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duplication of the alimentary tract is an important surgical condition , which includes a wide variety of mass lesions . we encountered a patient who presented with perforation of the duplication , which was associated with malrotation with midgut volvulus . being an extremely uncommon surgical emergency , it is being presented with a brief review of the relevant literature . a 4-year - old male child was referred to us for complaint of pain in abdomen . however , there was occasional history of abdominal pain , which was relieved by medication . on examination , his abdomen was distended , but it was non - tender . a computerized tomography ( ct ) scan of abdomen was advised for confirmation of the diagnosis . on next day , just after ct abdomen , the patient suddenly developed severe abdominal pain . after initial stabilization , the patient was explored under general anesthesia . on exploration , we noticed malrotation of the gut , which was associated with two turns of midgut volvulus . ladd 's bands were also present . the peritoneal cavity was grossly contaminated with fecal fluid . the perforation was at the mesenteric side , and it was associated with a soft mesenteric mass communicating with the normal bowel . the perforation was just at the junction of the mesenteric mass and the normal bowel [ figure 1 ] . the other thumb forceps is in the perforated duplication after performing the ladd 's procedure , attention was placed towards the perforation . on attempting to resect the mesenteric mass , we noticed two lumens in the bowel distal to the perforation site and single lumen proximal to that [ figures 2 and 3 ] . when an attempt to ascertain the length of the duplication was made by inserting two ryle 's tube through the lumens , it was reaching up to ileocecal region . as the general condition of the patient was poor , complete resection of the bowel was not done , and a double barrel ( triple barrel , to be more precise ) was fashioned . ( a ) duplication cyst , ( b ) junction of duplication and normal bowel , and it was the site of perforation , ( c ) normal ileum , ( d ) duplicated ileum reaching up to cecum , and ( e ) cecum and probable site of duplication termination in the postoperative period , there was wound infection with superficial wound dehiscence . the patient was discharged after 3 weeks with proper follow - up advise . during the follow - up these abnormalities include developmental obstructive defects of the small intestine , anomalies of rotation and fixation , intestinal duplications , etc . duplications of the alimentary tract are rare congenital malformations and may occur anywhere in the intestinal tract . the initial suspicion , on the basis of usg , was of some cystic mass lesion compressing the upper small bowel . the ct plates , reviewed later on , also showed twisting of mesenteric vessels suggestive of malrotation . probably the perforation of the duplication was not spontaneous ; it may be because of the volvulus and resultant ischemia of the wall . as malrotation with midgut volvulus is always a surgical emergency , and perforated duplication is also a surgical emergency , a combination of the two entities is definitely a surgical emergency , which needs immediate intervention . the ideal treatment would have been a ladd 's procedure , along with resection of the complete duplication . this was , however , not possible due to the poor general condition of the patient and large length of the duplication , which may had led to extensive resection of the bowel . the association of duplication of small bowel and malrotation , though described in the literature , is a rare one . . to conclude , this being one of a very rare combination of two pediatric surgical emergencies ; needs proper surgical and postoperative management . the exact preoperative diagnosis may be difficult , but a high degree of suspicion is warranted .

duplication of the alimentary tract is an important surgical condition . it may occur anywhere in the gastrointestinal tract . an important complication of this entity is perforation of the normal or abnormal gut . malrotation with midgut volvulus can be a surgical emergency . we present a patient , who presented as malrotation with midgut volvulus associated with perforated ileal duplication . the patient was successfully managed .

there have been few reports in the literature regarding trans - orbital penetrating injuries from a non - missile , low - velocity object ; these incidents are usually caused by violence , accidents or suicide attempts . a penetrating object of > 5 cm in length could reach the cranial cavity through the orbital roof or the superior orbital fissure . self - inflicted penetrating brain injuries from a ballpoint pen have only been discussed in a few case reports . in this report , the author reviews a case of a self - inflicted , trans - optic canal , intracranial penetrating injury that was inflicted with a ballpoint pen in a medical setting . a 60-year - old man was admitted to our medical ward due to aspiration pneumonia . he had a medical history of diabetes mellitus , end - stage renal disease ; a tuberculosis bacilli - related thoracic spine infection with paraplegia , and a previous coronary artery bypass graft . during his third day at the hospital , he obtained a ballpoint pen and inserted it into his left eye . on physical examination the ballpoint pen protruded from his left upper eyelid ; it was firmly lodged in his left medial orbit between the globe and nose , causing left eye proptosis ( fig . 1 ) . brain ct scanning revealed a tubular foreign body that was located in the anteroposterior plane extending from the orbital apex and directly into the parasellar region ( fig . 2 ) . the metallic portion of the foreign body was entrapped in left optic canal ( fig . there was no evidence of intracranial hemorrhaging or a rupture in the globe ( fig . 4 ) . the plastic ballpoint pen and metallic tip was withdrawn from the orbit smoothly at bedside , and no craniotomy was required . the ballpoint pen had been inserted to an estimated depth of 7 cm through the eyelid and into the orbit . we initiated intravenous broad - spectrum antimicrobials and vancomycin therapy and continued these medications for three weeks . the follow - up ct scan showed no retained foreign bodies or intracranial hemorrhaging ( fig . 2 months after the injury , the patient presented with complete left ophthalmoplegia and blepharoptosis but intact visual function . figure 1:the ballpoint pen was firmly lodged in his left medial orbit between the globe and nose . figure 3:the ballpoint pen tip reaches into the parasellar region via the optic canal . figure 5:the follow - up ct scan shows residual hematoma in the orbital cavity ; no retained foreign bodies or intracranial hemorrhaging . the ballpoint pen was firmly lodged in his left medial orbit between the globe and nose . the follow - up ct scan shows residual hematoma in the orbital cavity ; no retained foreign bodies or intracranial hemorrhaging . medically - ill patients are more likely to attempt suicide by jumping or by hanging or cutting . numerous psychodynamic and biochemical theories exist to explain self - inflicted eye injuries , which can range from autoenucleation to severe trans - orbital , intracranial penetrating injuries . if not treated promptly , these injuries can result in serious neurologic damage or even death . brain and face ct scans are the primary modalities used in the neuroimaging examinations of patients with intracranial penetrating injuries . mri is generally not recommended for use in the acute management of penetrating brain injuries , because it can be potentially dangerous in cases of retained ferromagnetic objects due to possible object movement in response to magnetic torque . however , mris can be useful if a wooden object caused the penetrating brain injury . cerebral angiography , ct angiography or mr angiography can be used when there is evidence of possible vascular or cavernous sinus injury . embolization and proximal and distal control of the carotid artery prior to the removal of the foreign body allow for rapid control of any hemorrhage . reports about intracranial penetration via the orbit with various types of foreign bodies have been published . occasionally , the eye is spared remarkable injury due to the tough scleral coat and the motility of the globe . an intact globe or the absence of focal neurologic deficits dose not excludes the presence of a lethal intracranial trauma . the surgical indications following penetrating orbital injuries are retained foreign bodies , cerebrospinal fluid leakage immediately after a trauma , displaced bone fractures , intracranial hematomas and evidence of direct vascular injury . in the majority of cases , foreign body removal and neurovascular decompression can be accomplished by a craniotomy around the wound . however , non - operative management has been successful in several case reports , depending on the nature of wounding instrument . patients that sustain intracranial penetrating injuries and nondisplaced orbital fractures without bone fragments and that have no evidence of any brain parenchymal injury may undergo a removal of an externally accessible foreign body without a craniotomy . however , this process should not be taken as the standard treatment recommendation for similar situations . the removal of a penetrating foreign body outside the operating room may lead to life - threatening hemorrhage in rare cases . abscesses typically develop within 35 weeks after injury , with staphylococcus aureus being the most common organism . it has been recommended that broad - spectrum antimicrobials should be prescribed in all penetrating brain injury cases for at least 714 days . in our patient , the injury had resulted in a complete left ophthalmoplegia and blepharoptosis at the 2-month follow - up . however , in a reported series of 33 patients with traumatic superior orbital fissure syndrome , majority of patients had regained moderate extraocular muscle function in all three cranial nerves at the 6-month follow - up visit . inpatient suicide among medically - ill patients is a relatively rare event that is often difficult to predict and prevent . traditional risk factors such as a history of psychiatric illness , substance abuse or suicidal tendencies may not be typically present in medical / surgical patients at risk for suicide - attempts . constant surveillance of agitated patients at risk for suicide - attempts and planned interventions to calm them , along with securing their surroundings may be beneficial prediction and prevention approaches .

trans - orbital penetrating injuries are not common . if not promptly treated , these injuries can lead to serious disabilities and even death . a 60-year - old man , who had multiple underlying diseases , was admitted to our medical ward for the treatment of aspiration pneumonia ; he attempted suicide by inserting a ballpoint pen into his left eye . ct of the brain showed a foreign body penetrating through the left optic canal into the intracranial parasellar region without obvious intracranial haemorrhage . the foreign body was withdrawn smoothly at bedside without a craniotomy . the patient was then transferred to the icu for neuro - observation . the patient recovered with complete left ophthalmoplegia but intact visual function . acute management of a trans - orbital penetrating injury involves prompt neuroimaging examinations and knowledge of common recurring patterns of injury . all clinicians should be aware of the psychological condition of each patient , and suicide precautions should be considered during clinical practice .

who defines neurofibroma as a benign tumor of peripheral nerve sheath phenotype with mixed cellular components , including schwann cells , perineurial hybrid cells and intraneural fibroblasts . neurofibroma is an unencapsulated neoplasm containing small nerve fascicles in an unstructured collagenous matrix and arises from schwann cells . neurofibroma is caused due to inactivation / mutation of nf-1 gene , which is located on the long arm of chromosome 17 . this gene encodes for a protein known as neurofibromin , which plays a role in cell signaling . since then only a few ( < 50 ) cases have been documented in the literature . ellis et al . have published an excellent study covering a total 35 intraosseous benign nerve sheath tumors occurring in jaws , 23 of these cases were neurofibroma and 12 neurilemmomas . in only 3 of the cases of neurofibroma was von recklinghausen 's disease diagnosed and only 1 of these cases had multiple tumors affecting both maxilla as well as mandible . friedrich et al . , compared 22 patients with disseminated neurofibroma and 26 patients with plexiform neurofibroma affecting oral and maxillofacial region in nf-1 patients . , found that among 303 cases of benign nerve sheath tumors , about 45% involved the head and neck region , and approximately 9% occurred in the oral cavity . their analysis of 66 cases of neurofibroma revealed the following distribution concerning the site of occurrence of neurofibroma in the head and neck area : tongue , 12 ; palate , 12 ; mandibular ridge / vestibule , 15 ; maxillary ridge / vestibule , 9 ; buccal mucosa , 10 ; lip , 4 ; mandibular intrabony , 2 ; gingiva , 1 ; and floor of the mouth , 1 . moreover , in the past literature , they found only 29 cases of solitary neurofibroma of the mandible . when solitary neurofibroma occurred in mandible there was definite female predilection ( 2:1 ) and was most frequently localized in the posterior section of the mandible . the average age of occurrence is 27.5 years ranging between 14 and 45 years old . a 62-year - old edentulous female patient was referred with facial asymmetry and remarkable swelling extending from the right body of mandible to the left body of mandible since 7 - 8 months . tenderness was present over the lesion along with neural deficit ( paresthesia ) over the lower lip . she had a history of total extraction 14 months ago because of poor periodontal health . there was no history of trauma or dental pain , and the total extraction procedure was uneventful . the patient then got her complete dentures made , which were found to be ill - fitting at the time of reporting to our institution . skin over the swelling was apparently not involved and showed no evidence of scars , sinus or any discharge . there was no evidence of crepitus or egg shell crackling in relation to the lesion . intraorally the buccal plate was found to be expanded in anterior and left mandibular body region , which resulted in the obliteration of left buccal vestibule [ figure 1 ] . the past medial history did not reveal any major illness however she was anemic and was under medication ( injection vitcofol ) for the same . there were no caf au lait spots or subcutaneous nodules on the patient 's trunk , and no evident axillary freckling noted . orthopantomographic findings showed well - defined radiolucency extending from right body region to left body region of the mandible [ figure 2 ] . three - dimensional computed tomography revealed thinning of lower border and pathological fracture in left body region of the mandible . ultrasonography of the local part showed a heterogeneous predominantly hypoechoic soft tissue lesion involving the right and left half of the mandible and no evidence of any vascularity was noted within it . preoperative radiograph ( orthopantomography ) aspiration of the lesion was negative and hence it was decided to perform an incision biopsy under local anesthesia . histopathology of the incisional biopsy revealed admixture of nerve fibers ( mostly inferior alveolar nerve ) and fibrous tissue [ figure 3 ] . histopathology ( admixture of nerve fibres ) the resection of the mandible was carried out from left ramus to the right ramus region since the lesion was too extensive . four months later the patient was taken up for secondary reconstruction using the free fibula graft ( single barrel ) . postsurgical follow - up after 2 years revealed no recurrence and no functional discrepancies were encountered [ figure 4 ] . the patient is now planned to be taken up for rehabilitation by placement of dental implants . follow - up radiograph ( orthopantomography ) ( showing well taken up free fibula graft ) about 90% of the neurofibromas are associated with neurofibromatosis type 1 , and hence the presence of a solitary case requires physical examination and familial history to exclude von recklinghausens disease . our patient did not have caf au lait spots on the trunk nor any other common clinical features suggestive of von recklinghausen 's disease . solitary neurofibroma is a benign , slow growing neoplasm , relatively circumscribed but not encapsulated , originating within a nerve and composed of schwann cells , perineural cells and mature collagen . in our case bilateral inferior alveolar nerve involvement in the central part of the tumor and deep invasion of the tumor cells into the surrounding bone was observed on histological examination . this may be a typical finding suggesting that the tumor arises from the inferior alveolar nerve . therefore , resection from left mandibular ramus to right mandibular ramus along with removal of the overlying mucosa because of the potentiality of the tumor invasion into the surrounding tissue was carried out . the absence of encapsulation makes complete surgical removal of a solitary neurofibroma difficult which probably accounts for some cases of recurrences . also , it is necessary to rule out the differential diagnosis schwannoma and perineuroma as proposed by ide et al . our literature search has not revealed such extensive lesions at this specific age as mentioned in our case . hence , this case may be considered as a unique entity . it is always important to consider solitary intraosseous neurofibroma as the first manifestation of neurofibromatosis , and a thorough clinical and radiographic follow - up is necessary since recurrence and malignant changes have been reported .

neural tumors located centrally in jaw bones are relatively rare compared with soft tissue neurofibromas . less than 50 cases have been reported in the literature with a predilection for mandible . this article aims to elucidate a unique case of intraosseous neurofibroma of mandible in a 62-year - old edentulous female patient associated with facial asymmetry due to the swelling extending from the right body of mandible to left body of mandible . the uniqueness of this case is related to the age and extensiveness of this lesion . a review of clinical , radiographic , histological , and immunohistochemical features , and the surgical management pertaining to this case are discussed along with a review of the literature .

a 58-year - old man suddenly developed a numb sensation in his trunk and leg on the left side . he had no history of hypertension , diabetes mellitus , cardiac problem ( including arrhythmia and coronary heart disease ) , or previous stroke , and he was a nonsmoker . a neurological examination performed the day after presentation revealed that he was alert and oriented , and did not have dysarthria or dysphagia . both pupils were of equal size and reactive , without nystagmus , ophthalmoplegia , or horner 's syndrome . muscle strength was intact in the extremities . a sensory examination including a pinprick test and a cold sensory test revealed that pain and temperature sensations were decreased by about 80% in the left trunk ( below the t4 dermatome ) and leg . however , he did not report a definite difference in the sensation between the trunk and leg on the left side . cerebellar function , as assessed by finger - to - nose , tandem gait , and romberg 's sign test , also was preserved . he complained of an uncomfortable sensation in his left leg and foot on a hopping test , but showed no falling tendency or gait disturbance . diffuse- and t2-weighted magnetic resonance imaging ( mri ) of the brain , performed on the second hospital day , showed a small lesion with a high signal intensity in the right lower medulla oblongata consistent with acute infarction ( fig . thoracicspine mri and somatosensory evoked potential ( sep ) were performed to exclude spine lesions , and revealed no abnormal findings . results from laboratory studies , including complete blood cell and platelet counts , erythrocyte sedimentation rate , blood electrolytes , chemistry , liver enzymes , cholesterol , triglycerides , and homocysteine , and the prothrombin and partial thromboplastin time were all normal . chest x - ray , echocardiogram , and electrocardiography also were all normal . the patient was treated with antiplatelet agents , and showed a gradual improvement of sensory deficits to about 60% of normal sensation without fluctuation of symptoms . the clinical features of lmi can have diverse neurological manifestations due to the anatomical characteristics of the medulla.4 according to previous reports , ataxia was the most common neurological symptom in lmi , and was more common in patients with lesions located in the laterocaudal part of the medulla.5 contralateral hypalgesia is the next most frequent neurological symptom of lmi.4 the most common pattern of sensory abnormality in lmi is loss of pain and heat sensations on the ipsilateral side of the face and on the lower part of the body on the contralateral side , which is associated with other common manifestations such as vertigo , unsteadiness , horner 's syndrome , and dysphagia.3,6 however , pure sensory deficits as an isolated symptom are not a feature of lmi . moreover , pure sensory deficits in a dermatomal distribution as in the present patient have been not reported previously . in our case , pure sensory deficit with a t4 sensory level occurred as a single and isolated manifestation of lmi without any of the other common neurological symptoms . we attributed this to the lesion being restricted to the right mediolateral aspect of the medulla , posterior to the inferior olivary nucleus . moreover , sensory deficit below the t4 level on the contralateral side of the body in our patient was due to the somatotopical organization of the spinothalamic tract , because the sacral afferent fibers are located in the lateral medullary part and the cervical afferent fibers ascend more medially.6 the lesion did not extend sufficiently far to the posterolateral medulla to affect the ipsilateral descending tract and nucleus of the trigeminal nerve , thus sparing sensations in the ipsilateral face . the crossed ventral trigeminothalamic tract courses to the medial part of the spinothalamic tract and carries pain and heat sensations from the contralateral side of the face . thus , if the lesion extends more medially to involve ipsilateral cervical sensory fibers as well as the contralateral trigeminothalamic tract , this will lead to ipsilateral sensory deficit of the entire body without dermatomal representation or contralateral facial hypesthesia . however , if the lesion extends more posterolaterally to involve the ipsilateral spinocerebellar tract , this will lead to vertigo and ipsilateral ataxia . numerous reports have provided evidence that restricted acral sensory deficits frequently occur after small strokes in the thalamic and cortical areas . for example , fisher stated that isolated paresthesia of the face , arms , and legs suggests thalamic involvement,7 and kim also observed that dominant sensory involvement of the upper lip , thumbs , and index fingers occurred with thalamic and thalamocortical infarction.8 therefore , the somatotopic topography of the ventralis posterior nucleus of the thalamus is relatively well known . reported a patient with vibration and position sensory defects below the l5 sensory level caused by medial medullary infarction,9 and phan and wijdicks described a patient with pain and temperature sensory losses below the t9 sensory level associated with disequilibrium due to lmi following vertebral artery dissection.10 the present patient represents a rare case of lmi presenting with loss of pain and temperature sensations below the level of the t4 sensory dermatome as a unique neurological deficit . the observations reported here will help to improve our understanding of the somatotopic topography of the brainstem , especially of the medulla .

in rare cases restricted sensory deficits along the somatotopic topography of the spinothalamic tract can develop from a lateral medullary infarction . to our knowledge , isolated dermatomal sensory deficit as a single manifestation of a lateral medullary infarction has not been reported previously . a 58-year - old man presenting with sudden left - sided paresthesia complained of sensory deficit of pain and temperature below the left t4 sensory level without other neurologic deficits . diffuse- and t2-weighted magnetic resonance imaging ( mri ) of the brain showed high signal intensities in the right lower medulla oblongata , whereas thoracic - spine mri and somatosensory evoked potentials produced normal findings .

the humanized monoclonal antibody bevacizumab ( avastin genentech / roche ) is increasingly used to treat malignant solid tumors . this antibody recognizes and blocks vascular endothelial growth factor ( vegf)-a . the latter is a chemical signal that stimulates the growth of new blood vessels ( angiogenesis ) . in the kidney , podocyte - speci?c deletion of a single vegf allele causes proteinuria and capillary endotheliosis in rodents , and disrupted glomerular vegf signaling is strongly implicated in the pathogenesis of human preeclampsia , a syndrome characterized by proteinuria and hypertension [ 2 , 3 , 4 ] . in the institutional review case series described here , six patients developed a syndrome characterized by proteinuria and hypertension after starting therapy with bevacizumab . history of patients before commencing treatment , was unremarkable for hypertension and kidney disease , while urinalysis was normal . patients were identified clinically after developing edema , hypertension , proteinuria , and/or hypoalbuminemia ( table 1 ) . all six patients developed proteinuria grade 2 ( 23 + protein in dipstick urinalysis or 1.03.5 g in 24-hour urine for protein ) or higher , and new or exacerbated hypertension required on average two antihypertensive medications . glomerulonephritis and microangiopathic hemolytic anemia were excluded based on the results of blood and urine sediment tests . in most patients , subsequently , in patients with follow - up information , there was a dramatic improvement ( patients 1 , 2 , 3 , 5 ) of proteinuria . since 2003 , at least 481 patients have been treated with bevacizumab at our institution ; thus , the cumulative crude incidence of renal adverse events is 1.2% . however , the true prevalence of bevacizumab - associated renal toxicity is likely higher because patients were not routinely screened in a systematic , prospective , and long - term manner for the development of new proteinuria . interestingly , all patients experienced prolonged progression - free survival , defined as the time interval from treatment initiation to documented progression or death . with the exception of one of the patients , who received paclitaxel and bevacizumab as first - line treatment for metastatic breast cancer , all other patients received the antibody in combination with various agents as fourth- or fifth - line treatment . progression - free survival of more than 16 months for taxane / anthracycline refractory metastatic breast cancer , or of more than 6 months for a heavily pre - treated patient with metastatic non - small cell lung cancer , compared favorably to reported trials of such patient populations [ 5 , 6 ] . even the patient with small cell lung cancer died as a result of septic shock secondary to infection , without evidence of disease progression . nephrotic - range proteinuria , which denotes structural damage to the glomerular filtration barrier , occurs in 12% of bevacizumab - treated patients . although several potential causes of this type of proteinuria have been suggested [ 8 , 9 ] , it is difficult to distinguish the general effects of therapy , such as an immunologic response to the monoclonal antibody , from the direct effects due to inhibition of endogenous vegf signaling in non - cancerous tissues . recently , it was shown that local reduction of vegf within the kidney was sufficient to trigger the pathogenesis of thrombotic microangiopathy by the use of a conditional gene targeting to delete vegf from renal podocytes in adult mice . this resulted in a profound thrombotic glomerular injury , providing evidence that the glomerular injury of patients treated with bevacizumab is probably due to a direct targeting of vegf by the antiangiogenic therapy . given that the altered glomerular permeability appears to be a direct consequence of vegf inhibition , proteinuria may indeed correlate with drug efficacy . interestingly , hypertension , which represents another vascular toxicity of bevacizumab , has already been proposed as a predictive marker for antiangiogenic treatment efficacy . whether the development of proteinuria might also serve as a surrogate marker of antitumor efficacy is unknown . this could be proven only in the context of a clinical trial designed specifically to address this question . however , a large number of patients should be enrolled in such a study due to the relative low incidence of grade 2 or higher proteinuria . in addition , the recent fda oncologic drugs advisory committee 's vote in favor of removing the metastatic breast cancer indication from the drug labeling makes the design of such a trial highly unlikely . on the other hand , treatment options for these life - threatening advanced cancers are limited , and optimizing safe and effective drug dosing may be critical to achieve the best therapeutic impact . clinicians should be aware of the hypothesis that individuals experiencing bevacizumab - induced proteinuria potentially represent a group of patients who derive a great benefit from anti - angiogenic treatment and consider the pros and cons before withholding this effective anticancer therapy .

nephrotic - range proteinuria , which denotes structural damage to the glomerular filtration barrier , occurs in 12% of bevacizumab - treated patients . the glomerular injury and subsequent proteinuria is probably due to a direct targeting of vascular endothelial growth factor ( vegf ) . we report a case series of six patients who developed a syndrome characterized by proteinuria and hypertension after starting therapy with bevacizumab and who experienced prolonged progression - free survival . given that altered glomerular permeability appears to be a direct consequence of vegf inhibition , we hypothesize that proteinuria may indeed correlate with drug efficacy . optimizing safe and effective drug dosing is critical to achieve the best therapeutic impact due to limited treatment options for many life - threatening advanced cancers . clinicians should be aware that the development of proteinuria might serve as a surrogate marker of bevacizumab antitumor efficacy and determine the appropriate criteria for withholding this effective anticancer therapy .

non - traumatic convexal subarachnoid hemorrhage ( csah ) observed at the convexity of the brain is a relatively uncommon entity with various vascular and nonvascular causes . : cerebral venous thrombosis ( cvt),1 ) reversible cerebral vasoconstriction syndrome ( rcvs),4 ) vascular malformations , vasculitides,12 ) infectious aneurysms,10 ) moyamoya disease or syndrome,22 ) severe carotid atherosclerosis,6 ) posterior reversible encephalopathy syndrome ( pres),24 ) cerebral amyloid angiopathy ( caa),5 ) and nonvascular disorders , such as primary and secondary brain neoplasms7 ) or abscess.18 ) cerebral infarcts in the territory of the anterior cerebral artery ( aca ) are reported to comprise 0.5 - 3% of all ischemic strokes9)11 ) and few studies have specifically assessed the clinical characteristics of stroke patients with aca infarction.2 ) we report a case of aca cerebral infarction with spontaneous csah lead to stenosis of the aca . it is a infrequent case , but is worth consideration that the management and evaluation of these patients . a 59-year - old female patient visited emergency room with right side subjective weakness spontaneously . however , the national institute of health stroke scale ( nihss ) was 0 . initial computed tomography angiography at one and half hours after symptom onset demonstrated subarachnoid hemorrhage ( sah ) localized in the left frontal convexity and mild focal stenosis at both a2 segments . also the magnetic resonance diffusion - weighted images ( dwi ) revealed an acute infarction of anterior cerebral arterial territory ( fig . 1 ) . we could not find any vascular lesion on computed tomographic angiography ( cta ) and magnetic resonance angiography ( mra ) and treated with dual antiplatelet drugs ( cilostazole [ otsuka pharmaceutical co. , ltd . tokyo , japan ] 50 mg bid / day plus aspirin [ bayer pharma ag . , she has done well for a follow - up period and her modified rankin scale was 0 at day 5 . the follow - up evaluation was performed at out - patient clinic after 5 months . cta shows that the sah was washed out and encephalomalatic change in left aca territory . mri also reveals that no evidences of acute infarction in dwi and hemorrhagic transformation in susceptibility weighted imaging ( swi ) ( fig . although the prevalence of non - traumatic convexal sah is reported to be 7.5% of all spontaneous sah patients,13 ) little has been conscious of concerning the incidence of csah accompanying with acute infarction among many different etiologies of csah . demostrated the image protocol to cover the wide spectum of entities potentially responsible for csah that brain cta with a paired channel at both arterial and venous phases and mr imaging including gre t2 sequences , flair , dwi , mra 3d tof , contrast - enhanced venogram , and pre- and postgadoliniumt1-weighted imaging.3 ) however , we evaluated the cta and mr imaging cluding t2 , dwi , swi and 3d tof mra . cta and mra are useful to determine the vascular causes of csah such as vascular malformations , rcvs , vasulitides , high - grade stenosis , moyamoya disease , and septic aneurysms . in addition , mr imging is ascertainable diagnositic tools between dural and cortical cvt , and non - vascular causes such as , caa , pres , neoplasm , abscess and cavernoma . in this case , aca territory infarction seemed to occur hemodynamically because of stenotic lesion on a2 segment and hypoperfusion on brain spect with tc-99 m hmpao . nakajima et al . assumed that the accompanying an infarction and non traumatic csah might demonstrate that hemodynamic insufficiency because of arterial stenosis or occlusion get to the critical point . for instance , after an acute infarction due to occlusive disease by the embolic or hemodynamic mechanism , ensuing dynamic changes of intracranial perfusion pressure might bring about the csah.14 ) also cuvinciuc et al . explained that the main mechanism of csah because of chronic arterial occlusive diseases is considered to be the rupture of dilated vulnerable compensatory pial vessels.3 ) a large randominzed controlled trial studied clopidogrel and aspirin in high - risk patients with acute nondisabling cerebrovascular events ( chance ) was finished in china . the result revealed that antiplatelet double therapy with clopidogrel plus aspirin was better than aspirin alone for reducing the risk of recurrent stroke and not increase the risk of bleeding among patients with high risk transient ischemic attack ( tia ) or minor infarction23 ) due to our patient 's acute hemorrhage on the frontal convexity , we were concerned the hemorrhagic transformation and rebleeding because dual antiplatelet therapy ( clopidogrel plus aspirin ) was associated with a significant trend to increase moderate bleeding.17 ) so we treated with cilostazol plus aspirin successfully . the patient 's symptom was improved and there was no evidence of rebleeding on following studies . tan et al . reported that cilostazol , alone or with aspirin , decrease recurrence of ischemic stroke significantly , poststroke intracranial hemorrhage , and extracranial bleeding in patients with a prior ischemic stroke as compared with other antiplatelet treatments.21 ) cilostazol , a selective inhibitor of cyclic nucleotidephosphodiesterase 3 , increases activated intracellular cyclic adenosine monophosphate ( camp ) concentrations and thus inhibits platelet aggregation.19 ) cilostazol is a known direct arterial vasodilator,15 ) and has antiatherosclerotic effect,8 ) which can strengthen the endothelial barrier20 ) and additionally may play a role in neuroprotection.16 ) acute infarction with spontaneous convexal sah is rare but it is worth to work up to identify the etiology of csah using the cta or mra and mr image including t2 , dwi , swi . and we suggest that dual antiplatelet dugs ( cilostazole and aspirin ) are taken into account for treatments that improved the neurologic symptoms and reduced the concerns about stroke recurrence and rebleeding .

non - traumatic convexal subarachnoid hemorrhage ( csah ) is a comparatively infrequent with various vascular and nonvascular causes , it rarely occurs concomitant to acute ischemic stroke . we report a case of a 59-year - old woman , visited emergency room with right side subjective weakness spontaneously . magnetic resonance diffusion - weighted images revealed an acute infarction of anterior cerebral arterial territory . computed tomographic angiography showed a left frontal csah without any vascular lesions . and other laboratory studies were non - specific . we treated with dual antiplatelet drugs ( cilostazole [ otsuka pharmaceutical co. , ltd . tokyo , japan ] and aspirin [ bayer pharma ag . , leverkusen , germany ] ) . she has done well for a follow - up period . ( 5 months ) this case demonstrates the csah with acute infarction is rare but need to work up to identify the etiology and antiplatelet dugs are taken into account for treatments .

hallucinations have been described since antiquity , and are well - recognized as components of mental illness . chronic hallucinatory psychosis is one entity which falls under other nonorganic psychotic disorder in international classification of disease-10 revision . while auditory hallucinations are more commonly encountered in nonorganic psychotic disorders , visual hallucinations can be seen in a range of neurological , psychiatric and ophthalmological conditions . antipsychotic medications are the principle mode of treatment but they often fail to exert any response in persistent visual hallucinations . it has been reported that antiepileptics are useful to treat visual hallucinations in charles bonnet syndrome , but their efficacy in functional cases is less studied and less reported . we present a case of successfully treated , antipsychotic resistant visual hallucinations in a patient with chronic hallucinatory psychosis by carbamazepine . mh , a 45-year - old male , residing in urban jharkhand , india from a poor socioeconomic background , with nil - significant past or family history and no known psychoactive substance use , was admitted to central institute of psychiatry with 4 years continuous history of seeing images of two - dimensional human figures or faces with associated fearfulness and suspiciousness . the patient had developed low mood and occasional death wishes for last 6 months secondary to these symptoms . initial evaluation revealed a depressed affect , hopelessness , death wishes , delusion of persecution and reference , and complex visual hallucinations . routine investigations including neuroimaging ( computed tomography brain , magnetic resonance imaging brain and electroencephalogram ) were also within normal range . he had been treated earlier with an adequate dose of atypical ( risperidone 6 mg for 6 months and olanzapine 15 mg for 3 months ) and typical antipsychotics ( fluphenazine decanoate 25 mg long - acting depot every 2 weeks for 9 months ) with no improvement in the visual hallucinations . after admission , he was started on haloperidol ( initial dose of 10 mg / day , hiked up to 15 mg / day ) and fluoxetine ( initial dose of 20 mg / day , hiked up to 40 mg / day ) . after 6 weeks of treatment , patient showed improvement in persecutory delusions and depressive symptoms , but the visual hallucinations persisted unabated . considering case reports of persistent visual hallucinations that responded to antiepileptic medications in organic hallucinosis , patient was started on 100 mg of carbamazepine per day that was increased to 800 mg / day over a period of 1 week . the frequency and duration of the hallucination improved , and within 4 weeks , visual hallucinations resolved completely . in clinical settings , complex visual hallucinations have varied etiologies , and the treatment varies accordingly . recent literature suggests that visual hallucinations result from release phenomenon due to the modulation of the thalamo - cortical network . pattern completion in the neural network model of thalamus has been hypothesized in visual hallucinations of various etiologies such as charles bonnet syndrome , psychedelic drug consumption , somatic hallucinations in phantom limbs , cognitive hallucinations in schizophrenia , and other psychotic disorders . in this model , hallucinations are postulated to be produced when the thalamus fills deprived areas in order to complete patterns , and hence effective treatment of some of these disorders involve peripheral stimulation along with central inhibition and hence that the neural circuits generating the disorders are depressed according to the proposed model of synaptic plasticity . the ability of carbamazepine to decrease gamma - aminobutyric acid turnover and increase glutamate turnover probably inhibit the hyper - excited neuronal circuits responsible for visual hallucinations , resulting in the required central inhibition . contrary to our present report , few reports on the development of visual and auditory hallucinations following treatment with carbamazepine and other antiepileptics have been published in the past . more recently , complex visual hallucinations have been described with carbamazepine and phenytoin sodium ; auditory hallucinations have been reported with carbamazepine at therapeutic serum levels . in these cases , after extensive investigation , the authors concluded that the hallucinations resulted from a direct effect of the antiepileptic drugs and ruled out all other possibilities including migraine and seizures . though in our patient visual hallucinations resolved with carbamazepine , rather than having worsened , this is not in contradiction with the past reports . the hallucinations reported in the past are likely to have occurred due to a faulty central inhibition , where the inhibitory neurons were affected instead of hyper - excited neurons , in vulnerable individuals ( seizure or migraine diathesis or genetic predisposition ) with rapid changes in serum drug concentrations resulting in release hallucinations . this proposal of vulnerability factors giving rise to paradoxical responses is further supported by the rare occurrence of such hallucinations with carbamazepine use in general clinical practice . thus , our case illustrates a novel use of carbamazepine in the treatment of visual hallucinations in the nonorganic psychosis . often the most challenging cases faced in clinical psychiatry are those with treatment - resistant symptoms , which can prove distressing to patients . our approach in this case was to combine contemporary ideas in neurophysiology and therapeutic evidence in related disorders and apply these to clinical practice in a targeted way . we recognize this to be a single case of novel therapeutic use of carbamazepine ; however , we feel that further research in this field is indicated .

visual hallucinations are commonly present in various neurological and psychiatric conditions such as schizophrenia and other hallucinatory psychosis . current conceptualization of hallucinations assume pattern completion model of thalamus to be responsible for the origin of this type of the perceptual abnormality and proposes that central inhibition of such circuits may treat hallucinations . we present a case of chronic hallucinatory psychosis with significantly distressing visual hallucinations , resistant to antipsychotics , which successfully responded to carbamazepine . this case illustrates the novel use of an antiepileptic in the treatment of resistant visual hallucinations . targeted therapy of this kind can be considered in the future , although more evidence is required in this field .

