.4%, and mean corpuscular volume of 71.1 fL. Peripheral blood smear showed no significant abnormalities with normal reticulocytes. Blood and urine cultures showed growth of Pseudomonas aeruginosa. Tests for Streptococcus pneumoniae, epstein–barr, herpes simplex, and influenza | lip ulcers and was given lidocaine. The mother, her health proxy, noted the symptoms did not improve after 2 days, so she brought her to the ED. Patient was admitted for sepsis secondary to right middle lobe community acquired pneumonia and urinary tract infection. In addition to RA, the patient’s medical history includes asthma, pneumonia, mild intellectual disability, and anemia. Due to the patient’s mental disability, her mother, who is her primary caregiver and health |
33,244 | 102,384 | loss for 10 days. At 16 months of age (10 years back), she underwent fenestration of posterior fossa arachnoid cyst with ventriculoperitoneal (VP) shunt insertion when she had become lethargic and lost motor milestones. She improved and returned to baseline and was doing fine.\nThree weeks before presentation to our center, she developed persistent frontal headache and vomiting which progressively increasing. On the 7th day of illness, she was evaluated elsewhere by an ophthalmologist. Visual acuity was reportedly normal. There was no papilledema. Magnetic resonance imaging (MRI) was done, which showed | a posterior fossa arachnoid cyst with VP shunt in situ and normal-sized ventricles []. Cerebrospinal fluid (CSF) examination revealed acellular CSF with normal biochemistry, but opening pressure was not measured. She also had aching over the limbs. Headache decreased after | pulse methylprednisolone with no improvement. At presentation at our center (3 weeks after onset of illness), she was conscious, drowsy, and had a normal general physical examination and hemodynamically stable without any features of Cushing's triad but had neck stiffness.\nExamination revealed absent perception of light bilaterally without papilledema. Pupils were dilated and not reacting to light, with ptosis of the right eyelid with bilateral impaired abduction of the eyeballs. Facial sensation was normal with diminished corneal reflex bilaterally, with jaw weakness. There was no facial weakness, palatal, or tongue weakness. Neck flexors as well as extensors were weak.\nThere was symmetrical flaccid quadriparesis. All deep tendon reflexes were |
36,170 | 152,049 | taken oral antibiotics prescribed at a local clinic, her symptoms did not show improvement. On the fourth day of her illness, she was referred to a secondary hospital and was diagnosed as pneumonia. She was admitted to that hospital and was treated with antibiotics of ceftriaxone and clarithromycin, intravenously. On the sixth day of her illness, her fever subsided. However, she abruptly developed left hemiparesis and left facial palsy, and was referred to Inha University Hospital. Past medical history of the patient and family were unremarkable.\nOn admission, she | was fully conscious and oriented. Vital signs showed a blood pressure of 127/60 mmHg, heart rate of 102 beats/min, respiratory rate of 24 breaths/min, and body temperature of 37.6℃. Her heart beat was regular without murmurs, while breath sounds were coarse with inspiratory crackles auscultated on both lung fields. On neurologic examination, pupils were isocoric with | profiles and plasma lipoprotein levels were normal. Analysis of auto-antibodies associated with autoimmune and rheumatologic diseases, including antiphospholid antibodies, anticardiolipin antibodies, antinuclear antibodies, anticytoplasmic antibodies, anti-DNA antibodies, and rheumatoid factors were all negative. No other bacterial or viral organisms were documented in the serum or CSF on culture studies. Serum antibody titers to M. pneumoniae detected by ELISA 3 weeks after admission were 7,300 U/mL for IgM and 26.65 AU/mL for IgG.\nThe patient was discharged on the 32nd hospital day after receiving the inpatient rehabilitation |
42,252 | 106,368 | Nigeria since childhood. She was regular with her routine follow-up visits at sickle cell center.\nShe was admitted to the Central Hospital Benin City, Nigeria on April 05, 2019 on account of anemia and chronic leg ulcer of 11 months' duration. There was no improvement in the healing process as a result of poor | follow-up visits at sickle cell center.\nShe was admitted to the Central Hospital Benin City, Nigeria on April 05, 2019 on account of anemia and chronic leg ulcer | with sterile saline and debrided of nonviable slough and necrotic material prior to sampling for microbial culture. The margins of the wound was separated to avoid touching the wound edge with the sterile swab. The tip of the swab stick was extended deeply to reach the base of the lesion and rotated over the area of viable tissue, using sufficient pressure to extract fluid from the wound tissue and transported immediately to the laboratory for microbial culture. Wound swab for microscopy, culture, and sensitivity (m/c/s/) yielded growth of Staphylococcus aureus which was sensitive to clavulanic acid and amoxicillin. This necessitated her being placed on oral Augmentin 625 mg bid and had wound debridement. She was |
21,203 | 189,328 | not revealed by dipole analysis previously. This indicates that SAM can reproducibly localize interictal epileptiform activity despite the presence of large artifacts due to the VNS implant. (The dipole localization in the presence of VNS artifact is shown in B for comparison. The dipole tails have been omitted for clarity.) Examination of the virtual electrodes reconstructed from the SAM(g2) focus demonstrated MEG epileptiform discharges that correlated with the simultaneously recorded scalp EEG during the second recording (C), and, | importantly, that lacked the high-amplitude fluctuations present in the raw MEG data that were induced by the VNS (B). (For comparison, the raw MEG sensor data prior to VNS implantation are depicted in the top part of B.) Furthermore, during the patient’s second | focus was not localized with any modality, she received a VNS.\nHowever, the patient continued to have seizures after the VNS implantation. Because we had subsequently implemented SAM(g2) as an alternative to dipole analyses, the patient returned for a second MEG scan. SAM(g2) was used to analyze this second MEG recording, as well as the previous recording performed prior to VNS |
25,702 | 66,762 | tube. For pain management, we instilled Chirocaine para vertebral block at five levels with additional local infiltration of the port sites. The RATS procedure was accomplished without mentionable blood loss or other intraoperative complications.\nOn histopathological examination, the lymph nodes showed no abnormalities. Examination of the lining of the cystic cavity showed collagenous stroma, prominent capillaries and a few lymphoid aggregates. There were a few | The RATS procedure was accomplished without mentionable blood loss or other intraoperative complications.\nOn histopathological examination, the lymph nodes showed no abnormalities. Examination of the lining of the | A 15-year old girl was referred to an orthopedic surgeon with complaints of a consistent nagging pain in her left shoulder which were provoked by physical exertion and had persisted for over a year. Shoulder radiography revealed no abnormalities of the left shoulder joint, although a remarkable abnormal aspect of the left upper part of the chest was described, for which she was referred to the Pulmonology Department.\nAdditional patient history revealed limited physical exercise tolerance compared to her peers, mostly due to dyspnea and pain; she had no other complaints. She had no history of smoking or drug abuse. Her medical history was unremarkable except for a fall from a horse one year prior to presentation. |
35,108 | 31,122 | the aneurysm. However, he carefully preserved the STA within the supragaleal space of the skin flap. Early next morning, a postoperative CT was performed with acceptable results of midline shift regression (d).\nHowever, the patient was hemodynamically unstable, requiring continuous vasopressor support and it was impossible to obtain a valid neurological exam. Eight hours after the initial surgery, a second procedure was scheduled, aiming to treat the dissecting aneurysm. After skin flap eversion and durotomy, the neurosurgeon (first author) preferred dissection of the arterial donor from the skin flap and performed a protective bypass on the distal M4 segment of the middle temporal branch of the MCA (a). The reason for this was that performing dissection in the area | regression (d).\nHowever, the patient was hemodynamically unstable, requiring continuous vasopressor support and it was impossible to obtain a valid neurological exam. Eight hours after the initial surgery, a second procedure was scheduled, aiming to treat the dissecting aneurysm. After skin flap eversion | of vasospasms based on TCD measurements (insonation depth of 20–25 mm in the temporal region).\nAfter vasospasms receded, the patient was transferred to his local intensive care unit on the 17th day after the second surgical |
19,890 | 22,552 | abnormal lymphadenopathy raised the concern for breast cancer. As a result, biopsies of the calcifications and axillary lymph node were recommended. She agreed to the biopsy during the current visit and received financial assistance to proceed with diagnostic interventions, including a stereotactic core biopsy of the amorphous calcifications and an ultrasound-guided biopsy of the morphologically abnormal axillary lymph node. Histopathological results of the biopsies showed moderately differentiated invasive ductal carcinoma of the right breast with metastasis to the right axillary lymph node. Specifically, the invasive | with diagnostic interventions, including a stereotactic core biopsy of the amorphous calcifications and an ultrasound-guided biopsy of the morphologically abnormal axillary lymph node. Histopathological results of the biopsies showed moderately differentiated invasive ductal carcinoma of the right breast with metastasis to the | A morphologically abnormal lymph node measuring 15 mm was also noted in the right axilla (Figure ).\nBecause of these abnormal findings, her lesions on mammography were classified according to the Breast Imaging, Reporting and Data System (BI-RADS) as BI-RADS category 4 suspicion for malignancy. In the left breast, there was no evidence of suspicious masses, calcifications, or other abnormal findings. In consideration of her age, abnormal mammogram in the past, current amorphous calcifications, and abnormal lymphadenopathy, |