the middle third of the ulna is the commonest site as this region has the thinnest cortex and smallest cross - sectional area morphologically compared to the proximal or the distal third , and is vulnerable to stress from torsional forces . stress fractures of the ulna have been reported to be associated with certain sports such as tennis . we present a case of a spontaneous complete fracture of the ulna metaphysis with concomitant stress reaction of the proximal radius occurring in a patient who had been dependent on below elbow crutches for 15 months . the case acts as a reminder that spontaneous complete fractures may be the end result of abnormal stress , and that stress fractures of the ulna may be related to the use of crutches . a 60-year - old left hand - dominant woman presented 3 days after hearing a crack in the left forearm whilst taking her jumper off . relevant past medical history included severe osteoarthritis of the hips , knees and back requiring below elbow crutches to mobilise . she was taking non - steroidal anti - inflammatory medications for pain relief . on examination , there was diffuse swelling over the proximal ulna associated with tenderness over the site . she was treated conservatively and provided with alternative crutches to avoid weight bearing on the forearm . 1anterior - posterior ( ap ) and lateral plain radiographs demonstrate a transverse fracture through the proximal metaphysis of the ulna anterior - posterior ( ap ) and lateral plain radiographs demonstrate a transverse fracture through the proximal metaphysis of the ulna a repeat plain radiograph at 5 weeks showed signs of fracture union . however , in view of the unusual site of the fracture , a magnetic resonance imaging ( mri ) scan was requested . mri was performed on a 1.5 tesla siemens scanner using a body coil as the patient s body habitus did not permit the use of a surface coil available in our institution . in addition , there was bone marrow oedema in the proximal radius without a definite fracture line appearances consistent with a stress reaction ( fig . there was no evidence of neoplasm or infection . a subsequent computed tomography ( ct ) scan showed no fracture line in the radius and no signs of underlying bone pathology in either of the bones ( fig . a axial short tau inversion recovery ( stir ) demonstrates fracture of the proximal ulna and surrounding soft tissue oedema . b coronal t1w image demonstrates the transverse fracture of the proximal ulnar metaphysis ( arrow ) and low signal changes in the proximal radius at the same level as the ulnar fracture . c coronal stir demonstrates the ulnar fracture ( arrow ) high signal changes in the proximal radius ( arrow head ) representing bone marrow oedema again demonstrated . no sinister features are seenfig . 3computed tomography ( ct ) scan of the left forearm ; sagittal reformat shows the transverse fracture through the proximal ulnar metaphysis with associated callous formation magnetic resonance imaging ( mri ) of the left forearm . a axial short tau inversion recovery ( stir ) demonstrates fracture of the proximal ulna and surrounding soft tissue oedema . b coronal t1w image demonstrates the transverse fracture of the proximal ulnar metaphysis ( arrow ) and low signal changes in the proximal radius at the same level as the ulnar fracture . c coronal stir demonstrates the ulnar fracture ( arrow ) high signal changes in the proximal radius ( arrow head ) representing bone marrow oedema again demonstrated . no sinister features are seen computed tomography ( ct ) scan of the left forearm ; sagittal reformat shows the transverse fracture through the proximal ulnar metaphysis with associated callous formation stress fracture of the ulna due to the use of crutches is rare . previously published case reports describe stress fracture / reaction of the ulna diaphysis [ 25 ] , of which two patients had complete fractures . we report a case of a complete stress fracture of the ulnar metaphysis resulting from the use of crutches . ulnar stress fractures have been described in a variety of sporting activities including tennis , weight lifting , baseball , polo and japanese fencing . stress fractures occurring in the non - weight bearing bones can cause diagnostic confusion with pathological fractures if the clinical history is not clear or when such fractures occur in the setting of an underlying primary malignancy elsewhere . the first report of a stress fracture of the ulna resulting from the use of crutches was described by mcgoldrick and obrien , in a patient who was non - weight bearing following treatment for osteochondritis dissecans of the knee . they described bilateral complete stress fractures involving the mid - diaphysis of the ulna occurring at identical sites , and postulated direct contact of the ulna with the upper crutch ring in combination with a forward bending force as the likely cause . a similar case of a bilaterally symmetrical complete stress fracture of the ulnar diaphysis , which resulted from the use of walking aid for a year , was reported in a 95-year - old patient . garcia suarez et al . reported a further case of an incomplete crutch - related stress fracture of the ulna occurring at the junction of the middle and distal third in a patient treated for osteochondritis of the knee . they postulated that cyclical weight bearing on crutches , with the wrist in a position of flexion , ulnar deviation and pronation , increased the axial load through the ulna , leading to fracture . more recently , amin et al . reported a case of ulnar stress reaction from crutch use in a patient who had undergone above - knee amputation for recurrent osteosarcoma of the tibia . none of the reported cases showed concomitant stress reaction of the ipsilateral radius . in our case , it was thought that the likely mechanism of injury was due to a combination of tractional and torsional force , together with direct pressure on the proximal forearm bones from the upper crutch ring as postulated in the previous case reports [ 24 ] . furthermore , mri and ct showed no evidence of an underlying lesion to suggest a pathological fracture in our case , and the fracture progressed to union without complication . in conclusion , both clinicians and radiologists involved in the management of such patients should be aware of stress fracture / reaction of the forearm bones that can occur from the use of crutches , which may help in early detection and treatment , preventing further disability in these patients .

we report a case of complete stress fracture of the ulna and stress reaction of the radius resulting from the use of crutches in an overweight patient with severe lower extremity arthritis . plain radiograph showed an undisplaced complete fracture of the proximal metaphysis of the ulna . magnetic resonance imaging ( mri ) was performed to exclude a pathological cause in view of the unusual fracture site , which confirmed the plain radiographic findings and additionally demonstrated a stress reaction in the proximal radius . there are three cases of stress fracture of the ulnar diaphysis resulting from the use of crutches reported previously in the english literature and a further case of bilaterally symmetrical ulnar diaphysial fracture reported in the danish literature . we report the first case of ulnar metaphysis stress fracture with concomitant stress reaction of the radius .

the national tb prevalence survey in eritrea was conducted from february through october 2005 ( 6 ) . in 40 selected villages , a census ( which included information about sex and age ) was taken of 875 persons in each village . all persons > 15 years of age were asked to provide a morning and a spot sputum sample . persons who had 2 positive sputum samples were informed about the test results and referred for treatment . those who had 1 positive sputum sample were referred to a nearby healthcare facility for further smear examination . if results of smear examination were negative , thoracic radiographs were taken and evaluated by 2 experienced radiologists . the case definition for a sputum smear positive case was at least 2 sputum specimens positive for acid - fast bacilli by ziehl - neelsen staining and microscopy or at least 1 sputum specimen positive for acid - fast bacilli and radiographic abnormalities consistent with active pulmonary tb ( classification of the national tuberculosis control program in eritrea ) . using the prevalence estimate obtained from the survey and 2 different models , we calculated the cdr for 2004 . in model 1 , described by styblo , cdr = ( notification rate / prevalence rate ) / ( 0.5 + 0.83 [ notification rate / prevalence rate ] ) ( 7,8 ) . in model 2 , described by dye et al . , cdr = ( notification rate / prevalence rate ) / ( [ notification rate / prevalence rate ] + 0.5 ) ( 9,10 ) . we then compared the calculated cdr with the cdr estimated by the world health organization ( who ) to evaluate whether comparable conclusions about tb case detection would be obtained . a total of 38,047 persons were included in the prevalence survey . of those > 15 years of age , 18,152 ( 94.6% ) provided at least 1 sputum sample ( figure ) . the prevalence of new smear - positive tb was estimated at 90/100,000 ( 95% confidence interval [ ci ] 35145/100,000 ) in persons > 15 years of age . in 2005 , 44.7% of the eritrean population was < 15 years of age ( 11 ) , which resulted in an overall new smear - positive tb prevalence of 50/100,000 ( 95% ci 1980/100,000 ) under the assumption of no cases in persons < 15 years of age . summary of tuberculosis prevalence survey in eritrea , 2005 . in 2004 , 17/100,000 new smear - positive cases were reported ( 2 ) . for eritrea , the cdr provided by who is considerably lower than that calculated from the results of the national tb prevalence survey . both estimates indicate that eritrea has not reached the 70% target for case detection . however , the who estimate suggests that the program needs to improve case detection by a factor of 5 , whereas the survey estimate suggests that case detection needs to be improved by a factor of 1.6 . two explanations may account for the large difference : 1 ) the cdr derived from the tb prevalence survey is too high because of an underestimation of the prevalence of smear - positive tb , or 2 ) the cdr estimate published by who is too low because of an overestimation of the incidence of smear - positive tb . in the national tb prevalence survey , measures were taken to ensure high quality of the results ; e.g. , training of data collectors , repeat census taking , reexamination of all slides found positive on fluorescence microscopy , and reexamination of a 5% random sample of the negative slides . persons who had smear - positive tb may have been missed because they did not provide a specimen ; however , because only 5% of eligible persons did not provide a specimen , this can explain only a slight underestimation . furthermore , recorded reasons for not providing a specimen seem to be unrelated to a higher chance of having tb . the quality of the provided specimens may have been suboptimal because instructing and motivating persons to provide a sputum sample is challenging . for diagnosis of tb , microscopic examination of saliva is less sensitive than examination of sputum ; however , in 50% of saliva samples from patients with a positive sputum sample , bacilli can be demonstrated ( 12,13 ) . for 27,647 samples that appeared to be saliva , smear assuming that only 50% were detected , a maximum of 12 smear - positive tb patients may have been undetected . taking this into account results in a prevalence of 87/100,000 . using this estimate , model 1 provides a cdr of 30% and model 2 a cdr of 28% the possibility that persons who provided a saliva sample were not able to produce a sputum sample because they did not have pathologic pulmonary changes should also be taken into consideration . estimation of the incidence of smear - positive tb in eritrea is complicated by the fact that no data from tuberculin or prevalence surveys were available . the only data available for eritrea were reporting data , which experts assessed as being of low quality ( 14 ) . use of this limited information will result in an uncertain incidence estimate , which may result in an unreliable cdr . for most countries in africa , little information is available for estimating the prevalence of disease and progress towards the millennium development goals ( http://unstats.un.org/unsd/mi/mi_goals.asp , accessed 2006 aug 30 ) . on the basis of case reporting , tb was rightly declared an emergency by african health ministers at the who africa regional committee in maputo in 2005 ( 15 ) . to be able to fight this emergency , more reliable information about the prevalence of tb in africa is needed . furthermore , for global tb control , reliable information about the tb epidemic in africa is needed because 28% of the incident smear - positive cases occurred in the who african region in 2004 ( 2 ) . in conclusion , the example of eritrea shows that a large gap may exist between available estimates of tb prevalence and actual tb prevalence in africa . national tb prevalence surveys in africa would help provide better information on tb prevalence and case detection .

we used results from a national tuberculosis prevalence survey in eritrea to calculate case detection rate ( cdr ) and compared it with the published cdr . the cdr obtained from the survey was 40% , whereas the cdr published by the world health organization was 3 lower ( 14% ) .

hemangioma is the commonly found benign neoplasm involved on head and neck.1 - 3 ) it is also one of the most common benign vasofomative neoplasms of mainly infancy and childhood.4 - 6 ) according to the previous studies , hemangiomas are classified into capillary , cavernous , and miscellaneous forms like verrucous , venous , arteriovenous.1,2,6 ) the majority of hemangioma in early childhood regressed spontaneously.7 ) however , an appearance and spontaneous regression of hemangioma in adults is very rare , especially in prearicular sinus.8 ) therefore , clinically , haemangiomas in adult are strongly required to appropriate management including surgical excision . in the present case study , we report a rare and an unusual case of haemangioma of the preauricular sinus with a review of the literature . a 44-year - old female came to our department with a 5-month history of intermittent right preauricular swelling and febrile sensation . she denied having had hearing loss , aural fullness , otaglia , tinnitus , and painful sensation . an ovoid shaped mass was softly palpable on 1 cm anterior from the tragus of right ear . the other findings of the head and neck were not significant but particularly , there was no pit around the softly palpable mass . also , there was no secretion and painful sensation with pressure . computed tomography ( ct ) demonstrated a 0.9 cm sized soft tissue mass in anterolateral to the right external auditory canal , which enhanced with contrast . the isolated mass was ovoid shaped and well - marginated without evidence of bony erosion of outer ear ( fig . 1 ) . based on the physical examination and computed tomography , preauricular fistula , salivary gland tumor , and enchondroma were possible diagnosis . under general anaesthesia , the mass was smoothly excised via the preauricular approach . the standard technique for preauricular sinus excision was used with a careful elliptical incision anterior to the crus and tragus on the superior portion of the mass and dissection without epithelial remnants . the size of the surgical specimen was 1.00.8 cm , reddish and soft ( fig . pathologic evaluation revealed well circumscribed , exophytic mass , delineated by squamous epithelium and proliferative small vessels ( fig . she was also reviewed 1 and 3 months after surgical excision without the leision recurred . hemangioma is a benign vascular soft tissue tumor that is probably an abnormal development of embryonic vasculature.6,7 ) according to previous studies , hemangiomas are located in not only trunk or extermities , but also head and neck region . however , hemangioma in preauricular sinus has been rarely reported in the literature.9,10 ) from this case , we learned and experienced the occurrence of hemangioma in preauricula sinus . before surgical excision the most common presenting symptoms and clinical signs of malignancy in auricle or parotid area are slowly growing palpable mass , which symptoms could be possibly painless , pain with tenderness , and repeated swelling with pain . reviewing the literature , the peak incidece of benign and malignancy parotid gland tumor for korean population are in the fifth decade for both males and females , and the eighth decades in males , third to fifth decades in females , respectively.11 ) considering the duration of symptoms , it varied from a few weeks to several years for both benign and malignancy . however , no pit , which is typically found in preauricular sinus , was observed and then the pathological finding of the specimen showed the hemangioma arising in a preauricular sinus . if more diagnostic tools or needle aspiration for pathological findings were performed before surgical excision , more valuable diagnostic results would be obtained for more precised diagnosis . both contrast - enhanced ct and mr imaging are the useful diagnostic tools . considering this case , mr imaging would be superior to ct because previous reported studies show that mr imaging clearly differentiated cavernous hemangiomas from hypervascular tumors.2 ) therefore , mr imaging would be a considerable diagnositc tool when evaluating a head and neck neoplasm , which could give more precise information to decide which treatments would give a better outcome . according to the vessel type , three histopathological types of hemangioma have been reported.12 ) a capillary type is characterized by prediminant capillary structures with proliferative activity that are invading to surrounding tissue , and a short clinical history . cavernous type is characterized by large vessels with occasional mitotic activity and longer clinical history . lastly , mixed type is characterized by having both the capillary and cavernous structures and similar clinical feature of cavernous type.12 ) treatment options for hemangioma of head and neck area include irradiation , injection of sclerosing agents , embolization , and most effectively , surgical excision.4,6 ) careful surgical dissection is important to exclude malignancy and to prevent recurrence after surgery , which is caused by incomplete excision . embolization and irradiation would be inadequate treatment because embolization alone is not effective if not followed by surgical excision , and irradiation has high complication potential , especially in children.8,9 ) furthermore , surgical dissection is recommended because hemangiomas are hardly spontaneously regressed and their size would be generally increased in adulthood.2 ) in this case , therefore , surgical excision through a preauricular approach was the better treatment than other options . furthermore , no complications or recurrence have been observed yet . hemangiomas are benign vascular tumors that are very rarely seen and reported in a preauricular sinus . from this single case report , the authors emphasize that radiologic findings would be generally insufficient for the correct diagnosis , and careful surgical excision is the treatment of choice .

hemangioma is one of the most common benign neoplasm involved on head and neck . however , cavernous hemangiomas are relatively rare in preauricular sinus space and has rarely been reported around the world . recently , a 44-year - old female patient came to our clinic with cavernous hemangioma involving the preauricular sinus . this case was surgically managed via excision . preoperatively , it was difficult to differentiate the mass of hemangioma clinically and diagnostically from a preauricular fistula , a salivary gland tumor , or an enchondroma . this case report describes the subcutaneous hemangioma on a preauricular sinus , which is rarely seen in korea . the clinical presentation and management are discussed with a review of the literature .

spinal epidural lipomatosis ( sel ) leads to accumulation of adipose tissue within the spinal canal . the excessive fat depositions associated with sel may cause direct mechanical compression of the spinal cord or nerve roots involving the lumbar and thoracic spine.1,2 it is most frequently seen in patients exposed to chronic glucocorticoid therapy and typically presents as back pain , radiculopathy , claudication , and paraparesis.3 diagnosis of sel remains challenging and typically involves computed tomography or magnetic resonance imaging ( mri ) to rule out other conditions such as spinal tumors , spinal abscess , hematoma , disc prolapse , and demyelinating diseases . mri is the most sensitive and specific test for assessing adipose tissue and it may also suggest the histological nature of the compressive lesion.46 the treatment approach depends on the severity of the symptoms and the related neurological impairment . conservative management is indicated for mild symptoms , and consists of weight reduction , tapering of exogenous steroids , and physical therapy . in patients with debilitating symptoms , decompression is achieved through laminectomy and debulking of the hypertrophied epidural fat.4,7 we present the case of a 35 year - old woman who , after hospital admission , developed progressive neurological impairment related to idiopathic sel . a 35 year - old african american woman with a past medical history of type 1 diabetes mellitus and end stage renal disease presented to our emergency room via ambulance after being found unresponsive by her boyfriend at home . the patient had recent complaints of lower extremity weakness and denied use of glucocorticosteroids in the past . her admission weight was 61 kg , and her height was 152 cm ( body mass index [ bmi ] : 26.4 kg / m ) . the patient was initially admitted to our medical intensive care unit with a diagnosis of bacteremia and was found to have a methicillin - sensitive staphylococcus aureus tricuspid valve endocarditis . after initial stabilization , and treatment of her infection , the patient complained of the inability to stand or ambulate , especially on her right side . mri without contrast of the thoracic spine showed extensive epidural fat , consistent with lipomatosis , extending from t1 through t9 ( figure 1 ) . mri with contrast of the thoracic spine confirmed this and failed to show any evidence of epidural abscess . at this point , a posterior decompression laminectomy was performed from t3 through t7 . during surgery , following surgery the patient was eventually transferred to a rehabilitation hospital , where she continued to improve her functional status . the patient continued to improve and was ambulating at follow - up 11 months later . one proposed mechanism implies that elevated levels of cortisol lead to hypertrophy of adipose tissue that is already present in the extradural space of the thoracic and lumbosacral spine.2,8 despite this , approximately 17% of cases are idiopathic.9 typically , males are more commonly affected than females . it has been reported that sel of the thoracic levels causes myelopathy while sel at the lumbar levels results in radiculopathy . the manifestations of this disorder can also mimic other conditions such as : spinal tumors , spinal abscess , hematoma , and demyelinating conditions . treatment of this disorder usually begins with conservative measures such as weight loss along with steroid tapering and analgesics . however , in patients who present with signs or symptoms of spinal compression , the recommended first line treatment is surgical decompression . this procedure has been shown to be effective in a large percentage of case reports for symptomatic relief.3 our case is unusual in that it arose in a non - obese female patient , with no known glucocorticoid exposure and rapid symptom progression . this led to a decompressive laminectomy prior to trial of conservative treatments secondary to the presence of spinal cord compression . this spinal cord compression was established by mri and later confirmed via operative visualization . a second surgical option available instead of laminectomy would be the re - insertion of the lamina with titanium miniplates . this procedure has shown decreased postoperative deformities . however , the rate of postoperative deformity is low ; especially when more than 50% of facet joints are left intact.10 sel should be considered in the evaluation of patients with low back pain , persistent radicular pain and progressive myelopathy , particularly in obese patients or those with chronic steroid exposure .

spinal epidural lipomatosis ( sel ) is a rare condition characterized by overgrowth of normal adipose tissue in the extradural space within the spinal canal that can lead to significant spinal cord compression . it is most commonly reported in patients receiving chronic glucocorticoid therapy . other causes can include obesity and hypercortisolism . occasionally , idiopathic sel will occur in patients with no known risk factors , but cases are more generally reported in obesity and males . we present the case of a 35 year - old non - obese woman found to have rapidly progressive sel that was not associated with any of the common causes of the disorder .

brucellosis is a multi - systemic zoonotic infection which is common in the middle east , central asia , the mediterranean basin and central america . although brucella endocarditis is an uncommon complication , it remains the main cause of brucellosis - related mortality . here we report the clinical and transesophageal echocardiographic findings of an interesting case with brucella endocarditis of an aortic root pseudoaneurysm following bentall operation . a 40-year - old veterinarian with bicuspid aortic valve developed type a aortic root dissection following hypertensive crisis and underwent bentall operation a year ago . four months after the operation , he complained of fever , malaise , arthralgia of the left hip joint , anorexia and weight loss . the erythrocyte sedimentation rate was 103 , wright = 1/1280 and 2-mercaptoethanol ( 2me ) = 1/320 . combination antibiotic therapy with rifampin 900 mg / day per os ( po ) , doxycycline 200 mg / day po and ciprofloxacin was started and continued for 6 months resulted in disappearance of his symptoms . then after he was well untill about 14 days prior to his recent admission , when he again developed hip pain , fever , shortness of breath , profound fatigue and weakness . the erythrocyte sedimentation rate was elevated , his 2me increased from 1/320 to 1/640 . because of recurrence of brucella symptoms , a transthoracic echocardiogram was done which showed a competent non - stenotic prosthetic aortic valve with no vegetation . the mitral and tricuspid valves were normal ; however , there was question of vegetations attached to the inner surface of the dacron wall . bactec blood cultures 5 were obtained and he was empirically started on multiple antibiotics including doxycycline . at this time the patient was transferred to our university hospital . sinus tachycardia , left anterior hemiblock and non - specific st - t wave changes in lateral leads were found in his initial electrocardiogram . an emergency transesophageal echocardiogram and color doppler mapping revealed the detachment of valve - conduit from the annulus and the mitral - aortic intervalvular fibrosa and a large aortic pseudoaneurysm with multiple sessile and mobile vegetations attached to its dacron walls ( fig . 1 and 2 , supplementary movie 1 ) . the prosthetic aortic valve appeared to have normal motion and to be free of any vegetation . color - flow imaging showed the entrance of most of the cardiac stroke volume into a large pseudoaneurysm covering almost the entire circumference and length of the dacron graft as far as it could be seen ( fig . 1 and 2 , supplementary movie 1 ) . a huge pseudoaneurysm was detected at surgery and the whole valve - conduit was replaced with a 25 mm homograft . his condition improved and he was discharged on day 7 , in a stable condition . before discharge , the initial blood and vegetation cultures were reported to be positive for rifampin - resistant brucella melitensis . he was treated with doxycycline 200 mg / day po , plus ciprofloxacin and gentamicin 5 mg / kg / day intramuscularly for 14 days . our patient had a unique presentation namely brucella endocarditis of a pseudoaneurysm of an aortic composite graft . endocarditis following bentall operation is quite rare and life threatening if untreated.1 ) brucellosis is a systemic disease mainly affecting the musculoskeletal system . brucella infection was considered as the possible underlying cause for the dehiscence of the conduit from the aortic annulus and formation of pseudoaneurysm in our patient.2 ) infection of a prosthetic cardiac device is a rare complication of brucellosis ; however , it should be highly considered in any case with recurrent symptoms such as our patient . overall , early diagnosis and prompt medical and surgical interventions are essential for patients ' survival3 ) since endocarditis continues to be the principal cause of mortality in the course of the disease . transesophageal echocardiography and color doppler mapping have become the most popular non - invasive , cost effective and easy - to - do procedure of choice for detection of the complications associated with bentall procedure and composite grafts . these include pseudoaneurysms , which may occur in 7% to 25% of cases , supravalvular aortic stenosis , which occurs less often4)5 ) and endocarditis , which is the least frequent complication and was observed in our patient . in conclusion , this rare case report is additive to the previously reported albeit , infrequent complications of brucella - induced cardiac prosthetic endocarditis.6 ) it emphasizes the need for a high clinical suspicion in susceptible cases , particularly those with recurrent brucellosis and shows the utmost importance of transesophageal echocardiography for the diagnosis and guiding of therapy in such patients .

the occurrence of brucella endocarditis following bentall operation is a rare and life threatening condition , particularly when it is complicated by development of a pseudoaneurysm . here we present a 40-year - old veterinarian with bicuspid aortic valve , who developed type a aortic root dissection and required bentall operation . his past medical history was positive for an episode of treated brucellosis . four months after the operation , he developed signs , symptoms and serological findings of brucellosis for the second time and was treated with antibiotics . then after he was well untill about 14 days prior to his recent admission , when he again developed hip pain , fever , shortness of breath , profound fatigue and weakness . his transthoracic echocardiography was suggestive of endocarditis . a transesophageal echocardiogram revealed detachment of valve - conduit from the annulus and the mitral - aortic intervalvular fibrosa and the presence of a large aortic pseudoaneurysm with multiple vegetations attached to its dacron walls . a huge pseudoaneurysm was detected at surgery and the whole valve - conduit was replaced with a 25 mm homograft . blood and vegetation cultures turned to be positive for brucella melitensis . early echocardiographic diagnosis and prompt surgical intervention were helpful for survival of our patient who had aortic pseudoaneurysm complicated by brucella endocarditis .

eosinophilic fasciitis , first described by shulman in 1975 , is a rare scleroderma - like disease characterized by symmetrical and painful swelling with progressive indurations and thickening of the skin . extracutaneous manifestations may rarely occur and include symmetrical polyarthritis , tenosynovitis , esophageal dysmotility , pulmonary fibrosis , pericarditis and hematologic diseases . the characteristic histological features are fascial inflammation with lymphocytes and eosinophils as well as thickened and fibrotic fascia . the inflammation and fibrosis may extend to the lower dermis , but lymphocytic infiltration and degeneration of the underlying muscle are rarely observed . we report a patient working as a yoga instructor who developed eosinophilic fasciitis on the chest and extremities histologically associated with myositis . a 69-year - old japanese woman , who had practiced yoga for 30 years and had worked as a yoga instructor for the past 2 years , noticed induration of the skin on her chest for 13 months prior to consultation . she also noted exertional pain in the indurated areas , and the number and size of the skin lesions gradually increased . she had no history of l - tryptophan or toxic oil product ingestion or statin medication use . on initial consultation , raynaud 's phenomenon , sclerodactyly , pitting ulcer on the fingers and nail fold bleeding were absent . laboratory examination revealed eosinophilia ( 0.71 10/l , normal < 0.45 10/l ) , but serum creatine kinase , myoglobin , aldolase , igg , iga and igm levels were within the normal limits and antinuclear antibodies were negative . t2-weighted magnetic resonance imaging ( mri ) showed significant hyperintense thickening of the fascia of the lower extremities ( fig . histopathological examination of a biopsy specimen from an area of induration showed marked fibrinoid degeneration of the fascia ( fig . immunohistochemistry manifested predominant cd8 + lymphocytic infiltrates ( fig . 2c ) as well as a limited number of cd4 + lymphocytes ( fig . oral administration of prednisolone ( 0.5 mg / kg / day ) and discontinuation of yoga significantly improved the lesions and pain . there are no universally accepted diagnostic criteria for eosinophilic fasciitis . according to the diagnostic criteria proposed by pinal - fernandez et al . , the patient fulfilled two major criteria , including clinical features and histological findings , and three minor criteria , including eosinophilia > 0.5 10/l , groove sign and/or peau d'orange findings , and a hyperintense fascia on t2-weighted mri . in addition , systemic sclerosis was excluded on the basis of clinical features , laboratory data and histological findings . eosinophilic fasciitis is histologically characterized by a fibrous and inflammatory thickening of subcutaneous septa , fascia and the perimysial collagenous scaffold . macrophages and cd8 + t lymphocytes are reported to be the predominant cells in the inflammatory infiltrate . some cd8 + lymphocytes contain granzyme b , suggesting a cytotoxic cellular immune response in eosinophilic fasciitis , which could be triggered by infectious or environmental agents . although eosinophil infiltrates are present in 6975% of patients with eosinophilic fasciitis , they may be absent at the chronic stage and are not essential for the diagnosis [ 6 , 7 ] . in our patient , eosinophils infiltrating the fascia degranulate locally , resulting in release and accumulation of cationic granules with toxic and potentially fibrogenic properties in the tissues . in the patient with both eosinophilic fasciitis and eosinophilic cellulitis , an abnormal circulating t cell clone and increased interleukin 5 production have been observed , suggesting that this phenomenon might be responsible for eosinophilia and eosinophil - mediated tissue injury . interstitial myositis has been observed in 68% of patients with eosinophilic fasciitis , but clinical myositis and muscle degeneration are rarely reported . in the present case , the degree of myositis was limited , and serum creatine kinase , aldolase and myoglobin levels were within normal ranges . in some cases of eosinophilic fasciitis , elevated creatine kinase levels and abnormal electromyographic changes have been reported . typically , in the acute phase of the disease , muscle mri shows a markedly increased signal intensity within the fascia on fluid - sensitive sequences and a remarkable fascia enhancement after gadolinium administration in up to 80% of patients . in the present case , involvement of the trunk and morphea - like skin lesions are recognized risk factors for the development of persistent fibrosis and resistance to therapies . in spite of a good response to systemic steroid therapy thus far , long - term physical therapy and follow - up are needed in the present patient , who had both truncal involvement and morphea - like skin lesions . eosinophilic fasciitis can be triggered by drugs , toxic exposure , physical exertion , bacterial infection and associated diseases such as autoimmune diseases , hematologic diseases and solid neoplasms . among these , 3046% of eosinophilic fasciitis patients have a history of intense physical exertion or trauma associated with the onset of the disease [ 2 , 6 ] . the present patient had practiced yoga for 30 years and had been a yoga instructor for 2 years before the onset of symptoms . in yoga , individuals maintain specific postures and perform exercises involving stretching of the extremities and bending of the trunk and/or extremities . the exercises are usually synchronized with breathing and are practiced by many for health and relaxation . although the affected area of the skin overlaid muscles being exercised in the present case , it is unclear whether the skin eruptions were caused by exercise .

eosinophilic fasciitis is clinically characterized by symmetrical scleroderma - like indurations of the skin with pain . the histological features are fascial inflammation with lymphocytes and eosinophils as well as thickened and fibrotic fascia . lymphocytic infiltration and degeneration of the underlying muscle are rarely observed . we report a 69-year - old japanese woman who presented with multiple areas of glossy induration and painful peau d'orange - like lesions on the chest and four extremities . t2-weighted magnetic resonance imaging showed significant hyperintense thickening of the fascia of the lower extremities . histopathological examination of a biopsy specimen from the induration showed marked fibrinoid degeneration of the fascia and the neighboring muscle with mixed cellular infiltration of lymphocytes and eosinophils . the predominant cd8 + lymphocytic infiltrates were observed by immunohistological study . a diagnosis of eosinophilic fasciitis with myositis was made . oral administration of prednisolone and discontinuation of exercise significantly improved the lesions and pain .

the diagnosis was accredited to claudius amyand , who was the first person to describe the condition in 1735 . the entity is rare with a reported incidence of 0.5 - 1% for those associated with normal appendix . we hereby present , to the best of our knowledge , the first case of recurrent nonperforated amyand 's hernia repaired with a biological mesh . a 71-year - old male patient presented to the emergency department with an acute onset of a right groin pain of 24-hour duration . his surgical history includes a plug and patch ( ultrapro hernia system ) repair of a symptomatic right inguinal hernia 17 months earlier and a sigmoid resection for complicated diverticulitis 20 years earlier . a physical examination revealed a nontoxic appearing male with an exquisitely tender , nonreducible , small right inguinal hernia . his laboratory results revealed a leukocyte count of 9.2 10/mm(normal ( 4.3 - 10.8 ) 10/mm ) . a right incarcerated recurrent inguinal hernia was suspected , and this was confirmed by a computed tomography scan [ figure 1 ] . the patient was therefore taken to the operating room emergently for right groin exploration . at exploration , a chronically incarcerated , inflamed appendix within the indirect hernia sac [ figure 2 ] was identified . appendectomy was performed through the groin incision , and the indirect hernia was repaired with a biological mesh ( flex - hd ) due to the contaminated field [ figure 3 ] . the postoperative period was uneventful , and the patient was discharged home 2 days after the surgery . at 5-month follow - up , ct scan of abdomen / pelvics showing incarcerated amyand 's hernia ( arrow indicates inflammed appendix within the hernia sac ) appendix within the indirect hernia sac final repair with a biological mesh amyand 's hernia was credited to claudius amyand after he performed the first reported successful appendectomy in an 11-year - old boy in 1735 . the patient presented with an enterocutaneous fistula due to the perforation of the appendix by a pin within an inguinal hernia sac . the procedure lasted half an hour and involved an open appendectomy with the primary repair of the hernia defect . ironically , the first appendectomy in the united states occurred in 1887 and was also a case of appendicitis in an inguinal hernia . the appendix can also be found in a femoral hernia , which is known as de garengeot hernia . the reported incidence of a normal appendix within the inguinal hernia is approximately 1% ; however , the presence of appendicitis in the inguinal hernia is only 0.l% . left - sided amyand had been described,[79 ] and it is often associated with situs inversus , mobile cecum , and malrotation of the intestines.[79 ] most patients present with a nonreducible and tender inguinal hernia . preoperative diagnosis is difficult , but imaging with computed tomography ( ct ) scan can suggest the diagnosis , as was in our case . management is surgical and it is based on intraoperative findings according to losanoff : type 1 - normal appendix ; type 2- inflamed appendix ; type 3 - inflamed appendix with abdominal sepsis or perforated appendix ; type 4- inflamed appendix and other unrelated abdominal pathology . the management of losanoff type 2 - 4 requires appendectomy followed by primary hernia repair . the use of a prosthetic mesh to repair amyand 's hernia with losanoff type 2 - 4 findings has been reported . the management of losanoff type 1 requires hernia repair with or without appendectomy , and this is very controversial . proponents for routine appendectomy believe that the removal of the appendix at the first operation will decrease the risks of appendicitis and future surgery . however , antagonists to this practice argues that leaving the appendix in situ will allow for the use of a prosthetic mesh for the hernia repair and future use of the appendix as a conduit for urinary diversion when the need arises . in the present case , routine appendectomy was deferred in the first operation because of the intraoperative finding of losanoff type 1 amyand . at recurrence , the appendix was incarcerated , inflamed , and injected , and this prompted immediate appendectomy . we used flex - hd for the repair , and this is an acellular hydrated dermal matrix derived from human allograft skin developed by ethicon through alliance with musculoskeletal transplant foundation ( http://www.ethicon360.com/products/flex-hd-acelular-hydrated-dermis-family ) . similar to other biological meshes , this allograft serves as a scaffold to support cellular repopulation and vascularization . amyand 's hernia is a rare entity with diverse presentation , preoperative diagnostic dilemma , and requirement of knowledge of two surgical problems : symptomatic hernia and appendicitis . management is surgical and includes hernioplasty with or without appendectomy depending on the intraoperative findings , and routine prophylactic appendectomy is not indicated . the biological mesh plays a role in the management of losanoff type 2 - 4 amyand 's hernia . the views expressed in this case report are those of the authors and do not reflect the official policy of the department of the navy ( don ) , department of army ( doa ) , department of defense ( dod ) , or us government . the views expressed in this case report are those of the authors and do not reflect the official policy of the department of the navy ( don ) , department of army ( doa ) , department of defense ( dod ) , or us government .

amyand 's hernia is a rarity and a recurrent case is extremely rare . a 71-year - old male with a previous history of right inguinal hernia repair presented to the emergency department with a 1-day history of pain in the right groin . a physical examination revealed a nonreducible right inguinal hernia . a computed tomography scan showed a 1.3-cm appendix with surrounding inflammation within a right inguinal hernia . an emergent right groin exploration revealed an incarcerated and injected non - perforated appendix and an indirect hernia . appendectomy was performed through the groin incision , and the indirect hernia defect was repaired with a biological mesh ( flex - hd ) . we hereby present this unique case the first reported case of recurrent amyand 's hernia and a literature review of this anatomical curiosity .

in this issue yu and coworkers present data on variation in treatment patterns for severe sepsis using a large cohort of patients at eight academic medical centers in the usa . this cohort was described previously by the same authors in a landmark paper exploring the epidemiology of severe sepsis . their new findings are that treatment patterns varied widely across the eight hospitals , despite the fact that the hospitals were all teaching centers and all in the same country . although those investigators explored associations between the use of several elements of care and subsequent hospital mortality , the only significant correlation was that of delayed antibiotic use with higher mortality a finding reported by others . second , should we be surprised that the variation was generally not associated with differences in outcome ? variation due to differences in patient case - mix can be appropriate and represents individually titrated care . variation not explained by differences in case - mix is more concerning , and suggests that some patients are receiving more care than necessary whereas others receive less . yu and coworkers report significant ' residual ' variation not obviously explained by differences in case - mix . one might argue over the rigor with which one can satisfactorily control for case - mix differences , but we generally concur with the authors ' findings . whether this variation matters depends on the effect on outcomes . there are two broad sets of outcomes economic and patient - centered . generally , more intense care is more expensive . although there are instances when ' more care sooner ' may offset downstream costs , as suggested recently with early - goal directed therapy , greater use of interventions usually drives health care costs up . this is an unwanted outcome unless patient - centered outcomes improve as a consequence . that yu and coworkers did not show differences in patient - centered outcomes certainly , there is mounting evidence that some of the studied interventions , such as application of the pulmonary artery catheter , have very small effects at best . however , this explanation is insufficient because it is likely that some of the interventions , given their potent physiologic effects , have some influence on outcome . for example , better titration of care secondary to information gained by pulmonary artery catheter use may be offset by complications of catheter use , such as pulmonary embolism or bloodstream infection . third , although interventions have potential benefits , failure to administer them at the right time to the right patients obscures any benefit . for example , aggressive resuscitation in the early phase of severe illness improves patient outcomes , as with early goal - directed therapy , but can cause harm if used later in the course of illness . fourth , the simultaneous study of multiple interventions , used variably in an uncontrolled manner , precludes isolation of treatment effects , given the constraints of sample size and analytic techniques in this particular study . thus , it appears there is variation that is unexplained by differences in case - mix and associated with increased costs , yet there is no obvious gain in patient - centered outcome . , we knew how to control infection but other elements of care were highly empiric . at that time there was no knowledge of the ' appropriate ' rate of use of many modalities . today , we have much better evidence to direct care of critically ill patients [ 9,15 - 20 ] . for example , sepsis care involves control of infection , organ support , and manipulation of the sepsis cascade . control of infection is achieved through prompt administration of antibiotics and surgical drainage when appropriate . organ support is more complicated , but better understood when broken down into its component parts . treatment for respiratory failure includes a trial of noninvasive positive pressure ventilation before intubation . once intubated , patients should have spontaneous breathing trials , daily awakening , continuous or frequent subglottic suctioning , h2 blockade , and semirecumbent positioning . if the patient develops acute respiratory distress syndrome , then the tidal volume should be lowered to 6 ml / kg . similarly , cardiovascular support includes early - goal directed therapy , metabolic support includes tight insulin control , and renal support includes avoidance of low - dose dopamine . finally , we can now manipulate the sepsis cascade with drotrecogin alpha ( activated ) and steroids . the problem is that it is unclear whether we are adopting this evidence into practice . several recent studies have demonstrated that publication of trial results have no impact on physician practice , even within the institutions that one would think are most likely to incorporate new evidence , for example teaching hospitals and hospitals that participate in trials [ 27 - 30 ] . in addition , of course , there is a plethora of information from other fields about the slow diffusion of evidence to the bedside . for example , despite strong clinical evidence of the benefits of thrombolytic therapy for myocardial infarction , it was only slowly accepted into routine cardiology practice . thus , the findings of yu and coworkers may well still hold today , despite a far clearer roadmap for optimal sepsis care . so , what can we do going forward ? by measuring rates of modality use , yu and colleagues are describing processes . at the time of the study , we did not know which processes were best for many elements of care . that has changed . now that we know what use is ' appropriate ' , we could measure compliance with these processes to inform on the quality of care . analogous to measuring -blocker use after myocardial infarction , we could operationalize simple measures to reflect the consistency and quality of our organ support and sepsis management . for example , each day a given patient is on a ventilator , the following checklist could be reviewed : has the patient had a spontaneous breathing trial today ? ; has sedation been interrupted to allow full wakening ? ; and is the head of the bed elevated ? a rate of ' appropriate ventilator management ' is thus easily calculated by dividing the number of ' yes ' days by the total number of ventilator days . in contrast , outcome measures , such as standardized mortality ratios , require far greater resources and are fraught with controversy . in part because of their simplicity , the joint commission on accreditation of healthcare organizations ( an independent , not - for - profit organization that sets the standards by which health care quality is measured in the usa ) will begin to implement process measure based evaluations of hospitals as soon as 2004 ( pronovost p , personal communication , april 2003 ) . however , process measures need not be confined to the ' judges ' of our care . asking the resident each morning , ' has the patient had a spontaneous breathing trial in the past 24 hours ? ' and so on , is a big step forward in increasing process measurement and decreasing variability . in conclusion , yu and coworkers have held a mirror to our practice . they point out the variability that , given the literature from other fields , we might even have predicted . the challenge is not to accept this information passively . with emerging evidence of the ' right ' way to provide critical care , we can hope that a mirror to our future care will show us less variability and greater quality of care . dca is supported by ahrq / nhlbi ( r01 hs / hl11620 - 02 ) , nhlbi ( r01 hl69991 - 01 ) , nigms ( r01 gm61992 - 01 ) and the robert wood johnson foundation .

there is important variation in the care of critically ill patients . while some of this variability is appropriate , and represents individually titrated care , residual variation indicates over- and under - use of precious resources and is clearly concerning . recent advances in critical care medicine provide " road maps " to standardize care and use evidence - based medicine to improve patient outcomes . knowledge about which therapies to use , and under what circumstances to use them , could form a basis for measuring the consistency and quality of our care processes . these simple process measures can be easily incorporated into daily rounds and serve to inform on the quality of our care .

historically , the interest in these syndromes began in the 19 century and essentially focused on the adrenal cortex . in 1849 , thomas addison first described the clinical and pathologic features of adrenocortical failure in patients who also appeared to have coexisting pernicious anemia . in 1981 , neufeld and colleagues distinguished two major polyglandular autoimmune ( pga ) syndromes , and other authors subsequently began to add to our knowledge of these conditions . in 2004 , the frequency of type ii pga in humans is rare , being described in about 1.4 - 4.5/100,000 inhabitants . the case we present here is a 38-year - old female patient who presented to emergency department in a state of shock with a history of recurrent vomiting , abdominal discomfort , and mild fever since last 3 days . on direct inquiry , she gave a history of anorexia , weight loss , postural blackouts , and generalized weakness since last 6 months . she was mother of two children and had amenorrhea since last 8 years . on examination patient was thin built with body mass index 22 . based on these investigations , we found that patient had multiple endocrine insufficiencies , including addison 's disease ( decreased cortisol level and increased adrenocorticotropic hormone level ) , hypothyroidism ( decreased free t4 and increased thyroid - stimulating hormone ) and primary ovarian failure ( amenorrhea with increased follicle - stimulating hormone and luteinizing hormone ) . patient was initially treated with intravenous fluids , antibiotics , and dopamine infusion , but the patient 's condition did not improve . after investigations showed addison 's disease and hypothyroidism intravenous hydrocortisone and oral l - thyroxine she improved with these measures and could be discharged after 1 week on oral prednisolone , fludrocortisone , l - thyroxine , estrogen and progesterone . autoimmune polyendocrine syndrome type ii ( aps ii ) occurs primarily in adulthood , usually around the 3 and 4 decades of life . it is associated with human leukocyte antigen ( hla)-dr3 and/or hla - dr4 haplotypes , and the pattern of inheritance is autosomal dominant with variable expressivity . the individual is then exposed to the autoimmune trigger , which could be an environmental or intrinsic factor . next , a subclinical phase of active production of organ - specific auto antibodies occurs . aps ii consists of addison 's disease plus either an autoimmune thyroid disease or type i diabetes mellitus associated with hypogonadism , pernicious anemia , celiac disease , recent primary biliary cirrhosis , myasthenia gravis , parkinson disease , vitiligo , alopecia and seronegative arthritis . the clinical features consist of a constellation of the individual endocrinopathies . clinical history and examination suggesting evidence of > 1 endocrine deficiency should prompt testing , to include serum autoantibody screening and an evaluation of end - organ function . the screening panel includes autoantibodies to 21-hydroxylase , 17-hydroxylase , thyroid peroxidase , glutamic acid decarboxylase , islet cells , antitissue transglutaminase antibodies , parietal cell and anti - intrinsic factor antibodies . currently , the treatment of the apss is dictated by the individual disorders . with the exception of celiac disease and graves disease , clinically overt syndrome is considered only the tip of the iceberg , since latent forms are much more frequent . organ - specific autoantibody screening in patients with monoglandular autoimmune endocrinopathies facilitates the identification of those at risk of developing a future aps . early identification and treatment of associated autoimmune endocrine disease

autoimmune polyendocrine syndrome type ii ( aps ii ) , also known as polyglandular autoimmune syndrome type ii or schmidt syndrome , is constellations of multiple endocrine gland insufficiencies . it is a rare , but most common of the immunoendocrinopathy syndrome . it is characterized by the obligatory occurrence of autoimmune addison 's disease in combination with thyroid autoimmune diseases and/or type i diabetes , hypogonadism , hypophysitis , myasthenia gravis , vitiligo , alopecia , pernicious anemia , and celiac disease . here , we report a case of 38-year - old female patient presented with shock , further diagnosed to have aps ii .

the occurrence of autoimmune bullous disease in a child is very rare [ 1 , 2 , 3 ] . pemphigus vegetans is the rarest form of pemphigus , occurring only in 12% of all cases [ 2 , 3 ] . it is characterized by vegetative plaques in the inguinal folds , flexural areas , and oral mucosa accompanied by the presence of autoantibodies against desmoglein 3 [ 4 , 5 ] . the involvement of oral mucosa is usually associated with severe pain , eventually leading to weight loss and malnutrition . marasmus , a type of protein - energy malnutrition , could affect immunity and increase the risk of infection . in this report , we would like to present the first case of pemphigus vegetans in a child with marasmus . even though the exact underlying mechanism is yet to be fully understood , we try to describe the possible mechanisms in this condition and stress the importance of a multidisciplinary approach for a successful treatment . a 12-year - old boy in marasmic condition presented with painful , clear , fluid - filled blisters accompanied by crusts on almost the entire body . three and a half years later , he complained of extreme pain in the mouth , which resulted in poor ability of oral food intake . blisters and vegetative lesions soon followed . physical examination showed a slender body , with a height of 130 cm , a weight of 22 kg , and a bmi of 13.01 . blisters , erosions , and hemorrhagic crusts with hypertrophic verrucous vegetative plaques were found on the armpits , trunk , extremities , and in the perianal region ( fig . histopathological examination on the vegetative lesions found on the extremities revealed a suprabasal cleft with scattered acantholytic cells and hyperkeratosis . direct immunofluorescence ( dif ) staining showed deposits of immunoglobulin g on the surface of the keratinocytes ( fig . he was given a diet of 1,500 kcal / day , consisting of soft food ( 3 times / day ) and an extra liquid diet ( 3 times 100 ml ) as a collaborative treatment from the pediatric and nutrition departments . significant improvements in the skin lesions and nutritional status were observed within 15 days after the start of treatment . erosions have a tendency to develop into granulation tissue and crusting , known as vegetative lesions , often found on the groin , armpits , thighs , hands , eyelids , and in the perioral region . this lesion was caused by intercellular autoantibodies against desmoglein 1 and 3 as adhesion molecules in the desmosomes of keratinocytes [ 1 , 2 ] . the diagnosis of pemphigus vegetans was based on clinical features , histopathology examination , and a dif test . most patients initially present with stomatitis , which was also the case in our patient . diagnostic findings for pemphigus vegetans included eosinophilic spongiosis , suprabasal acantholysis , epidermal hyperplasia , and intraepidermal abscesses filled with eosinophils as the lesions age , while dif examination showed deposits of immunoglobulin g and complement c3 on the keratinocytes , which were evident in the biopsy of our patient 's vegetative lesions . concurrent development of autoimmune bullous disease and marasmus indicated the variability of the immunological mechanisms of the disease . gerriets et al . presented a case of malnutrition leading to decreased adipocyte mass , thus changing the cd4 + and cd8 + count and by extension , their functions . this condition is associated with a decrease in th1 cytokines interleukin-2 and interferon- , eventually resulting in an increased susceptibility to infection and protection against autoimmunity . on the other hand , a case report by bull et al . showed an association between human immunodeficiency virus ( hiv ) infection and autoimmune bullous diseases . one possible underlying mechanism for autoantibody production in this disease was as a part of nonspecific polyclonal stimulation seen in the early - stage hiv disease . another possible underlying mechanism was that the loss of specific immunomodulatory cd4 + allows the expansion of b - cell clones responsible for the production of autoantibody . assuming that patients with malnutrition have similar conditions as hiv - infected patients , alteration of cd4 + function may be considered as one possible underlying mechanism for the development of autoimmune disease in malnutrition . however this finding suggests that marasmus may have several effects on the immune system , leading to the development of autoimmune bullous disease . other related cases could further enlighten us of the complex association between autoimmune diseases and marasmus . prednisone is usually administered in a dosage of 12 mg / kg body weight / day . this patient received 6 mg / day intravenous dexamethasone ( equals to 2 mg / kg body weight / day of prednisone ) for 2 weeks , and there was a significant improvement in his skin condition , indicated by the lack of new lesions . an appropriate ongoing intravenous fluid regimen was started under the guidance of the medical team . from the pediatric and nutrition departments , the patient 's initial weight at admission was 22 kg , and after 2 weeks of treatment , it had increased to 23.7 kg . with this case report we hope to add to the knowledge of the underlying mechanism of pemphigus vegetans in marasmus patients and the importance of a multidisciplinary approach to improve outcomes .

pemphigus vegetans is a clinical variant of pemphigus vulgaris , accounting for 12% of all very rare pemphigus cases in children . the involvement of the oral mucosa in this disease is usually accompanied by severe pain that aggravates the patient 's malnourished condition . conversely , malnutrition may also reduce vulnerability towards autoimmune diseases . although pemphigus vegetans has never been reported to develop in a child with marasmus before , we encountered a case of pemphigus vegetans in a severely malnourished patient . a 12-year - old boy in marasmic condition presented with painful , clear , fluid - filled blisters , accompanied by erosions , crusts , and vegetative lesions on almost all parts of the body . histopathological examination of the lesions revealed a suprabasal cleft , and direct immunofluorescence staining showed deposits of immunoglobulin g in the epidermal intracellular spaces . the patient was treated with a multidisciplinary approach , and intravenous corticosteroid was administered for 2 weeks with an appropriate diet . there were significant improvements in the skin lesions and his nutritional status . although pemphigus vegetans may occur in children with malnutrition , the underlying mechanism for the development of autoimmune diseases in malnutrition remains unclear .

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

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

we used a longitudinal health insurance database for people with catastrophic illnesses including md and cancer provided by the taiwan health research institute . patients newly diagnosed with md and free of cancer would be eligible in our cohort ( icd-9-cm codes : 359.0 - 359.2 ) . we skipped the first two years ' data of the health insurance program in taiwan to ensure new md cases and selected individuals whose first - ever issue of md certificate occurred during the period 1997 - 2009 . the first - ever cancer status was also obtained by linkage to the catastrophic illness database ( icd-9-cm codes : 140 - 208 ) . we calculated background cancer incidences for the general population from the cancer registry provided by the bureau of health promotion in taiwan during the same period . age- and sex - standardized incidence ratios ( sirs ) , taken as the observed number of cases divided by the expected number of cancer cases , were used as measures of relative risk , and 95% confidence interval ( ci ) was calculated after assuming a poisson distribution of the observed number of cancers . the sas statistical software ( sas system for windows , version 9.1.3 ; sas institute , cary , nc , usa ) was used to perform statistical analysis table 1 demonstrates the characteristics of patients with md ( icd-9-cm codes : 359.0 - 359.2 ) . because myotonic md ( icd-9-cm code : 359.2 ) was not considered a catastrophic illness until 2005 , only 82 patients were registered and no cancer was observed in this group . for congenital md ( icd-9-cm code : 359.0 ) and progressive hereditary md ( icd-9-cm code : 359.1 ) , there were 685 and 505 cases ( males : 69.5% and 80.6% ) , the median ages at diagnosis were 16 and 13 years , and the mean follow - up durations were 7.12 and 5.06 years , respectively . cancers were reported in 10 patients with congenital md and in 3 patients with progressive hereditary md during the study period . females exhibited an increased cancer risk , yielding an sir of 3.37 ( 95% ci = 1.38 - 8.25 , p = 0.008 ) in congenital md and 2.95 ( 95% ci = 0.95 - 9.19 , p = 0.062 ) in hereditary progressive md . we report here a population - based study with the largest sample of congenital and hereditary progressive md cases to date to address their cancer incidence ratios relative to general population in taiwan . as an innate limitation , age at diagnosis is merely a proxy variable for the actual age of onset in md patients . the median age at diagnosis of md patients was practically higher than the expected age of onset . furthermore , we could not identify the exact md subtype based on the icd-9-cm code numbers . accordingly , it is difficult to explain why the median age at diagnosis of patients with congenital md was paradoxically older than that of patients with hereditary progressive md . regardless of these pitfalls , the study is still reliable to test the hypothesis that genetic defects in md may be associated with an increased cancer risk . first , the statistical power for cancer risk may be underestimated because of a time lag for md diagnosis . second , if the dataset of md ( icd-9-cm codes : 359.0 - 359.1 ) are combined to eliminate misclassifications , there will be no bias for total cancer risk in each sex population , yielding an sir of 3.18 ( 95% ci = 1.57 - 6.46 , p = 0.001 ) for females and 1.07 ( 95% ci = 0.44 - 2.63 , p = 0.876 ) for males . in our study this finding is in contrast to that of gadlalla et al . , which showed that both male and female patients with myotonic md have an increased cancer risk . this disparity may be reasoned by small samples of male patients and a high mortality in affected males with x - linked recessive md in early adulthood , leading to a reduced cancer incidence , . interestingly , most cancers were observed after 40 years of age , supporting that a longer life span is needed for cancer development . in conclusion , genetic defects in hereditary md may increase cancer risks in females , and a sex difference should be further investigated .

muscular dystrophies ( md ) comprise a heterogeneous group of hereditary myopathic diseases . in this group , myotonic md is associated with an increased cancer risk . however , the cancer risk in other types of md is unclear . to address this gap in knowledge , we assessed data obtained from the taiwan health insurance program database . a total of 1,272 patients with md diagnosed between 1997 and 2009 were enrolled . they were followed up for cancer during the same period by record linkage with the cancer certification in taiwan . age- and sex - standardized incidence ratios ( sirs ) of overall and site - specific cancers were calculated . for congenital and progressive hereditary md , there were 685 and 505 cases ( males : 69.5% and 80.6% ) , the median ages at diagnosis were 16 and 13 years , and the mean follow - up durations were 7.12 and 5.06 years , respectively . in addition , cancers were developed in 10 patients with congenital md and 3 patients with progressive hereditary md . female md patients exhibited an increased cancer risk , yielding an sir of 3.37 [ 95% confidence interval ( ci ) = 1.38 - 8.25 ] in congenital md and 2.95 ( 95% ci = 0.95 - 9.19 ) in hereditary progressive md . site - specific cancer sirs were not powered to be significantly different . in conclusion , genetic defects in hereditary md may increase cancer risks in females and a sex difference should be further investigated .

genus arcanobacterium comprises the species arcanobacterium haemolyticum , arcanobacterium hippocoleae , arcanobacterium pluranimalium , and arcanobacterium phocae . more recently a. canis and a. phocisimile were described as novel species of this genus [ 2 , 3 ] . arcanobacterium pyogenes together with arcanobacterium bernardiae , arcanobacterium bonasi , and arcanobacterium bialowiezense was reclassified to the newly described species trueperella . the original description of a. phocisimile was based on physiological and biochemical characteristics , chemotaxonomic analysis , and 16s rdna sequencing results of two strains isolated with several other bacterial species from a vaginal swab and an anal swab of two free living harbour seals of the german north sea . in the present study both initially described a. phocisimile strains and three additional strains obtained from three harbour seals were identified and further characterized phenotypically by maldi - tof ms analysis and genotypically by amplification and sequencing of various molecular targets . the a. phocisimile strains used in the present study included the previously described type strains a. phocisimile 2698 ( lmg 27073 ; ccm 8430 ) and a. phocisimile 4112 . additionally investigated a. phocisimile 3047 was isolated ( post mortem ) together with bacillus spp . , enterococcus spp . , erysipelothrix rhusiopathiae , and -haemolytic streptococci in the year 2005 from the lung of a female harbour seal with bronchopneumonia and perforation of stomach . the harbour seal was found dead in rantum , sylt of the german north sea . also investigated a. phocisimile -haemolytic streptococci from an anal swab and a. phocisimile 4125 together with pseudomonas spp . and -haemolytic streptococci also from an anal swab of two apparently healthy female harbour seals , respectively . a. phocisimile 4113 and a. phocisimile 4125 were isolated in 2007 during a monitoring program of free living harbour seals of the german north sea . all three newly investigated a. phocisimile strains were initially characterized phenotypically and by 16s rdna sequencing [ 3 , 4 ] . both a. phocisimile strains previously mentioned in the species description and the three a. phocisimile strains of the present study were further analysed by maldi - tof ms and genotypically by amplification and sequencing of the previously described molecular target 16s-23s rdna intergenic spacer region ( isr ) and the genes rpob and gap [ 4 , 6 , 7 ] . all three strains newly characterized in the present study could reliably be identified as a. phocisimile by phenotypic properties and by 16s rdna sequencing . the phenotypic properties appeared to be almost identical to both previously characterized a. phocisimile strains ( table 2 ) . however , a positive pyrazinamidase reaction of a. phocisimile seems to be the only reliable biochemical property for differentiation of a. phocisimile from pyrazinamidase negative a. phocae . as shown by numerous authors maldi - tof ms is a powerful tool for species characterization of a broad spectrum of gram - positive and gram - negative bacteria [ 810 ] . this technique had previously been successfully used for rapid and reliable identification of bacteria of genera arcanobacterium and trueperella [ 5 , 11 ] . the maldi - tof ms analysis of the present study revealed that by using the current bruker data base , all five strains of this hitherto unknown species could not be identified to species level . however , using the maldi biotyper 3.1 software package the log ( score ) values of a. phocisimile 4112 , a. phocisimile 3047 , a. phocisimile 4113 , and a. phocisimile 4125 matched against a. phocisimile 2698 with log ( score ) values between 2.69 and 2.74 indicating that all five strains belong to this newly described species . inclusion of a. phocisimile in the bruker reference database will allow for the identification of this new species in future . a dendrogram analysis of the maldi - tof ms results is presented in figure 1 . the genotypic classification by 16s rdna sequencing revealed that the three novel a. phocisimile strains of the present study yielded 100% identity to both a. phocisimile strains described previously , also including the type strain a. phocisimile 2698 ( figure 2 ) . comparable to previously described a. canis all five a. phocisimile from the present study could additionally be classified by amplification and sequencing of isr ( fn563000 , fn563002 , hg316083 , hg316084 , and hg316085 ) , gene rpob ( hg316078 , hg316079 , hg316080 , hg316081 , and hg316082 ) , and gene gap ( hf679531 , hg316074 , hg316075 , hg316076 , and hg316077 ) yielding for all three molecular targets an identity of 99.4% , 99.8% , and 99.8% , respectively , for all five strains among each other . a typical dendrogram using the sequencing results of the target genes the results of the present study revealed that phenotypic properties , the determination of peptidic spectra by maldi - tof ms , and the various genotypic targets allow for a reliable identification of a. phocisimile and a further differentiation of a. phocisimile from closely related a. phocae which could also be isolated from marine mammals . however , all a. phocisimile strains of the present study were isolated together with various other bacteria , partly from obviously healthy animals , indicating that the pathogenic importance of this species for marine mammals remains unclear . arcanobacterium phocisimile type strain and four additional a. phocisimile strains isolated from harbour seals were identified phenotypically , by matrix assisted laser desorption ionization time of flight mass spectrometry ( maldi - tof ms ) , by sequencing 16s rdna , and , as novel molecular targets , by sequencing 16s-23s rdna intergenic spacer region and the genes rpob and gap indicating that maldi tof ms and the molecular targets might help to identify this novel species .

arcanobacterium phocisimile , a newly described species with the type strain a. phocisimile 2698 t isolated from a vaginal swab of a harbour seal and four additional a. phocisimile strains also isolated from four harbour seals could reliably be identified by phenotypic properties , by matrix assisted laser desorption ionization time of flight mass spectrometry ( maldi - tof ms ) , and by sequencing the genomic targets 16s rdna and 16s-23s rdna intergenic spacer region and the genes rpob and gap . the a. phocisimile strains investigated in the present study were isolated together with several other bacterial species indicating that the pathogenic importance of a. phocisimile remains unclear . however , the detection of peptidic spectra by maldi - tof ms and the presented phenotypic and genotypic approach might help to identify a. phocisimile in future .

in the previous issue of critical care , huang and colleagues try to answer the unresolved question of the prognostic value of sepsis - related cardiomyopathy . since margaret parker and colleagues originally reported in 1984 that 65% of patients had significant left ventricular ( lv ) systolic dysfunction in the early phase of sepsis associated with acute lv dilatation ( > 100% increase in size ! ) and that such patients had a better prognosis , various groups have failed to replicate these results , leading to confusion and controversy . the article by huang and colleagues is interesting because it reports a large meta - analysis including more than 700 septic patients available for lv analysis . the meta - analysis failed to find any evidence for a protective effect of a decreased lv ejection fraction ( ef ) . nevertheless , the nonindexed lv dimension was moderately higher among survivors than nonsurvivors . these results have to be interpreted with caution since in most studies included in the meta - analysis patients with lv systolic dysfunction received inotropic drugs . in the study by cariou and colleagues in 10 patients , most patients were infused with epinephrine or dobutamine . in the study performed by our group in 68 patients , bouferrache and colleagues reported recently that dobutamine significantly improves the macrocirculation in patients with a low flow state who show a 40% increase in cardiac output despite normal venous oxygen saturation . de backer and colleagues demonstrated that the proportion of functional capillaries was decreased in septic patients compared with volunteers and that dobutamine , by inducing a 21% increase in cardiac output , led to a nearly complete reversal of such alterations . in the study by rivers and colleagues , demonstrating a better prognosis in the early goal - directed therapy group , close to 14% of patients received dobutamine in the first 6 hours in the interventional group versus 0.8% in the control group . finally , rhodes and colleagues , kumar and colleagues , and vallet and colleagues reported similar results - a huge decrease in mortality in septic patients who respond to dobutamine in terms of cardiac output [ 9 - 11 ] . more interestingly , however , the article by huang and colleagues allows us to try to clarify the meaning of lv function in septic shock patients . a lot of confusion exists . in all experimental models of septic shock , lv contractility impairment - called septic cardiomyopathy - has been reported to be constant . in these studies , as in the study by barraud and colleagues , intrinsic contractility is assessed using a parameter that is not dependent on load conditions ; that is , systolic elastance . unfortunately , this assessment requires the generation of pressure / volume loops , something difficult to achieve in human subjects at the bedside . this difficulty is why in clinical practice most intensivists use lv systolic function parameters that are for the most part dependent on load conditions . more than 20 years ago , robotham and colleagues nicely reiterated that lvef reflects the coupling between lv contractility and lv afterload . in other words , a normal lvef may be observed when the arterial tone is severely depressed , despite seriously impaired intrinsic lv contractility . everyone understands that it is crucial to remember this in septic shock , in which arterial tone is initially severely decreased . lv systolic function , evaluated using an echocardiograph or another device , is more a reflection of arterial tone ( and its correction ) than of intrinsic lv contractility . in a 1990 study , jardin and colleagues elegantly showed that patients with a normal lvef had a significantly lower systemic vascular resistance than patients with a low lvef in whom resistance was corrected . as shown in figure 1 , it is then easy to understand that the incidence of lv systolic dysfunction greatly depends on the time of the evaluation . this dependence only reflects the fact that , during resuscitation and treatment , vasoplegia and then lv afterload are corrected , thus unmasking septic cardiomyopathy . h6 , h12 , h24 , h72 , the time ( hours ) between admission and echocardiographic evaluation . with these points in mind , we can revisit the results of margaret parker and colleagues ' study : it is not that the patients with a low ef survived better , but rather that the other patients had an increased mortality due to persistent profound vasoplegia . this was suggested by our group in a study where 100% of patients with a hyperkinetic state ( lvef 67 7% ) finally died , compared with ' only ' 43% of patients with a hypokinetic state ( lvef 34 10% ) . weng and colleagues showed recently that high peak systolic velocity measured at the mitral annulus by tissue doppler imaging might be associated with mortality in patients with septic shock , suggesting that profound vasoplegia inducing high contractility is linked to poor prognosis . in conclusion , it will be very difficult to demonstrate that lv systolic dysfunction is associated with prognosis . septic cardiomyopathy is constant and lv systolic function is more a reflection of the status of lv afterload . rather , we have now to demonstrate what the best mortality - reducing strategy is when there is lv systolic dysfunction . persistence of a hyperkinetic state is a warning signal suggesting that the septic process is not under control and that the patient has a high probability of dying .

the meta - analysis of huang and coworkers failed to find any evidence for a protective effect of a decreased left ventricular ( lv ) ejection fraction ( ef ) . these results have to be interpreted with caution since in most studies included in the meta - analysis patients with lv systolic dysfunction received inotropic drugs . we have some arguments suggesting that such a treatment may improve macrocirculation and microcirculation and finally prognosis . this paper allows us to clarify the meaning of lv function in septic shock patients . in all experimental models of septic shock using the load - independent parameter of lv systolic function , lv contractility impairment , called septic cardiomyopathy , has been reported to be constant . however , lvef reflects the coupling between lv contractility and lv afterload . a normal lvef may be observed when the arterial tone is severely depressed , as in septic shock , despite seriously impaired intrinsic lv contractility . lv systolic function , evaluated using an echocardiograph or another device , is then more a reflection of arterial tone ( and its correction ) than of intrinsic lv contractility . as a consequence , the incidence of lv systolic dysfunction greatly depends on the time of the evaluation , reflecting the fact that , during resuscitation and treatment , vasoplegia and then lv afterload are corrected , thus unmasking septic cardiomyopathy . with these points in mind , we can revisit the results of margaret parker 's original study : it is not that the patients with a low ef survived better , but rather that the other patients had an increased mortality due to persistent profound vasoplegia .

expander / implant - based breast reconstruction following nipple - sparing mastectomy ( nsm ) has recently become a standard treatment . women with small non - ptotic breasts are good candidates for prosthetic - based breast reconstruction . however , in women with large and/or ptotic breasts autologous breast reconstruction is preferred due to the superior results in terms of aesthetics and natural feel . the deep inferior epigastric perforator flap and the latissimus dorsi ( ld ) flap are the most common methods of autologous breast reconstruction . indeed , the ld flap is often used in combination with an implant to provide sufficient volume . the thoracodorsal artery perforator ( tdap ) flap is also used in combination with either a tissue expander or a permanent implant . sakai et al . reported the utility of inframammary adipofascial flap for reconstruction after subcutaneous mastectomy . we have used the inframammary adipofascial flap for breast - conserving surgery ( bcs ) in the inferior portion of the breast , . this flap can be used to provide sufficient volume for prosthetic - based breast reconstruction after nsm . we therefore used an inframammary adipofascial flap for a young woman with moderate - ptotic breasts . a physical examination revealed no palpable mass in either breast and mammography showed no abnormal findings . ultrasonography ( us ) revealed a distended duct and clumped hypoechoic nodules in the lower outer quadrant of her left breast . us - guided vacuum - assisted biopsy was performed , and a histological analysis showed ductal carcinoma in situ . after the cut margin of the specimen was found to be positive , she underwent breast reconstruction combined in which an inframammary adipofascial flap was combined with a tissue expander after nsm , 3 months after her partial mastectomy . before operation , the inframammary fold ( imf ) and the area of the adipofascial flap were designed with the patient in a standing position . since the adipofascial flap would be not released from the muscle 23 cm below the imf ( in order to preserve the perforators in the flap ) , a new imf ( neo - imf ) was drawn at 23 cm below the original imf in a supine position . of note , the original imf marked on the skin in a standing position rises 23 cm in the head side direction in a supine position . therefore , the level of imf when the subject is in a standing position dose not differ markedly before and after surgery , when the neo - imf is secured to the chest wall 23 cm below the original imf in a supine position . de - epithelialization of the skin of the area between the original imf and the neo - imf was performed and used the area was used as a part of the flap . when a length of 7 cm from the inframammary skin incision was reached , the fat and the anterior sheath of the rectus abdominis muscle was cut semicircularly in a tongue shape at the intended area . the surgeon grasped the tip of the tongue - like flap with a forceps and cut along the edge of the flap and anterior sheath , then pulled it up and released the flap from the rectus abdominis muscle . if the fat flap did not include the rectus muscle sheath , then the fat would be very fragile ; thus it was important to pull it up together with the rectus muscle sheath . this adipofascial flap was pulled up by separating the rectus muscle and the anterior rectus sheath as far as the neo - imf ; care was taken to preserve a few perforators . de - epithelialization of the skin of the area between the original imf and neo - imf was performed . after inserting a tissue expander under the major pectoral muscle , the elevated and hinged flap was remodeled with respect to the inferior portion of the breast shape and secured to the major pectoral muscle with several absorbable sutures . after modeling the breast mound with this adipofascial flap , the skin was sutured at the area of the inframammary line ( fig . 1 , fig . 2 ) . the residual tumor was also found to be a ductal carcinoma in situ . after the expansion of the expander ( 11 months after the second operation ) , she underwent surgery to replace the expander with a permanent implant through the inframammary skin incision . the patient has been well since the surgery , without any recurrence of the cancer , and the cosmetic results were also evaluated to be good ( fig . the breast size of most japanese females is relatively small , thus prosthetic - based breast reconstruction is suitable for some japanese patients . however , some patients have mild- or moderate- ptotic breasts , even though their breasts are not large . in the united states , breast reconstruction with implant and acellular dermal matrix ( adm ) , which enables the reconstruction of mild or moderate ptotic breasts , has become a common . however , because this procedure is not used in japan , it is difficult to reconstruct a ptotic- breast with an implant . furthermore , very few japanese patients undergo contralateral breast surgery for symmetrization because national insurance does not cover this procedure . the combination of an implant with an ld flap is well accepted for postmastectomy reconstruction . however , these techniques require a skin incision that is different from that which is used for mastectomy . as reported here , an inframammary adipofascial flap can be performed in combination with an implant through the same skin incision on imf as nsm , thus there is little damage to the donor site . moreover , the mobilization of the inframammary adipose tissue of old patients with fatty breasts can easily cause fat necrosis because their inframammary adipose tissues are usually fatty and weak . thus inframammary adipofacial flap is not indicated for elderly obese patients , even when bcs is indicated . the inframammary adipofascial flap in combination with an implant after nsm is only suited for young patients with dense moderate - ptotic breasts . however , it should be noted that risk of contralateral breast cancer is relatively high in young patients . this procedure is also available for treating contralateral breast cancer , and diep , ld and tdap are can be performed after an adipofascial flap . this is the first known case report of an inframammary adipofascial flap with an implant . the indications for an inframammary adipofascial flap in combination with an implant are limited ; however , this method is useful for breast reconstruction after nsm for young patients with moderate - ptotic breasts . the authors declare that there is not any source of funding for this surgery case report . data were collected in accordance with guidelines for human subjects research , as approved by the institutional review board of mie university hospital ( 2837 ) . tomoko ogawa : study design , data collection , data analysis and writing the paper tomomi yamakawa : study design .

highlightsprosthetic - based breast reconstruction can be used in combination with autologous flaps to achieve symmetry.the inframammary adipofascial flap is a new autologous flap for use in combination with prosthetic - based breast reconstruction after nipple - sparing mastectomy ( nsm).total breast reconstruction using the inframammary adipofascial flap with an implant can be performed through the same skin incision on the imf as nsm.this method is useful for breast reconstruction after nsm for young patients with moderate - ptotic breasts .

scoliosis is defined as a condition of side - to - side spinal curves that measure greater than 10. the spine of a person with scoliosis shows an s or a c line on an x - ray1 . the complex 3d deformity of the spine and the trunk is especially serious in growing healthy children as it influences their progression in relation to multiple factors during any rapid period of growth2 . scoliosis is classified as functional and structural scoliosis , with structural scoliosis further divided into idiopathic , neuromuscular , congenital , and neuropathic types3 . the idiopathic form of structural scoliosis is diagnosed only when the history and the clinical and radiological findings do not provide clear evidence for any specific etiology4 . the pathological symptoms include breathing impairment , back pain , disability , progressive segmental instability during adult life , lower perception of health , adverse psychological impacts , and poor perception of self and body image5 . the scoliosis research society ( srs ) recommendation is to apply both physical therapy and bracing for improvement of scoliosis1 . physical therapy scoliosis specific exercises ( psse ) are recommended . the exercises proposed by the barcelona scoliosis physical therapy school ( bspts ) differ from the conventional exercises as they treat spine alignment as well as respiratory insufficiency6 . the purpose of this study was to confirm the effectiveness of treating ais patients using bspts concept training the subject of this study was a 15-year - old male middle school student whose height and weight were 171 cm and 50 kg . he was classed as a1 according to bspts as his pelvis translated to the concave thoracic side , he showed trunk imbalance to the convex thoracic side , and he had a long thoracic rib hump descending into the lumbar region2 . the subject consented to participate after receiving an explanation about the purpose and procedure of the study . this study was approved by the institutional review board of pusan national university hospital ( e-2016049 ) . the effect of bspts training was confirmed by comparing pretest and posttest ( 8 weeks after training ) measurements of cobb s angle , angle of rotation of the spine , and breathing pattern . cobb s angle was measured in the standing posture by an a - p full spine x - ray7 . the changes in the breathing pattern were determined by measuring the rib cage circumference expansion in the resting and maximal inhalation phases in the standing posture . the subject s training was supervised by a physical therapist certified in bspts formal education . the subject underwent eight weeks of exercise in the exercise center , three times per week for one hour . this was corrected in this subject by having him perform symmetric diaphragm contractions while lying on his side . his diaphragm movement in the supine position was facilitated by having him lie on his side ( on the concave side of thorax ) and while prone on his knees ( especially on the weak side ) . chest mobilization ( especially in the ventral flat zone ) was performed using exercises that employed bspts concepts . the principle of correction of the bspts included self - elongation , asymmetrical sagittal straightening , functional curve pattern correction , breathing mechanics , and stabilization . cobb s angle of the upper thorax decreased from 33 to 31 degrees , and the angle of the lower thoracic decreased from 37 to 29 degrees . scoliometer measurements of the upper thorax decreased from 4 to 1 on the left side , and the measurements of the lower thorax decreased from 9 to 6 on the right side . the rib cage circumference expansion ( axilla - xyphoid - waist ) was maintained from 8173.567 cm to 8173.567 cm at rest and changed from 84.57668 cm to 8577.569 cm at maximal inhalation . the bspts method includes the following essential principles : the first is self - elongation through axial elongation , including counter flexion and lateral deviation relative to pelvic stabilization . the second is asymmetrical sagittal straightening to correct the alignment of the spine , based on the sagittal plane . the third is functional curve pattern correction to correct the alignment of the schema blocks in the coronal plane according to the curve classification method . the fourth concerns breathing mechanics , which is breathing in a state of structural correction of posture . the last is stabilization , with eccentric contraction of the concave side and concentric contraction of the convex side during expiration2 , 8 . kim , hwangbo9 subjected idiopathic scoliosis patients to psse treatments three times a week for 12 weeks and found a reduction in thoracic cobb s angle of approximately 49% , from the 23.6 to 12. the trend found in the present study is consistent with these previous results , as the upper thoracic cobb s angle had decreased by about 6% after the eight week treatment , while the lower thoracic angle decreased by about 22% . however , the previous studies did not confirm the trunk rotation or the scalability of the thorax as the exercises progressed . kim , hwangbo10 also reported a reduction in trunk rotation angle of approximately 58% , from 11.86 to 4.9 and an increase in the breathing volume of about 42% , from 2.83 to 4.04 . in the present study , the trunk rotation angle had decreased by about 75% in the upper thorax and about 33% in the lower thorax . the abdomen circumference , determined during inhalation in the breathing pattern examination , increased by about 2% , which was consistent with previous research results and trends . the eight week exercise period was relatively short , so a larger psse effect would be expected if the exercises were performed over a longer time . this study has the limitation of having only a single subject ; however , the results confirm that bspts exercise can inhibit the progression of idiopathic scoliosis and help to restore the correct spinal curve . the addition of bsbts exercise to the treatment of scoliosis patients would therefore create an effective exercise method .