35,899 | 102,845 | in length and 15 cm in breadth. An intraoperative frozen section analysis was done that revealed a chronic inflammatory reaction and no evidence of sarcoma. The defect after excision of the mass was filled with frozen allograft. The excised specimen was solid with a fibrotic wall; on gross examination, after dissecting the specimen, a mop was found ( and ).\nThe sample was sent for histological study which revealed fibrous strands, clots, hemolyzed pigments of red blood cells inflammatory cells, and multiple fiber strands. The foreign material was studied under polarized light () and | inflammatory reaction and no evidence of sarcoma. The defect after excision of the mass was filled with frozen allograft. The excised specimen was solid with a fibrotic wall; on gross examination, after dissecting the specimen, a mop | and 15 cm in breadth. An intraoperative frozen section analysis was done that revealed a chronic inflammatory reaction and no evidence of sarcoma. The defect after excision of the mass was filled with frozen allograft. The excised specimen was solid with a fibrotic wall; on gross examination, after dissecting the specimen, a mop was found ( and ).\nThe sample was sent for histological study which revealed fibrous strands, clots, hemolyzed pigments of red blood cells inflammatory cells, and multiple fiber strands. |
35,938 | 94,882 | exacerbation of the SIRS II (see ).\nFurthermore we switched the medication to the selective β\n1-blocker metoprolol. The patient stabilized quickly again but the fever continued. Since all blood cultures remained negative, we hypothesized that the source of recurrent endotoxemia may be gastrointestinal. One week later we decided to remove as many potential sources of infection as possible. We removed not only the central venous catheter but also the G-Tube. Subsequent blood cultures and the central venous catheter cultures were negative, but resistant E. coli was recovered from the jejunal end of the feeding tube. The infant improved with oral | ).\nFurthermore we switched the medication to the selective β\n1-blocker metoprolol. The patient stabilized quickly again but the | Since all blood cultures remained negative, we hypothesized that the source of recurrent endotoxemia may be gastrointestinal. One week later we decided to remove as many potential sources of infection as possible. We removed not only the central venous catheter but also the G-Tube. Subsequent blood cultures and the central venous catheter cultures were negative, but resistant E. coli was recovered from the jejunal end of the feeding tube. The infant improved with oral treatment with cotrimoxazole. His supplemental oxygen requirements ceased during his oxygen saturation rose to 90% and the pulmonary |
16,839 | 11,862 | found to be normal with no rents. The aorta was closed. Surgical exploration could not be extended on the right side because of dense adhesions due to the past surgery.\nThe patient was then repositioned and right thoracotomy done, which showed a 2 × 2 cm laceration on right lower lobe of the lung from which blood was draining freely, probably sustained during chest tube insertion. This was repaired. No other source of bleeding could be identified. Postoperatively, drainage from chest tube decreased but did not subside. CTA was repeated, which again revealed the hematoma of the same | size with some contrast leak just above the celiac artery on the anterolateral wall of the aorta. Thus, the decision was taken to stent the descending thoracic aorta above the celiac artery level.\nStenting of the descending thoracic aorta was done via the right femoral artery approach under fluoroscopic guidance from just below the arch vessels to just above the celiac axis. However, even poststenting blood drainage did not subside, and serial chest X-rays showed increasing collection in the right pleural | tachypneic (room air –84%) with decreased air entry on the right side and with normal hemodynamics values. Cardiac auscultation revealed normal heart sounds and no cardiac murmur. A chest X-ray was done which showed a massive right-sided pleural effusion, and a right intercostal tube drainage was done at an outside hospital which drained 1 L of blood immediately and 1 L subsequently.\nThe patient was referred to our institute with the diagnosis of massive right hemothorax. An ultrasound of |
979 | 79,796 | of the right lower leg and popliteal fossa during the 5th month of pregnancy. She had undergone five attempts of intracytoplasmic sperm injection (ICSI) and hormonal therapy previous to this pregnancy. The gestation had been without pathological findings to this point and the family history of the woman did not show any malignant tumors. The first medical consultation due to the swelling was in the 6th month at her general practitioner, who performed a sonography and advised an MRI scan. This was finally done at the 11th july 2012 which showed a hyperintense mass of 6,7 cm × 4,7 cm × 3,8 cm | did not show any malignant tumors. The first medical consultation due to the swelling was in the 6th month at her general practitioner, who performed a sonography and advised an MRI scan. This was finally done at the 11th july 2012 which showed a hyperintense mass | 23rd of October until the 29th of November 2012 with a total radiation level of 56 Gy.\nThe routine follow-ups did not show any pathological abnormalities. The last clinical examination on the 7th of July 2014 showed an indolent scar after posterior approach to the right lower leg and popliteal fossa without palpable mass or skin defects. The movement of the knee had |
29,453 | 114,978 | by echocardiography during a preoperative work-up for spinal surgery. He did not have a family history or cardinal features of any heritable disorder of the connective tissue. A transthoracic echocardiographic examination showed an enlarged sinus of Valsalva (55 mm in diameter) with moderate aortic regurgitation (). The maximal diameters of the sinotubular junction and ascending aortic tubular portion were 44 and 40 mm, respectively (). The left ventricular ejection fraction was 65% with no regional wall motion abnormalities. A transesophageal echocardiographic examination | examination showed an enlarged sinus of Valsalva (55 mm in diameter) with moderate aortic regurgitation (). The maximal diameters of the sinotubular junction and ascending aortic tubular portion were 44 and 40 mm, respectively (). The left ventricular ejection fraction was 65% | man was referred for the surgical management of an aortic root aneurysm found by echocardiography during a preoperative work-up for spinal surgery. He did not have a family history or cardinal features of any heritable disorder of the connective tissue. A transthoracic echocardiographic examination showed an enlarged sinus of Valsalva (55 mm in diameter) with moderate aortic regurgitation (). The maximal diameters of the sinotubular junction and ascending aortic tubular portion were 44 and 40 mm, respectively (). The left ventricular ejection fraction was 65% with no regional wall motion abnormalities. A transesophageal echocardiographic examination showed aortic valve cusp coaptation at a level close to the middle of the sinuses of Valsalva (). The |
8,138 | 90,791 | infectious agent may have molecular similarity to a self-antigen and may therefore induce an autoimmune response [].\nImmune deregulation secondary to HIV infection may lead to increased risk of developing an autoimmune disease. Development of autoantibodies may be part of the nonspecific polyclonal B-cell stimulation seen in early stages of HIV infection secondary to interleukin (IL)-1 and IL-2 release by HIV-infected macrophages [].\nOn the other hand, the loss of specific immunomodulatory CD4 T cells may allow the expansion of | stimulation seen in early stages of HIV infection secondary to interleukin (IL)-1 and IL-2 release by HIV-infected macrophages [].\nOn the other | positive.\nThe histopathologic exam of perilesional tissue showed on a subepidermal blister with an inflammatory infiltrate in the upper dermis composed of lymphocytes and eosinophilic leucocytes (Fig ).\nThe overall features were suggestive of mucous membrane pemphigoid. In the absence of immunofluorescence studies, in this case, the diagnosis was firmly based on a classic clinical presentation of MMP: severe vesicles, erosions and crusts on mucous membranes, typically affecting the oral cavity and eyes []. A direct immunofluorescence test could not be done because the patient was a prisoner and the pathology laboratory of the prison camp does not have the necessary technology for immunofluorescence |
17,198 | 62,162 | was voluntary admitted for treatment at the Villa Garda Hospital Eating Disorder Unit, Italy, on 21 December 2015. The treatment based on an adapted inpatient version of CBT-E—an enhanced form of CBT designed to treat patients with eating disorder psychopathology—has a standard duration of 20 weeks, comprising 13 weeks of inpatient therapy followed by 7 weeks of day hospital [, ].\nThe patient reported no psychiatric disorders nor family history for eating disorders or any other significant psychiatric conditions. Her eating disorder had begun at the age of 30 years, when she had a body weight of 49 kg and a body mass index (BMI) of 19.6 kg/m2. | After the death of her mother, the patient adopted a strict diet and excessive exercising (i.e., walking for long distances for a duration of 4-5 hours a day), which determined a progressive weight loss of about 10 kg over a few months and the onset of secondary amenorrhoea. In the years that followed the patient maintained a body weight of around 39 kg through extreme and rigid dietary rules and excessive daily exercising. At the age of 48 years, | behaviours (i.e., self-induced vomiting and laxative or diuretic misuse) over the past three months. Her EDE global score was 1.83, which is slightly higher than 1 standard deviation (SD) above the community mean (i.e., above 1.74) [].\nLaboratory tests at admission, before refeeding commenced, showed marked reductions in natremia (123 mEq/L; normal range 136–144 mEq/L) and chloremia (89 mEq/L; normal range 101–111 mEq/L) and very high values of serum creatine kinase (3,238 IU/L; normal values: 38–234 IU/L). In association with the high serum creatine kinase levels, the patient also reported generalised skeletal pain, which |