[ purpose ] this study was performed to confirm physical therapy scoliosis specific exercises on adolescent idiopathic scoliosis patients . [ subject and methods ] a 15-year - old male middle school student with scoliosis . cobb s angle , angle of rotation of the spine , and breathing pattern were measured before and after 8 weeks training . [ results ] after 8 weeks training , cobb s angle , angle of rotation of the spine , and breathing pattern were improved better . [ conclusion ] these results indicate that physical therapy scoliosis specific exercises improves scoliosis curves and could provide an effective intervention and management of scoliosis .

the clinical syndrome of zinc deficiency is characterized by a triad of acral dermatitis , alopecia and diarrhea . zinc deficiency can be inherited , in the form of acrodermatitis enteropathica ( ade ) , a disorder of zinc absorption or acquired , usually described in alcoholics . zinc is an essential element playing important catalytic , structural and regulatory functions in the human body . deficiency of zinc results in multi - systemic manifestations , sometimes having fatal outcomes if not picked up early and corrected . the clinical syndrome of zinc deficiency is characterized by a triad of acral dermatitis , alopecia and diarrhea . we present a case of acquired zinc deficiency showing the typical triad in a 24-year - old female patient , diagnosed and treated wrongly earlier , and highlight the dramatic response that occurred with zinc supplementation . a 24-year - old housewife presented with erosions on the body and recurrent diarrhea of 6 months duration . six months ago , she initially developed a blister and erosion on her left leg ; later she developed similar erosions on hands , perioral area , perineum , and over bony prominences . she had a history of weight loss of around 5 kg in 6 months , along with hair loss , fatiguability , soreness of mouth and poor wound healing . she was treated with systemic steroids by a private practitioner , who suspected pemphigus vulgaris , but she did not have any improvement . on physical examination , the pale looking well built lady had multiple well defined , moist , erythematous erosions with irregular margins over bilateral dorsa of hands and feet , perioral area [ figure 1a ] , cubital fossae , perigenital [ figure 1b ] , perineal area , gluteal region and thighs . otherwise , all her routine investigations including sugar profile , serology for human immunodeficiency virus ( hiv ) , and hepatitis b surface antigen ( hbsag ) were normal . skin biopsy showed epidermal spongiosis and pallor , broad parakeratosis , thinning of granular layer and superficial dermal infiltrate , consistent with nutritional deficiency . she was discharged on daily zinc and iron supplements , after total clearance of skin lesions in two weeks [ figures 2a and b ] . on ( a - b ) perioral and perigenital involvement by erythema , oozing and crusted lesions ( a and b ) clearance of lesions following zinc therapy after 2 weeks zinc is an important constituent of the catalytic site of many vital metalloenzymes in the body like carbonic anhydrase and alkaline phosphatase . zinc finger proteins , like those seen in retinoic acid and vitamin d receptors play an important role in structural differentiation of many organs including the skin . zinc transporting proteins are expressed by two gene families , znt and zip that play opposite roles in zinc trafficking . zinc levels progressively decrease in human breast milk ; however bioavailability is higher in breast milk than cow 's milk . ade was first described in 1936 by brandt and later identified as a definitive disease in 1942 by danbolt and closs as an acral rash associated with diarrhea . in 1973 , moynahan and barnes associated the clinical finding with low plasma zinc level by demonstrating improvement of the patient with zinc supplements . it is inherited as an autosomal recessive with an estimated incidence of 1 per 500,000 children . the onset usually , is shortly after the introduction of cow 's milk or low - zinc formulas classical ade is believed to be a result of a defect in a zinc transporting protein encoded on chromosome 8q24.3.5 by the gene slc39a4 . it is a histidine - rich transmembrane protein known as hzip4 , involved in zinc uptake . acquired zinc deficiency has been reported in numerous conditions like anorexia nervosa , alcoholism , inflammatory bowel disease , blind loop syndromes , total parenteral nutrition , defect of mammary zinc secretion ( lactogenic ade ) , sprue and other intestinal malabsorption syndromes , pancreatic disorders , burns , malignancies and renal disorders . the typical dermatologic findings of zinc deficiency are dry , scaly , sharply demarcated , red , eczematous patches on the face ( periorificial ) and anogenital area , which can become vesicular , pustular or desquamative . on the extensor surfaces of the arms and legs , psoriasiform plaques are typical . scalp can show generalized alopecia in profound deficiency or dry , brittle lusterless hair and banding of hair in milder cases . the systemic features of zinc deficiency are diarrhea , anorexia , growth retardation , photophobia , comeal opacities , hypogeusia , hyposmia , hypogonadism , amenorrhea , anemia , impaired wound healing , hoarseness , neuropsychiatric problems , and perinatal morbidity , due to increased zinc requirement in pregnancy . immunologic abnormalities like decreased t cell , neutrophils , natural killer ( nk ) cell and macrophage function result in secondary colonization of erosions and infections . in the histopathology , necrolysis , a term describing cytoplasmic pallor , vacuolization , ballooning degeneration , and subsequent confluent necrosis of keratinocytes within the superficial stratum spinosum and stratum granulosum of the epidermis is said to be almost pathognomonic . important clinical differential diagnoses would be epidermolysis bullosa , cystic fibrosis , glucagonoma syndrome , widespread candidiasis , pellagra , seborrheic dermatitis , hypovitaminoses , atopic dermatitis , celiac disease , and congenital periorificial and palmoplantar keratoderma . the most serious complication of ade is the high morbidity and mortality caused by secondary infections . the most common pathogens are candida albicans , staphylococcus aureus and pseudomonas aeruginosa . in the past , accepted treatment nowadays is with supplementation of elemental zinc at a dose of 2 mg / kg/ day , at least two or three times the recommended dietary allowance of 15 mg / day . the most accurate way of establishing diagnosis is by measuring plasma or serum zinc levels , though ade with normal zinc levels has been reported . when patient is on zinc therapy , monitoring should be done periodically to measure zinc levels , complete hemogram with erythrocyte indices , differential count , serum copper level and occult blood in stool . this case is being reported to highlight that isolated zinc deficiency can occur in adults and should be considered to prevent mismanagement of this otherwise easily treatable condition . acquired zinc deficiency has been reported in numerous conditions like anorexia nervosa , alcoholism , inflammatory bowel disease , blind loop syndromes , total parenteral nutrition , defect of mammary zinc secretion ( lactogenic ade ) , sprue and other intestinal malabsorption syndromes , pancreatic disorders , burns , malignancies and renal disorders .

acrodermatitis enteropathica is an autosomal recessive inherited disorder of zinc absorption . acquired cases are reported occasionally in patients with eating disorders or crohn 's disease . we report a 24-year - old housewife with acquired isolated severe zinc deficiency with no other comorbidities to highlight the rare occurrence of isolated nutritional zinc deficiency in an otherwise normal patient .

avoidance of donor hla mismatches against which a recipient has formed an antibody is standard practice . as a consequence , hla - sensitized patients are disadvantaged in terms of transplant opportunity . under the uk deceased donor organ allocation scheme , low resolution hla - a , b , cw , dr and dq typing of donor and recipient provides the basis upon which sharing occurs . in this scheme a problem is encountered in progressing a sensitized patient to transplantation when their profile of hla specificity includes antibodies against self antigen . this situation can occur because of the development of antibodies against allelic level variants of antigens represented within the patient s type . in the circumstance that the patient then receives an offer , a risk for a positive crossmatch exists through recipient reactivity against the non - self allelic variant of antigenic the recipient was a 51-year - old female relisted for transplantation following failure of a mismatched graft after 15 years . the patient was sensitized with an hla antibody profile that precluded receipt of offers from 80% of the donor population . after 7 years of waiting , an hla fully matched offer was accepted for the patient . while the lymphocytotoxic crossmatch was fully negative ( compatible ) , the flow cross match was strongly t- and b - cell positive . it had previously been noted that the patient had formed antibodies to self hla - a2 , characterized upon single - antigen bead testing ( one lambda ) as being limited to the hla - a*0201/03/06 allelic variants . it had been decided not to list hla - a2 as an antibody defined unacceptable antigen because of the patient s already broad sensitization and the impact on her matchability. flow crossmatch positivity was therefore presumed due to non - self hla - a*02 allelic antibody . following discussion , the decision was taken to progress with the transplant with a risk - adjusted post - transplant management plan . immediate renal function was obtained and the patient s serum creatinine level declined to 130 by 2 days post - transplant . g / l ) , mycophenolate mofetil 750 mg twice a day and prednisolone 20 mg daily . follow - up investigations confirmed the patient s hla - a2 allelic level type as hla - a*0220 and the donor as hla - a*0201 . structural analysis of these types identified just one amino acid difference ( asp to lys ) at position 66 creating a single eplet mismatch in the donor . screening of the patient s time - of - offer serum sample confirmed the presence of hla - a*0201 antibodies at a moderate level ( mfi = 5245 ) . hla - a*0201 antibodies remained detectable in the day 3 post - transplant pre - plasmaphaeresis sample ( mfi = 4225 ) . at 57 days post - transplant , the patient continues to do well , despite persistence of hla - a*0201 antibodies ( mfi = 4953 ) , with a serum creatinine level of 120 mol / l . under the current uk deceased donor kidney allocation scheme , reporting requirements for donors are for low - resolution hla - a , b , cw , dr and dq typing . under these arrangements , the presence of allele - specific antibodies in the recipient represents a problem for allocation when the patient s own hla type includes an alternate allelic variant of the same antigen . the number of allelic - level variants of some hla can be well in excess of 100 providing considerable scope for intra - allelic group sensitization . constraints imposed by organ ischaemia time together with the logistics of cadaveric organ allocation make the suggestion that allocation should take allelic - level matching into account impracticable . under the existing uk scheme , available remedies include revising the patient type to avoid offers matched for the relevant antigen or to accept offers which include the antigen and then evaluate risks of transplantation based on results of compatibility tests . where the extent of patient sensitization is limited , the former approach is arguably most valid , as it would reduce the risk of a positive crossmatch and the need for reallocation . this decision must be informed as a result of time - of - crossmatch discussions between the laboratory and clinical teams and requires patient workup to have included high - confidence serum - specificity analysis . as igg can accommodate a span of only 915 nm between antigen recognition sites , it is tempting to speculate that the clinical risk of transplanting across the allelic incompatibility in the present case was reduced by the low target epitope valency on the renal endothelium . this may have had the effect that target epitopes were too widely separated to be bridged by bivalent antibodies with inference for stability of antibody binding , as has been demonstrated in in vitro systems , and efficient initiation of processes such as complement and leucocyte activation . a high degree of clinical interest exists in regard to transplantation in the face of donor - specific hla antibodies and the optimal approach to the problem has yet to be defined . in exploring this issue , focus has been on the influence of the antibody level and class , and while these considerations apply to the current case , it is speculated that the issue of target epitope valency is equally worthy of consideration .

under current uk standards of deceased donor typing , the formation by the recipient of hla antibody against an allelic variant of a self antigen creates a particular problem for organ allocation . in the reported case , the decision to transplant was taken in the situation of a positive flow crossmatch result attributed to allelic antibody . the potential that target antigen density contributed to this patient s subsequent good outcome is discussed .

during an 8-month period , may 1 through december 31 , 2007 , hdhhs received 145 salmonella case reports in which patients resided in houston . the hdhhs laboratory performed pfge for 106 ( 73% ) isolates from the houston case - patients . the remaining 39 houston cases had been reported by providers that did not forward the isolate to hdhhs . the hdhhs laboratory used a standardized pulsenet salmonella protocol for pfge and compared pfge patterns for these isolates by using bionumerics 4.0 software ( applied maths , sint - martens - latem , belgium ) . using a hypothesis - generating questionnaire , immediately upon receiving the case the first author interviewed 96 ( 91% ) of the 106 case - patients with an assigned pfge pattern . the hdhhs laboratory posted the pfge patterns weekly to hdhhs epidemiologists , who then further investigated the clusters attempting to identify common sources . * hdhhs , houston department of health and human services ; pfge , pulsed - field gel electrophoresis . rate was calculated as number of cases/100,000 population / year , based on the 8-month study period . epidemiologists considered a group of salmonella cases to be a cluster if 1 ) pfge patterns of all isolates were indistinguishable ; and 2 ) specimens were collected each within 90 days of at least 1 other case . a more inclusive 90-day interval was used , rather than the 60-day interval used by pulsenet , because the number of cases in a local pfge cluster is typically small . a case that was not in a cluster was considered a singlet case . analysis of 106 salmonella isolates from houston residents yielded 74 distinctive pfge patterns , of which 66 were forwarded to the texas department of state health services ( dshs ) for comparison with the dshs laboratory s database and to further identify clusters . eight singlet patterns were not further analyzed because of lack of staff in the laboratories . the dshs returned a list of state i d numbers and county of residence for case - patients with matching isolate pfge patterns , and hdhhs and dshs epidemiologists conferred about the data . of the 106 salmonella cases with identified pfge patterns , 42 assembled into 10 clusters , with 213 cases per cluster . pfge patterns for 8 of these clusters matched patterns in the dshs statewide database , and patterns of 5 clusters matched those in other states obtained during the same period ( table 2 ) . * pfge , pulsed - field gel electrophoresis ; dshs , texas department of state health services . the case was linked by pfge to a pulsenet cluster , but the patient denied having been exposed to the hypothesized epidemiologic link . hdhhs identified a likely exposure for 3 local pfge clusters ( table 2 ) . the first cluster , s. enterica serovar braenderup jbpx01.0516 ( pulsenet nomenclature ) , included 2 houston case - patients and 5 case - patients residing in adjoining counties . four isolates in the dshs database had this pfge pattern , of which 3 had been obtained from case - patients who resided in brownsville , texas , near matamoros . hdhhs posted the pfge pattern on pulsenet listserve , and the ohio department of health responded with information regarding a concurrent outbreak of the same strain in a church group whose members became ill while visiting southern texas . s. enterica serovar enteritidis jegx01.0004 , one of the most common patterns in the hdhhs and dshs pfge databases , was noted by hdhhs to be occurring at above expected levels in december 2007 . the pennsylvania department of health posted outbreak clusters in pennsylvania with the same strain , associated with the consumption of improperly cooked eggs . nine of the 13 ( 69% ) houston case - patients reported eating eggs during the week before illness onset . in 2 houston households , persons became sick after eating eggs purchased in farmers markets . the north carolina division of public health linked a third pfge cluster , s. enterica serovar paratyphi b var . two of 4 houston patients and another patient in victoria , texas , reported having contact with miniature turtles . during the 8-month study , the hdhhs laboratory also sent patterns for 56 ( 87% ) of the 64 singlet isolates to dshs , which coupled 11 ( 20% ) of these with more cases in their statewide database . an isolate of s. enterica serovar typhimurium jpxx01.1037 matched a pulsenet pfge cluster pattern attributed to a nationally distributed packaged vegetable product . the other isolate , s. enterica serovar typhimurium jpxx01.1354 , matched a pattern linked to an outbreak investigated by wisconsin division of public health in which case - patients were exposed to hamsters . for these singlets , hdhhs was unable to confirm an epidemiologic link between the houston case and the national outbreak ( table 2 ) . using pfge patterns , hdhhs discerned vehicles of transmission for local clusters . such findings could enable a local health department to intervene to address outbreaks currently in progress . even small clusters are strong indicators because the actual number of cases in an outbreak is typically vastly larger . consistent cooperation between hdhhs and dshs epidemiologists enabled them to see houston pfge patterns in a context of statewide and national patterns and clusters . a houston pfge pattern that was part of a local cluster was quite likely to match a dshs ( statewide ) or cdc ( national ) pattern . this finding is in contrast to results for 56 singlet patterns ; only 11 were found to match patterns of cases outside the local area . of course , a 100% follow - up would have been better , but this study demonstrates the successes that are possible through routine surveillance by a local health department , given its resources . in an ideal situation , a pulsenet - certified laboratory performs local surveillance in sustained close cooperation with epidemiologists who conduct timely investigations based on laboratory findings .

to identify sources of transmission for area clusters , in 2007 the houston department of health and human services conducted an 8-month study of enhanced surveillance of salmonella infection . protocol included patient interviews and linking the results of interviews to clusters of pulsed - field gel electrophoresis patterns detected by the local pulsenet laboratory .

oligochaete worms , as the second largest group of the annelida , occur in a wide variety of freshwater environments . within this diverse group , limnodrilus hoffmeisteri claparde , 1862 ( oligochaeta : tubificinae ) , is one of the most common and abundant aquatic oligochaetes . like all other oligochaetes , the species is a hermaphrodite , with a complex reproductive system . typically , each body segment possesses 4 bundles of chaetae ( chitinous bristles projecting from the body ) . the chaetae , vary considerably in size and shape between families , and consequently are used extensively in identification . the life cycle of this species includes a stage that involves shedding of eggs into aquatic or moist environments with subsequent development into earthworms . these worms are capable of producing high population densities in paddy fields , eutrophic lakes , and rivers . thus , bathing , picnicking , or field working without protection measures may bring the potential risk of ingress . along with helminths and parasitic nematodes , occasional cases of non - parasitic worm infections ( caused by enchytraeus sp . however , aquatic oligochaete human infections have not been reported in china up till now . in this study , we are reporting a case of oligochaete nasal infection in a 25-year - old chinese man . after detailed microscopic examinations and molecular identification , the infected specimen was identified as l. hoffmeisteri . the infectious agent was eliminated and was no longer detectable in the patient s nasal cavities after treatment with zentel ( albendazole ) . these data will assist clinicians to be aware of this diagnosis and properly guide preventable measures to those who are in risk ( such as aquaculture farmers , fishery workers , and ornamental fish hobbyists ) . the patient was a 25-year - old male residing in zhangjiakou city , hebei province , china employed by a coalmine machinery factory . he initially presented with severe nasal itching , rhinorrhea , and continuous sneezing followed by a nose bleed 2 days prior to consultation . mucosal damage to kiesselbach s area ( on the antero - inferior part of the nasal septum ) , was diagnosed by nasal endoscopy . the worms extracted from the nasal discharge of the patient were identified by using morphological and molecular methods . the observed worm length was 1545 mm , and worm width was 0.60.8 mm ( fig . the prostomium of the observed worms was cone - shaped , and contained about 110 proglottids ( fig . long and thin bifid chaetae with a curved distal end were observed on the dorsal pre- and post - clitellar regions ( fig . the ratio of the length of the dorsal bifid chaetae to the ventral chaetae was approximately 1.15 . the penile sheath was long and tubular , and the length to width ratio ranged from 10.3 to 11.3 ( fig . the morphological characteristics of the species were consistent with a previously published description of l. hoffmeisteri . furthermore , genomic dna was extracted from individual worms using a genomic dna purification kit ( tiangen , china ) for amplification of the small subunit ribosomal rna ( rrna ) region ( fig . 2 ) . the sequences obtained showed 99% identity with l. hoffmeisteri ncbi genbank entries ( nos . a neighbor - joining ( nj ) tree constructed from ssu sequences grouped the worm isolated from the patient into the same cluster as l. hoffmeisteri ( fig . , the morphological characteristics and molecular data confirmed that the species isolated from the patient was l. hoffmeisteri . fortunately , the oligochaete worms were no longer detectable in the patient s nasal cavities following treatment with 400 mg zentel ( albendazole ) and yunnan baiyao ( also called yunnan paiyao , a hemostatic powdered medicine ) once daily for 6 days . l. hoffmeisteri is the best known and is considered to be the dominant species of the genus . although uncommon , the infection can occur in people after exposure to contaminated water . in the present study , for the first time we have reported the case of l. hoffmeisteri infection in the nasal cavity of a chinese man . as a result of this study , total 444 live red worms were isolated and examined from the nasal discharge of the patient by the first affiliated hospital of hebei north university . measurements of l. hoffmeisteri , including the body and penile sheath size , prostomium shape , and the ratio of the length of the dorsal bifid chaetae to the ventral chaetae , were performed . the specimens were identified as microdrile tubificid l. hoffmeisteri claparde , 1862 ( tubificidae ) and megadrile dichogastrid dichogaster bolaui michaelsen , 1891 ( octochaetidae ) , respectively . in our study , we demonstrated a case of human nasal infection with l. hoffmeisteri in china . the likely source of infection of the chinese patient was fish bait used by the patient to feed domestically maintained tropical fish . it is likely that finger - to - nose contact with the fish bait gave rise to the associated infection . a second potential infection source may be a local reservoir used by the patient for recreational purposes 6 months prior to the infection . such opportunistic infection by l. hoffmeisteri occurs more frequently in individuals who are exposed to aquatic environments through labor occupation or leisure activities , usually with skin or mucosal lesions , paresthesia or itching at the ingress site , as well as associated systemic manifestations . accurate identification of pathogenic agents of these opportunistic infections is critical for the proper selection of clinical complementary tests and detailed anamnesis . to summarize , this is the first report of nasal infection with l. hoffmeisteri in a human in china . this l. hoffmeisteri nasal infection can serve as a reminder that oligochaete worms can result in human infections . this also demonstrates that appropriate hygiene precautions are important during field working and leisure activities .

the infection by limnodrilus hoffmeisteri claparde , 1862 ( oligochaeta : tubificinae ) in humans is relatively uncommon . the present report is to describe an incidental human infection with oligochaetes in the nasal cavity of a chinese man , a 25-year - old man residing in zhangjiakou city , hebei province , china presenting with nose bleed , severe itching , continuous sneezing , and rhinorrhea . a lot of oligochaete worms were found in the nasal discharge of the patient . the detected worms were identified as limnodrilus hoffmeisteri ( annelida : oligochaeta ) based on morphological and molecular characteristics . this incidental l. hoffmeisteri nasal infection is the first case in china and indicates that oligochaete worms can be encountered in humans .

carcinosarcoma is a biphasic malignant tumor characterized by a mixed composition of carcinomatous and sarcomatous regions . following the first report by virchow1 in 1864 the most common sites were head and neck , and female urogenital system.2 in the gastrointestinal tract , carcinosarcoma arised in the esophagus , stomach and biliary tract is usually reported,3 whereas carcinosarcoma of colon has been reported rarely.4 - 20 indeed , there was only one case report of cecal carcinosarcoma.7 in this report , we described carcinosarcoma of the cecum and reviewed 17 reported cases . a 72-year - old woman with valvular heart disease was admitted to our hospital for investigation of hematochezia . laboratory tests showed low hemoglobin concentration ( 7.4 g / dl ; normal range , 13 to 17 g / dl ) , mean cellular volume ( 74.4 fl ; normal range , 80 to 97 fl ) , and mean corpuscular hemoglobin - mean ( 23.3 pg ; normal range , 26 to 34 pg ) . the serum levels of carcinoembryonic antigen ( cea ) , carbohydrate antigen 19 - 9 , and alpha fetoprotein were within normal limits . on colonoscopic examination , a 3-cm sized yamada type iv polypoid mass with surface ulceration was noted at the cecum ( fig . the spindle cells had round to ovoid nuclei with coarse chromatin pattern , distinct nucleoli , and formed fascicular pattern ( fig . the polygonal cells had large bizzre nuclei and abundant eosinophilic glassy cytoplasm and lacked of cohesiveness ( fig . histologically , the tumor showed anaplastic feature and did not make any organoid pattern , it was not able to determine the nature of differentiation of tumor cells . the mucin stains such as pas , mucicarmine , and alcian blue failed to reveal mucin - producing cell . to determine the nature of tumor cells , immunohistochemical staining for cytokeratins ( pancytokeratin , cytokeratin 7 , 19 , and 20 ) , epithelial membrane antigen ( ema ) , vimentin , smooth muscle actin ( sma ) , desmin , cea , c - kit , cd34 , s-100 protein , and hmb45 were performed . 2c ) , but there was a distinct area showing immunoreactivity to epithelial markers such as cytokeratins , ema ( fig . . the tumor did not express other specific markers , such as sma , desmin , s-100 protein , c - kit , cd34 , and hmb45 ( table 1 ) . although epithelial component was hardly defined by histological examination , in view of the immunoprofile , the final diagnosis was carcinosarcoma . because the resection margin was involved by malignant cells , right hemicolectomy was performed , 3 weeks later . the chest computed tomography scan showed an abnormal nodule , but it was pathologically confirmed in biopsy as chondroid hamartoma . carcinosarcoma of the colon is a rare neoplasm composed of both carcinomatous and sarcomatous elements . it was also called as sarcomatoid carcinoma , carcinoma with mesenchymal stroma , carcinoma with sarcomatous change , spindle cell carcinoma , and pleomorphic anaplastic carcinoma.9 among them , the term ' sarcomatous carcinoma ' is considered to be the best one for description of tumors in which the sarcomatous components , at least focally , expressing cytokeratin , but the term ' carcinosarcoma ' is officially used in world health organization classification.9 we reviewed the clinicopathological features of previously reported 17 cases ( table 2).4 - 20 the ages of patients ranged from 13 to 89 ( mean , 67.6 ) years . ten patients were women and seven were men . sometimes , colonic carcinosarcoma deeply invaded the bowel wall , metastasized widely , resisted multi - agent chemotherapy , and caused early patient death.7,12 the prognosis was so dismal that several patients died within a few months ( 10 cases ) . most cases occurred in left side colon ( 12 patients ) , including descending , sigmoid , and rectum . only 2 and 3 cases occurred in transverse and ascending colon , respectively . carcinosarcoma had a tendency to distantly metastasize ( 7 cases).7,12 - 14,17,19,20 metastasis sites were liver ( 3 cases),7,12,19 lymph node ( 3 cases),13,14,20 omentum or peritomeum ( 3 cases),12,14,17 and spleen ( 1 case).12 although histogenesis of carcinosarcoma is uncertain , most of the tumors containing carcinoma and sarcomatous components are considered as monoclonal growth rather than collision of tumors , and there is a report explaining this phenomenon by activation of epithelial - mesenchymal transition.21 the immunoprofile of our case does not conflict with interpreting this tumor as a result of epithelial mesenchymal transition . in summary , the present report describes a case of carcinosarcoma of the cecum in a 72-year - old woman .

carcinosarcoma of the colon is rare . seventeen cases have been reported in the english literature . most cases occurred in the left side of the colon . indeed , there is only one reported case of cecal carcinosarcoma . carcinosarcoma has a tendency to distantly metastasize and shows dismal prognosis . we report a case of carcinosarcoma in the cecum and review the literature describing colonic carcinosarcoma .

the presence of the vermiform appendix within an inguinal hernia was first described by claudius amyand in 1736 . it has an incidence of 1% and is complicated by acute appendicitis in 0.08% of cases . we report a case of amyand 's hernia occurring in an 85 year old woman , who presented with a tender , discharging , right inguinal swelling . an 85-year old woman presented to the surgical outpatient department ( sopd ) with a 3-week history of a discharging swelling in the right groin . initially the swelling had exuded a small volume of serous fluid , but over the previous week , this had changed to a large volume of yellow viscous fluid that required her to redress the area up to 5 times daily . her groin was treated conservatively on a presumptive diagnosis of a groin abscess arising from an infected inguinal node . examinations in the sopd revealed an erythematous , tender swelling in the right groin , with an opening exuding malodorous fluid that had caused marked skin excoriation . on abdominal examination she was tender to palpation in the right groin and guarding and rebound tenderness were absent in the right iliac fossa . a colocutaneous fistula was suspected clinically , when over several days the discharge became faeculent . a ct fistulogram showed a fistulous tract communicating with the caecum and the peritoneal cavity ( figures 1 and 2 ) . she subsequently underwent an elective laparotomy for a planned right hemicolectomy , on a presumptive diagnosis of either a caecal tumour or inflammatory process . contrast can be seen to fill the caecum , confirming the presence of a fistula . through a right iliac the appendix was found in the inguinal canal with its tip communicating with the skin and exuding faeces . histopathology revealed a non - inflamed appendix with dilated serosal capillaries , suggestive of trauma and an opening at its tip . at laparotomy , looking down at the pelvis through a right iliac fossa transverse incision , caecum is seen ( white arrow ) and the appendix with its tip ( yellow arrow ) can be seen lying in the inguinal canal . in 1736 claudius amyand , surgeon to king george the ii , performed the first appendicectomy , removing the appendix from the inguinal hernia sac of an 11 year old boy ( 1 ) . since then an inguinal hernia containing the vermiform appendix , whether it be inflamed or not inflamed , is given the eponymous name similar to this report , the child on whom amyand operated on had an enterocutaneous fistula , which was proven to originate from the appendix when the perforation was traced with a pin . interestingly the first appendicectomy performed in the usa by robert j hall in 1886 , was performed on a perforated appendix within an inguinal hernia , similar to amyand s case decades prior . amyand s hernia is a rarity , with the incidence of an uncomplicated appendix found in the inguinal canal being 1% , while the finding of appendicitis in the inguinal canal is rarer again , with dalia reporting an incidence of just 0.08% , in 1341 patients with inguinal hernias over a 13 year period ( 2 ) . it is commoner in men and is almost exclusively right sided , most likely due to the usual anatomical position of the appendix , although there have been reports of left sided amyand s hernia and in such cases there is usually an associated situs inversus , mobile caecum or intestinal malrotation ( 3 ) . in a review of 18 cases , the median age was 42 years , with the oldest age noted in literature being 89 years ( 4 ) . it is thought that the appendix of amyand s hernia is more likely to become inflamed , compared to an anatomically normal appendix , given that it is retained in that location by adhesions and becomes vulnerable to trauma ( 5 ) . there is no consensus whether appendicitis is the primary pathological mechanism or whether the primary event is its herniation making it more vulnerable to trauma , coupled with changes in abdominal pressure due to muscle contraction which compresses the appendix , thereby decreasing blood supply and encouraging bacterial overgrowth and inflammation ( 6 ) . unique to this case is that the appendix was histologically normal , with the exception of dilated serosal capillaries . despite the absence of inflammation , amyand s hernia is difficult to diagnose clinically and is rarely diagnosed preoperatively . in a review of 60 cases over a 12 year period the difficulty in diagnosis has its origins in the considerable variation of symptoms that patients present with , depending on if the appendix is normal , incarcerated or perforated with the commonest presenting symptom being painful inguinal or inguinoscrotal swelling while the history and examination usually point to an incarcerated hernia ( 8) . preoperative ct has revealed the previously unsuspected diagnosis in an occasional report and is useful in establishing the diagnosis early but is not routinely used in clinical situations where a complicated hernia is suspected . laermann et al illustrated that combining ct with multi planar reconstruction is the most useful technique , to better visualise the appendix and its relationship with surrounding structures , thus aiding in confidently making the correct diagnosis pre - operatively ( 6 ) . in our case , the appendix could not be visualised , given that the patient has bilateral hip prosthesis , which produced artefact at the level of the appendix . treatment of amyand s hernia depends on the inflammatory state of the appendix . in an uncomplicated case , appendicectomy is advocated followed by simple repair of the hernia using the same incision ( 9 ) . in the presence of contamination there was a general consensus by most authors that a normal appendix in the hernial sac does not require appendicectomy , given that such an organ containing faeces increases the risk of septic complications ( 9 ) . in conclusion , we report herein a rare case of amyand s hernia presenting as an enterocutaneous fistula in the right groin of an 85 year old female patient . it is difficult to diagnose clinically and diagnosis can the aided by a high index of suspicion and accurate interpretation of a ct scan .

the finding of the vermiform appendix in an inguinal hernia has an incidence of approximately 1% . the condition is given the eponymous name amyand s hernia . however in just 0.08% the condition is complicated by an acute appendicitis . the clinical presentation varies , depending on the extent of inflammation of the appendix and is most often misdiagnosed as an incarcerated inguinal hernia . as such it is rarely recognised prior to surgical exploration . we report a case of amyand s hernia in an 85 year old woman , which presented as a right groin enterocutaneous fistula . ct scanning illustrated a fistulous tract in the right groin , which communicated with the caecum and the peritoneal cavity . she underwent laparotomy , which revealed that the appendix appeared inflamed , lay in the inguinal canal and was the origin of the enterocutaneous communication .