6,552 | 149,360 | this sacrifice was to starve the tumor of its blood supply and minimize the degree of intraoperative bleeding. The endovascular sacrifice of the ICA was accomplished without incident. One-week later, the patient was taken to the operating room for resection.\nSurgical exposure of the carotid sheath revealed a large mass in the region of the carotid bifurcation. Exposure from the skull base to the omohyoid muscle allowed sequential separation of the jugular vein and the vagus, accessory, and hypoglossal nerves from the mass. The entire carotid bifurcation was dilated without separation of planes between the internal and external carotid arteries, | artery, we elected to endovascularly sacrifice the internal carotid artery (ICA) in preparation for surgical resection. The purpose of | through it. The lymph node showed distinctive features including follicles composed of concentric rings of mantle zone lymphocytes around germinal centers as well as prominent vascularity of the germinal centers, often showing a single penetrating arteriole [Figure and ]. Immunostaining patterns from the lymph |
29,795 | 78,466 | the ICU 48 hours later.\nAir embolism subsequent to an invasive procedure is a rare adverse event which can lead to serious long-term neurological deficits or cause fatal cardiopulmonary compromise [].\nThe symptoms of air embolism associated with ERCP occur or worsen when the patient is repositioned from prone to supine. The diagnosis is confirmed after visualizing air in the vena cava, portal vein, hepatic veins, right atrium, right ventricle, left atrium, left ventricle, or brain using different radiological aids such as transthoracic or transesophageal echocardiography or chest X-ray. However, the diagnosis of an air embolism can be complex, | murmurs, and paleness, requiring high concentrations of vasopressors. Symmetric expansion of chest under controlled assisted ventilation mode was indicated with the following parameters: respiratory frequency 18, 50% FiO2, PEEP 6, peak pressure 12 cm H2O, mean pressure 8.4, relationship inspiration: expiration 1 : 2.3, and tidal volume 352 mL. The patient continued receiving medical treatment and, after a favorable clinical outcome, she was discharged of | vomit and diarrhea. Her history included multiple episodes of biliary strictures managed with a self-expanding coated stent implant. At admission, her vital signs were stable, she had adequate oxygen saturation, and she had no fever. Lab reports evidenced elevated alkaline phosphatase and normal bilirubin levels.\nTo evaluate a probable biliary obstructive syndrome, an abdominal ultrasound and a magnetic resonance cholangiopancreatography were performed (), which |
38,385 | 99,863 | packed RBCs for medical optimization before his planned surgery.\nHe underwent an excision of the left zygomatic bone, left total parotidectomy with facial nerve sacrifice, and selective left neck dissection levels of I–IV []. The reconstruction of the left facial defect was performed with an anterolateral thigh free flap with microvascular anastomosis [Figure and ]. Pathology studies showed deeply invasive squamous cell carcinoma invading the parotid gland. All the margins and excised lymph nodes were negative for cancer.\nUpon his postoperative follow-up, he was, expectedly, noted to have iatrogenic Bell’s palsy. His ophthalmology examination | revealed no corneal epithelial defect and he was started on high-viscosity artificial tears. The radiation oncology team recommended adjuvant radiation therapy to the deeper structures of the | Pathology studies showed deeply invasive squamous cell carcinoma invading the parotid gland. All the margins and excised lymph nodes were negative for cancer.\nUpon his postoperative follow-up, he was, expectedly, noted to have iatrogenic Bell’s palsy. His ophthalmology examination revealed no corneal epithelial defect and he was started on high-viscosity artificial tears. The radiation oncology team recommended adjuvant radiation therapy to the deeper structures of |
16,000 | 166,567 | Professor Eckhard Mayer, Thoracic Surgery Department, Bad Nauheim, Germany). During discussion between the experts at both institutions, the question was raised as to whether a spontaneous dissection of the pulmonary arterial walls with secondary thrombus formation in the walls was possible, and a diagnosis of mediastinal fibrosis was accepted.\nFour months after her first admission, the patient was electively rehospitalized to initiate specific treatment in June 2013. In view of her coronary artery disease without evidence of ischemia, the decision was made to start treatment with bosentan instead of sildenafil. On this admission, | an echocardiogram showed no signs of pulmonary hypertension, and no enlargement of the right ventricle or paradoxical septal shift was detectable by an experienced examiner. The patient had not had any complaints for at least 2 months, and was started on bosentan without any problems.\nThe patient was evaluated 2 months later by Swan-Ganz catheterization of the right heart on full-dose bosentan 125 mg twice daily for 4 weeks. | pressure was 8 mmHg and borderline for right heart decompensation. The pulmonary arteries were shown to be dilated on angiography, but there was no indication of peripheral obstruction or chronic thromboembolic pulmonary hypertension. The left marginal artery and diagonal branch showed an angiographic stenosis of 70% ( and ), and left ventricular |
21,913 | 46,588 | urine and blood amino acids, the urine sulphite test, and the serum uric acid were all within normal ranges. Convulsions continued despite the normalization of the blood sugar level and the multiple antiepileptic drugs. Then, an important observation was made. It was observed that the patient was extremely alert to acoustic and tactile stimuli and that these stimuli triggered the convulsions. In the repeated | the urine sulphite test, and the serum uric acid were all within normal ranges. Convulsions continued despite the normalization of the blood sugar level and the | there was no electroencephalographic abnormality accompanying the seizures triggered by stimuli and no other findings except for movement artefacts. Upon observing that the nasal pillow mask triggered seizures, the diagnosis of hyperekplexia was considered and treatment with clonazepam was started. The midazolam, phenobarbital, and levetiracetam that he had been taking were gradually reduced in dose and stopped. Considering the effects that minimal stimuli had, CPAP was replaced by an oxygen hood for ventilation and stimulating interventions were minimalized. The patient then displayed a significant decrease in the intensity and number of |
11,805 | 94,994 | 50 to 60, he lost most of his teeth. At age 25, he was diagnosed with periodontitis. Nonetheless, he had not seen a dentist for this problem or performed any personal oral hygiene.\nOur patient complained of pain in the oral cavity especially on the tongue, buccal mucosa and had difficulty in chewing and swallowing solid food for six months.\nHis past medical history was significant for a tonsillectomy as a child. All the symptoms in his medical reviews were negative. Spirometric pulmonary tests were normal. High resolution computed tomography | early age. At age 24, he started to smoke since he thought smoking would help to stop bleeding. Currently, he smokes 1-1.5 packs a day. At age 30, he started to experience difficulty in eating and complained of tooth mobility and gum bleeding. He claimed that his teeth ached a lot and as a result the teeth were extracted by a non-dentist or himself. Consequently, at the age of | two painful, small flat-based ulcers with erythematous halos and a white ulcer bed were detected, localized on the right and left buccal mucosa.\nCultures from the plaques on the tongue and oral cavity were all negative for bacteria and fungi. The biopsies were obtained from the tongue, buccal mucosa and retromolar trigon. Secondary amyloidosis (AA type), was diagnosed by histological and immunohistochemical findings (Figure ).\nOur patient received comprehensive periodontal therapy, which |
39,089 | 45,412 | fluorescence in situ hybridization (FISH) as described previously\n[], utilizing a custom-designed break apart probe set on the original biopsy sample (Figure \n). The mononuclear nuclei exhibit one fused red/green signal corresponding to a normal 17p USP6 locus (black arrow) and a pair of split green and red signals (white arrows) indicating a rearrangement of the USP6 locus consistent with the diagnosis of aneurysmal bone cyst.\nFurther follow up was unremarkable for another 19 months until a control MRI in February 2013 revealed a small (< 1 cm) lesion in the area of the distal osteotomy and the | described previously\n[], utilizing a custom-designed break apart probe set on the original biopsy sample (Figure \n). The mononuclear nuclei exhibit one fused red/green signal corresponding to a normal 17p USP6 locus (black arrow) and a pair of split green and red signals (white | pathologic mitotic activity was noted. The osteoclastic giant cells were numerous and contained up to over 50 nuclei.\nSurgical therapy two months later consisted of a curettage through an antero-lateral and dorsal incision with dissection of the radial nerve branches to preserve maximal function. Histology of the recovered fragmented tumor revealed similar results to the biopsy (Figure \nB) rendering the diagnosis of an incompletely resected giant cell tumor of soft tissue. Residual tumor has been followed clinically and on imaging with a new local progression noticed at the end of 2010. MRI in February 2011 |