cochlear implants have been used to restore hearing in patients with severe to profound sensorineural hearing loss . since cochlear implantation major complications were those requiring surgical revision or resulting in a serious medical condition such as large scalp necrosis , severe infection , meningitis , and device failure . skin flap necrosis is one of serious complications because it results in exposure of the implant , thereby requiring explantation . methylene blue dye has been widely used for the localization of the implant site . to date , no literature has reported complications after methylene blue dye injection . herein , we report an unusual case of skin flap necrosis due to bone marking with methylene blue after cochlear implantation . a 55-year - old woman with profound , sensorineural hearing loss underwent cochlear implantation with a nucleus24 contour ( cochlear ltd . , sydney , australia ) . preoperative temporal bone mri and ct scans were normal with the exception of microplate and screw in the right pterion . she did not undergo skin flap thinning and underwent successful implantation with complete electrode insertion through the cochleostomy by way of the facial recess . however , 8 weeks after surgery , the woman presented with a bluish discoloration over the implant site , which was consistent with bone marking using methylene blue . the lesion developed a progressive thick , blue eschar formation and skin flap necrosis ( fig . 11 weeks after surgery , she subsequently underwent wound debridement and skin flap closure ; this procedure involved a linear skin incision made around the eschar in the postauricular region . a simple dissection allowed for removal and debridement of the eschar and the necrotic , discolored part of the skin and temporalis muscle ( fig . 2 ) . the receiver - stimulator was identified and carefully preserved during removal of the eschar and soft tissues . the patient received intravenous antibiotics for 3 days and oral antibiotics for 2 weeks as a precautionary measure . the postoperative rehabilitation and implant function were excellent . during the 12-month follow - up , it can be caused by infection , hematoma , shape of the flap incision , or other abnormalities . infection caused by various pathogens such as p. aeruginosa is a serious risk factor for flap necrosis . the pathogen can induce biofilm formation and result in recurrent infections , with the risk of implant extrusion . while this complication can be treated by re - intervention or aspiration , it may evolve into flap necrosis . smaller incisions with smaller skin flaps are used to reduce vascular compromise and minimize the risk of flap necrosis . in addition , chronic pressure on the overlying skin such as using strong magnet can lead to flap necrosis . this process has high morbidity and delays the use of the cochlear implant ; hence , early recognition and treatment of this complication are important . methylene blue has been used extensively as a tool to localize the implant site in cochlear implantation . methylene blue dye is a cationic thiazine that causes toxic effects and local inflammation by producing oxides and free radicals . this dye also has vasoconstrictive effects by inhibiting the nitric oxide - mediated cyclic guanosine monophosphate pathway , which is responsible for smooth muscle relaxation and vasodilation . excessive use of this dye , particularly in tissues that are poorly perfused , may cause serious skin necrosis . moreover , intradermal injection of methylene blue has toxic effects on the local tissue and hence should be avoided . skin necrosis after the use of methylene blue dye has been reported in breast surgery . described lesions range from localized blue staining , superficial ulceration and flap - site necrosis . debridement and primary closure were performed for the treatemt of partial necrosis and wound dehiscence . however , the patients with wide skin necrosis underwent removal of necrotic tissue and implant , followed by musculocutaneous flap reconstruction . in the present case , the patient did not undergo skin flap thinning and did not use strong magnet . however , the patient had a history of neurologic surgery that might have caused poor tissue perfusion . therefore , the flap necrosis might have developed due to the application of methylene blue to the site with poor local blood supply in the post - auricular area . during the surgery , blue - stained necrotic muscle and soft tissue these findings were similar to those seen in the cases of skin necrosis by methylene blue toxicity after breast surgery . wound infections are typically characterized by fever , erythema , leukocytosis and purulent drainage and present rather quickly after surgery . these characteristics were absent in our patient , and instead , a bluish discoloration developed 8 weeks after surgery ; therefore we believe that the flap necrosis resulted from the toxic effects of methylene blue dye . moreover , we can not completely exclude the possibility of intradermal injection of the dye . in the present case , the onset of skin necrosis was relatively late compared with approximately 1 week in the cases of breast surgery . we believed that the early onset of skin necrosis in the cases of breast surgery results from larger amount of injection volume ( 3 - 5 ml ) of the dye . when devascularization of tissues is expected such as revision surgery , prior surgery around temporal bone , thin skin flaps and excessive use of diathermy , the application of methylene blue as a bone marker is thought to be careful . care should be taken to minimize skin complications by injecting the dye only above the bone and avoiding intradermal injection . when there is a suspicion of flap necrosis due to the methylene blue application , timely management is necessary to avoid progressive flap necrosis and implant extrusion . we conclude that bone marking using methylene blue injection is another possible source of skin flap necrosis in cochlear implantation . early diagnosis and management is necessary to prevent further skin breakdown and subsequent device extrusion .

one of surgical complications in cochlear implantation is the necrosis of the skin flap above the receiver - stimulator coil . we present a case of 55-year - old woman who underwent cochlear implantation and developed a bluish skin necrosis due to bone marking . the planned position for the receiver - stimulator was marked using methylene blue through skin to bone . she did not undergo skin flap thinning and underwent successful implantation with complete electrode insertion . few weeks postoperatively , the patient developed bluish discoloration with progressive thick , blue eschar formation and skin flap necrosis . she subsequently underwent wound debridement and skin flap closure . cochlear explantation was not necessary . timely diagnosis and management about this complication is necessary to prevent further skin breakdown and subsequent device extrusion . this report identifies the marking using methylene blue as another possible source of skin flap necrosis in cochlear implantation , and surgeons should be aware of this potential complication .

cystic hydatid disease ( chd ) , also known as hydatidosis , is a zoonotic parasitic infection caused by echinococcus granulosus or dog tapeworm . humans are accidently infected by oral ingestion of food or water contaminated with dog feces containing echinococcus eggs ( 1 ) . chd is a helminthic disease with global distribution , especially in the middle east including iran ( 12 ) . in chd , the liver ( 60%70% ) , and lungs ( 1525% ) , are the most common infected organs , but any organ of the body can be involved ? the rates of the localization of hydatid cyst ( hc ) in different body organs vary in the literature ( 3 ) . even in region where hydatidosis is endemic such as iran , cervical region and/or neck hydatidosis is rare and its incidence is unknown ( 2 ) . only a few cases of hc located in submandibular glands have been reported in literature ( 4 , 5 ) . ultrasonography ( usg ) , computed tomography ( ct ) scan , x - ray graphy , fine needle aspiration cytology ( fnac ) and biopsy ( fnab ) , magnetic resonance imaging ( mri ) are valuable in identifying calcifications and the presence of daughter cysts . however , definite diagnosis should be confirmed by microscopic examination for hydatid sands ( also known as protoscolices ) supported by histopathology ( 2 , 3 , 6 ) . herein , we report , an unusual case of primary hc located in the mandibular angle mimicking branchial cleft cyst ( bcc ) . in july 2012 , a 25-yr - old woman was admitted to ent ( ears , nose , and throat ) clinic , bandar - torkman district , golestan province , northeastern iran , with one - year history of a progressively increasing swelling , pain and gradually growing mass located in the left side of neck region . physical examination showed a soft mass that was tender on palpation somewhat painful and moderately hard in the upper anterio - lateral surface left side of her neck . laboratory findings including sedimentation rate , and complete blood count ( cbc ) were normal and showed no eosinophilia . ultrasound showed a unilocular cystic lesion , mimicking a branchial cleft cyst ( bcc ) , 40 26 24 mm in size , with about 13 ml fluid in the anterior margin of sterneocleidomastoid muscle ( scm ) and posterior to the submandibular gland . ct scan of the cervical region revealed a cystic lesion with thin borders and wall . fnac was inducted under aseptic conditions using a 22-gauge needle and about 2 ml of clear fluid was aspirated . the aspirated materials were smeared on the slides , also these were centrifuged , and then sediment was examined under light microscope . cytology direct smears revealed a few protoscolices ( black arrow ) and hooklets ( white arrow ) ( 40 ) consequently , early diagnosis of hydatid cyst is confirmed by fnac . the patient was examined for more works up and rule out of hydatidosis in other organs of the whole body . ultrasonography and ct scan showed no involvement of the liver , lungs , submandibular glands , and any other organs . the received tissue grossly showed white gelatinous membranous tissue 44 cm in size and 0.2 cm in thickness . another fibroconnective tissue 0.5 0.5 0.5 cm in size received with the first one . microscopic examination of the tissue revealed germinal , acellular laminated layers and a few protoscolices ( fig . histopathology picture showing laminated layer ( hematoxylin and eosin a , 40 b , 10 ) the patient was given albendazole ( 400 mg twice daily ) , 4 days prior to the surgery together with for 4 weeks post - operation . throughout 20 months follow - up , there was no evidence of recurrence and hydatidosis in other locations of the body . all included the pictures in this report were taken in our research lab at sari school of medicine , mazandaran university of medical sciences . the primary hc occurrence in the neck is relatively uncommon and involvements of the submandibular glands are extremely rare . so far , a few case of hydatidosis in cervical region such as thyroid , parotid and submandibular glands have been reported from iran and other parts of the world ( 2 ) . however , mandibular angle involvement has not been previously reported . in the present report , the patient suffered from primary mandibular angel hydatidosis with no involvement of any other regions including submandibular glands . thus , to our knowledge , this might be the first report of mandibular angle hydatid cyst from iran and possibly the world . the mandibular anglehydatidosis , caused due to systemic diffusion through lymphatic route , is a strong possibility in case of unusual presentation locations . the cyst might remain asymptomatic for a long period , presenting a slow development rate ( 7 ) . unusual locations of hc have been reported around the world including the ureter , brain , uterus , heart , bones , kidney , spleen , cranium , and muscles , but soft tissue hydatid disease represents less than about 3% of all hydatid disease . although it can involve many body organs , involvement of the submandibular region is very rare ( 2 , 8) . the diagnosis of chd mostly depends on the clinical history , serologic tests , and diagnostic imaging though not all these techniques are definitive . however , for the evaluation of mass lesions in the cervical region , fnac and or fnab , as gold standard , are very valuable and reliable procedures in the differential diagnosis of chd ( 8 , 9 ) . fna can be a safe , fast , easy diagnostic method in the evaluation of suspected hc with no complications ( 9 , 10 ) . however , its application generally is recommended and requires to sufficient experience , due to the potential risk of anaphylactic reaction and/or dissemination . in our case , the patient had not any complications following fnac . thus , fanc could be suggested as a valuable , rapid , simple , and safe procedure to diagnose hydatid cyst especially in unusual locations . hc may involve mandibular angle without glands involvement . given that throughout ultrasound , the mandibular angle hydatid cyst presents with a cystic mass , mimicking a branchial cleft cyst ( bcc ) and or dermoid cyst ( 11 ) . hc must be considered in differential diagnosis of soft tissue mass in the cervical region especially in endemic countries such as iran . therefore , it should be managed through surgery to prevent diffusing cyst to other regions of the body and anaphylactic reaction .

we report an unusual case of primary hydatid cyst of the mandibular angle without glands involvement , in the left supraclavicular region of the neck with no involvement of any other regions of the body . in july 2012 , a 25-yr old woman , from golestan province , northeast iran was admitted to our ent clinic , with one - year history of a progressively increasing swelling , pain and gradually growing mass located in the left side of neck region . the patient was diagnosed by fine needle aspiration cytology ( fanc ) and histopathology examination . hydatid cyst should be considered in differential diagnosis of soft tissue mass such as branchial cleft cyst ( bcc ) and or dermoid cyst in the cervical region especially in endemic areas . moreover , fanc could be recommended as a valuable , rapid , simple , and safe procedure to diagnose hydatid cyst especially in unusual locations .

neutrophilic eccrine hidradenitis ( neh ) is known as an inflammatory disease of the eccrine sweat glands and is histologically characterized by necrosis and vacuolar degeneration of eccrine coil cells and dense neutrophil accumulation around the secretory coils . previous reports suggest that neh normally develops in patients with malignancies following chemotherapy such as cytarabine , although hemodialysis , behet 's disease or infectious diseases , or nonchemotherapeutic drugs such as granulocyte colony - stimulating factor ( g - csf ) are also associated with neh [ 2 , 3 ] . however , generalized neh in healthy adults without any disorders is extremely rare and its precise pathogenesis is still under consideration . dermcidin is a dominant sweat antimicrobial peptide with broad - spectrum activity which is specifically and constitutively expressed in the sweat glands . minami et al . reported that , in normal skin , the secretory coils of the eccrine sweat glands were positive for dermcidin and that , in contrast , the eccrine ducts lacked expression of dermcidin . this peptide is reported to be secreted into eccrine sweat directly . therefore , to investigate the destruction of secretory coils of eccrine glands in neh , in this report , we demonstrate immunohistochemical staining for dermcidin and give a possible explanation for the downregulation of dermcidin in secretory coils of affected eccrine glands in a patient with neh . a 69-year - old japanese man visited our outpatient clinic with a 15-year history of disseminated pruritic papules on his trunk and extremities ; however , the eruptions were limited to the summer months . interestingly , the pruritic papules disappeared without any treatment after the outside temperature went below 20c in fall . physical examination showed numerous erythematous papules and plaques on the forearms and the back ( fig . the histopathological studies of the lesional skin revealed degeneration of the eccrine coils associated with dense accumulation of neutrophils ( fig . moreover , immunohistochemical staining demonstrated that the secretory portion of the eccrine glands in the affected lesion significantly decreased the reactivity with antidermcidin antibody , while that in the nonaffected lesion was strongly stained with the antibody ( fig . as previously reported , the expression of dermcidin was not recognized in eccrine ducts . taking these clinical , histological , and immunohistological findings into account , we diagnosed this patient with generalized neh . without any additional treatment , the pruritic papules disappeared in the middle of september . in this report , we present a case of therapy - resistant generalized neh in an otherwise healthy adult . any treatment , including topical very strong or even the strongest steroid ointments and systemic antihistamines , was not effective . of particular interest is that the eruptions spontaneously resolved in fall when the outside temperature went below 20c . actually , bachmeyer and aractingi suggested that 90% of the neh cases occur in patients with acute myeloid leukemia . other associations include nonchemotherapeutic drugs such as granulocyte g - csf , hemodialysis , behet 's disease and infectious diseases ( e.g. serratia marcescens , enterobacter cloacae , staphylococcus aureus , streptococcal endocarditis , nocardia , hiv-1 ) [ 2 , 3 , 6 , 7 , 8 , 9 ] . however , generalized neh without any disorder is extremely rare . in fact , there is no case of generalized neh in healthy adults in english literature . in healthy children , although 61 cases of idiopathic palmoplantar hidradenitis have been reported previously [ 10 , 11 , 12 ] , the eruptions usually occur mainly on the soles and palms , and only 4 cases of generalized neh in healthy children have been reported . one possible trigger for the outbreak of generalized neh is constantly high temperature . to sum up , our present case is the first report in english that describes generalized neh in a healthy adult ( table 1 ) . the first one postulates that neh is the consequence of a direct cytotoxicity of a drug secreted in the sweat in eccrine coils and duct cells , while the other one suggests that neh is one from the spectrum of neutrophilic dermatoses , as are sweet 's syndrome and hematological malignancies . dermcidin is constitutively secreted by the eccrine sweat glands and not induced by skin inflammation or injury . it appears to be the dominant sweat antimicrobial peptide with broad - spectrum activity not affected by low ph or increased salt concentrations , and is known to be secreted into eccrine sweat directly . in our case , interestingly , the staining for dermcidin in affected secretory coils of eccrine glands , which were surrounded by significant numbers of neutrophils , were almost negative . in contrast , secretory portions of eccrine ducts without neutrophil accumulation expressed dermcidin and the staining level of dermcidin in the area not affected by neh was almost similar to those in healthy adults . these results suggest that , in neh , the secretory coils of eccrine glands may be destroyed by neutrophils , resulting in the decrease of sweat in the affected skin , and this may cause the spontaneous regression of the disorder . in this report , we present a case of generalized neh in a healthy adult . the precise mechanisms of neh are still unknown . our present case gives a possible explanation for the mechanism of neh in a healthy adult but further evidence from more case reports is needed .

we describe a healthy 69-year - old japanese man with generalized neutrophilic eccrine hidradenitis ( neh ) . he visited our outpatient clinic with a 15-year history of disseminated pruritic papules on his trunk and extremities ; the eruptions , however , were limited to the summer months . histological findings reveal a dense accumulation of neutrophils around the sweat glands with degenerated secretary coils . interestingly , immunohistochemical staining showed that the expression of dermcidin on the secretory portion of eccrine glands was significantly decreased in the affected lesion . to our knowledge , this is the first report in english of generalized neh in a healthy adult that shows the downregulation of the expression of dermcidin in affected eccrine glands .

lipomatous hypertrophy of the interatrial septum ( lhis ) is an exaggerated growth of normal fat existing within the septum and is not a true tumor . the septal hypertrophy may be as much as 2 cm in thickness and is seen primarily in older patients and in those who are obese . it has been suggested that this disorder is associated with the presence of coronary artery disease in proportion to the degree of atrial septal thickness . lipomatous hypertrophy of the interatrial septum is indistinguishable from lipoma except that the former occurs in the atrial septum with a typical distribution ( generally sparing the fossa ovalis ) . in the absence of symptoms of atrial arrhythmias , heart block or rare vena caval obstruction nowadays , with advanced imaging techniques , lhis are picked up incidentally in the course of work - up for other conditions . such a case is presented here and imaging findings and literature on this lesion are reviewed . a 70-year - old female with a history of hypertension , atrial fibrillation , pacer implantation for symptomatic bradycardia , and a prior cerebrovascular accident was transferred to our institution for further evaluation and management of a recently identified persistent methicillin - sensitive staphylococcus aureus bacteremia . during workup of her bacteremia although no vegetations were seen on either pacer wires or cardiac valves , a massive homogeneous thickening of the superior portion of the interatrial septum was noted [ figure 1a and b ] . this mass effect extended to the posterior and roof portions of the right atrial wall as well as to the superior vena cava , causing proximal compression of this vessel [ figure 1c and d ] . in view of these findings , a chest computed tomographic examination was requested for better definition of this mass density . following contrast administration , the mass effect noted by transesophageal echocardiography was identified as intrapericardial fat density that extended toward the interatrial septum without evidence of infiltration of the interatrial septum directly [ figure 2 ] . additionally , a nodular opacity was also found in the lateral left upper lobe with a greatest diameter of 1 cm that was thought to be a potential septic embolus given the recent history of bacteremia ( not shown ) . ( a ) standard mid - esophageal four - chamber transesophageal view showing right atrium ( ra ) , right ventricle ( rv ) , left atrium ( la ) , and left ventricle ( lv ) , as well as the pacer wire , ( b ) pulling up the transesophageal probe to interrogate posterior aspects of both right and left atria demonstrated the presence of a diffusely homogeneous mass effect noted in the posterior aspect of the right atrium as demarcated by the arrow heads , ( c ) at a 90 angle , bi - atrial mid - esophageal view , both left ( la ) and right ( ra ) atria are seen . the homogeneous mass is also seen compressing the superior vena cava ( svc ) with the pacer wires , ( d ) another view of the mass , demarcated by arrows , from the superior aspect of the right atria compressing the superior vena cava ( svc ) shown by the hatched arrow transverse chest computed tomographic view showing the fat density in relation to the pacer wires , left atrium ( la ) , right coronary artery ( rca ) , and aortic valve ( av ) the initial continuous infusion of nafcillin was later changed to oxacillin , as surveillance blood cultures were all negative . the plan was to remove her transvenous pacer and replace it once she had completed her antibiotic therapy and follow - up blood cultures off antibiotics remained negative . lipomatous hypertrophy of the interatrial septum ( lhis ) is a rare , but increasingly recognized benign cardiac lesion characterized by excessive deposition of fat in the interatrial septum . while the true incidence of lhis has not been determined ; the expanding use of non - invasive imaging techniques in recent years has quoted an incidence up to 8% , compared to an incidence of 1% based on autopsy reports . although the exact etiology of lhis remains unclear , some theories have suggested the existence of embryonal mesenchymal cells within the primitive atria that can develop into adipocytes with an appropriate stimulus , particularly obesity and advanced age . the resultant effect is adipocyte hyperplasia and fat accumulation occurring in the epicardium , that is an extracardiac deposition fat , rather than within the interatrial septum as recently illustrated by silbiger , et al . in this report , the authors demonstrated how the walls of the left and right atria fold inward toward each other , forming a fat - filled depression between them called waterston 's groove . fat contained in this region is not a true interatrial septal density , but in reality is fat that overlies the epicardial surface of the heart . transesophageal echocardiography is one of the most commonly used imaging modalities to interrogate cardiac structures , in which routine examination of the interatrial septum is performed . the characteristic echocardiographic appearance of lhis involves an interatrial septal thickness > 2 cm usually represented by an hourglass appearance denoted by fat mass superior as well as inferior , sparing the fossa ovalis in between . most patients with lhis are usually asymptomatic ; however , in some cases , this fatty infiltration can either cause intraatrial conduction disturbances and atrial arrhythmias or when this fatty infiltration extends beyond the atrial septum may cause right atrial inflow obstructive symptoms . however , there are times that echocardiography alone is not capable of characterizing myocardial tissue , particularly when the extent of the process as described in our case is so massive . in such cases , the spatial resolution of cardiac mri is ideal in providing detailed information about the size and location of such masses . furthermore , with its ability to evaluate t1 and t2 characteristics of the mass , as well as the ability to use fat - suppression techniques in addition to gadolinium , the histopathologic characteristics of a mass can be clearly evaluated by cardiac mri . alternatively , chest computed tomography can be also used to help make the diagnosis . in this case , however , careful recognition of some anatomical findings might be useful in distinguishing this rare , but increasingly recognized benign cardiac lesion with other cardiac pathology .

a case of a 70-year - old female with a history of hypertension , atrial fibrillation , pacer implantation for symptomatic bradycardia , and a prior cerebrovascular accident , and had developed persistent methicillin - sensitive staphylococcus aureus bacteremia is reported here . as part of her evaluation , a transesophageal echocardiogram was performed , and even though no vegetations were seen on either pacer wires or cardiac valves , a massive homogeneous thickening of the superior portion of the interatrial septum extending to the posterior and roof portions of the right atrial wall as well as to the superior vena cava causing proximal compression of this vessel was noted . computed tomographic examination of the chest helped to determine that this mass density was not a tumor but in fact intrapericardial fat . imaging findings and existing literature on this topic are reviewed .

pulmonary alveolar proteinosis ( pap ) is characterized by accumulation of surfactant proteins in the alveoli due to defective surfactant clearance by alveolar macrophages . the clinical course of the disease is variable , ranging from respiratory failure to spontaneous resolution . a crazy - paving pattern is suggestive of , but not specific , to pap . lung biopsy ( by open - lung surgery , video - assisted thoracoscopic surgery or tblb ) is the gold standard for the diagnosis of pap . a 54-year - old male , non - smoker , non - alcoholic , known diabetic and hypertensive , presented with fever , dry cough , and progressive breathlessness for one month . initial evaluation in a different hospital confirmed hypoxia and pft ( pulmonary function tests ) was suggestive of a restrictive pattern . he was labeled as having interstitial lung disease and was discharged on oxygen and steroids . ct chest showing and # x0022 ; crazy pavement and # x0022 ; appearance his symptoms worsened gradually and he presented to our institution on high flow oxygen and was found to be pao2 - 42 on fio2 of 1 . patient was admitted in icu , blood gases showed type i respiratory failure with a pao2 of 53 mm of hg on fio2 of 0.6 . the chest x - ray [ figure 1b ] showed bilateral reticular shadows affecting the lower zones ( left > right ) . after counseling , a repeat bronchoscopy with tblb was done , which showed pulmonary alveolar proteinosis on histopathology ( pas stain was strongly positive ) [ figure 2 ] . as the patient was deteriorating , it was decided to treat him with whole lung lavage ( wll ) . chest x - ray at presentation pas stain positivity on histopathology patient was intubated with a double - lumen endotracheal tube for wll . the left lung was lavaged first with 15.5 l of warmed ( at 37c ) normal saline using aliquots of 500 ml . it had characteristic opaque , milky appearance with dense sediments on standing , which were strongly positive for pas stain . characteristic milky effluent with sediments patient 's oxygen requirement decreased to 2 - 3 liters / min post - extubation . abg showed ph-7.44 , pao2 - 62 on fio2 of 0.4 , and paco2- 44 . blood samples were sent to university of cleveland ( usa ) for anti - gm - csf antibody titers , which were reported to be highly positive , so recombinant gm - csf was started . the patient was discharged on n - acytyl cystine nebulization and rgm - csf therapy for 3 months . his chest x - ray [ figure 4b ] after 8 months was almost normal . his oxygen saturation on room air was found to be 92% , and he was carrying out his routine activities including work without getting breathless . pulmonary alveolar proteinosis ( pap ) is a rare disorder , in which lipoproteinaceous material accumulates within alveoli . pap occurs in three clinically distinct forms : genetic , auto - immune ( also called idiopathic or primary ) , and secondary . the genetic form comprises a heterogeneous group of disorders caused by mutations in the genes encoding surfactant protein b or c or the receptor for gm - csf . primary pap is associated with presence of anti- gm - csf antibodies preventing uptake of surfactant proteins by alveolar macrophages resulting in their accumulation . secondary pulmonary alveolar proteinosis develops in association with conditions involving functional impairment or reduced numbers of alveolar macrophages . such conditions include some hematologic cancers , inhalation of inorganic dust or toxic fumes and certain infections . less common symptoms include fever , chest pain , or hemoptysis , more so in the presence of secondary infections . the signs on physical examination can be unremarkable , but there are inspiratory crackles , cyanosis , and digital clubbing in a small percentage of patients . in uncomplicated cases , the chest radiograph usually reveals bilateral ill - defined nodular or confluent pattern , suggestive of pulmonary edema but without other radiographic signs of left - sided heart failure . high - resolution ct shows patchy , ground - glass opacification with superimposed interlobular septal and intralobular thickening , a pattern commonly referred to as crazy paving . pft can be normal but typically shows a restrictive ventilatory defect with a disproportionate and severe reduction of the carbon monoxide diffusing capacity . the impairment of gas exchange is secondary to filling of the alveoli with phospholipoproteinaceous material leading to ventilation and perfusion mismatch . clinical and radiographic findings often suggest the diagnosis of pap in suspected cases , while findings on examination of a bal specimen can establish the diagnosis . there are also large , acellular , eosinophilic bodies in a diffuse background of granular material that stains with pas as well as elevated levels of surfactant proteins . on light - microscopy , the architecture of the lung parenchyma is found to be preserved unless there is infection . current therapy for all types of pap remains wll , although for the congenital form of the disorder , successful lung transplantation has been reported . therapy for secondary pulmonary alveolar proteinosis generally involves wll and the treatment of the underlying condition . primary pap has been treated successfully since the early 1960s by wll , and this procedure remains the standard of care today . the median duration of clinical benefit from lavage has been reported to be 15 months . patients usually respond to one procedure of wll ( both lungs ) , but a few may require repeated wll . several prospective phase 2 trials of gm - csf therapy for idiopathic pulmonary alveolar proteinosis have been undertaken . the study conducted by seymour et al , evaluated the effectiveness of gm - csf in pap , the results have been encouraging , but the mechanism of the effect of gm - csf treatment is not entirely clear .

pulmonary alveolar proteinosis represents a rare syndrome characterized by the accumulation of proteinaceous phospholipid - laden material in the alveoli . this leads to impaired gas exchange and arterial hypoxemia of varying degrees . the diagnosis is confirmed by lung biopsy . sequential whole - lung lavage ( wll ) first described in 1963 is the standard of care . we report a case of a male diagnosed of having pulmonary alveolar proteinosis ( pap ) on transbroncial lung biopsy ( tblb ) . he was treated with sequential wll ( left followed by right , left being more involved on chest x - ray ) followed by recombinant gm - csf , with good result .

it is regarded as an unusual healing pattern of appendicitis in contrast to the conventional pattern . this type of tissue reaction can involve any organ but the most common sites are kidney and gallbladder . most of the patients present with a picture of acute or subacute abdominal pain and occasionally with a mass lesion in the right iliac fossa . mass lesions in the right iliac fossa can mimic locally advanced cancer but they have a benign course and can be cured by surgical resection . to avoid extensive resection , intraoperatively , imprint cytology can be used to decipher the cause of the mass . due to the rarity of xa itself and the use of imprint cytology for intraoperative diagnosis the case is being presented . a 47-year - old female was brought to the surgical emergency room with the complaints of severe pain abdomen , vomiting , and fever . on clinical examination , there was tenderness on the mcburney 's point , rebound tenderness , and a palpable lump . routine blood tests revealed a total leucocyte count ( tlc ) of 14.0 10/l and the erythrocyte sedimentation rate ( esr ) was 90 mm ist hour . ultrasonography remained inconclusive and computed tomography ( ct ) scan of the abdomen showed a large soft - tissue mass in the right lateral pelvis with adherent loops of intestine . the walls of intestine were thickened along with three enlarged lymph nodes in the vicinity . radiologically differential diagnosis of inflammatory versus neoplastic mass was given and the patient was taken up for exploratory laparotomy . on exploration , a jumbled up mass in the right iliac fossa with adherent and thickened large intestine and lymph nodes was identified . intraoperative imprint cytology was performed following which a limited right colon resection and lymph node removal were done . smears revealed benign glandular epithelial cell groups and sheets of xanthoma cells along with multinucleate histiocytic giant cells in the background of neutrophils and mononuclear inflammatory cells [ figure 1 ] . imprint cytology showing foamy histiocytes , lymphocytes , and histiocytic giant cells ( giemsa , 40 ) a jumbled up mass , comprising 2-cm part of small intestine , 5.5-cm long swollen appendix , adherent omentum , and 3-cm long large intestine , was received along with six lymph nodes . cut surface of the appendix showed markedly thickened wall with obliterated lumen showing gray white and yellow foci . microscopic examination revealed appendicular lining with focal ulceration and dense inflammatory cell infiltrate in the wall comprised of lymphocytes , plasma cells , histiocytes , eosinophils , foci of sheets of foamy macrophages , pools of extravasated mucin , marked foreign body giant cell reaction , and fibroblastic reaction against it [ figure 2 ] . microscopic view showing ulceration of lining epithelium with underlying inflammatory infiltrate ( h&e , 40 ) ( inset shows a high power view of foamy histiocytes and two giant cells ) smears revealed benign glandular epithelial cell groups and sheets of xanthoma cells along with multinucleate histiocytic giant cells in the background of neutrophils and mononuclear inflammatory cells [ figure 1 ] . imprint cytology showing foamy histiocytes , lymphocytes , and histiocytic giant cells ( giemsa , 40 ) a jumbled up mass , comprising 2-cm part of small intestine , 5.5-cm long swollen appendix , adherent omentum , and 3-cm long large intestine , was received along with six lymph nodes . cut surface of the appendix showed markedly thickened wall with obliterated lumen showing gray white and yellow foci . microscopic examination revealed appendicular lining with focal ulceration and dense inflammatory cell infiltrate in the wall comprised of lymphocytes , plasma cells , histiocytes , eosinophils , foci of sheets of foamy macrophages , pools of extravasated mucin , marked foreign body giant cell reaction , and fibroblastic reaction against it [ figure 2 ] . microscopic view showing ulceration of lining epithelium with underlying inflammatory infiltrate ( h&e , 40 ) ( inset shows a high power view of foamy histiocytes and two giant cells ) xanthogranulomatous inflammation is a well - documented but uncommon entity that occurs at many sites in the body . though initially described in kidney in 1944 , it occurs in other organs including fallopian tubes , endometrium , testicle , female and male genital tract , gallbladder , pituitary , colon , retroperitoneum , adrenal , and appendix . xanthogranulomatous appendicitis ( xa ) is a rare entity with only 11 cases reported in literature . of these three cases presented as mass lesion , chuang et al . in 2005 reported a case of a 39-year - old man who was admitted with fever , lower abdominal pain , and a mass in the right iliac fossa . with a suspicion of cancer , hemicolectomy was performed but on histopathological examination it turned out to be xa . omar et al . , in 2011 reported a rare case of xa and cecal angiolipoma in a patient who was admitted with acute appendicitis and an appendicular mass . in 2013 , mado et al . reported a case of a 78-year - old patient with abdominal pain , and the ct scan showed a 4-cm irregular mass near the caecum . the patient was operated with a clinical diagnosis of appendiceal mucocele , but the histopathological findings were consistent with xa . our case also presented with a mass lesion in the right iliac fossa and was explored with the possibility of carcinoma colon . the proposed mechanisms for the occurrence of xanthogranulomatous inflammation are defective lipid transport ; immunological disorders altering the chemotaxis of leucocytes and macrophages ; reaction to a specific infectious agent , such as proteus and escherichia species ; infection by low virulence organisms ; and lymphatic obstruction . the particular mechanism eliciting xa are organ obstruction , suppurative infection , hemorrhage , defective lipid transport , and local hypoxia . our case was remarkable for the finding of xa in a 47-year - old female who presented with acute abdomen and a mass lesion in the right iliac fossa that is suggestive of a cecal growth . this case is reported because of its rare presentation and the possibility that xa should be considered in the differential diagnosis of carcinoma colon . this case also shows the usefulness of on - site touch cytological evaluation for quick diagnosis .

xanthogranulomatous reaction can occur in any organ but the most common sites are kidney and gallbladder . xanthogranulomatous appendicitis ( xa ) is a rare clinical entity . there are a few case reports of xa diagnosed on histopathology but none on cytology . here we report a case of a 47-year - old lady who presented with acute abdomen and was found to have a mass lesion in the right iliac fossa . she was diagnosed with xa intraoperatively on imprint cytology that was subsequently confirmed on histopathological examination . due to the rarity of xa itself and the use of imprint cytology for intraoperative diagnosis the case is being presented .

vdd leads are usually connected to a vdd device , only in exceptional circumstances they are connected to a dual chamber device ( dr ) ; in this latter case , the device can be switched to aai mode . leads dislodgment are among the most common complications of cardiac pacing , they usually occur hours or days after device implantation . lead repositioning is difficult or impossible when it is a chronic lead dislodgment ; accordingly , management decision in these cases should take into account the clinical settings and ventricular pacing backup for patient safety . an 80-year - old male patient had a dual chamber pacemaker ( pm ) ( talos dr biotronik ) connected to a vdd lead and programmed in vdd mode , it was implanted three years previously for paroxysmal second degree atrioventricular block . the patient record showed that the implantation procedure was simple , a vdd device was not available during the operative period and it was decided to connect a vdd lead to a dr device programmed in vdd mode . 24-hour - post - operative pacing parameters were satisfactory , the patient was discharged on the second post - operative day . the patient has not been seen for a pm check since the implantation date ( non - compliant patient ) , he presented lately for gastrointestinal disorder for which he was hospitalized , there was no history of syncope or other relevant cardiac symptoms . ekg showed a spontaneous rhythm at 70 bpm , narrow qrs , a long pr interval with intermittent wenckebach phenomenon , chest x rays ( fig . 1 ) showed a relative cardiomegaly and a dislodged lead with displacement of the atrial ring into the right ventricle and the tip of the lead making a small loop at the apex of the right ventricle . lateral x - ray projection was not available ( bedridden patient ) , and cardiac echogram confirmed the position of the lead in the right ventricle . pm check showed unmeasurable ventricular pacing threshold with no capture at maximum output and a p wave ( in reality = r wave ) at 8 mv , r wave ( from tip electrode ) at 18.9 mv and impedance at 1120 ohms . the patient was reluctant to have any interventional procedure in order to relocate ( or change ) the lead ; consequently , pacing mode was switched to aai resulting in vvi - like pacing mode ( fig . 2 ) with intermittent loss of capture at nominal setting ( 3.6v/0.4 ms ) , the threshold was at 2.0/0.4 ms and accordingly the atrial output was programmed at 4.5v/0.4 ms ( fig . this case shows an example of a dislodged vdd lead connected to a dr pm with the atrial ring being displaced into the right ventricle , and a non measurable ventricular threshold . given the clinical settings , the condition was managed by programming an aai mode . in this case , having a dr device connected to a vdd lead allowed to switch to aai pacing mode ensuring a minimal ventricular pacing backup ; nevertheless , even if this coincidence ( dr device + vdd lead + lead dislodgment + management with aai mode ) was beneficial , this kind of dislodgment is rare and it is not a reason to make it a regular practice to connect a vdd lead to a dr pm . the first point to raise is the importance of regular device follow - up,1 this issue is of utmost importance and every effort should be made to ensure that patients especially those with dependent pm - have a regular pm check . a typical follow - up visit should include a targeted cardiovascular evaluation , assessment of the underlying rhythm , thresholds , and appropriate reprogramming to optimize device function and longevity . this patient was fortunate in being non - dependent and having an adequate ventricular rate despite the atrioventricular dissociation ; the time of dislodgment is undefined given that the patient had no follow up since the implantation , but we hypothesize that it happened in the days following the implantation procedure . the second point to raise is the importance of factors associated with perioperative morbidity:2 six variables were found to be independent predictors of events after first pm implantation : lower body mass index , heart failure , indication , subclavian vein access , active fixation of atrial lead , and dual chamber pm . in a study3 conducted to assess complications of pm implantations in the elderly , lead dislodgment was found among the most common complications ; nevertheless and according to the same authors , older age , was not found by itself associated with a significant increase in complication rates . given the increased life expectancy , pacing in the elderly is an increasingly frequent procedure ; shen et al4 found that pacing in the elderly improved quality of life , with a complication rate comparable to younger patients when no significant cardiac comorbidities are present . nevertheless and according to the same author , pm implantation in the very elderly is accompanied with higher risks of worsening of cardiac , neurologic , or orthopedic disabilities and this was related to the general clinical settings rather than to pm implantation by itself . chronic lead dislodgment is not always easy to relocate because of fibrosis and adherence , also the clinical setting ( non dependent patient , age > 75 years old ) and patient reluctance to any interventional procedure leading to conservative management ; in this case , a dr pacer connected to vdd lead gave the opportunity the switch to aai mode and so to ensure a minimal backup pacing in this setting .