38,325 | 50,385 | were no signs of intraabdominal metastases. The postoperative recovery remained without complications. The premature eutrophic infant (1900 g, APGAR 7/8/9, pH 7.36) only had a short adaption disorder and CPAP (continuous positive airway pressure) therapy in the first minutes of life. There were no further major events in the treatment of the newborn.\nPathology confirmed a 12.5 cm × 11 cm × 10.5 cm measuring, mostly cystic, partly necrotic, knotty pre-bulged tumor, which was located on | resection was performed, while preserving a small gastric pouch and the post-pyloric duodenum. A distal pancreatectomy and, as the splenic vein seemed to be infiltrated as well, a splenectomy with resection of the splenic vessels followed. Finally, a reconstruction of the gastrointestinal tract analogical to commonly performed bariatric surgeries, speaking of a Roux-en-Y reconstruction with gastrojejunostomy, completed the surgery. Macroscopically, there | therapy in the first minutes of life. There were no further major events in the treatment of the newborn.\nPathology confirmed a 12.5 cm × 11 cm × 10.5 cm measuring, mostly cystic, partly necrotic, knotty pre-bulged tumor, which was located on the posterior gastric wall and |
6,165 | 203,795 | levothyroxine 175 mcg once daily were administered via a nasogastric tube. He instantly responded to the therapy with a favorable clinical improvement. His mental status started to improve several hours after treatment and at the third day of hospitalization he showed a GCS of 15/15; his body temperature increased from 34 °C to 36.5 °C approximately 10 | tube. He instantly responded to the therapy with a favorable clinical improvement. His mental status started to improve several hours after treatment and | department in our institution due to generalized weakness in April 2018. One month prior to admission, his family noted that he showed poor oral intake and consistently complained of epigastric discomfort. He was diagnosed as having impaired fasting glucose and hyperlipidemia at the age of 42 on routine medical checkup. Eight months ago, he underwent total thyroidectomy with both central and sentinel lymph node dissection due to papillary thyroid carcinoma and the pathologic stage was diagnosed as T3N1bM0 on the permanent pathologic report. After that, the first radioactive iodine (RAI) therapy was conducted and an iodine [–] whole body scan was planned to determine whether to perform the second |
26,480 | 12,929 | medicated with drugs (analgesic, omeprazole, paracetamol) for relief of symptoms until an MRI scan was obtained and a corrective surgery planned. Routine investigations were done. The patient’s complete blood count was within normal limits with a hemoglobin level of 11.1 g/dl and erythrocyte sedimentation rate of 62 mm/first hour. Her white blood cell | count was 12 × 109/L with a differential count of 62.5% neutrophils, 29% lymphocytes, and 6.8% monocytes. Her red blood cell (RBC) count was 3.97 × 1012/L. Her platelet count was 431 × 109/L. Routine urine and microscopic examinations showed no features of infection (quantity: sufficient, | (RBC) count was 3.97 × 1012/L. Her platelet count was 431 × 109/L. Routine urine and microscopic examinations showed no features of infection (quantity: sufficient, color: straw, albumin, sugar, and phosphate: nil, pus cells: 4–6/high-power field [HPF], epithelial cells: 3–4/HPF, RBCs: nil). Further evaluation with ultrasound showed distended endometrial cavity filled with complex fluid (Fig. ) with low-level internal echoes and nonvisualization of the right kidney. A provisional diagnosis of uterus didelphys, hematometra, hematocolpos, and agenesis of the right kidney was made. Pelvic MRI and intravenous urography (IVU) |
42,069 | 63,467 | distress from the neck pain. He had unremarkable vital signs with a BMI of 25. His physical examination was normal. X-rays of his chest and spine were normal. His blood work revealed anemia with hemoglobin of 11 g/dl, marked hypoalbuminemia of 1.7 g/dl and a total protein of 3.6 mg/dl. He had a blood urea nitrogen of 33 mg/dl and serum creatinine of 1.0 mg/dl. His triglycerides were elevated at 265 mg/dl, cholesterol of 209 mg/dl and a calculated LDL of | 132 mg/dl. His previous blood work done a few days ago at our rheumatology clinic showed an elevated erythrocyte sedimentation rate of 53 mm/h, TSH 10.6 and free T4 1.27 ng/ml. A urinalysis showed 1+ blood with 9 RBC, hyaline | episodes of neck pain with radiation down his spine and lower extremities for the past year. It was described as a sharp and sometimes cramping, 8–10/10 in intensity, intermittent and was triggered by activity like lifting heavy objects. Two weeks prior to admission he was evaluated at a local clinic for the same complaints, treated with ibuprofen and referred to our rheumatology clinic where a workup was in progress.\nHis pain became more intense prompting him to seek medical attention and was admitted to our hospital for evaluation. He noted that he had |
13,071 | 139,233 | associated neurological symptoms in the left upper limb, we performed an MRI of the cervical spine (Fig. ) to identify any underlying neurological pathology. This MRI revealed a multi-level cervical syringomyelia.\nOverall, our findings were suggestive of neuropathic arthropathy of the left shoulder and left CMC joint secondary to cervical syringomyelia.\nOwing to the non-dominant hand involvement, stage of disease and unequivocal results of surgery in the literature (see Discussion), we undertook non-operative management of the patient consisting of medications (anti-inflammatory, analgesia and antacid), orthoses (thumb spica splint application at night), patient education (avoidance of aggravating factors and repetitive stress) and physiotherapy (shoulder and thumb range of motion and gentle stretching | left shoulder and left CMC joint secondary to cervical syringomyelia.\nOwing to the non-dominant hand involvement, stage of disease and unequivocal results of surgery in the literature (see Discussion), we undertook non-operative management of the patient | (Fig. ) to identify any underlying neurological pathology. This MRI revealed a multi-level cervical syringomyelia.\nOverall, our findings were suggestive of neuropathic arthropathy of the left shoulder and left CMC joint secondary to cervical syringomyelia.\nOwing to the non-dominant hand involvement, stage of disease and unequivocal results of surgery in the literature (see Discussion), we undertook non-operative management of the patient consisting |
24,381 | 85,576 | imaging of the brain showed mild focal atrophy of parietal and occipital lobes. A detailed cognitive examination was completed using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) [] and Behavioral Assessment of Dysexecutive Syndrome [] and no deficits were found.\nWithin the third month of this episode, the patient was transferred to a specialist psychiatric rehabilitation | atrophy of parietal and occipital lobes. A detailed cognitive examination was completed using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) [] and Behavioral Assessment of Dysexecutive Syndrome [] and no deficits were found.\nWithin the third month of this episode, the patient | persecutory delusions believing that the police were having sex with her and that she was being recorded through cameras. She was not treated with psychotropic medications at the time. From the records, her symptoms appear to have remitted spontaneously and she was discharged. She was lost to follow-up thereafter.\nThe patient is from Zimbabwe and was granted asylum status approximately ten years previously after coming to the UK. She was employed with |
14,746 | 140,762 | diagnosis of fibrolamellar carcinoma can be difficult to establish by examining a needle-biopsy specimen and several passes or an open wedge biopsy may be necessary to obtain adequate tissue.\nFL-HCC generally has an indolent course, there may be a protracted prodromal period characterized by nonspecific symptoms, including | examining a needle-biopsy specimen and several passes or an open wedge biopsy may be necessary to obtain | constitute 20-50% of cases. Of these lesions, 60% are less than 5 cm in diameter, but the lesion may increase in size over time. They are usually asymptomatic. It is unclear if growth is affected by oral contraceptives, therefore contraceptives need not be discontinued. No malignant potential exists. FNH has a central scar which may be due to degenerative arteriovenous malformation. Occasionally, the presence of a large lesion causes abdominal discomfort and upon imaging may be mistaken for a malignant tumor, particularly the fibrolamellar variant of HCC.\nThe lesion may |
22,624 | 28,488 | of distal DVT, the diagnosis of recurrent DVT, differentiation of acute thrombosis from post-thrombotic syndrome, and interpretation of VTE biomarkers.\nDiagnostic evaluation should begin with consideration of the patient’s pretest probability for acute VTE. The risk of VTE in the general population is proportional to age with risk going from 1/10,000 in early adulthood to almost 1/100 in those over 80 []. This patient has multiple additional thrombotic risk factors (e.g., obesity and inflammatory bowel disease) that elevate his risk beyond an age adjusted baseline [,,].\nAs in patients with suspected first VTE, no single clinical feature is sufficient to rule in or out a diagnosis of recurrent DVT. Clinical prediction rules | it has gotten worse over the last 2 weeks. He rates the pain as being severe today. He denies any shortness of breath or chest pain. D-dimer is measured at 1500 ng/mL.\nThis patient case evokes many complex questions regarding VTE diagnosis, including the use of ultrasound for diagnosis | reserved for patients with increased pretest probability for acute DVT to avoid the possibility of false positive findings.\nBack to the case: A positive pretest probability adjusted D-dimer, multiple thrombotic risk factors and accelerated tempo of lower extremity symptoms, is concerning for acute VTE and necessitates an ultrasound of the affected leg. Proximal U/S of his left leg is negative with no visualized thrombus.\nThe negative proximal U/S rules out a clinically important proximal DVT but does not exclude an isolated distal DVT (IDDVT). IDDVTs are defined as thrombus |