an 80-year - old patient having a dual chamber dr pacer connected to a vdd lead presented with chronic lead dislodgment with the atrial ring displaced into the right ventricle . there was no ventricular capture at maximal ventricular output , and given the clinical settings , the condition was managed with a conservative approach , the mode was switched to aai ensuring a minimal adequate ventricular pacing backup in a non dependent patient .

one model for the development of intestinal type gastric cancer is a prolonged progression from atrophic gastritis to intestinal metaplasia ( i m ) followed by dysplasia and ultimately cancer . helicobacter pylori ( h. pylori ) infection has been shown to be an important risk factor for the development of gastric adenocarcinoma [ 2 , 3 , 4 ] . other potential risk factors for the development of gastric cancer include cigarette smoking , high salt intake , family history of gastric cancer , and pernicious anemia [ 5 , 6 , 7 , 8 ] . we present a patient who progressed in 14 months from histologically documented normal gastric mucosa to moderately differentiated intestinal type adenocarcinoma in the background of atrophic gastritis and i m . the patient is a 74-year - old african - american female who initially presented in 2008 with odynophagia . upper endoscopy performed at that time was unremarkable with the exception of a lipoma in the proximal stomach ; mucosal biopsies from this area were unremarkable , including a warthin - starry stain for h. pylori . the evaluation was notable for a cervical esophageal web on esophagram , which was confirmed during repeat upper endoscopy in july 2009 . esophageal dilation was performed at that time and the patient 's dysphagia initially improved ; random biopsies obtained from the antrum of the stomach and esophagus were both normal . the patient reported recurrent dysphagia in september 2010 without overt gastrointestinal bleeding , early satiety , nausea , vomiting , or unintentional weight loss . repeat upper endoscopy demonstrated a presumptive recurrent proximal esophageal web that was successfully dilated as well as a 1 cm nodular area with overlying friability and depressed center in the body of the stomach that was not present on prior upper endoscopies ( fig . biopsies from this area demonstrated intramucosal carcinoma and i m without evidence of h. pylori infection . radial array endoscopic ultrasound ( eus ) ( gf - ue160 , olympus america incorporated , center valley , pa . ) examination was performed to assess the feasibility of endoscopic mucosal resection of the nodular area in the stomach . eus demonstrated no enlarged perigastric lymph nodes or abnormalities in the visualized left lobe of the liver but invasion of the nodular lesion into the submucosa ( fig . 2 ) . given the depth of invasion of the lesion by eus , endoscopic mucosal resection was not performed and the patient was referred for surgery . preoperative ct chest , abdomen , and pelvis as well as pet - ct did not demonstrate evidence of locally advanced or metastatic disease . the final pathology demonstrated pt1b , pn0 , pmx intestinal type moderately differentiated adenocarcinoma in the setting of atrophic gastritis and extensive i m with no malignancy at the resection margins . the patient 's past medical history is notable for early stage squamous cell carcinoma of the left vocal cord that had been definitively treated with external beam radiation in 2002 . she reported a 40 pack - year cigarette smoking history and had quit smoking in 2002 . her family history is negative for gastric cancer and the patient was born and raised in the united states . it is generally believed that the development of intestinal type gastric cancer is a prolonged process starting with the development of atrophic gastritis followed by i m . while this patient does have potential risk factors for the development of gastric cancer , namely a history of cigarette smoking and being of african - american descent , the rapid progression in 14 months from normal gastric mucosa to atrophic gastritis , i m , and cancer is unusual and contradicts the paradigm noted above . other risk factors for the development of gastric cancer such as h. pylori infection , family history of gastric cancer , and pernicious anemia were not present and the patient was not from an area with a high prevalence of gastric cancer . presumably , other unrecognized risk factors contributed to this patient 's presentation . gastric i m is a common entity that has been estimated to occur in up to 50% of patients in western countries . some investigators have suggested that endoscopic surveillance may be beneficial in patients with atrophic gastritis or gastric i m [ 10 , 11 ] . however , surveillance of all patients with gastric i m is controversial in western countries given the low incidence of gastric cancer [ 12 , 13 ] . irrespective of this issue , endoscopic screening was not an option in this patient since the diagnosis of gastric i m was made at the same time as the diagnosis of gastric cancer . this case is the first to our knowledge that documents the rapid development of intestinal type gastric adenocarcinoma in a patient with previously normal gastric mucosa , specifically without a precancerous lesion such as i m . further studies to identify previously unknown risk factors for gastric cancer as well as to better define which patients with atrophic gastritis or gastric i m are at higher risk for developing dysplasia and cancer are needed .

intestinal type gastric adenocarcinoma is felt to develop over a protracted time period through a series of defined steps . several potential risk factors for the development of gastric cancer have been identified , including a family history of gastric cancer and helicobacter pylori infection . we present the case of a patient with neither risk factor who progressed in a 14 month time frame from histologically normal gastric mucosa to early stage intestinal type gastric adenocarcinoma in the setting of diffuse gastric intestinal metaplasia and atrophic gastritis . this patient 's presentation conflicts with our current understanding of the development of intestinal type gastric adenocarcinoma .

weight - bearing exercises are often beneficial for strengthening muscles and they are being increasingly used in clinical practice . typically , weight - bearing exercises in a standing posture are performed while the feet are in contact with a stable floor or an object that generates compressive forces at the hip , knee , and ankle joints resulting from an individual s body weight . weight - bearing exercises increase muscle strength and neuromuscular control of the lower extremities in young athletes1 , 2 . partial weight - bearing exercises are used for patients with painful knee osteoarthritis or inflammation in the hip or knee joints3 , 4 . foot - arch exercises are used to reinforce the arch of the foot and strengthen the plantar muscles . these exercises increase the angle of the medial longitudinal arch5 and reduce the center of pressure6 . heo et al.7 reported that short - foot and toe - spreading exercises are effective methods for selectively strengthening the abductor hallucis muscle . kim et al.8 recommended the toe - spreading exercise to prevent or correct hallux valgus . the abductor hallucis muscle is an intrinsic muscle of the plantar foot , and its activity can be detected using surface electromyography ( emg)9 . myers10 noted that the plantar fascia and short toe flexors are connected with the triceps surae muscle group on the superficial back line . dissections show that the fascia clearly links the distal ends of the hamstrings to the proximal ends of the hamstrings and the gastrocnemii heads . according to the theory of anatomy trains , fascia in the lower extremity is clearly linked when the knees are extended , which leads to correct action of muscles in the lower extremity . however , almost all exercises used for strengthening the foot arch are usually performed when the subject is seated5 , 7 . therefore , this study investigated the effects of weight - bearing exercises performed while standing . considering the role of fascia in muscle function10 , we hypothesized that during foot - arch exercises the activity of the abductor hallucis muscle while weight - bearing in a standing posture would be higher than the activity with partial weight - bearing in a sitting posture . eleven healthy volunteers ( five males , six females ; mean sd age 26.09 2.91 years , height 166.54 11.54 cm , mass 58.45 14.13 kg ) participated in this study , which was approved by the inje university faculty of health science human ethics committee . the subjects reported no symptoms of injury at the time of testing , they were able to perform the exercises without pain , and they had no history of surgery or amputation of the foot or ankle in the past 6 months . the study participants results were within the normal range ( 59 mm ) in the navicular drop test11 . the emg signals of the abductor hallucis muscle activity was recorded using a mp150wsw data acquisition system ( biopac systems , santa barbara , ca , usa ) . all of the signals were amplified , band - pass filtered ( 20500 hz ) , and sampled at 1,000 hz using acqknowledge ver . 3.9.1 , then normalized to the peak maximal voluntary isometric contraction ( peak % mvic ) . the subjects practiced the short - foot and toe - spreading exercises in both the sitting and standing positions . while sitting , the trunk was maintained in an upright position during the exercise and the hips were not bent forward . in the standing posture , the feet were splayed outwards and the load of the body weight was placed on the dominant leg . when performing the short - foot exercise , the metatarsal was drawn toward the heel without toe flexion . for the toe - spreading exercise , the toes were spread and the heel was raised . then , the heel was lowered to the ground , increasing the medial longitudinal arch , and held in that position . the participants performed both exercises while both standing and sitting and maintained each position for 5 s. statistical analysis was performed using spss ver . 17.0 ( spss , chicago il , usa ) . the paired t - test was used to determine the significance of differences in the activity of the abductor hallucis during the short - foot exercises . for the toe - spreading exercise , the activation of the abductor hallucis was significantly greater ( p<0.05 ) when standing than sitting ( 59.1914.19 vs. 47.8817.95%mvic , respectively ) , while there was no significant difference in the results of the short - foot exercise between standing and sitting ( 56.4314.97 vs. 48.9814.95%mvic , respectively ) . to determine the effect of weight - bearing foot - arch exercises , this study compared the short - foot and toe - spreading exercises while subjects were standing and sitting . we hypothesized that the weight - bearing exercises conducted while standing would generate greater activation than partial weight - bearing exercises while sitting for both the short - foot and toe - spreading exercises . a possible reason for the differences between these two exercises is that the short - foot exercise shortens the abductor hallucis between the metatarsophalangeal joint and calcaneus , while the toe - spreading exercise maintains the stretch tension through maximal abduction of the toes . according to the length - force relationship , there is an optimal muscle length that generates the greatest muscle force , while a shortened or stretched muscle generates a lower force12 , 13 . therefore , we believe that shortening of the abductor hallucis influenced its activity during the short - foot exercise , as evidenced by the lack of significant change in emg activity between standing and sitting . first , measurements with surface emg electrodes are always affected by crosstalk from adjacent muscles . second , these results can not be generalized because the sample size was small . third , we did not quantify the amount of partial weight - bearing , so the subjects might have performed the exercises under different loads . many studies have reported that weight - bearing exercises are more effective for strengthening the skeletal muscles . however , our results suggest that the length - force relationship should be considered for weight - bearing foot - arch exercises .

[ purpose ] this study examined the effects of different weight - bearing postures on the activation of the abductor hallucis muscle during foot - arch exercises . [ subjects ] the study recruited 11 healthy volunteers who were pain - free , had no history of foot or ankle surgery , and were able to maintain a standing posture . [ methods ] the subjects performed short - foot and toe - spreading exercises while sitting and standing . [ results ] the abductor hallucis muscle activation in the toe - spreading exercise was significantly greater when standing than in sitting , while that in the short - foot exercise did not differ significantly between the two postures . [ conclusion ] the results of this study suggests that a weight bearing posture such as standing is the most effective method of increasing the emg activity of abductor hallucis muscle in the toe - spreading exercise .

cerebral venous thrombosis ( cvt ) is a distinct disorder with highly variable symptoms and courses . brain mri , magnetic resonance venography , and positive d - dimer assay confirmed the presence of cvt . the work - up for detecting the cause of the cvt revealed occult prostate cancer . occult malignancy including prostate cancer should be strongly suspected in older patients with idiopathic cvt . cerebral venous thrombosis ( cvt ) is an infrequently occurring type of cerebrovascular disease with a wide spectrum of clinical presentations and is notoriously difficult to diagnose . several disorders can cause or predispose patients to cvt , including all medical , surgical , and gyneco - obstetric causes of deep vein thrombosis in the legs , genetic and acquired prothrombotic disorders , cancer , hematological diseases , vasculitis and inflammatory systemic disorders , pregnancy and puerperium , infections , and several local causes such as brain tumors , arteriovenous malformations , head trauma , cns infections , and ear , sinus , mouth , face , or neck infections.1 diagnostic and therapeutic procedures such as surgery , lumbar puncture , jugular catheter , and some drugs ( particularly oral contraceptives , hormonal replacement therapy , steroids , and cancer treatments ) can also cause or predispose people to cvt . however , the relative likelihood of these causes varies with the age and country of origin of the patient.2 in the absence of an obvious provoking risk factor , the presence of an underlying malignancy is often considered because some types of cancer appear to be able to initiate or trigger a thrombotic diathesis through various mechanisms . however , cvt as the presenting sign of occult prostate cancer has not been reported in the english literature . three days prior to admission , he experienced difficulty in using a television remote control and writing a letter , he was clumsy with spoons and chopsticks , and he had forgotten the personal identification number of his bank account . he had no history of diabetes , hypertension , smoking , alcoholism , or cardiac disorders . a neurological examination revealed ideational apraxia , finger agnosia , alexia , and right - to - left disorientation . minimal dysarthria , right central type facial nerve palsy , and pronator drifting of the right arm were also noted . 1a ) . magnetic resonance ( mr ) angiography showed no arterial abnormality , but mr venography revealed occlusion of the left transverse sinus ( fig . the results of the following laboratory tests were normal or negative : electrocardiogram , complete blood cell count , sedimentation rate , blood sugar , lipid battery , homocysteine , fibrinogen degradation products , prothrombin time , partial thromboplastin time , lupus anticoagulant , antithrombin iii , factor viii , antiphospholipid antibody , anticardiolipin antibody , antinuclear antibody , antineutrophil cytoplasmic antibodies , protein c , protein s , c3 , c4 , ch-50 , c - reactive protein , and antistreptolysin o. however , the plasma levels of d - dimer were elevated ( 1,700 ng / ml ) . to search for the predisposing factors of cvt , we performed gastrofiberscopy , colonoscopy , chest ct , abdomen ct , and serological tumor marker studies , but no abnormalities were revealed . the level of prostate specific antigen was markedly elevated ( 11.8 ng / ml ) , so an aspiration needle biopsy sample of the prostate gland was taken . malignancy is associated with a high risk of developing thromboembolic disease and is related mainly to the generation of an intrinsic hypercoagulable state as a result of tumor induction of platelet aggregation and expression of various procoagulant factors including tissue factor and thrombin . circulating carcinoma mucins can induce platelet - rich microthrombi without thrombin , a process that is inhibited by heparins but not by warfarin . activation of the coagulation system appears to be intricately linked to processes that control tumor growth and angiogenesis.3 expression of tissue factor in tumors leads to an angiogenic phenotype via the up - regulation of vascular endothelial growth factor and down - regulation of the angiogenesis inhibitor thrombospondin.4 we found no similar reports in the literature of cvt as the presenting sign of occult prostate cancer.5 most series of thromboembolism associated with occult cancers are about deep venous thrombosis of the legs or pulmonary embolism.3,5 it is not clear what percentage of patients with unprovoked venous thromboembolism harbor an asymptomatic occult malignancy . several studies have found that approximately 8 - 12% of patients who presented with venous thromboembolism were diagnosed as having cancer after a relatively simple medical examination based upon symptoms and routine laboratory testing.6 - 8 over 5% of men diagnosed with prostate cancer have an antecedent thromboembolic event without any traditional risk factors for venous thromboembolism.5 however , there are no case reports involving prostate cancer patients with antecedent cvt in those series . because of the wide variety and nonspecificity of the presenting symptoms of cvt , it would be of great practical importance to develop an easy - to - perform test for the emergency room that would reliably rule out cvt . the presence of d - dimer , which comprises fragments of cross - linked fibrin digested by plasmin , indicates the activation of both the blood coagulation system and the fibrinolytic system . indeed , d - dimer concentrations are increased in most patients with recent cvt so that a negative d - dimer assay result may make the diagnosis of cvt highly unlikely . the sensitivity , specificity , and positive and negative predictive values of conventional d - dimer levels of > 500 ng / ml for the diagnosis of cvt are all 100%.9 our patient has some features that differ from typical patients with cvt . cvt is a distinct cerebrovascular disorder that , unlike arterial stroke , most often affects young adults and children . the majority ( about 75% ) of the adult patients are female , but this is not the case for children or the elderly . 8.2% of 624 consecutive adult patients with symptomatic cvt were aged 65 years or older.10 our case also has several implications for practice . cvt must be included in the differential diagnosis of elderly patients presenting with decreased alertness , delirium , or mental changes , because cvt does not usually present in the elderly as headache or isolated intracranial hypertension . the coincidence of these two entities can not be completely ruled out in older patients . however , occult malignancy including prostate cancer should be strongly suspected in older patients with idiopathic cvt .

backgroundcerebral venous thrombosis ( cvt ) is a distinct disorder with highly variable symptoms and courses . malignancy is known to be one of the predisposing factors of cvt.case reportwe present the case of a 69-year - old man with sudden behavioral changes . brain mri , magnetic resonance venography , and positive d - dimer assay confirmed the presence of cvt . the work - up for detecting the cause of the cvt revealed occult prostate cancer.conclusionsoccult malignancy including prostate cancer should be strongly suspected in older patients with idiopathic cvt .

since 1980 , when the first implantable cardiac defibrillator ( icd ) was implanted , the use of cardiovascular implantable electronic devices ( cied ) including permanent pacemaker and icd has become more popular . with growing indications , infectious endocarditis is a rare complication following implantation of these devices . in suspected cases , transthoracic echocardiography ( tte ) but , the incidence of constrictive pericarditis due to icd lead infection in dual active fixation method is rare . a 62-year - old man with history of diabetes and opium addiction for 20 years was admitted in 2007 at sina hospital , isfahan , iran , for evaluation of arrhythmia . however , left ventricular ( lv ) function was severely reduced with ejection fraction of 20% the patient was placed on anti - arrhythmia drugs ( amiodarone , 400 mg , orally , three times in day ) and discharged . one year later , the patient was admitted with repeated vt with severe lv dysfunction arrhythmia which did not respond to medical therapy . tte was unremarkable , tee showed large vegetations on the icd lead in ra and also vegetations on the anterior leaflet of tricuspid valve . the result of the blood culture was positive for staphylococcus aureus which was methicillin sensitive . septal motion abnormality ( septal bounce ) the decision was made to remove the device surgically throw median sternotomy in february 2011 . the cultures of excised vegetations were positive for staphylococcus aureus , e.g. , video 1 , figure 2 . leaflet of tricuspid valve , infected implantable cardiac defibrillator leads one month after the surgery , the patient returned to hospital with chest pain , malaise , and no fever . pericardial effusion with air - fluid level in a patient with previous implantable cardiac defibrillator ( non - contrast chest ct . mediastinal window ) one month later , the patient returned with severe lower extremity edema . echocardiography showed echo findings were as follows : moderate pulmonary arterial hypertension ( pap = 45 - 50 mmhg ) , moderate circumferential pericardial effusion with high - density material ( 18 mm ) at pericardium [ figures 4 - 8 ] . mitral valve inflow deceleration time constrictive pericarditis mitral valve velocity propagation significant respiratory variation in tricuspid inflow significant respiratory variation in mitral inflow sever diastolic dysfunction in mitral valve ( doppler ) surgical removal of vegetation of ant . generator and lead removal during ten months follow - up after pericardiotomy , dyspnea and edema improved significantly with no evidence of life - threatening arrhythmias . constrictive pericarditis following icd implantation is rare . with less frequent use of patch electrodes , koich keno et al . reported a case of delayed pericarditis 23 days after icd implantation with active fixation atrial lead method , but no endocarditis . they believed that constant contact of the atrial screw with pericardium was the cause of pericarditis . they believe that mechanical injury was the main reason for pericarditis . in all cases of reported icd infection with large vegetations , icd - related endocarditis is an uncommon but a serious complication , the incidence ranging from 0.5 to2% with high mortality rate close to 35% . the most common bacteria causing icd infection is staphylococcus aureus as it was in our case .

the usage of implantable cardiac defibrillator ( icd ) since 1980s is becoming more popular these days . the rate of both , endocarditis and constrictive pericarditis are low but it still needs attention . we are reporting a rare case of icd endocarditis as a result of toe infection in a diabetic patient . this was followed by infectious pericarditis after device removal by open heart surgery and then delayed constrictive pericarditis .

low back pain is a very frequent symptom at general orthopaedic consultation , and establishes a long term chronic illness between 2% and 7% of times . although , a great majority of the chronic low back pain is related to vertebral degenerative pathology , other possible reasons , even unusual , have to been considered like abdominal pathology ( pancreatic for instance ) and aortic abdominal aneurysms with chronic contained rupture or not . most of the times low back pain is the main symptom and first clinical approach for aortic abdominal aneurysms . sometimes the radiological study points the most likely etiological alternative , but the classical triad of abdominal ( or back ) pain , shock , and pulsatile abdominal mass might be the clinical picture for aortic abdominal aneurysms , that in some cases can compromise the vertebral integrity . the aim of this work is to introduce a case report that emphasize the need to relate the low back pain with atypical clinics appearances of entities , as aortic abdominal aneurysms , capables to compromise the patients prognosis and treatment . an active 75-year - old woman , 45 pack / year smoker , hypercholesterolemic , with progressive low back pain since last six months that gradually causes troubles for proper walking , was being studied in another hospital due to symptoms of pneumonia over latent lung - tuberculosis , whose complementary imaging proves reveal an infrarenal aortic dilatation with destruction of anterior wall of vertebral bodies l2 , l3 and l4 ( fig 1 ) . patient had an aortic abdominal aneurysm ( aaa ) , type iv of crawford safi scale , with rupture sealed against anterior vertebral body walls . computed tomographic angiography estimated a 5 4 9 cm aneurysmatic rupture , showing a total thrombosis and loss distinction with vertebral bodies of l2 , l3 and l4 ; and revealing lysis up to 30% of the anterior walls of them , being l3 the most damaged one ( fig 2 ) . also , the ct angiography revealed healthy kidney arteries and distal revascularization due to collateral vessels . magnetic resonance imaging ( mri ) highlighted a spondylodiscitis in this level where histological and infectious studies were not decisive . vascular surgeons did not consider appropriated surgical approach nor open or endovascular because of presence of healthy kidney arteries and distal flow from collaterals . orthopedics treatment consisted in instrumented lumbosacral arthrodesis with heterologous bone graft from l1 to s1 through posterolateral spine approach with pedicular screws ( fig 3 ) . postoperatively , the patient experienced reversible cardiac insufficiency episode but was discharged home in good health 20 days after intervention . at 12-months follow - up , the patient was out low back pain reaching a visual analogue scale of 2 ( pre - surgical vas of 8) , now walking without aids help and has recovered whole of her daily activities . , when aortic aneurysm is placed in abdominal segment , the associated vertebral erosion or lysis never is over 3% . contained rupture of aaa is established on a progressive way by a haematoma expansion at the posterior aneurysm wall that triggers vertebral erosion . specific mechanism for the vertebral lysis is not clear , due to exists several hypothesis implicating arterial pulse , aneurysm or haematoma infection , inflammatory processes , or just an unspecific reason . since 1965 , szilagy et al . , described the contained rupture of aaa as a clinical pathology that can appear as unspecific abdominal or back pain for a variable lapse of time when neuropathy or paraplegia of lower extremities could be established . these atypical clinic ways are able to hide bone metastasis , primary bone tumors , rheumatoid arthritis , osteomalatia , infectious processes like vertebral tuberculosis ( pott disease ) , vertebral pyogenic spondylodiscitis or psoas abscess . compressive or inflammatory neuroapraxia of ilioinguinal or iliohypogastric nerves explains the pain irradiation to inguinal , low abdominal , the testicle or anterior thigh areas when aortic aneurysm is placed abdominal . surgical repair of contained aaa should be directed to secondary re - rupture prevention , with an approximate survival near to 100% at selected patients for elective surgery . consequently , orthopedic surgery for back spine stabilization has to be elective in those cases when vertebral destruction is above 30% and clinic is directly related to spine instability . low back pain is a clinic entity very frequent at the general orthopaedic consultation , but not always is due to spine primary disease . we should consider aaa as other cause and routinely examine the abdomen at back pain consultations and seek complementary imaging proves when risk factors are present ( smoker , male , age > 65 , pulsatile abdominal mass , etc . ) . when main disease is solved ( with or without treatment ) javier garcia garcia contributed as data collector and analysing bibliography.david pescador hernandez and juan francisco blanco blanco contributed analysing data and reviewing the article text . written informed consent was obtained from the patient for publication of this case report and accompanying images . a copy of the written consent is available for review by the editor - in - chief of this journal on request .

highlightslow back pain is a common cause of medical consultation , and usually supposes a non - malignant prognostic.we report an abdominal aortic aneurism ( aaa ) as atypical etiology of low back pain.we should consider aaa as other cause of low back pain and routinely examine the abdomen and seek complementary imaging proves when risk factors for aaa are present.orthopedic surgery for back spine stabilization has to be elective in those cases when vertebral destruction is above 30% and clinic is directly related to spine instability .

thyroglobulin ( tg ) is excreted exclusively by thyroid cells and is one of the key factors in the follow - up of patients with follicular differentiated thyroid carcinoma ( fdtc ) . while lymph node metastasis may be associated with low tg levels , the highest level of tg is seen in bone metastasis . the sensitivity of tg is very high for detection of bone metastasis especially after thyroid stimulating hormone ( tsh ) stimulation . low tg associated with normal neck ultrasonography is reported to have a very high negative predictive value for persistent disease and is used in many clinical trials as a proof of patient response to treatment . we are reporting a patient with diffuse skeletal metastasis associated with low serum tg level bringing a point of caution in evaluation of patients with low tg . a 23-year - old man presented to our thyroid cancer clinic on may 2006 with a history of papillary thyroid carcinoma ( ptc ) . he was operated about 10 years ago with no follow - up and no radio - iodine therapy . primary pathology was ptc in a 4.5 cm 4.0 cm 3.0 cm nodule in the right thyroid lobe . the stage of the disease at the time of diagnosis was considered pt3nxmx . on presentation , he had no symptoms and neck examination revealed a small 1 cm mass in the thyroid bed in midline . he underwent repeat neck exploration , and pathology examination revealed adenomatous nodule . following discontinuation of levothyroxine for 4 weeks , thyroid values were measured in the serum and tsh was 150 miu / l , tg level was 3.5 ng / ml and anti - tg antibody level was 11 iu / ml . the biocode ( s. a , liege , belgium ) kit was used for determination of tg level with a sensitivity of 0.35 ng / ml and an inter assay variation of 4.8% and between assay variation of 6.1% . after 2007 , tg measurements were done using elecsys_electrochemiluminescent immunoassay from roche diagnostics ( meylan , france ) . anti - tg antibody was measured using elisa method ( trinity - biotech ) before 2007 and by elecsys electrochemiluminescent immunoassay from roche diagnostics ( meylan , france ) after 2007 . diagnostic whole body iodine scan was performed 2 days after administration of 74 mbq i-131 and widespread bone metastasis , regional lymph node metastasis , and thyroid bed uptake was detected [ figure 1 ] . patient had no complaint and after asking him about any bone pain , remembered just occasional mild low back pain . postablation whole body iodine scan ( anterior and posterior views ) performed 7 days after 7400 mbq of i-131 shows multiple areas of iodine uptake in the skull , sternum , thyroid bed , cervical spine , left clavicle , thoracic spine , lumbar spine , pelvis and left femoral diaphysis the patient was treated with 7400 mbq of 131-iodine . suppressive therapy was started , and measurement of tg was done after discontinuation of the drugs 8 months later . tsh level was 380 miu / ml with simultaneous tg level of 6 ng / ml and anti - tg antibody level of 11 iu / ml . treatment was repeated with another dose of 7400 mbq of i-131 . postablation whole body iodine scan again showed multiple foci of metastases with no significant change compared with the previous scan . radiography of the pelvis showed a small lytic lesion in the iliac bone with a rim of sclerosis [ figure 2a ] . ( a ) pelvic radiography shows lytic lesion in the right iliac bone with a rim of sclerosis . ( b ) computed tomography scan image from 2 lumbar spine shows a lytic lesion in vertebral body with sclerotic rim and internal septa . these findings strongly suggest low grade malignant lesion since that time , the patient has been treated 5 more times with i ( total accumulated dose 51.8 gbq i-131 ) . tg level was always below 6 ng / ml in spite of multiple bone metastases . thoraco - lumbar computed tomography scan was done for more confirmation and indicated the presence of skeletal involvement corresponding to the lytic lesions detected in the radiographies [ figure 2b ] . the patient underwent surgical biopsy from the lumbar spine ( l2 ) and the pathology result was positive for metastatic carcinoma . immunohistochemistry of the removed tissue was positive for thyroid transcription factor-1 and tg markers in tumoral cells , confirming thyroid origin of the lesions [ figure 3 ] . ( a ) carcinoma cells with follicle - like structure formation ( h and e , 10 ) . a low stimulated tg level ( < 1 ng / ml ) associated with normal neck ultrasonography is considered as the most reliable criteria for complete remission in low risk patients . also stimulated tg between 1 and 10 ng / ml concomitant with normal neck ultrasonography is considered as acceptable response . however false negative tg in the presence of metastasis is reported in 6.8% of patients , although most of the patients in this report had only lymph node metastasis and only one patient had bone metastasis . another study in 194 patients with differentiated thyroid carcinoma ( dtc ) , with a mean follow - up of 7.7 years found persistent disease in 1.5% of the patients . in that study , there was no patient with low serum tg level concomitant with distant metastasis . falsely low or high tg level is also reported in the presence of heterophile antibodies in serum of the patient . in our study tg was measured with two different techniques and showed persistently low tg and anti - tg level throughout the years of follow - up . in the present patient , inappropriate low serum tg level in the presence of widespread skeletal metastases was noted in spite of measurement of tg with two different kits and controlling for heterophile antibodies . only few cases of skeletal metastases associated with low tg level was reported in the literature , and only one of the reported cases had diffuse skeletal metastases . our patient brings more caution in definition of response as low tg and normal neck ultrasonography . our patient is a case of pediatric thyroid cancer , operated at the age of 13 years old . as distant metastases are more commonly seen in pediatric patients , diagnostic wbis may be useful in these patients irrespective of the result of tg or neck ultrasonography . early recognition and radio - iodine therapy are mandatory in the majority of these patients to prevent long term morbidity and possibly to improve survival . the other teaching point in our patient this finding again emphasis on careful scrutiny in patients with dtc and not relying only on tg level and symptoms . low tg level and absence of symptom does not exclude widespread skeletal metastases in patients with ptc .

thyroglobulin ( tg ) is frequently measured in follow - up of patients with differentiated thyroid carcinoma . a low stimulated tg level ( < 1 ng / ml ) associated with normal neck ultrasonography is considered as the most reliable criteria for complete remission in low risk patients . we are reporting a case of pediatric thyroid cancer with diffuse skeletal metastasis associated with low serum tg level bringing a point of caution in evaluation of patients with low tg .

they are mixed tumors , consisting of both epithelial and mesenchymal cells , that present a complete dental tissue differentiation ( enamel , dentin , cementum , and pulp ) . according to the latest classification of the world health organization ( who , 2005 ) , two types of odontomas can be found : complex odontomas and compound odontomas the latter being twice as common as the former . compound odontomas are usually located in the anterior sector of the upper maxilla , over the crowns of unerupted teeth , or between the roots of erupted teeth . the lesions are usually unilocular and contain multiple radiopaque , miniature tooth - like structures known as denticles . complex odontomas in turn are found in the posterior mandibular sector , over impacted teeth , and can reach several centimeters in size . radiologically , these lesions manifest as a radiopaque solid mass with occasional nodular elements , and surrounded by a fine radiotransparent zone . the lesions are unilocular and are separated from the normal bone by a well - defined corticalization line . clinically , these are asymptomatic lesions often associated to alterations in permanent or temporary tooth eruption . the diagnosis is usually established on occasion of routine radiological studies ( panoramic and/or intraoral radiographs ) , or on evaluating the cause of delayed tooth eruption . the treatment of choice is surgical removal of the lesion in all cases , followed by histopathological study to confirm the diagnosis.[13 ] this report describes a case of multiple odontomas in the mandible in the anterior region leading to impaction of the canine . a 22-year female reported to the department of orthodontics and dentofacial orthopedics for the treatment of her crooked teeth . she was examined clinically and had all the tooth erupted except the third molars in the upper arch with crowding in the maxillary anterior region . in the lower arch , all the teeth had erupted except third molars bilaterally and lower left lateral incisor . there was a mild space between the lower left central incisor and the canine . other significant findings were class - ii div-1 malocclusion with crowding in the maxillary anterior region . she was advised for orthopantomogram and true occlusal radiography , which revealed that there was a radiopaque lesion in the mandibular left lateral incisor region that led to the impaction of mandibular left lateral incisor [ figure 2 ] . the differential diagnosis contemplated was radiopaque lesions : odontomas , adenomatoid odontogenic tumor , calcifying epithelial odontogenic tumor , odontoameloblastoma , ameloblastic fibrodentinoma , and osteoma . opg showing the odontoma surgical exposure of the odontoma the treatment consisted of total removal of the radiopaque lesion along with the impacted lateral incisor as the position of lateral incisor was unfavorable to be aligned through orthodontic means . the patient was referred to the department of oral and maxillofacial surgery where her routine blood examination was done before undergoing surgery . the lesion was removed and consisted of eleven tooth - like masses [ figure 1 ] which were sent for histopathological examination , which confirmed the lesion being a well - formed odontoma [ figures 4 and 5 ] . multiple odontomas after surgical removal histological section of the odontoma showing enamel , dentin and pulp histological section of the odontoma showing enamel and dentin they are generally asymptomatic and constitute casual findings in the course of routine radiological studies , particularly in the second and third decades of life . there are two types of odontomas : complex odontomas and compound odontomas the latter being twice as frequent as the former . compound odontomas show a predilection for the anterior sector of the upper maxilla , while complex odontomas are typically found in the posterior mandibular region . the treatment of choice is surgical removal of the lesion in all cases , followed by histopathological study to confirm the diagnosis . radiologically , odontomas manifest as a dense radiopaque lesion surrounded by a thin radiotransparent halo . three developmental stages can be identified , based on the radiological features and degree of calcification of the lesion at the time of diagnosis . thus , the first stage is characterized by radio transparency due to the absence of dental tissue calcification , while the second or intermediate stage presents partial calcification , and the third or classically radiopaque stage exhibits predominant tissue calcification with the aforementioned surrounding radiotransparent halo . compound odontomas show an irregular radiopaque image with variations in contour and size , composed of multiple radiopacities corresponding to the so - called denticles . in the complex type of lesion , radiopacity is not specific ; rather , a disorganized , irregular single or multiple mass is identified . in both cases ( compound and complex odontomas ) , a radiotransparent halo corresponding to the connective tissue capsule is present.[68 ] the dental tissues that conform these denticles comprise a central core similar to pulp tissue , surrounded by primary dentin and covered with partially demineralized enamel and primary cement . most authors coincide that these lesions effectively appear more often in the upper maxilla,[6812 ] though some sources make no distinction between the two maxillas.[81012 ] the reported tendency of odontomas to arise in the region of the incisors and canines[6891316 ] is confirmed in our own series ( 54% of cases ) , followed in order of frequency by the posteroinferior region ( 26.2% ) . however , some studies have reported a similar incidence of odontomas in the anterosuperior zone and posterior mandibular region , or even describe an increased proportion of these lesions in the molar zone . odontomas are benign tumors frequently seen in oral cavity that sometimes produce no symptoms and constitute casual findings of routine radiological studies . however , they usually tend to cause signs and/or symptoms such as delayed eruption . if no signs or symptoms appear , and the lesions go undetected , they can remain within bone for many years without producing clinical manifestations .

odontomas are benign odontogenic tumors composed of enamel , dentine , and cementum and pulp tissue . they are usually clinically asymptomatic , but often associated with tooth eruption disturbances . the present study reports an unusual case of eleven odontomas in the left lateral incisor - canine region of lower jaw . a 26 years old female presented to the department of orthodontics and dentofacial orthopedics in h.p . govt . dental college and hospital shimla for the treatment of misaligned teeth . clinical examination revealed that the lower left lateral incisor was missing . patient was advised for radiographs , which revealed a mixed radiopaque lesion associated to impacted lower left canine . the histological report in this case indicated a compound odontoma .