43,245 | 62,140 | % hypertonic saline to reduce intracranial pressure. Her basal serum sodium levels were 140 mmol/l and she was commenced on a dose of 5 ml/kg 8 hourly, aiming to increase her sodium levels to 160 to 170 mmol/l. Her serum electrolytes were monitored 8 hourly. Her sodium levels rose to 163 mmol/l after the first 24 hours. It was decided to repeat another dose of 3 % hypertonic saline. However, during the latter part of the day she became polyuric and dehydrated. Her blood pressure | potassium, calcium, and magnesium were normal. She was empirically started on antibiotics administered intravenously for possible meningitis. Magnetic resonance imaging revealed gross hydrocephalus with suprasellar mass most likely due to craniopharyngioma (Figs. , , and ). A ventriculoperitoneal shunt was inserted and she was started on 3 | of >100 mmol/l can be seen in hypernatremia following ingestion of salt or infusion of 3 % hypertonic saline. Considering the clinical and biochemical factors, hypernatremia in our patient can be attributed to infusion of 3 % hypertonic saline in the background of cranial diabetes insipidus.\nAs we considered a sodium level of 226 mmol/l not compatible with life it was decided to correct her sodium levels rapidly. She was |
35,096 | 135,465 | of lower gastric corpus. It was classified as type IIb with dimensions of 2.0 × 1.0 cm. It had a nodular appearance and a faded mucosa (Fig. ). Over the next 7 years, she underwent endoscopy 4 times (August 2011, November 2012, March 2014, and July 2016). The 3 lesions did not show invasive features under white light endoscopy and the pathological diagnosis of endoscopic biopsies was LGD with moderate-to-severe atrophy and intestinal metaplasia (Figs. –).\nIn August 2017, at | did not show invasive features under white light endoscopy and the pathological diagnosis of endoscopic biopsies was LGD with moderate-to-severe atrophy and intestinal metaplasia | We describe a 62-year-old Chinese female who was diagnosed with multiple EGCs with successful eradication of Helicobacter pylori in December 2017. The first lesion located in the greater curvature of the antrum was detected at the patient's first endoscopy in July 2010. It was classified as type IIa + IIc with dimensions of 1.5 × 1.0 cm. It had a nodular surface with a central depression and redness (Fig. ). The patient was diagnosed with H pylori infection based on a |
18,201 | 91,902 | SAH was of aneurismal origin, due to the rupture of an anterior communicating artery (Acom) aneurysm () which was the actual reason for his accident. As the patient was neurologically intact and stable, an embolisation procedure for endovascular treatment of this aneurysm was decided for the following day (day 5 since the SAH event). Under general anesthesia, the right common femoral artery was punctured and a 6F appropriate vascular sheath was placed following our protocol for endovascular procedures. During the first attempt to catheterize the aortic arch for the standard pre-embolisation angiogram, an unusual dilatation of the thoracic descending aorta was noted, just distal | mobilized without any major complaint. On Monday however, brain CT interpretation by a more senior member of the medical staff suggested that this may not be a post-traumatic but rather an aneurismal subarachnoid hemorrhage (SAH). A CT angiogram confirmed that his | Caucasian, British-origin, male lorry driver was admitted to the hospital late on a Friday night after an unwitnessed single vehicle road accident. His lorry was by the side of the road and he was found unconscious in the vehicle and immediately transferred to the local District General Hospital. On admission, he had already fully recovered, being alert and orientated but he had no recollection of the accident. He was haemodynamically stable, with normal vital signs and no neurological deficit. He complained only at a moderate headache. Physical examination has revealed a bruise on the upper part of his left anterior chest |
11,759 | 70,192 | past medical history significant for bilateral fibrocystic breast disease resulting in bilateral subcutaneous mastectomy, followed by bilateral cosmetic breast reconstruction with textured silicone gel implants at age 30 (). Subsequently, she had multiple complications from the implants including capsule contractures, infections, chronic seroma, and ruptured breast implants, leading to capsulectomy and implant replacements 15 and 22 years post original implantation. During these periods, the patient was noted to have several areas of calcifications in both breasts (L > R) that had been monitored with | routine mammography. The patient noted that at 30 years post original implantation, her left breast became edematous; however, this self-resolved a few months later. Two years later, edema was noted again in the left breast and confirmed | Caucasian female had a past medical history significant for bilateral fibrocystic breast disease resulting in bilateral subcutaneous mastectomy, followed by bilateral cosmetic breast reconstruction with textured silicone gel implants at age 30 (). Subsequently, she had multiple complications from the implants including capsule contractures, infections, chronic seroma, and ruptured breast implants, leading to capsulectomy and implant replacements 15 and 22 years post original implantation. During these periods, the patient was noted to have several areas of calcifications in both breasts (L > R) that had been monitored with routine mammography. The patient noted that at 30 years post original implantation, her left breast became edematous; however, this self-resolved a few |
32,827 | 131,796 | gastric type and Peterson’s defect was not closed. The above described bowel trifurcation had sunken postero- inferior to the spleen and had herniated through a potential space underneath the spleen and torsed around the splenic vessels and hilum. This picture was consistent with perisplenic small bowel volvulus. As noted earlier there was a massively dilated proximal small bowel segment above the spleen, displacing it caudally. Careful adhesiolysis was performed inferior to the spleen to release the segment of the trifurcation. The bowel segments once reduced were assessed and appeared | The trifurcation of three bowel loops (Roux limb, biliopancreatic limb and common limb) were identified with identification of ligament of Treitz. The prior gastric bypass was of ante colic- ante | 42-year-old Hispanic female presented to the emergency room with a one-day history of epigastric abdominal pain, nausea and vomiting. The pain was mostly in left upper quadrant of abdomen, sharp, intermittent, without any alleviating or aggravating factors. It was associated with multiple episodes of nausea and bilious vomiting. Patient denied any fevers, chills, diarrhea, constipation and prior similar episodes. Her relevant past surgical history included Laparoscopic Roux-en-Y gastric bypass (LGBP) 13 years ago and recent robotic assisted Total abdominal hysterectomy with |
14,326 | 54,194 | this event was not reported that way in her medical record. Back home she presented with anxiety towards her son’s health. She was so preoccupied he could suffer from sudden infant death syndrome that she had to sleep with him. The couple started then to sleep apart and their sexuality went impaired. She describes a fusional relation with her son, she was indeed still sleeping with him until the event, even though he was 7 years old. After the child’s birth she | reported that way in her medical record. Back home she presented with anxiety towards her son’s health. She was so preoccupied he could suffer from sudden infant death syndrome that she had to sleep with him. The couple started then to sleep apart and their sexuality | and denigrating words towards her, a behaviour that her son tended to reproduce and against which she did not know how to react. She says that she was accepting it because family was the most important thing for her and must come before her own wellbeing. Since the beginning of 2019, the couple asked child protection services for help because their son presented with developmental issues and enuresis. At the same time her husband asked for divorce because he was seeing someone else for some months. The patient did not want this separation and hoped |
6,207 | 91,549 | Mitotic count was now up to five per ten high power fields and Ki-67 labeling index was up to 15% (Figure ). The tumor was focally positive for epithelial membrane antigen (EMA) and negative for CD31 and CD34. The lack of CD34 immunostaining excluded the possibility of hemangiopericytoma or solitary fibrous tumor of the meninges. Occasional cells were weakly positive for S-100 protein. In July 2007, follow-up MRI showed tumor progression | at the same CP angle site for which a redo SRS treatment was debated and finally delivered without significant acute toxicity. Of note, the question of chemotherapy was raised many times but the patient refused to receive any | small tumor recurrences in the parietal, occipital and cerebellar lobes for which he underwent stereotactic radiosurgery (SRS) with excellent results on tumor control. In September 2001, the patient developed additional recurrent lesions in multiple sites in the infratentorial, retroclival, left optic nerve sheet, and foramen magnum regions.\nHe was again treated by stereotactic radiosurgery with good tumor control defined as a complete disappearance or progressive decrease in lesion size. In June 2003, he received further SRS treatment to new cerebellar, premedullary and |
1,858 | 149,992 | A 65yrs old female came to our department with complaints of pain and swelling of the left hand along the thenar eminence and the proximal aspect of the thumb. She did not have history of any trauma prior to the development of swelling. The swelling was noticed two months ago and was progressive in nature and was painful on movements []. She simultaneously developed multiple swellings in the cervical region which most likely pointed towards cervical lympadenopathy []. She didn’t have any past history of tuberculosis or exposure to tuberculous contact. She did not have any associated | old female came to our department with complaints of pain and swelling of the left hand along the thenar eminence and the proximal aspect of the thumb. She did not have history of any trauma prior to the development of swelling. The swelling was | of 1st metacarpal along with lytic lesion at the base of the 1st metacarpal with haziness of the surrounding soft tissue []. On x-ray we came to a provisional differential diagnosis of pathological fracture secondary to a pyogenic infection, tuberculous osteomyelitis or soft tissue swelling, malignancy. An ultrasound revealed presence of an abscess. The USG was done to rule out any malignant involvement of the soft-tissue []. An MRI scan showed a large heterogeneous lesion at the 1st carpo-metacarpal joint space along with joint space widening []. The MRI scan suggested an abscess like picture most likely |