cotard s syndrome is a rare psychiatric disorder characterised by nihilistic delusions concerning one s own body . described in 1880 by jules cotard , a french psychiatrist , patients typically believe they are dead or their bodily organs and limbs are rotting and disintegrating . in accordance with the mental health act ( mha ) legislation , for a patient who is detained under section 3 of the mha 2007 and does not consent to treatment , where the responsible consultant considers treatment necessary , the mental health act commission must be contacted and the advice of a second opinion appointed doctor ( soad ) must be sought . a detained patient , who declines to give consent , can not be given electroconvulsive therapy ( ect ) unless the treatment is immediately necessary to save the patient s life or to prevent an immediate deterioration in their condition . treatment of cotard s syndrome secondary to an underlying mood disorder with ect has been observed to be extremely effective . we report the case of a female patient who has a long history of somatisation presenting with depression and cotard s phenomenon ; highlighting an ethical dilemma of treatment with ect within the united kingdom s mha . the patient is a 59 year old caucasian female who lives alone in a council flat and has been known to mental health services for depression with somatic features . she presented to the oleaster via the home treatment team with worsening symptoms of somatisation and a loss of mobility . these symptoms began over twenty years ago where the patient described severe back and leg pain associated with cramping , paraesthesia , paresis and anergy . she felt this was as a result of a spinal injury she sustained while giving birth to her son . her mental health deteriorated over the days preceding admission and this manifested itself by hopelessness , despair and suicidal ideation . she felt she was a rotting corpse and expressed the wish of wanting to die . furthermore , she was unable to shower because of the pain in her legs and consequently her personal hygiene deteriorated . the patient explained that the blood circulation to her legs was compromised therefore resulting in her legs rotting and falling off . in her opinion , she felt she had always been misdiagnosed and was pre - occupied about this . she asked why she was not in a nursing home as my legs are not working , rather than a mental health hospital . the patient also suffered from rumination , constantly focusing on her back and leg pain in addition to conveying somatic delusions . she had previously been discharged from inpatient services only two months prior to this admission . during her last inpatient stay , she was detained under section 3 of the mha 2007 . following initial treatment with antipsychotic and antidepressant medication she was therefore offered ect and after 2 sessions she refused to have further courses of ect . the patient at this time appealed against her detention and upon assessment appeared to have capacity . the soad concluded that the patient had capacity and ect was therefore not viable and consequently it was withdrawn . the patient was subsequently discharged on a community treatment order with follow up in the community . prior to this informal admission , the patient had been functioning well in the community , no longer pre - occupied with her legs and successfully undertaking her activities of daily living . her marked progress in the community resulted in her community psychiatrist reducing the doses of her antidepressant and antipsychotic medication . she has a history of hypertension and currently adheres to a depot pipothiazine injection every two weeks and duloxetine . the patient was brought up by her mother and stepfather , performing well at school and worked as a legal secretary until the birth of her first child . she was married for 18 years , however , is now divorced and attributes this to the problem with my legs . the patient has a 20 year history of smoking pack year history and previously consumed large quantities of alcohol , however has been abstinent for 1 year . there is no forensic history and she independently resides in a council flat , receiving benefits with regular support from her son . upon examination , the patient was dressed in appropriate clothing , however appeared dishevelled and unkempt . she was anxious , rubbing her legs with her hands , and pacing the room . she made poor eye contact , making it difficult to establish a robust doctor - patient rapport . there was presence of nihilistic delusions as the patient felt her legs were rotting , however , there were no delusions of poverty or guilt . she claimed there was nothing wrong with her mental health , attributing all her symptoms to a physical aetiology . the patient s physical examination was unremarkable and her full blood count , urea and electrolytes and thyroid function tests were normal . the patient was diagnosed with severe depression according to icd-10 , associated with cotard s phenomenon . her medication was readjusted to her previous dose in which her mental state was stable . initially , during the admission , the patient kept a low profile , minimally interacting with staff and patients . on multiple occasions she fell to the floor , unable to move , stating that she can not walk as her legs have fallen off . she had very poor dietary and fluid intake and showed evidence of severe weight loss . ect was explained and offered to the patient in which the patient agreed to consent for therapy . she also requested physiotherapy as she felt this helped with her back pain in the past . olanzapine was soon added and physiotherapy was discontinued as it was felt this was perpetuating her delusional beliefs . her insight improved with an understanding that there was an element of mental illness , however she still felt this was secondary to physical causes . the pipothiazine depot injection was stopped . after a course of twelve ects , the patient was eating and sleeping well , attending to her personal hygiene , her mood was subjectively and objectively euthymic and her nihilistic delusions had resolved . she has been followed up by the community mental health team and agreed to have maintenance ect . the patient has been undertaking her daily activities , showing no signs of depression and the interval between ect sessions is soon to be increased . this is in contrast to the patient s previous admission , where she was detained under section 3 of the mha 2007 , capacitated , and not consenting to ect . in light of previous admissions and a relapse in the community , maintenance ect was prescribed and has thus far resulted in complete remission of her mental illness . there is only one case reported where maintenance ect in cotard s syndrome has been used . maintenance ect is said to be underused and insufficiently studied , despite positive experience in severe mood disorders and for prevention of relapse . the association of cotard s syndrome with severe depression has been recognised and this report contributes to the current evidence base . this case demonstrates that cotard s phenomenon occurs in severe depression and while the role of ect in cotard s syndrome is already well established , maintenance ect has a role in the management of cotard s syndrome . the case also highlights that a capacitated but non - consenting patient can not be given ect , even if the patient is detained under the mha 2007 , which is an amendment of the mha 1983 . furthermore , this is in keeping with the mental capacity act 2005 ; but there are some ethical dilemmas for the treating doctor . in our case , we had to discharge the patient and wait until such a time , where she consented for ect and with treatment , subsequently improved .

treatment of cotard s syndrome with electroconvulsive therapy ( ect ) has been seen to be an effective treatment option when pharmacological options are not successful . recent changes in the mental health act 2007 used within the united kingdom has resulted in clinicians unable to prescribe treatment for patients who have capacity but are not providing consent for treatment . we report a case of a patient in the uk with cotard s phenomenon and severe depression , where the only effective treatment of ect was restricted due to changes in mental health law . the role of maintenance ect as well as the ethical dilemma faced is discussed .

in july 2007 , a 7-week outbreak of disease in cattle began in mugla , turkey . the disease was regarded as unusual or atypical for the region , and cases were reported to the uludag university faculty of veterinary medicine . similar reports were also received from izmir , canakkale , and istanbul through the end of august 2007 . the cattle had stomatitis , swelling of eyelids , respiratory distress , nasal and ocular discharge , redness and scaling of muzzle and lips , lameness , and udder erythema , and some were recumbent ( table 1 ) . body temperatures were elevated ( 39.7c41.1c ) , except for 1 animal , whose temperature was 37.5c , below the reference range for cattle ( 37.8c39.2c ) . however , heart rates ( mean 72 3 beats / min ) and respiratory rates ( mean 24 4 breaths / min ) were within reference ranges of 6080 beats / min and 1030 breaths / min , respectively , for cattle with suspected disease . cattle with ehd had tachycardia and tachypnea ( table 2 ) . causes of mucosal disease , stomatitis , and fever , including bovine viral diarrhea , foot and mouth disease , and infectious bovine rhinotracheitis , were considered , but the rate of spread and some of the clinical signs ruled out these diseases . however , the clinical signs of the disease were consistent with either ehd or btv infection ( 6,810 ) . these diseases were therefore considered as requiring further laboratory - based diagnostic assays . * ehd , epizootic hemorrhagic disease ; ce , conjunctival edema ; rm , reduced milk ; ue , udder edema ; rd , respiratory distress . pcr , elisa , and virus isolation were performed on selected samples from the 41 samples ( 11 whole blood samples , 4 serum samples , and 15 supernatant samples from the baby hamster kidney cells ) . nasal and ocular discharge redness and scaling of nose and lips . * ehd , epizootic hemorrhagic disease ; nd , not detected . pcr , elisa , and virus isolation were performed on selected samples from the 41 samples ( 11 whole blood samples , 4 serum samples , and 15 supernatant samples from the baby hamster kidney cells ) . mean , sem . a total of 41 blood samples were obtained from the affected cattle ( 35 holsteins and 6 brown swiss , 25 years of age ) . complete blood analysis showed that 5 of the cattle with ehd had low leukocyte counts ( appendix table ) . after use for hematologic analysis , samples were stored at 30c until virologic and serologic tests could be performed . samples from the 41 animals were tested by elisa for bovine viral diarrhea virus antigens ; results were negative . to isolate virus , we spread unclotted blood samples onto baby hamster kidney21 ( bhk ) cells . because ehdv had never been observed in turkey , no diagnostic procedures were available . we therefore submitted selected samples ( 11 whole blood samples , 4 serum samples , and 15 supernatant samples from the bhk cells ) to the world organisation for animal health reference laboratory for btv ( institute for animal health , pirbright , uk ) for virologic and serologic analysis . all samples were tested for btv by real - time rt - pcr and for ehdv by conventional rt - pcr ( 1315 ) . however , a conventional rt - pcr assay targeting genome segment 7 of ehdv ( 15 ) indicated that one of the cell culture supernatants , from an early case from mugla , was positive for ehdv ; this cow died 3 hours after clinical examination and sample collection . it is unusual to isolate ehdv by direct inoculation of bhk cells ; initial passage through eggs or the culicoides variipennis larvae cell line ( kc cells ) is usually required ( 15 ) . the 4 serum samples were also tested for ehdv - specific antibodies by elisa ( 12 ) ; only 1 sample was found to contain antibodies to ehdv . conventional rt - pcr of rna extracted from the 11 original blood samples gave inconclusive results . however , virus was isolated from 6 of the blood samples by using kc cells ( dsrna virus reference collection at the institute for animal health , reference collection nos . these 6 samples and the 1 original positive cell culture were further tested by serotype - specific rt - pcrs that targeted segment 2 for identification of ehdv serotype . this analysis identified all viruses as ehdv-6 , sharing 95.7% nucleotide sequence identity ( segment 2 , 110670 bp ) with the ehdv reference strain 318 . of the selected samples submitted for btv and ehdv testing , the positive identification of ehdv rna supports initial clinical identification of an ehd outbreak in turkey . the negative results from the blood samples may have resulted from degradation of viral rna during transfer to the laboratory or insufficient sensitivity in the conventional rt - pcr . the propagation of another 6 virus isolates ( tur2007/0106 ) by passage through kc cells indicates that virus was indeed present in the original blood samples , although not detected by conventional rt - pcr . that only 1 of the 4 original serum samples was positive for ehdv antibodies by elisa antibodies to btv can be detected from 8 days after infection ( 11 ) ; these samples may have been collected during the early stages of infection , before development of the immune response . ehd needs to be considered in the differential diagnosis of cattle with clinical signs that include fever ; stomatitis ; lameness ; salivation ; redness and scaling of the nose and lips ; swelling of the tongue ; and erosions of the pulvinus dentalis , palatinum , and nose . erosive lesion on pulvinus dentalis of cow seropositive for epizootic hemorrhagic disease virus , turkey , 2007 .

in 2007 , an outbreak of epizootic hemorrhagic disease ( ehd ) occurred in turkey . on the basis of clinical investigation , 41 cattle were suspected to have ehd . reverse transcription pcr and sequence analyses indicated that the virus belonged to ehd virus serotype 6 , thus confirming ehd virus infection of cattle in turkey .

a 62-year - old female presented with gradually increasing swelling of the right side face for 5-years duration . extra orally she had a diffuse , bony hard , non - tender swelling involving right side mandible ( expansion of ramus , angle , and posterior body region ) [ figure 1a ] . color and texture of the overlying skin was normal . intraorally mild buccal vestibule obliteration was evident in relation to the edentulous molar region extending posteriorly to the ascending ramus area . cortical expansion of right ramus ( a ) and computed tomography scan axial view showing an expansile osteolytic lesion involving ramus , angle , and body of right mandible ( b ) panoramic radiograph showed multilocular radiolucency involving the ascending ramus , angle and posterior body of the right side mandible . computed tomography scan showed an ill - defined expansile lytic lesion seen within the ramus and angle of right side mandible measuring approximately of size 4.2 cm 3.2 cm 4.5 cm , with the lesional cavity partially filled with fluid and irregular soft tissue density in the residual portion with thinned out cortex . aspiration yielded a fluid mixed with dark venous blood , and the mild oozing was stopped on applying gentle pressure for few minutes . incisional biopsy was done , and the sample on histopathologic evaluation did not reveal any specific features except for loosely arranged fibro cellular areas with focal hemorrhage [ figure 2a ] . blood filled spaces without endothelial lining in the fibro cellular area ( a ) and gross specimen showing central cavitation ( star ) , cystic spaces ( arrow ) , and cortical expansion ( b ) based on the incisional biopsy findings , a working diagnosis of aneurysmal bone cyst like change secondary to the unknown primary intraosseous lesion was made . considering the clinical and radiographic features and the age of the patient it was decided to perform surgical resection and the patient underwent resection of the right side mandible ( ramus to the molar area ) . macroscopically the resected specimen showed buccal cortical expansion with the cavitation of ramus and angle of the mandible with soft tissue mass confined to the peripheral parts of the lesion cavity [ figure 2b ] . microscopic examination of the hematoxylin and eosin sections of the soft tissue of the resected specimen showed ameloblastic follicular islands showing extensive granular transformation of the central stellate reticulum like cells in a fibrous stroma [ figure 3a and b ] . ameloblastic follicles are exhibiting cuboidal to columnar cells at the periphery and extensive granular cell changes at the center . ( a ) h and e , 4 and ( b ) h and e , 40 immunohistochemical study using anti - cytokeratin antibody showed a uniform and intense positive staining with peripheral ameloblastic cell and central granular cells [ figure 4a ] and anti cd-68 antibody showed intense positivity with central granular cells and negative reaction for peripheral ameloblastic cells [ figure 4b ] . peripheral ameloblastic cell and central granular cell showing cytokeratin positivity ( a ) and cd-68 positivity in central granular cells alone ( b ) ( 40 ) with the support of histopathology and immunohistochemical findings , a final diagnosis of granular cell ameloblastoma was made . ameloblastoma is one of the most common odontogenic tumors that do not always grow as uniform solid mass due its inherent potential to undergo cystic degeneration . microscopically cystic degeneration usually starts as a small area within the ameloblastic follicle and as they grow gradually , lack of nutrition leads to complete degeneration of central region of the follicle leading to clear space centrally within the follicle . the extent of cystic degeneration logically seems to be more in long standing cases , and it may not be rare to encounter a lesion with gross feature showing complete cavitations of the involved jaw bone . this macroscopic picture can potentially compromise the adequate representative sample procurement during the routine incisional biopsy . although any histopathological variant of ameloblastoma is prone for cystic degeneration , it can be speculated that the process is more aggressive and faster in granular cell variant of ameloblastoma . this is based on the fact that , phagocytosis of apoptotic remnants and adjacent neoplastic cells ( digestion of solid tumor components ) by the granular cells within the follicle as evidenced by the macrophage - specific lysosomes within the granular cells . macroscopic presentation of complete cavitations in the current case may be explained with the above said facts and the incisional biopsy sample did not show any evidence of ameloblastomous follicle , except for the presence of loosely fibrous stroma with multiple blood - filled spaces without any specific endothelial lining , simulating aneurysmal bone cyst histopathological feature . these stromal features that is , areas of hemorrhage are generally considered to be a secondary phenomenon in long - standing lesion as similar to the present case that facilitated us to give a more practical working diagnosis for the further management . ameloblastoma with its varied macroscopic presentation may offer difficulty in its representative sample procurement during the incisional biopsy and its accurate interpretation at the histopathological level . this may be more significant in granular cell ameloblastoma , hence more practical approach with proper clinical correlation will avoid unnecessary advanced imaging modalities such as magnetic resonance imaging and repeat of surgical , diagnostic procedure , thereby reduce the cost and stress of the patients in its management .

granular cell ameloblastoma is a rare variant of ameloblastoma , which is histopathologically characterized by the presence of large eosinophilic granular cells within the ameloblastic follicle . its accurate preoperative diagnosis is based upon clinical , radiological , and incisional biopsy findings . this article reports a case of granular cell ameloblastoma in a 65-year - old female , which on incisional biopsy showed the features suggestive of aneurysmal bone cyst . furthermore , the influence of macroscopic presentation of the current lesion on its accurate preoperative incisional biopsy diagnosis is discussed in detail .

epitheloid hemangioma , otherwise known as alhe , i.e. , angiolymphoid hyperplasia with eosinophilia , is a rare benign vasoproliferative disease of unknown etiology . it was first described by wells and whimstar in 1961 who considered it to be a late stage of kimura 's disease , but now both are considered to be separate entities . the condition commonly presents in middle age adults as discrete or grouped papules , plaques , and nodules in the head and neck region with slight female preponderance for periauricular lesions . a 45-year - old man presented to us with 10 - 15 nodules on scalp with history of bleeding following minor trauma . dermatological examination revealed multiple soft to firm erythematous , non - tender , non - pulsatile plaques , and nodules of size 0.5 - 1.5 cm arranged linearly on the scalp [ figure 1 ] . provisional diagnosis of pyogenic granuloma was made because of the morphology and history of bleeding . other differential diagnoses considered were nodular lepromatous leprosy , nodular sarcoidosis , and secondary syphilis . venereal disease research laboratory ( vdrl ) test and acid - fast bacilli ( afb ) were negative . soft to firm nodules over scalp ( case 1 ) a 35-year - old man presented to us with multiple asymptomatic papules and nodules over left auricle and adjacent area of scalp since 4 months . dermatological examination revealed multiple skin colored to slightly erythematous papules and nodules over the left auricle . the nodules were soft to firm , non - tender , non - pulsatile , free from underlying structures without any surface change . differential diagnosis of nodular lepromatous leprosy , nodular sarcoidosis , and secondary syphilis were considered . hemogram was normal except eosinophilia ( 11% ) , vdrl was non - reactive , and afb was negative while chest x - ray was normal . histopathological examination was confirmatory in both cases which revealed circumscribed lobules with clusters of proliferating capillaries . thick blood vessels lined by plump endothelial cells with perivascular infiltration of lymphocytes and eosinophils [ figure 2 ] . hp showing capillary proliferation with plump endothelial cells and eosinophilic infiltration ( 40 ) based on typical histopathological studies both cases were diagnosed as epitheloid hemangioma . radiofrequency ablation was done for smaller lesions and the base of larger lesions , following surgical excision a 45-year - old man presented to us with 10 - 15 nodules on scalp with history of bleeding following minor trauma . dermatological examination revealed multiple soft to firm erythematous , non - tender , non - pulsatile plaques , and nodules of size 0.5 - 1.5 cm arranged linearly on the scalp [ figure 1 ] . provisional diagnosis of pyogenic granuloma was made because of the morphology and history of bleeding . other differential diagnoses considered were nodular lepromatous leprosy , nodular sarcoidosis , and secondary syphilis . venereal disease research laboratory ( vdrl ) test and acid - fast bacilli ( afb ) were negative . a 35-year - old man presented to us with multiple asymptomatic papules and nodules over left auricle and adjacent area of scalp since 4 months . dermatological examination revealed multiple skin colored to slightly erythematous papules and nodules over the left auricle . the nodules were soft to firm , non - tender , non - pulsatile , free from underlying structures without any surface change . differential diagnosis of nodular lepromatous leprosy , nodular sarcoidosis , and secondary syphilis were considered . hemogram was normal except eosinophilia ( 11% ) , vdrl was non - reactive , and afb was negative while chest x - ray was normal . histopathological examination was confirmatory in both cases which revealed circumscribed lobules with clusters of proliferating capillaries . thick blood vessels lined by plump endothelial cells with perivascular infiltration of lymphocytes and eosinophils [ figure 2 ] . hp showing capillary proliferation with plump endothelial cells and eosinophilic infiltration ( 40 ) based on typical histopathological studies both cases were diagnosed as epitheloid hemangioma . radiofrequency ablation was done for smaller lesions and the base of larger lesions , following surgical excision epitheloid hemangioma , otherwise known as angiolymphoid hyperplasia with eosinophilia , is a rare benign vascular tumor with a characteristic histopathological appearance of proliferation of small to medium - sized blood vessels often showing a lobular architecture . many of these vascular channels are lined by enlarged ( epitheloid ) endothelial cells with perivascular inflammatory cell infiltrate composed mainly of lymphocytes and eosinophils . a rare variant of intravascular epithelioid hemangioma is described in which the whole of the lesion is intravascular . being relatively rare , it may be commonly misdiagnosed as nodular lepromatous leprosy , pyogenic granuloma , sarcoidosis , and secondary syphilis . peripheral blood eosinophilia is not a constant finding , and serum ige is not routinely available . alhe is usually used synonymously with kimura 's disease due to common features of male predominance , predilection for head and neck and infiltration in dermis by lymphocytes and eosinophils but rosaiet al . kimura 's disease lesions are subcutaneous nodules while alhe superficial erythematous papule and nodule , which bleeds easily with minor trauma . pathologically , lymphoid follicles with eosinophilic infiltration are more prominent in kimura 's disease while capillary proliferations with epitheloid changes are conspicuous in alhe . peripheral eosinophilia , raised ige level are found in most cases of kimura 's disease but only in < 10% cases in alhe . some authors consider alhe as a neoplasm developing from endothelial cells ; others suggest that it is secondary to an inflammatory vascular reaction secondary to complex immunologic mechanisms . other hypotheses implicating environmental factors such as insect bite , trauma , and infections have been reported . some authors consider that arterio - venous shunt is the main etiopathogenetic mechanism observed in 42% of the cases . the predominance of t - lymphocytes and a rearrangement of t - cell receptor ( tcr ) , in some cases , made some authors suppose that alhe is a low - grade neoplastic disease secondary to various stimuli . different treatment modalities have been attempted including cryosurgery , intralesional corticosteroids , lasers , intralesional interferon but upto a third of all treated cases do recur , due to its deeper vascular component . epitheloid hemangioma is a rare affliction with a challenging diagnosis and treatment . in spite of the benignity of this disease , it causes a therapeutic dilemma because of the cosmetic defects and recurrence following treatment . multiple nodular lesions in head and neck region especially periauricular helps in clinical diagnosis of this rare condition .

we report two cases of epitheloid hemangioma presented with multiple nodular lesions over head and neck region . one of them gave history of bleeding on minor trauma . pyogenic granuloma was considered as a differential diagnosis from the morphological appearance and history of bleeding . nodular leprosy , sarcoidosis , and secondary syphilis were also considered . histopathological examination of both was typical of epitheloid hemangioma , an entity commonly overlooked clinically due to its rarity .

mandibular fractures in infants ( younger than 1 year ) are uncommon . in the 0 - 1 year age group , the frequency has been reported to range from 0.9% to 2.6%1 . in terms of treatment , pediatric mandibular fractures are treated with a wide variety of fixation methods . although conservative treatment such as closed reduction is preferable because displaced fractures have relatively lower incidence in pediatric patients and tooth buds can be damaged , the open reduction - internal fixation method is possible for unfavorably displaced fractures2,3 . we report a case of an 11-month - old infant whose displaced fractured mandible was treated with an open surgery method . on june 11 , 2010 , an 11-month - old infant was brought to the department of oral and maxillofacial surgery , ajou university hospital after falling down from a baby carriage . the intraoral examination and standard radiography showed bony displacement between the lower right first and second primary incisor teeth.(fig . 2 ) specifically , the fracture was visibly displaced , and fragments were freely movable . a decision was made to treat the fracture with a combination of open reduction and internal fixation with microplate . surgery was performed under general anesthesia with sevoflurane , thiopental sodium , fentanyl citrate . after inducement , the patient was intubated with conventional endotracheal tube with 4.0 s cuff via the oral route without difficulty . horizontal incision was made in the anterior labial vestibule , approximately 3 mm inferior to the mucogingival junction . a mucoperiosteal flap was elevated to expose the fracture line , which ran obliquely from the right second primary incisor to the inferior border of the mandible with step on the buccal cortex and extended to the symphyseal region on the lingual side.(fig . 3 ) after gentle reduction of the displaced parasymphyseal fracture by interdental wiring , a four - hole l - shaped microplate ( overall length of 13 mm , thickness of 0.6 mm ; jeil medical co. , seoul , korea ) was adapted to the buccal side of the mandible close to the inferior border to avoid damaging the unerupted primary teeth and permanent tooth germs . after careful drilling , the plate was secured with four 3 mm , low - profile screws.(fig . 4 ) the short , low - profile screw was selected to avoid damaging the developing teeth and dental follicles . penicillin was administered twice daily at a dose of 50 mg / kg to prevent infection . the patient was discharged on the fourth postoperative day , with the interdental wiring removed about a week after the operation . in the follow - up period , 5 ) no deformities , functional restrictions , or complications such as mouth opening limitation were recorded . the fractured wound had healed , and there was evidence of bone growth over the margins of the plate . 6 ) total follow - up period was 3 months from the first surgery ; further follow - up was impossible since the patient 's family had immigrated to the united states . this has been attributed to the relatively small size of the mandible , resilient nature of the bones , relatively low tooth to bone ratio , and protected environment . for these reasons , facial fractures in infants occur mostly in the form of incomplete fractures or simple fractures without significant displacement4 . mandibular fractures in infants may result from the trauma of short falls . fractured mandible in infants is diagnosed clinically based on step deformity , hematoma in the floor of the mouth , and mobility of the fractured segments . for more complex fractures , open and closed reduction methods have been used . the debate on open treatment versus note , however , that recent literature5 - 8 shows a change in using open reduction and internal fixation ( orif ) in fracture stabilization . in contrast , non - treatment of unrecognized mandibular fractures leads to high incidence of orthognathic surgery and craniofacial treatment10 . the potential damage to tooth roots and follicles can be minimized with a careful technique , which involves placing the fixation screws in the lower mandibular border to avoid the dental follicle . closed reduction with splints fixed with circummandibular wires cir - cummandibular wiring is advantageous since it neither damages the tooth germs nor requires intermaxillary fixation ( imf ) . moreover , this method does not interfere with condylar growth , but it has limited indications , i.e. , it is useful only for anterior mandibular fractures without significant displacement when sufficient eruption of the teeth for fixation is completed . there are difficulties in imf - such as the arch bar - when this method is applied to infants due to the potential risk of condylar growth and imbalanced nutrition during fixation . such conservative treatments alone do little to control a significantly displaced fracture of the symphysis11 . on the other hand , severely displaced fractures and mobile fragments are common indications for open reduction and internal fixation12 . care should be taken to prevent damage to the tooth germs when a minimally traumatic technique is used in this region with microplates and low - profile screws and when plates are placed at the lower border13 . the titanium microplate and screws were subsequently removed after 9 weeks . according to previous research , plates and screws should be removed as early as 2 - 3 months after placement14 - 16 . the use of an absorbable plate was considered , but the smallest absorbable plate would have been too large and bulky considering the small size of the mandible . the fracture site was mobile and displaced , requiring rigid fixation . on the other hand , imf was contraindicated due to the absence of erupted dentition to support the fixation . bone quality and thickness as well as the degree of mobility between the fracture ends , erupted dentition , and possible hindrances to future growth are important considerations that affect the choice of treatment . in such cases , the restoration of mandibular continuity after a fracture is important not only for the immediate function but also for future mandibular development20 . displaced symphyseal fractures of the mandible in infants may be treated with open reduction when careful positioning of the plates at the lower border of the mandible is performed . this case with limited follow - up showed no facial growth or tooth eruption problems . nonetheless , further follow - up would be necessary to observe other problems such as the normal eruption of permanent canine as well .

mandibular fractures in infants are rare . this case report describes management of a mandibular fracture in an 11-month - old infant using a microplate and screws with open reduction . the surgical treatment was successful . because the bone fragments were displaced and only the primary incisors had erupted , conservative treatment , such as an acrylic splint and circummandibular wiring , was not recommended . nine weeks after surgery , the microplate was removed . the results showed complete clinical and radiological bone healing with normal eruption of deciduous teeth .

one of the major motivations behind the introduction of icus was to have nurses in immediate attendance so that patients could be constantly observed . through vigilance , a nurse is able to detect early changes in a patient 's condition , and , by alerting other team members , the nurse can subvert a disaster in the making . in australia and new zealand , icu nurses are actively involved in making decisions about ventilator management and frequently adjust ventilator settings without input from physicians . in a sense , they assume many of the responsibilities borne by respiratory therapists in the united states . to determine the practice in other countries , rose and colleagues conducted a multicenter self - administered survey of nurse managers of icus in eight european countries . about 63 to 88% of decisions regarding ventilator management were made by nurses in collaboration with physicians . regression analysis showed that collaborative decisions were more likely in icus that have a nurse - to - patient ratio of 1:1 and have weaning protocols in place . the major strength of the study is the large number of icus ( n = 586 ) surveyed by rose and colleagues . the inclusion of data from several countries provides new insight into the involvement of icu nurses in ventilator management . respondents were simply asked to select a category ( nurse , physicians , or nurses and physicians ) that best reflected their involvement in ventilator decisions . the word ' collaboration ' , however , has no universal meaning and can mean different things to different people . for one person , collaboration might mean nothing more than a nurse informing a physician that a patient 's condition has improved . for another , collaboration may mean that the nurse makes an explicit recommendation to decrease pressure support by 7cmh2o . this group is not representative of the average icu nurse , and may overestimate the independence of nurses in decision - making . to avoid the problem of self - report bias , which is inherent in surveys , ethnographers directly observe human events in the context in which they occur . an ethnographer would be able to capture what it is that a nurse actually does - rather than what nurses think they do . rose and colleagues focused on weaning , and noted that decision - making by nurses in this area has been linked to the introduction of weaning protocols . the survey reveals that nurse involvement in decision - making was twice as likely ( odds ratio 1.8 ) in icus that use weaning protocols . randomized controlled trials , in my opinion , have shown weaning protocols to be without benefit [ 3 - 5 ] . survey respondents reported that they frequently titrate pressure support and ventilator tidal volume and frequency without consulting a physician . this is not the practice of nurses or respiratory therapists in any icu in which i have worked - nor of any icu that i have visited . of note , 85% of the surveyed icus contained surgical patients . ventilating postoperative patients is relatively easy - in these patients , titration of ventilator settings can be rather formulaic . however , in icu patients with coexisting illnesses , such as those with acute respiratory distress syndrome or chronic obstructive pulmonary disease , the response to mechanical ventilation is frequently unpredictable . managing such patients requires a clinician who has a sophisticated understanding of physiology and can recognize unexpected responses that follow ventilator adjustments . for example , improper adjustment of pressure support in a patient with chronic obstructive pulmonary disease can lead to cheyne - stokes breathing ; can induce recruitment of abdominal muscles causing the patient to buck the ventilator ; or can escalate the amount of ineffective triggering . the part played by nurses in the care of patients is complementary to - and not subsidiary to - the role of physicians . the nurse is constantly present at the patient 's bedside , and an experienced nurse can sense problems in the making ( the sixth sense of an expert ) and institute steps to avert a catastrophe . nurses help patients cope with the most embarrassing and demeaning consequences of a critical illness . such intimate interaction means that the patient - nurse bond is more personal than the bond between patients and doctors . it would be most unfortunate if nurses were to become distracted from these vital and unique skills by diverting their attention to tasks of no benefit , such as the use of ventilator protocols . we owe a debt of gratitude to dr rose and her colleagues for informing the critical care community of how nurses are currently spending their time when caring for critically ill patients . the impact of the expanding role of nurses in ventilator management on patients ' well - being remains unknown .

in the previous issue of critical care , rose and colleagues report the results of a survey on the frequency with which icu nurses are involved in decision - making in ventilator management . about 63 to 88% of the decisions were made by nurses in collaboration with physicians , and as much as 68% of ventilator adjustments were performed by nurses independent of physicians . nurse involvement in decision - making was twice as likely in icus that use weaning protocols . the icu nurse performs many roles , the most important being the continuous observation of a patient . the diversion of a nurse 's attention from constant vigilance by performing tasks of no benefit , such as the use of weaning protocols , would be a most unfortunate turn of events .

atypical antipsychotics are believed to reduce the risk of extrapyramidal syndrome , including tardive dyskinesia ( td ) . quetiapine is reported to be less likely to induce td side effects and , in fact , has been shown to relieve symptoms of severe td1 ) and reduce td risk.2 ) quetiapine 's low affinity and fast dissociation from postsynaptic dopamine d2 receptors should contribute to low td symptom production.3 ) additionally , quetiapine reduces td side effects from clozapine , a drug already associated with very low td risk.4 ) however , since the first case report of quetiapine - related td side effects was published in 1999,5 ) quetiapine 's safety has been questioned . this case report describes severe , late - onset td side effects after long - term quetiapine use in a patient with psychotic depression . since td onset , the patient has had no significant findings based on comprehensive neurological examinations , brain magnetic resonance imaging , and electroencephalogram . the patient was a female homemaker who has suffered with psychotic depression for 3 years . her symptoms included depressed mood , lack of interest , lack of energy , suicidal ideation , insomnia , feelings of worthlessness , auditory hallucinations ( voices commenting around her ears and commanding her to die ) , and delusions of poverty . diagnosis was based on criteria of the diagnostic and statistical manual of mental disorders iv text revision ( dsm - iv - tr ) and the structured clinical interview for dsm - iv - tr . symptom severity was as follows : brief psychiatric rating scale-18 items ( bprs-18 ) score=31 , especially for hallucinatory behaviors ( 5 points ) , and hamilton rating scales for depression ( hrsd ) score=27 . quetiapine and duloxetine were delivered using gradual titration to relieve symptoms , and the final stable medication doses were quetiapine 600 mg / day and duloxetine 90 mg / day across 2.5 years . the patient 's depressive and psychotic symptoms responded to psychotropic medication and reached partial remission status ( bprs score=9 ; hrsd score=12 ) . she did not have extrapyramidal symptoms during the first two years after initiating the above medications . however , she began to experience severe perioral tremors with involuntary , repetitive , and irregular movements of tongue starting in the third year of quetiapine treatment . the protruding tongue with irregular movements was a significant detriment to her quality of life , as irregular movements occurred all day and were not relieved by anticholinergic medications . quetiapine - related td was suspected , and the quetiapine dose was tapered to 150 mg / day . however , after 3 months , td severity remained the same and seemed unresponsive to interventions , including switching to other atypical antipsychotics such as aripiprazole or ziprasidone . no significant exacerbations of psychotic or mood symptoms were observed after td onset and antipsychotic switch . the patient also received concurrent comprehensive neurological examinations , brain magnetic resonance imaging , and electroencephalograms . no significant alterations in brain anatomy or function were observed , and according to the neurological report , no organic etiology could be found to explain the presence of td . in this case , we observed unique , late - onset , and irreversible td side effects after long - term quetiapine use . late - onset td after 3 years might suggest independent factors . however , comprehensive neurological examinations and imaging studies could not pinpoint organic evidence to suggest that this patient 's td was independent of quetiapine use . late - onset td side effects in this patient appear irreversible even after decreasing quetiapine dose and switching antipsychotics . however , case reports of late - onset td have not been included in previous reports . rather , these reports mention the long - term safety of quetiapine in adolescent6 ) and adult patients.3 ) sacchetti and valsecchi7 ) showed that quetiapine has the lowest risk for td side effects when compared with olanzapine and clozapine in their long - term trial ( 154 weeks ) . quetiapine - related td was noted and described in an early case report about 15 years ago.5 ) however , some reports also mention contrary findings of quetiapine 's ability to relieve td.1,2,8,9,10,11,12,13 ) emsley et al.14 ) found that quetiapine could effectively reduce td severity in patients with established td , but the mechanism of this action is unclear . quetiapine is the atypical antipsychotic most similar to clozapine ( without its hematologic side effects ) based on receptor and pharmacologic profile , which may explain its treatment effects for td.11 ) quetiapine is believed to express lower affinity for d2 receptors in striatal and extrastriatal regions of brain,15 ) which could explain the mechanisms by which it can treat or relieve td side effects . the presence of mood disorders may be a possible reason for quetiapine - related td in this patient . sharma16 ) reported that patients with mood disorders were more prone to treatment - emergent td with quetiapine . recently , reports reveal quetiapine 's td side effects and suggest precautionary attention to td risk characteristics.17 ) a recent dopamine receptor imaging study showed that quetiapine occupies dopamine d2 receptors extensively in striatal regions , which likely contributes to td side effects.18 ) furthermore , low - dose quetiapine also seems to induce early - onset td in the neuroleptic - nave patient.19 ) recent reports provide evidence of quetiapine 's td risk as well as possible mechanisms . previously , it was suggested that quetiapine - related td could be relieved by tapering the dose or switching to another atypical antipsychotic such as aripiprazole.15 ) however , in this case study , td was not abated with quetiapine dose tapering or with a switch to other atypical antipsychotics . therefore , use of quetiapine should be approached with caution , with close attention paid to td risk factors .