30,049 | 108,529 | for future exacerbations. During a follow-up appointment by phone a month later, the patient reported that his cluster episodes had continued to respond to oxygen and were now infrequent, occurring at most once a week. At follow-up 3 months later, he reported resolution of his cluster headaches.\nThe patient notably had no prior history of cluster headaches. Over the previous 2 years, he did have rare sporadic episodic throbbing headaches lasting 4–72 h and associated with vomiting, photophobia, and preceding visual disturbances consistent with migraines. | 5 min. He had one attack each day after this therapy began. The patient was discharged after 4 days with home oxygen as needed | between attacks. A head computed tomography (CT) showed no acute pathology. He was referred to Magnetic Resonance Imaging of the brain and cerebral and neck arteries. He was doing well without recurrence, so the family elected to defer this due to the isolation precautions associated with COVID-19. He did eventually get imaging done about a year later when he presented for different reasons. He had no acute or subacute structural abnormalities of concern within his brain, and his vessel imaging showed stable and known absence of flow-related enhancement within the right innominate, right common, internal, and external carotid arteries, and right vertebral artery.\nThe patient’s headaches were unresponsive to non-specific treatments |
2,115 | 91,637 | septation of the cyst, the surgical option to remove the cyst by the laparoscopic technique was discussed with the patient, which she agreed to.\nShe was admitted at 20 weeks' gestation. She was asymptomatic and the height of the fundus at 20 weeks corresponded to 26 weeks' gestation. After induction of general endotracheal anaesthesia, a nasogastric tube was passed to remove any gaseous distension of the stomach. The uterine fundus was palpated and a Verres needle was inserted through the Palmer's point. After insufflation with CO2 to a pressure of 20 mmHg, a | she agreed to.\nShe was admitted at 20 weeks' gestation. She was asymptomatic and the height of the fundus at 20 weeks corresponded to 26 weeks' gestation. After induction of general endotracheal anaesthesia, a nasogastric tube was passed to remove any gaseous distension of the stomach. The uterine fundus was palpated and a Verres needle was inserted through the Palmer's | ports, 5 mm each, were inserted under direct vision, the right and left lateral ports at the level of the umbilicus. Normally, right and left ports are inserted but it was impossible to reach the left side from the right port, therefore a further left port was inserted between the left lateral port and the Palmer's point port. The two left port placements facilitated exposure of the ovarian cyst, adhesiolysis of the bowel from the left adnexa, avoided potential injury to |
11,901 | 94,568 | evaluated provocative patellofemoral tracking during flexion and extension of the knee by pressing on the inferior lateral pole of his patella. The achieved patellar stability was not sufficient and his patella was still moving medially more than 50% of its width. We dissected a strip of his iliotibial band approximately 1 cm wide and 4 cm in length, thus leaving distal base of the strip attached to Gerdy's tubercle. Using this strip, we augmented the patellatibial ligament. As the medial subluxation of his patella was more prominent in extension, we tensioned the strip in extension.\nPost-operatively our patient's knee was immobilized using a brace for six weeks. He was allowed to walk | patella was still moving medially more than 50% of its width. We dissected a strip of his iliotibial band approximately 1 cm wide and 4 cm in length, thus leaving distal base of the strip attached to Gerdy's tubercle. Using this strip, we augmented the patellatibial ligament. As | patellofemoral tracking during flexion and extension of the knee by pressing on the inferior lateral pole of his patella. The achieved patellar stability was not sufficient and his patella was still moving medially more than 50% of its width. We dissected a strip of his iliotibial band approximately 1 cm wide and 4 cm in length, thus leaving distal base of the strip attached to Gerdy's tubercle. Using this strip, we augmented the patellatibial ligament. As the medial subluxation of his patella was more prominent in extension, we tensioned the strip in extension.\nPost-operatively our patient's knee was immobilized using a brace for six weeks. He was allowed to walk with partial weight bearing after the first post-operative |
24,571 | 80,405 | possible odors). Medical treatment consisting of topical and systemic steroids failed and an endonasal endoscopic polypectomy and revision ethmoidectomy were performed in May 2014. Simultaneously, the bony nasal vault was narrowed by forced digital compression without osteotomies (). The bone appeared to be thinned sufficiently to give in upon digital compression. Impression of the bony nasal sidewall resulted in a visible depression in the overlying skin which was corrected by a transcartilaginous decollement of the skin and subcutaneous tissues in a supraperiosteal plane. No nasal packing was inserted. A nasal cast was applied and left in | revision ethmoidectomy were performed in May 2014. Simultaneously, the bony nasal vault was narrowed by forced digital compression without osteotomies (). The bone appeared to be thinned sufficiently to give in upon digital compression. Impression of | During this further follow-up, the sense of smell was not documented.\nIn March 2014, the 38-year-old patient was again referred to the ENT Department of Cantonal Hospital in St. Gallen, Switzerland, because of complete bilateral nasal obstruction with polyps visible in both nares and a progressive widening of the bony and cartilaginous nose. The patient reported a recurrence of nasal obstruction and a loss of sense of smell over the last 2-3 years and an increasingly noticeable nasal deformity in the last 12 months. Also pressure was felt over the maxillary but not frontal sinuses frequently. Postnasal drip symptoms were present in most days. Nasal treatment consisted of sporadic application of topical mometasone spray. Bronchial asthma |
17,774 | 37,923 | the importance of continued work and development in this field.\nAs part of our effort to further this work, we are currently enrolling patients into an ongoing United States based Institutional Review Board (IRB) approved prospective clinical trial []. Patients selected for this approach include those with biopsy proven resectable adenocarcinoma of rectum located 4–12 cm from anal verge who are otherwise eligible to undergo | standard open or laparoscopic low anterior resection with temporary diverting stoma. Tumors must be preoperatively staged as node negative, T1 (high risk features), T2 or T3 based on pelvic MRI with no evidence of metastasis on staging CT scans. For preoperatively staged T3N0 tumors, patients must have completed full-course neoadjuvant treatment. Procedures are performed following the same steps as described in cadavers, using an abdominal and perineal team working | with 40 mm outer diameter, three 5 mm, and one 10 mm access channel and an air inlet tube through which CO2 can be inflated. The extraperitoneal rectum was completely mobilized using this device. Once the lateral rectal attachments were divided, the rectovaginal peritoneal reflection was identified and perforated to gain access to the abdominal cavity. A |
315 | 101,296 | terrified him for which he desperately wanted to visit the hospital. However considering his mother at high risk of complications from the COVID-19 infections, he was too perplexed to decide what to do. Another thought of his children being at risk of the infection if he visited a hospital heightened his anxiety. He recalls himself having sleepless nights wondering what is better in the current scenario for the safety of his whole family without adversely affecting his mother's health. He remembered having episodes of anger, frustration | on his kids and wife over small immaterial things. However, when the situation continued and had almost felt devastated for >2 months he finally thought to visit the hospital once.\nWhen he presented to the outpatient department to show his mother, it seemed evident that he was in great psychological distress. The mother was evaluated and suspected of an infection for which treatment was prescribed. However, we thought of communicating with him regarding his fears, distress, and anxiety. Once he was comfortable, he expressed | up for treatments in the hospital, caring for her at home after surgery and supporting her emotionally as well. As his father was not educated and sister too young to understand, he did not share much of his loneliness and distress with anyone. After the surgery slowly over a period of a year, his mother's health improved, which relieved his distress.\nThe second complex caregiving episode was when his father died due |
35,163 | 69,431 | prior to his hospitalization, with hemoglobin of 7.9 g/dL and was started on oral iron by his primary care pediatrician. At his outpatient follow-up visit, because of persistence of his symptoms, repeat laboratory testing was performed and showed his hemoglobin had decreased to 7.3 g/dL. His serum potassium was 7 mEq/L, serum bicarbonate was low at 15 mEq/L, and serum creatinine was elevated at 8.7 mg/dL (estimated glomerular filtration rate [eGFR] 11 mL/min/1.73 m2). He was admitted to the pediatric intensive care unit via the emergency room where he received furosemide and sodium polystyrene. Studies | to evaluate his renal disease included a renal ultrasound which revealed normal sized kidneys with bilateral grade 2 hydronephrosis without dilated ureters and with a distended, but thin-walled bladder; a voiding cystourethrogram showed no | at discharge from the hospital, he had a serum creatinine of 1.7 mg/dl (eGFR 58 mL/min/1.73 m2). His subsequent clinical course was complicated by episodes of fever and neutropenia, typhlitis, and neurotoxicity from etoposide and vincristine needing extensive rehabilitation. At his last clinic visit, 5.5 years after diagnosis and 4 years after completing chemotherapy, his PET scan showed no hypermetabolic lesions to suggest active disease, his blood pressure was normal, and his serum creatinine was stable at 1.2 mg/dL (eGFR 94 mL/min/1.73 m2). On his most recent ultrasound, he had |
30,717 | 26,258 | of partial nephrectomy and no contrast was going down the ureter. So, the drain was pulled out 2 cm under CT guidance. CT scan then showed free drainage of urine along the ureter. The drain was left in place for two days during which it did not drain any urine. The patient felt well with no fever, so the drain was removed three days later. During all this time, the kidney did not show any significant dilation on either ultrasound or CT scan.\nPostdischarge, | he did well initially, but in few days, he started to develop urinary tract infections that were occasionally associated with low-grade fever but no abdominal pain. Ultrasound again did not show any abnormality. One month later, he was readmitted with high-grade fever. CT scan showed an ongoing leak which was, this time, more medial with minimal dilation of the collecting system. A trial | not show any abnormality. One month later, he was readmitted with high-grade fever. CT scan showed an ongoing leak which was, this time, more medial with minimal dilation of the collecting system. A trial to insert a JJ stent failed and retrograde pyelography showed normal ureter up to approximately 3 cm below the ureteropelvic junction which had a blind end and there was a fistula between the upper ureter and lower calyceal system (ureterocalyceal fistula) (Figures and ). Using an ureteroscope, a trial to negotiate the way to the UPJ was not successful. |
26,376 | 118,716 | a re-rupture of the spleen and the patients desire to have his spleen removed, it was decided to perform a splenectomy and patient was prepared with vaccinations for pneumococcal, meningococcal and Haemophilus infections.\nIn January an uncomplicated laparoscopic splenectomy was performed. Intraoperatively, the enlarged spleen | perform a splenectomy and patient was prepared with vaccinations for pneumococcal, meningococcal and Haemophilus infections.\nIn January an uncomplicated laparoscopic splenectomy was performed. | with since 1 day acute abdominal pain in the left hemi-abdomen. He was nauseous and had vomited. The abdominal pain appeared in attacks and patient was sweaty. His defecation pattern was unchanged and there were no urogenital complaints. There was no history of trauma. Patient did not use any medicine and thus also no anti-coagulants. Patient had an uneventful medical history except for analysis of nonspecific chest pain by the cardiologist in 2005 where no cardiac pathology was found.\nPhysical examination showed a a pulse of 108 beats per minute, blood pressure 133/78 mmHg, 92% saturation with 2 L oxygen and temperature of 38.6°C. There was tenderness in the left |
14,264 | 58,798 | severe lower abdominal pain. The patient had a history of cyclical abdominal pain and primary amenorrhea. Her height was 145 cm, weight 41 kg and she had normal secondary sexual characters. Examination under local anesthesia revealed a blind-ending vagina of about 5-6 cm in length and the cervix was not visible through the vagina. Investigations revealed normal routine blood tests, hormonal profiles, and karyotype 46XX. Ultrasonography demonstrated a retroverted uterus with hematometra extending up to the upper part of the cervix; non-canalized lower part of the cervix, absence of proximal part of the vagina, and normal adnexa. These findings were corroborated by magnetic | resonance imaging (MRI) of the pelvis which demonstrated a normal endometrial cavity with hematometra extending into the upper part of the cervix (Figure ). The lower part | under local anesthesia revealed a blind-ending vagina of about 5-6 cm in length and the cervix was not visible through the vagina. Investigations revealed normal routine blood tests, hormonal profiles, and karyotype 46XX. Ultrasonography demonstrated a retroverted uterus with hematometra extending up to the upper part of the cervix; non-canalized lower part of the cervix, absence of proximal part of the vagina, and normal adnexa. These findings were |
25,671 | 141,021 | crease in the lower lip and high arched palate []. He also had club feet, and long tapering fingers, with middle finger being overlapped by other fingers. The neurological and systemic examination was normal.\nInvestigations revealed a normal hemogram, liver, and kidney function tests. Ultrasonographical evaluation of the abdomen revealed no abnormality. Magnetic resonance imaging of the brain revealed mild thinning of the corpus callosum without any other abnormalities. Echocardiography was | in the lower lip and high arched palate []. He also had club feet, and long tapering fingers, | chromosomal anomaly and amniocentesis was done for fluorescent in-situ hybridization for chromosome 21 and karyotype analysis. The fluorescent in-situ hybridization for chromosome 21 showed two signals in each cell. Karyotype showed an “extra genetic material” on a long arm of chromosome 6 []. The parents were counseled about the risk of mental retardation in the baby and were advised to undergo chromosomal analysis. They, however, decided to continue the |
14,415 | 134,025 | available. The patient was staged with a localized destructive lesion with no metastasis associated with a high LDH.\nChemotherapy was started using an adriamycin and L-asparginase containing regimen (UKALL 2003 protocol) because this type of non-Hodgkin lymphoma (NHL) usually responds well to such chemotherapy with cranial prophylaxis. At the end of the induction phase of treatment, he entered a very good partial remission ().\nDuring | the consolidation phase, he developed sagittal vein thrombosis and febrile neutropenia as a complication of chemotherapy. Chemotherapy was stopped for a short period and supportive treatment started with a very good response. However, after a week he developed a progressive lesion. Chemotherapy was restarted with concomitant radiotherapy, again with a partial response (). The patient began | lymph nodes were not enlarged. The chest was also normal clinically and radiologically. A computed tomography (CT) scan of the face and paranasal sinuses revealed an irregular enhancing lesion in the affected region of the nose extending both nasal cavities and the ethmoid sinus with erosion and perforation of the nasal septum. The |
26,463 | 11,629 | existing metal-ceramic restorations were removed (Fig. A) and double probing was performed to measure the depth of the gingival sulcus and the location of the bone, so as to determine the limit of tooth preparation. All teeth were prepared with vertical preparation technique to eliminate the existing finish line, as described Agustín-Panadero et al. () (Fig. B). The splinted PMMA-based provisional prosthesis was cemented (Temp Bond Clear, Kerr) on the prepared teeth and the intrasulcular zone of the restoration | measure the depth of the gingival sulcus and the location of the bone, so as to determine the limit of tooth preparation. All teeth were prepared with vertical preparation technique to eliminate the existing finish line, as described Agustín-Panadero et al. () (Fig. B). The splinted PMMA-based provisional prosthesis was cemented (Temp Bond Clear, Kerr) | Inc) (Fig. B).\nThe definitive fixed dental prosthesis was made based on the biologic and functional parameters of the provisional restorations. A prosthesis made from PMMA resin reinforced with graphene oxide was designed (Exocad software, exocad GmbH) and milled (Fig. C). Passive fit, interproximal contacts and occlusion were checked in the patient´s mouth.\nAfter all the parameters were confirmed, the prosthesis was cemented with a dualpolymerizing resin cement (Variolink Esthetic DC, Ivoclar Vivadent) that was then light-polymerized (Fig. D,E). The patient was given oral hygiene instructions and information on how to take care of the new prosthesis.\nFollow-up evaluations were made 1 week and 1, 3 |
34,246 | 115,936 | at 1 min and 8 at 5 min. Cord blood gas studies showed a pH of 7.30 and base deficit of -2.2.\nPhysical examination revealed a weight of 2675 g (25th centile), length 47 cm (30th centile), head circumference 33 cm (40th centile). No visible anomalies were noted at birth. The pertinent physical findings were cranial bruit and a grade 2/6 soft systolic heart murmur at the left sternal border.\nChest radiography immediately after birth showed cardiomegaly. An echocardiogram performed at 1 h of life showed pulmonary hypertension, patent foramen ovale, dilated superior vena cava and | because of the massive VOGM causing a steal phenomenon, evidence of heart failure, worsening doppler studies, and fetal monitoring showing fetal compromise, the decision was made to proceed with delivery and to achieve optimization of management in the neonate. An elective uncomplicated primary cesarean section was performed because of fetal cardiac failure and breech presentation. The neonate had Apgar scores of 4 | arteries are from bilateral middle cerebral arteries, bilateral anterior cerebral arteries and posterior cerebral arteries.\nOver the first few days, the infant gradually became tachypneic and had a hyperdynamic precordium. Medical treatment of cardiac failure (furosemide, digoxin, and milrinone) was begun on the second day of life. Since the patient showed signs of cardiac decompensation despite the cardiac failure therapy, embolization with N-butyl cyanoacrylate (NBCA) was performed via the umbilical artery catheter at 7 d of age. The patient was intubated and placed on a conventional ventilator at 10 d of age. Trans-femoral embolizations were performed on the 10th, |
41,179 | 16,197 | paralysis of the right CNs IX to XII. Contrast-enhanced computed tomography (CT) of the head and neck revealed an interruption of flow in the right sigmoid and transverse sinuses, with no apparent tumor on contrast-enhanced CT scan. Coagulation profile including the prothrombin time, activated partial thromboplastin time was normal. She was diagnosed with Collet-Sicard syndrome caused by thrombosis of the sigmoid and transverse sinuses. She was treated with anticoagulant therapy, and the hoarseness and paralysis of the accessory nerve improved, but recanalization of the sigmoid sinus and transverse sinus was not identified. The hoarseness | later worsened again, when she was 31 years old. In another hospital, contrast-enhanced CT scan revealed a tumor in the jugular foramen extending into the deep | woman without the history of oral contraceptives use presented with hoarseness, dysphagia, vomiting, and headache. Later physical examination in our neurology department also revealed paralysis of the right CNs IX to XII. Contrast-enhanced computed tomography (CT) of the head and neck revealed an interruption of flow in the right sigmoid and transverse sinuses, with no apparent tumor on contrast-enhanced CT scan. Coagulation profile including the prothrombin time, activated partial thromboplastin time was normal. She was diagnosed with Collet-Sicard syndrome caused by thrombosis of the sigmoid and transverse sinuses. She was treated with anticoagulant therapy, and the hoarseness and paralysis of the accessory nerve improved, but recanalization of the sigmoid sinus and transverse sinus was not identified. |
41,700 | 159,865 | (Z-med, NuMED Inc., Hopkinton, NY, USA) under rapid pacing using a temporary pacemaker. Under angiographic guidance, a 29 mm CoreValve was slowly deployed at the aortic annulus. An immediate post-procedural aortogram showed good position of the CoreValve with mild AR (). The vascular access site at the left subclavian artery was closed surgically without any complications. The post-procedural echocardiography demonstrated well functioning bioprosthetic aortic valve with mild paravalvular AR. The peak and mean pressure gradients across the aortic valve decreased from 97 and 59 mm Hg to 42 and 23 mm Hg, respectively. The aortic valve area increased from | under rapid pacing using a temporary pacemaker. Under angiographic guidance, a 29 mm CoreValve was slowly deployed at the aortic annulus. An immediate post-procedural aortogram showed good position of the CoreValve with mild AR (). The vascular access site at the left subclavian artery | the diameter of the aortic annulus by echocardiography was 25 mm. The left ventricle (LV) showed a dilated enddiastolic dimension (64 mm) with LV hypertrophy. The LV systolic function was globally reduced with an LV ejection fraction (EF) of 39%. Based on the coronary angiography, the stent at the left main artery was patent. However, the stent implanted at the distal left circumflex artery showed in-stent restenosis, which was subsequently treated with a 3×30 mm paclitaxel-eluting balloon (SeQuent® Please, B. Braun Melsungen AG, Berlin, Germany). The previously inserted stents at the right and left iliac arteries were patent, however computed tomography (CT) angiography revealed that the minimal lumen diameter of the stented |
11,088 | 23,359 | mass with calcifications and suprasellar extension. A CT scan of the abdomen showed cholelithiasis and was negative for any acute pathology.\nThe patient was admitted for further evaluation of syncope. Sepsis was considered given his leukocytosis and hypotension. A CT scan of the head showing a questionable embolus was followed by a neurological evaluation to test for a possible stroke. The patient was admitted to a telemetry unit to rule | rate of 85 beats/minute. The patient was afebrile. The patient's initial laboratory workup results are presented in Table . His electrocardiogram showed normal sinus rhythm. His chest X-ray findings were unremarkable. A CT scan of the patient's head showed an apparent hyperdensity in the left intracranial internal carotid artery just proximal to the bifurcation, representing an artifact or the presence of an embolus. It also showed an apparent sellar | these episodes. He described a room-spinning sensation when he awoke associated with ringing in the ear. He regained consciousness within one to two minutes. While attempting to stand, he again lost consciousness. In the ED, the patient denied any symptoms.\nIn the ED, his physical examination was significant for symptomatic orthostatic hypotension. Vitals included blood pressure of 88/54 mmHg and a heart |
29 | 119,317 | were reported. However, in the months following birth, the parents observed progressive enlargement of her right cheek and a differing eyelid width. According to the patient, the facial asymmetry had become more marked over the following years but had not increased in the past few | years. No other family members were affected. Patient's mother reported a normal pregnancy. The enlargement extended from the midline to the preauricular region and inferiorly to the lower border of mandible []. The skin of the involved right side of the face was normal in appearance with no alteration in thickness. The extraoral examination revealed that the right side of the mandible was larger than the left side. The outer contour of the right ear was slightly | early contact in both central occlusion and right lateral movement. A discrepancy in range of mandibular motion was observed. The patient was referred for radiography. The radiographs confirmed the clinical findings. The panoramic radiograph [] showed that the right condyle, ramus, condylar neck, and the body of the mandible were enlarged. There was significant deposition of bone growth on the right mandible, and the bony trabeculation alteration was observed. The size of the right inferior dental canal was normal compared to the left mandibular canal and was displaced. Crowns and roots of the right mandibular molars were larger |
1,995 | 70,207 | were also visible on the navigation monitor, and therefore, we could treat them with care. The navigation pointer was inserted into the wound and moved along the SP until it reached the intended resection spot (Fig. ). After the resection spot was confirmed, the SP was pinched off using bone-holding forceps while the thicker portion was cut down by piezoelectric surgery (Fig. ). The resected SP was then taken out (Fig. | the tip of the SP to enable easy access with minimal injury. An oral lingual incision (20 mm) was made in the mucosa posterolateral to the pharyngopalatine arch and superior to the tonsillar bed, without tonsillectomy. The blood vessels surrounding the SP | available to the surgeon in real time. This was possible because of the maximum mandibular opening position during CT and MRI and in the operating room following the use of the interocclusal splint. In this case, as the splint was not in direct contact with the surgical site, it was not sterilized but was chemically disinfected with benzalkonium chloride.\nUsing the navigation pointer, the tip of the elongated SP was detected based on the |
20,352 | 138,235 | aneurysm as necessary and ligated the popliteal artery on the distal side of the proximal anastomosis. We also secured the wound to prevent contamination. We dissected the skin directly above the aneurysm (). Pus had been noticed to have accumulated under the fascia. In addition, the tissue surrounding the aneurysm was full of pus. We then cultured samples of pus collected from each site. The aneurysm had a thin, fragile, edematous wall and was adjudged a true aneurysm. We were unable to clearly identify the adventitia of the aneurysm because of the infection. Blood flow was controlled using a tourniquet wrapped around the thigh. After peeling off the proximal and | distal side of the popliteal artery, the aneurysm was excluded with ligation of the popliteal artery. The aneurysm was opened and decompressed. Organized thrombus formation was detected, and evidence of purulence was noted; multiple samples, including tissues from the aneurysm sac, were extracted for culturing. The thrombus closer to the aneurysm wall had small holes consistent with the gas image on CT. No | purulence was noted; multiple samples, including tissues from the aneurysm sac, were extracted for culturing. The thrombus closer to the aneurysm wall had small holes consistent with the gas image on CT. No such structures were noted on the thrombus inside the aneurysm, and it had a uniform surface (). Subsequently, the proximal part of the popliteal artery was closed, and the distal part of the popliteal artery was ligated. Finally, we attached the vacuum-assisted closure (VAC) system to |
14,943 | 26,496 | and total immunoglobulin E was 107 kU/L.\nAn abdomen-pelvis CT demonstrated subcapsular hematoma in the right hepatic lobe (Fig. ). Hemoperitoneum probably caused by multifocal hepatic capsular arterial bleeding was also detected. There was no evidence of bowel perforation. In a previous CT scan taken 1 year before, there had been no evidence of any aneurysm changes in the hepatic vessels. A celiac angiogram demonstrated multiple, various sized hepatic aneurysms in both lobes (Fig. ). The small aneurysms resembled the appearance of a string of beads, characteristically observed in polyarteritis nodosa | in the right hepatic lobe (Fig. ). Hemoperitoneum probably caused by multifocal hepatic capsular arterial bleeding was also detected. There was no evidence of bowel perforation. In a previous CT scan taken 1 year | The pain was not accompanied by vomiting or fever. The patient had previously been treated at the Department of Medicine in Samsung Medical Center with a diagnosis of EGPA. After successful suppression of blood hypereosinophilia with combination of prednisolone and azathioprine in recent months, she had been in the process of tapering prednisolone down to 15 mg per day. However, after dose reduction, her eosinophil counts slowly increased to 1989 cells/µL and levels of aspartate aminotransferase and alanine aminotransferase were elevated from normal to more than 300 U/L with mild abdominal pain. Consequently, her |
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