the atypical antipsychotics were believed to induce less extrapyramidal syndrome , including tardive dyskinesia ( td ) . since the introduction of the quetiapine , it is also reported with less td side effects . it even can relieve the symptoms of severe td and reduce the risk of td . the quetiapine 's low affinity and fast dissociation from postsynaptic dopamine d2 receptors should give the least risk of producing the symptoms of td . the quetiapine even can reduce the td side effects related to clozapine , which has the lowest risk for td . however , since the first case report of td side effects related to quetiapine published on 1999 , the safety of quetiapine in td aspect has been questioned . therefore , we want to share this case report , which was written to describe the severe late - onset td side effects after long - term use of quetiapine in a patient with psychotic depression . the patient had no significant findings after concurrent comprehensive neurological examinations , magnetic resonance imaging of brain and electroencephalogram since the onset of td .

aneurysms of the major thoracic veins are rare . because they are usually asymptomatic , they are diagnosed incidentally during the evaluation of mediastinal widening on chest roentgenography and treated conservatively ( 1 - 3 ) . development of complications such as rupture , venous obstruction , and thrombosis has been described and may require surgery ( 4 - 6 ) . we report a 55-yr old male patient with superior vena cava ( svc ) aneurysm which showed rapid progression and complicated by thrombosis and hemodynamically significant acute pulmonary thromboembolism ( pte ) with review of the literature . a 55-yr - old male presented with acute chest pain , dyspnea , and hypotension on december 8 , 2009 . the patient has been followed without any medications for incidentally detected asymptomatic svc aneurysm for last 2 yr ( fig . 1a ) , and the size of the svc aneurysm did not change ( fig . chest radiography at admission showed marked widening of the right middle mediastinum due to abnormal soft - tissue density suggesting the rapid expansion of previously noted svc aneurysm ( fig . echocardiography revealed marked enlargement and hypokinesia of the right ventricle ( rv ) with moderate pulmonary hypertension suggesting acute pe . chest computed tomographic angiography ( cta ) showed about 6.9 6.1 9.9 cm sized lobulated giant saccular aneurysm originating from mainly svc and partially involving left brachiocephalic vein with internal thrombi ( fig . considerable amounts of thromboembolic filling defects in left pulmonary artery , both left and right lobar , segmental , and subsegmental arteries were also noted ( fig . 2b ) . three - dimensional reconstruction with endovascular views showed the giant saccular svc aneurysm with 4.1 3.7 cm sized internal thrombi , and the thrombi protruded into the svc through the narrow aneurysmal neck ( fig . 2c , d ) . venous cta of the lower extremities and abdominal cta showed no evidence of deep vein thrombosis or other venous aneurysms . to exclude the possible hypercoagulable status as a cause of pulmonary thromboembolism , surgical exclusion of svc aneurysm with pulmonary embolectomy was planned , but the patient and family refused surgery . therefore , thrombolytic therapy using recombinant tissue plasminogen activator with the dose of 200 mg was administered intravenously for 2 hr for hemodynamically significant pte , and the rv function and pulmonary artery pressure was normalized on fu echocardiography . however , the patient complained recurrent chest pain and dyspnea on the next day . fu cta revealed more decreased amounts of thrombi in the left pulmonary artery and its branches , but the amounts of thrombi in the svc aneurysm , svc , right pulmonary artery and its branches were increased . mobilization of thrombi from the svc aneurysm due to thrombolytic therapy was the possible cause of recurrent pte , and it was expected that further embolization of thrombi would be fatal to the patient . therefore , surgical treatment was strongly recommended . femoral arterial and venous cannulation was done to prepare for accidental rupture of aneurysm during sternotomy . after dissection of the aneurysm , the other venous cannulation at the innominate vein and isolation of the proximal and distal portion of the aneurysm was done . under cardiopulmonary bypass , aneurysmal wall was opened longitudinally after snaring of proximal and distal portion of the aneurysm and innominate vein . aenurysm which contained fresh thrombi was thin - walled and had relatively normal venous endothelium grossly ( fig . 3a ) , and the histopathologic examination showed compatible findings of true aneurysm ( fig . thin - walled aneurysmal wall was completely resected and subsequent reconstruction of the superior vena cava was performed with glutaraldehyde fixed autologuous pericardium that was already harvested . outer surface of the pericardium was buttressed with dacron to prevent potential formation of pseudoaneurysm . a transverse arteriotomy was made in the pulmonary trunk to the left main pulmonary artery and another incision was made in the right main pulmonary artery , and the fresh and organized thrombi were gently extracted . following the successful surgical management , the mediastinal widening on chest radiography was normalized ( fig . the patient was discharged and treated by anticoagulation with warfarin for 6 months to achieve complete resolution of the possible remained pulmonary arterial thrombi . aneurysms of the major thoracic veins are rare and usually asymptomatic , even though several complications including aneurysmal rupture , thrombosis , or venous obstructions have been reported ( 4 - 6 ) . however , the development of acute pte associated with thrombosed venous aneurysms , like the present case , is extremely rare . there had been only 2 cases of acute pte caused by thrombosis of the major intrathoracic venous aneurysms in the literature ( 7 , 8) . the present case gives several important messages in the treatment of asymptomatic or complicated intrathoracic venous aneurysms . first , although the svc aneurysm did not produce any kind of symptoms or size change for 2 yr , the present case showed sudden rapid growing of the aneurysms with internal thrombus formation . therefore , the benefit of surgical therapy to prevent the developments of fatal complications should be considered in saccular svc aneurysm at the time of diagnosis , even in asymptomatic cases . in case of fusiform svc aneurysm , conservative management second , long - term anticoagulation with warfarinization might be considered to prevent aneurysmal thrombosis and subsequent pte , especially in a fusiform aneurysm . in case of saccular aneurysm , however , rupture of the aneurysm is the major complication in addition to thromboembolism . in case of rupture during anticoagulation therefore , the benefit of anticoagulation should be counter - balanced by the risk of rupture . third , surgical aneurysmectomy and pulmonary artery embolectomy would be a treatment of choice in patients with svc aneurysm complicated by thrombosis and massive pe as discussed in the previous reports ( 4 - 8 ) . in conclusion , we report a very rare case of svc aneurysm which showed rapid expansion and complicated by thrombosis . the acute rv dysfunction may be caused by massive pte from the thrombosed svc aneurysm and improved by surgical aneurysmectomy and embolectomy .

aneurysms of the major thoracic veins are rare . they are usually asymptomatic and thus treated conservatively . we report an extremely rare case of rapidly progressing superior vena cava ( svc ) aneurysm complicated by thrombosis and acute pulmonary thromboembolism ( pte ) with right ventricular dysfunction . thrombolytic therapy for hemodynamically significant acute pte was harmful to the patient in the present case , because it induced further thrombosis and mobilization of the thrombi within the aneurysm , subsequently causing de novo pte . surgical aneurysmectomy combined with pulmonary artery embolectomy would be a treatment of choice in patients with svc aneurysm complicated by acute pte .

a 60-year - old woman ( height , 162 cm ; weight , 61 kg ) visited pain clinic with tactile allodynia and electric shock - like pain in the left dorsal scapular area around the t3 dermatome , which had been diagnosed as phn about 1 month previously and attack of the herpes zoster was 1 year ago . the 100-mm visual analogue scale ( vas ) of allodynia and electric shock - like pain was rated between 70 and 80 mm on a scale from 0 ( no pain ) to 100 ( worst pain imaginable ) . the interlaminar epidural block was performed at the t3 - 4 space by the paramedian approach with 5 ml of 0.2% ropivacaine and 20 mg of triamcinolone acetate . pregabalin and morphine at doses of 150 mg and 10 mg , respectively , twice a day , amitriptyline at a dose of 10 mg before sleep and topical lidocaine patches were prescribed . dosages of all drugs were adjusted depending on the side effects during the follow - up period . epidural blocks were repeated twice with a 1-week interval and the continuous intravenous infusion of ketamine ( 60 mg ) was performed over a period of 1 hour twice a week under careful monitoring . after 1 month elapsed , electric shock - like pain was reduced to a vas score of 30/100 , but allodynia was not diminished ( vas score of 70/100 ) . after 4 months elapsed , we decided to administer magnesium sulfate via the intravenous route . and it was done with continuous intravenous infusion of 1,000 mg of magnesium sulfate in 50 ml of normal saline for 1 hour . before and after infusion , the serum magnesium levels were checked . after magnesium therapy , she felt very good about her pain and the vas of allodynia was reduced to 40 - 50 . at 1-week follow - up , she was very satisfied with the treatment and reported the reduction of allodynia on the dorsal scapular area of up to 50% ( vas 25 - 30/100 ) . however , the serum magnesium level had increased above normal range ( 2.3 meq / l to 2.9 although it was below the serum level reveals of the adverse effect , we decided to stop intravenous infusion of magnesium sulfate . for more accurate and safe delivery of magnesium to the target site , we applied magnesium using the transforaminal epidural injection technique . with the patient 's informed consent , left t3 tfemi identification of the t3 nerve root sheath and epidural space was performed using contrast media ( fig . 1 ) . then , 100 mg of magnesium sulphate and 1 ml of 0.2% ropivacaine ( total volume , 2 ml ) was carefully injected . tfemi was repeated twice with a 1-week interval ( total of three times ) and the degree of pain decreased gradually during the follow - up period . one week after the last procedure , the vas score of allodynia decreased to 15/100 and all medications except pregabalin were discontinued . the vas was 10/100 throughout 1-month follow - up , and pregabalin had also been tapered . to our knowledge , no previous report has described about the magnesium administration by the transforaminal epidural route in patients with neuropathic pain . here , in our report of phn patient , this treatment resulted in effective pain relief . previous studies have demonstrated the anti - allodynic effects of nmda receptor antagonists in neuropathic pain disorders . among the currently available nmda receptor antagonists , ketamine is the most widely used one for the treatment of neuropathic pain . however , ketamine is not always effective and psychomimetic side effects are frequent . magnesium can antagonize nmda receptor channels by blocking calcium influx in a voltage - gated manner . intravenous administration of magnesium is efficacious in the management of various conditions associated with neuropathic pain , including phn . demirkaya and colleagues revealed 1 g i.v . mg sulfate is effective in the treatment of migraine attacks and collins and colleagues reported that 70 mg / kg magnesium sulphate infusions in 4 hours for 5 days reduced pain in patients with complex regional pain syndrome . whether intravenous administration of magnesium can achieve a sufficient concentration in the cerebrospinal fluid to block nmda receptors is unclear and studies have reported on the limited efficacy of magnesium when administered via the intravenous route . furthermore , even if the dose of intravenously administered magnesium is not sufficient to present toxicity , patients are still at risk of magnesium overdose . neuraxial administration of magnesium is an " off - label " use , and the safety of this technique in human subjects is still undetermined . however , animal studies showed that intrathecally administered magnesium was free of neurotoxicity , and recent studies have demonstrated the safety of magnesium administration via the epidural or intrathecal route in humans . in fact , the exact site of action of epidurally administered magnesium ( i.e. , spinal or supraspinal ) remains unclear . however , comparison with previous reports regarding intravenous magnesium administration suggested that the low dose epidural magnesium used in our patient was unlikely to result in systemic effects . in conclusion , tfemi showed a favourable result in the treatment of intractable allodynia associated with phn . this study was performed in only a single case , and further investigations are required to determine the efficacy of tfemi in the management of allodynia in patients with phn .

although postherpetic neuralgia ( phn ) is a common chronic pain syndrome , the pathophysiology of this disorder is not well known and management is often very difficult . n - methyl - d - aspartate ( nmda ) receptor antagonists are known to be effective in phn , and magnesium , a physiological blocker of nmda receptors , is widely used to treat various chronic pain disorders . here , we present a case of the phn refractory to conventional treatment , which was treated successfully with transforaminal epidural injection of magnesium sulphate at the affected dermatome .

a 57-year - old woman came to iizuka hospital on march 12 , 2005 , with malaise and anorexia . although she was a healthy hepatitis b virus carrier and negative for serologic markers of hepatitis a and c , testing upon admission showed elevated levels of liver enzymes ( alanine aminotranferase 752 iu / l , aspartate aminotransferase 507 iu / l , and -glutamyl transpeptidase a serum sample collected on march 16 was positive for both immunoglobulin m ( igm ) and igg antibodies to hev when tested by an antibody enzyme - linked immunosorbent assay using recombinant viruslike particles ( 7 ) . this led to the diagnosis of hepatitis e. the hepatitis was typical , acute , and self - limiting , and the patient recovered by the end of march . the patient 's husband traditionally hunted boar for food 3 or 4 times a year , and she had eaten boar meat on 2 occasions . with her husband , she ate the meat as part of a hot pot on december 28 , 2004 , 11 weeks before her illness , and again , grilled , on january 19 , 2005 , along with 10 other people ( including her husband ) 8 weeks before her illness . disease did not develop in the other 10 people . except for this wild boar meat , since she had not traveled abroad in the past 30 years , transmission must have occurred in japan . two portions of meat from the wild boar ( meats 1 and 2 ) eaten on december 28 , 2004 , and 1 portion from the other wild boar ( meat 3 ) eaten on january 19 , 2005 , remained and were frozen . juice was obtained from the sliced meat by centrifugation at 10,000 g for 15 min . polymerase chain reaction ( rt - pcr ) was conducted to amplify part of open reading frame 2 ( orf2 ) , which corresponds to nucleotides ( nt ) 59396297 of the genotype 1 hev genome ( genbank d10330 ) , with external sense primer hev - f1 ( 5-taycghaaycaagghtggcg-3 ) and antisense primer hev - r2 ( 5-tgytggttrtcrtartcctg-3 ) . a nested pcr was conducted with internal sense primer hev - f2 ( 5-ggbgtbgcngaggaggaggc-3 ) and internal antisense primer hev - r1 ( 5-cgacgaaatyaattctgtcg-3 ) . a pcr product of 359 bp including the primer sequences was obtained from meat 3 by nested pcr . hev rna was not detected in the patient 's serum by the same amplification method . new primers for the nested rt - pcr were designed for a region within the 359 base region based on the meat 3 sequences , which corresponded to nt 59836243 . the first pcr was performed with external sense primer hev - wb - f1 ( 5-acctctggcctggtaatgct-3 ) and antisense primer hev - wb - r2 ( 5-gagaagcgtatcagcaaggt-3 ) . the nested pcr was performed with internal sense primer hev - wb - f2 ( 5-tattcatggctctcctgtca-3 ) and internal antisense primer hev - wb - r1 ( 5-acagtgtcagagtaatgcct-3 ) . these primers allowed amplification of 281 nt , including the primer sequences from the patient serum collected on march 16 , 2005 . in contrast , meats 1 and 2 were negative with these new primers . to further analyze the rna in the patient serum and meat 3 , rna genomes encoding an entire orf2 were amplified as overlapping segments , nucleotide sequences were determined , and phylogenetic analysis was carried out with avian hev as an outgroup . two sequences , 1 from the patient ( dq079629 ) and the other from meat 3 ( dq079630 ) , were classified into genotype 3 ( figure ) . only 1 nt difference was observed in the 1,980 nt of the entire orf2 ; the nucleotide sequence identity was 99.95% . these data demonstrated that hev infection was transmitted from the wild boar meat to the patient on january 19 , 2005 . phylogenetic tree of hepatitis e virus ( hev ) reconstructed with avian hev as an outgroup . nucleotide sequences of the entire open reading frame 2 were analyzed by the neighbor - joining method . currently , deer , pig , and wild boar are suspected sources of foodborne zoonotic transmission of hev in japan , and genotypes 3 and 4 of hev are believed to be indigenous ( 46,9,10 ) . direct evidence for transmission of genotype 3 hev from animals to humans was observed in acute hepatitis in 4 persons who had eaten uncooked deer meat that contained 10 copies of hev rna ( 4 ) . however , the rare finding of hev antibody - positive deer in japan suggest that deer are not the major zoonotic reservoir of hev in this country ( 11 ) . in contrast , high antibody - positive rates in domestic pig and wild boar , including hev genotypes 3 and 4 , have been frequently detected , suggesting that persons who eat uncooked meat are at risk for infection with hev ( 12,13 ) . this report is the first to provide direct evidence of zoonotic foodborne genotype 3 hev transmission from wild boar to a human .

we investigated a case of hepatitis e acquired after persons ate wild boar meat . genotype 3 hepatitis e virus ( hev ) rna was detected in both patient serum and wild boar meat . these findings provided direct evidence of zoonotic foodborne transmission of hev from a wild boar to a human .

patients afflicted with congenital fibrosis of the extraocular muscles type i ( cfeom - i ) usually suffer from a nonprogressive restrictive motility disorder , with or without ptosis , with the eyes usually fixed in an infraducted position.1 both strabismus surgery and ptosis correction are required to achieve an aesthetically pleasing and functionally acceptable result in cfeom patients.2 an 11-year - old girl was referred by the operating surgeon for the management of simple congenital ptosis surgery overcorrection. there was negative family history of ptosis and past history was remarkable only for levator resection surgery performed by a general facial plastic surgeon 2 months prior to presentation in gaza . on examination both eyes were partially amblyopic with a visual acuity of 20/25 ( od ) and 20/70 ( os ) . both eyes were fixed in an infraducted position ( 20 ) and were immobile vertically but had limited motility horizontally with a peculiar chin - up position despite the retracted eyelids [ figure 1 ] . the patient neither displayed a marcus gunn jaw winking phenomena nor any synkinetic movements on attempted elevation . no preoperative pictures were available to evaluate the ptosis but the parents maintained that she always had severe bilateral congenital ptosis . vertical palpebral fissure height was 20 mm ( os ) and 18 mm ( od ) . the eyelid contour was excellent but she had mild lash ptosis in the medial half of the right upper eyelid . when instructed to forcefully close the eyelids , she had 8 mm of lagophthalmos with significant corneal exposure , and an absent bell 's phenomena , but curiously there was no evidence of corneal affection . a schirmer 1 test ( 5 minutes without anesthesia ) was performed , and the result was 10 mm wetting ( od ) , and 9 mm ( os ) . she was classified as a simplex case of cfeom type i because of negative family history and the typical clinical picture . note the infraducted eyes and the significant chin - up position despite the retracted upper eyelids the patient underwent a single - stage adjustable bilateral 12-mm inferior rectus recession under general anesthesia . forced duction testing performed at the beginning of the procedure showed both eyes were completely immobile vertically . at the conclusion of the procedure , a forced duction test demonstrated that upwards motility was improved . to safeguard against lower eyelid retraction one week after surgery , the patient was orthophoric in the primary position with a residual 1 mm of upper eyelid retraction , significant reduction of lagophthalmos , and partial recovery of bell 's phenomena [ figure 2 ] . one week after inferior rectus recession . note the orthophoric eyes and the residual eyelid retraction because of the acceptable final cosmetic outcome , the parents declined further eyelid lowering although they were informed of the persistent risk of corneal exposure because lagophthalmos was reduced but not completely relieved . cfeom represents a large spectrum of restrictive strabismus syndromes with or without ptosis , which are heterogenous both phenotypically and genotypically14 patients afflicted with the classic cfeom i are usually born with bilateral ptosis with eyes fixed in an infraducted position . although cfeom i is typically a familial disease inherited in an autosomal dominant pattern , isolated while cfeom syndromes was classically thought to be due to a congenital abnormality of muscle development , i is now considered to have a neurologic etiology and the term congenital cranial dysinnervation disorders ( ccdd ) was coined to encompass not just cfeom but also duane retraction syndrome , hoxa1 spectrum , horizontal gaze palsy with progressive scoliosis , mbius syndrome , hereditary congenital facial palsy , marcus gunn jaw winking , and even hereditary congenital ptosis.58 this case report demonstrates that performing ptosis surgery alone in cfeom does not have any beneficial effect even on the abnormal head posture as patients would still need to tilt their heads to compensate for the infraducted eyes [ figure 1 ] . in fact , it might even result in disastrous corneal complications due to significant lagophthalmos that would invariably ensue . how the cornea remained symptom free for 2 months after the ptosis surgery remains unknown although it is not unprecedented in cfeom patients.49 an adequate tear film , and a diligent mother may help explain the absence of keratopathy after what could have been a catastrophic levator resection . in conclusion , this unusual case illustrates the necessity for a careful assessment of ocular motility and the bell 's phenomenon in every case of congenital ptosis prior to surgical correction of the ptosis .

fibrosis syndromes comprise a rare form of severe limitation of ocular motility . an 11-year - old girl was referred for the correction of eyelid retraction . the eyelid retraction occurred immediately following levator resection surgery performed by a plastic surgeon who missed the restrictive extraocular muscle abnormalities . on examination , both eyes were fixed in an infraducted position ( 20 prism diopters ( ) ) , with a chin - up position and significant lagophthalmos . bilateral 12-mm inferior rectus recession with adjustable sutures was performed , which resulted in significant reduction of lagophthalmos and elimination of the head tilt .

abiotrophia species sometimes cause sepsis and bacteremia , and are especially known as one of the major pathogens of infective endocarditis . a 48-year - old unemployed woman was admitted to our hospital with a two - week history of severe low back pain . she suffered from parkinson 's disease , but she was not a compromised host . on admission , she was unable to sit up because of the pain . her vital signs were as follows : temperature 38.2 c , pulse 80 beats / min , and blood pressure 100/68 mmhg . physical examination revealed moderate tenderness to palpation on the spinous processes of lower lumbar spine . the peripheral white blood cell count was 11,600/mm , and her c - reactive protein level was 9.9 mg / dl . plain x - ray showed degenerative changes of the lumbar vertebrae with narrowing of the disk spaces at l3 - 4 , and l4 - 5 . magnetic resonance imaging revealed edema and contrast enhancement of the l4 and l5 vertebral bodies with high signal intensity in the l3 - 4 and l4 - 5 intervertebral discs on the t2-weighted images ( fig . cultures of disk biopsy samples and blood yielded gram positive cocci in short chains with scanty growth on chocolate agar . further subculture with supplemented medium and subsequent 16s ribosomal rna gene sequencing identified the pathogen as abiotrhophia adiacens . as a result of the survey regarding bacteremia origin , we could detect the dental caries . the patient was treated with intravenous ampicillin ( 8 g / day ) for 6 weeks . the clinical and laboratory test abnormalities improved within 2 weeks . at 6-month follow - up , spinal infections can be devastating and result in significant pain , deformity , and neurologic deterioration . staphylococcus aureus is the most common etiologic organism of spinal infections , followed by escherichia coli , streptococcus species , s. epidermidis , and pseudomonas species ; however , causative microorganism remain unidentified in 2540% of the cases . abiotrophia species ( a. adiacens and a. defectiva ) have formerly been referred to as nutritionally variant streptococci because of their fastidious nutritional growth requirements . the organisms grow poorly on conventional solid media , and require pyridoxal or thiol group supplementation . use of brucella hk agar or gam agar plate is helpful for detection of abiotrophia species . prolonged incubation ( at least 72 h ) is also recommended . spinal infection due to abiotrophia species is extremely rare , and only four cases have been reported to date ( table 1 ) . in the previous reports , this organism was identified only from blood sample by using columbia blood and chocolate agar plates . in the present case , we first confirmed the diagnosis by direct identification of abiotrophia adiacens from infected disk . abiotrophia species are one of the major pathogens of infective endocarditis accounting for 5% of cases . abiotrophia endocarditis carries higher morbidity and mortality than endocarditis caused by other streptococci , reflecting their strong virulence . abiotrophia discitis reported previously occurred concomitantly with infective endocarditis although repeated echocardiography showed normal study in our case . patients with history of infective endocarditis or valve disease may be candidate for exploration of abiotrophia discitis . we were able to detect her dental cavity , and it could be a predisposing factor of bacteremia . considering their fastidious nature , it is likely that most cases of abiotrophia discitis are falsely classified as culture - negative discitis ; therefore , their role in pyogenic discitis may be underestimated . adequate diagnosis and treatment of this entity requires a high index of suspicion for the organism , even if cultures are negative . written informed consent was obtained from the patient for publication of this case report and accompanying images . a copy of the written consent is available for review by the editor - in - chief of this journal on request . k.u . assisted in the surgery , was involved in the preoperative work up and postoperative care of the patient , and wrote the paper . performed the surgery , was involved in the preoperative work up and postoperative care of the patient , and helped in the preparation of the write up . k.t . were involved in the preoperative work up and postoperative care of the patient , and revised the final article . y.h . and k.o .

introductionabiotrophia species have been referred to as nutritionally variant streptococci because of their fastidious nutritional requirements for growth . abiotrophia species are difficult to identify with conventional solid culture.presentation of casea 48-year - old woman was admitted to our hospital with severe low back pain and body temperature of 38.2 c . magnetic resonance imaging revealed edema and contrast enhancement of the l4 and l5 vertebral bodies with high signal intensity in the l3 - 4 and l4 - 5 intervertebral discs on the t2-weighted images . the patient underwent needle biopsy of the l3 - 4 disk . cultures of disk biopsy samples and blood yielded gram positive cocci in short chains with scanty growth on chocolate agar . further subculture with supplemented medium and subsequent 16s ribosomal rna gene sequencing identified the pathogen as abiotrhophia adiacens . the patient was treated with intravenous ampicillin . at 6-month follow - up , the patient was free of symptoms.discussioncausative microorganisms remain unidentified in 2540% of spinal infection cases . abiotrophia species grow poorly on conventional solid media , and require pyridoxal or thiol group supplementation . use of brucella hk agar or gam agar plate is helpful for detection of abiotrophia species . we first confirmed the diagnosis by direct identification of abiotrophia adiacens from infected disk . abiotrophia species are one of the major pathogens of infective endocarditis accounting for 5% of cases . considering their fastidious nature , it is likely that most cases of abiotrophia discitis are falsely classified as culture - negative discitis ; therefore , their role in pyogenic discitis may be underestimated.conclusionsubculture using nutritionally supplemented media is crucial for their identification .

the introduction of positive end - expiratory pressure ( peep ) into the practice of mechanical ventilation in patients with acute respiratory distress syndrome ( ards ) was among the most important milestones in critical care therapy . however , despite the clear benefits of this therapeutic tool in improving severely compromised gas exchange , potential dangers related to the use of peep mainly suppression of cardiovascular and other organ function became evident from experimental data even before that time . during the past few decades a huge amount of research on this topic has been conducted , providing us with important insights into the interaction between mechanical ventilation with peep and physiological function in critically ill patients [ 3 - 5 ] . nevertheless , it is not yet possible to determine clearly the balance between benefit and deleterious effects of peep , and the controversy on how to set peep at the bedside persists . current strategies of mechanical ventilation for patients with acute lung injury or ards increasingly recommend fairly high levels of peep . in view of this , any data that may improve our understanding of the benefits and dangers of peep are particularly important . in this issue of critical care , bruhn and colleagues this is because , at first glance , fairly high levels of peep up to 20 cmh2o apparently did not compromise haemodynamics or significantly affect gastric mucosal arterial partial carbon dioxide tension gap ( pco2 ) in these patients . however , proper interpretation of these data requires consideration of important limitations imposed by the study design . in fact , one should not conclude that peep up to 20 cmh2o is generally safe in patients with ards in terms of haemodynamics or even regional organ perfusion . rather , as demonstrated by previous studies , adequate replacement of intravascular fluid volumes is required to maintain cardiac output and regional perfusion during mechanical ventilation with high peep levels . in their study , which nicely corroborates previous findings , bruhn and colleagues paid meticulous attention to maintenance of haemodynamics with fluid replacement and intravenous administration of catecholamines at each peep stage , and they were successful in this in all but one patient . ( unfortunately , that patient did not complete the study , and hence we do not know whether the failure to maintain haemodynamics may also have impaired gastric mucosal arterial pco2 . ) therefore , the important message from the study is that , even at high levels of peep ( 20 cmh2o ) , it is possible to maintain haemodynamics and adequate gastric mucosal perfusion with fluid and catecholamine therapy . such an approach , however , should be considered a prerequisite for safe peep ventilation . some additional limitations were addressed in part by the authors themselves , and should be kept in mind when considering the findings of the study . first , the patients included fulfilled the criteria for ards when they entered the study , but their respiratory status apparently improved between entrance into the study and the start of evaluation . in fact , arterial oxygen tension / fractional inspired oxygen ratio was greater than 200 in five out of eight patients , and respiratory system compliance was only moderately decreased in most patients . second , ards may represent widely differing pathophysiological conditions depending on its primary cause , which may derive from pulmonary or extrapulmonary disorders . in the case of abdominal diseases leading to ards ( which was the case in three out of eight patients ) , intra - abdominal pressure may be increased , thus compromising both systemic haemodynamics and perfusion of intra - abdominal organs independent from peep derived cardiocirculatory effects at thoracic levels . therefore , the impact of peep on regional perfusion may depend to a significant degree on the primary cause of ards . finally , in the study the arterial carbon dioxide tension significantly increased between baseline and application of 20 cmh2o peep . this might have interfered with regional perfusion , thus potentially influencing the findings of the study . the limitations mentioned thus far should not be interpreted as a critique of the study , which is clear in terms of the study design and conclusions drawn from the findings . indeed , the authors elegantly demonstrate how peep may safely be employed even at high levels , at least in patients with moderate ards . however , the limitations mentioned above are indicators of the huge complexity of the interactions between mechanical ventilation and organ perfusion , which continue to limit our understanding of the impact of mechanical ventilation in critical care . ards = acute respiratory distress syndrome ; pco2 = partial carbon dioxide tension gap ; peep = positive end - expiratory pressure .

a recent study by bruhn and colleagues , discussed here , confirms that even high levels of positive end - expiratory pressure ( peep ) up to 20 cmh2o may be applied in conditions of moderate acute respiratory distress syndrome . such levels of peep were found to be safe in terms of their impact on cardiac output and adequacy of gastric mucosal perfusion once systemic haemodynamics were stabilized by adequate fluid replacement and catecholamine therapy . however , we strongly recommend that the reader does not oversimplify the conclusions of that study . peep therapy is not inherently safe with respect to haemodynamics and regional organ perfusion , but it may be used safely , even at high levels of up to 20 cmh2o , if haemodynamic therapy is appropriate .

there is no mechanism to shed iron in humans other than with natural blood loss during menstruation . hepcidin is a peptide synthesised in the liver and is the main regulator of iron homeostasis [ 1 , 2 , 3 ] . the hepcidin gene is principally expressed in hepatocytes and to a lesser extent in neutrophils and macrophages [ 4 , 5 , 6 , 7 ] . when total body iron stores are low with reduced circulating serum iron levels the iron sensoring mechanism is thought to be a complex process , the details of which have not been fully elucidated as yet . the resultant reduction in circulating hepcidin concentrations will modulate ferroportin activity and lead to greater uptake and export of iron in duodenal enterocytes . therefore a direct dynamic correlation exists between serum iron and hepcidin synthesis as a feedback mechanism to reduce iron entry or accelerate entry reflecting the changing iron requirements . in addition to serum iron , an erythropoietic signal also influences hepcidin synthesis , but the specific mediator has not been described as yet . the hepcidin - ferroportin interaction in duodenal enterocytes is the rate - limiting step for iron export from duodenal enterocytes which in turn influences iron uptake into the enterocyte involving the dmt1 ( divalent metal transporter protein 1 ) from the intestinal lumen . hepcidin plays a central role in the pathogenesis of hereditary haemochromatosis [ 6 , 8 , 9 , 10 ] by failing to suppress iron uptake and export from duodenal enterocytes leading to iron overload , the hallmark of this disease . haemojuvelin encoded by the gene hfe2 is a critical upstream regulator of hepcidin expression . in patients with iron deficiency , hepcidin synthesis in addition to haemojuvelin , another signal protein called bone morphogenic protein ( bmp ) also influences hepcidin synthesis and is thought to be the central regulator affecting hepcidin synthesis responding to changes in serum iron [ 8 , 12 ] . hepcidin synthesis is reduced in transferrin receptor 2 haemochromatosis , another rare form of haemochromatosis , which is independent of mutations in hfe gene . high hepcidin levels are also thought to account for anaemia of chronic disease and anaemia in patients with chronic renal failure . we describe a patient with lead poisoning in whom iron studies were undertaken . as one of several investigations a 38-year - old female was referred to the outpatient clinic for recurrent severe abdominal pain . she had been unwell for two years and had been seen in several gastroenterology clinics with unexplained abdominal pain and anaemia . the patient had exhaustive gastrointestinal investigations including gastroscopy , colonoscopy , barium follow through and ct scan of the abdomen which were all normal . the urinary porphyrin results raised the possibility of lead poisoning and this was confirmed by two separate blood samples taken for serum lead level . her haemoglobin was 8.3 g / dl ( 1216 g / dl ) , mcv 91 fl ( 82100 fl ) . her esr was 28 mm / h and c - reactive protein was < 7.0 mg / l ( normal < blood porphyrins showed elevated erythrocyte zinc protoporphyrin at 1,731 nmol / l and erythrocyte free protoporphyrin at 748 nmol / l . urinary porphyrin showed raised total coproporphyrin i and ii level at 20,415 nmol / l ( < 115 nmol / l ) . her serum lead level was 779 g / l ( normal < 100 g / l ) and on repeat testing was found to be raised at 707 a blood sample was taken for the measurement of hepcidin prohormone by elisa method ( drg diagnostics , immunodiagnostic systems ltd , bolton tyne and wear , uk ) . the sample was stored at 80c and allowed to return to room temperature before analysis and the result was 2,489 ng / ml . in healthy volunteers , prohepcidin levels have previously been reported to be less than 450 ng / ml [ 9 , 14 ] . the source of lead poisoning was not identified . hepcidin is an acute phase protein and its synthesis will be increased in inflammatory diseases as a result of stimulation by interleukin-6 [ 15 , 16 ] . our patient did not have any evidence of concurrent inflammation or infection when her hepcidin was measured . plasma hepcidin assay , as opposed to prohepcidin assay , is not commercially available , although a semiquantitative proteinchip system has recently been described . there is no reason to suspect that a direct linear relationship would not exist in vivo between the prohormone prohepcidin and hepcidin . a raised prohepcin must indicate that her hepcidin level , if it was possible to measure it , would have been high too . prohepcidin is a 60 aminoacid peptide cleaved by proteases to form the biologically active 25-peptide hepcidin . this is thought to be responsible for trapping iron in macrophages , resulting in reduced serum iron levels . sideroblastic anaemias are a heterogenous group of inherited or acquired disorders characterised by defective haemoglobin synthesis within erythroblasts leading to ineffective erythropoiesis . to our knowledge , this is the first report describing raised prohepcidin levels in a patient with refractory anaemia from lead poisoning . it is likely that lead toxicity resulted in accelerated synthesis of hepcidin in hepatocytes or macrophages which in turn caused refractory anaemia . this is thought to be due to iron trapping in macrophages and failure of iron uptake in erythroid precursor cells in the bone marrow . in anaemia of chronic disease , to some extent , zinc functions as an alternative protoporphyrin ligand by incorporating into protoporphyrin during haem synthesis . in anaemia of chronic disease , this can lead to increased zinc protoporphyrin levels . therefore another mechanism in the pathogenesis of anaemia in lead poisoning could be disrupted haem synthesis involving defective iron incorporation into haem , a process that may be mediated by hepcidin .

recent research evidence suggests a central role for hepcidin in iron homeostasis . hepcidin is a hormone synthesized in the liver . hepcidin is also thought to play a vital role in the pathogenic mechanism of anaemia in patients with inflammation or chronic disease . a 38-year - old female who presented with recurrent abdominal pain was found to have raised urinary porphyrins and a blood lead level of 779 g / l . her haemoglobin level was 8.3 g / dl . her mcv was normal . serum ferritin , b12 and folate were normal . her serum prohepcidin level was 2,489 ng / ml ( normal < 450 ng / ml ) . to our knowledge , this is the first report of raised prohepcidin levels in a patient with anaemia of chronic disease resulting from lead poisoning .

cavernous hemangiomas ( chs ) are defined as benign vascular structures inserted within the neural tissue , occurring in the central nervous system , and consisting of a dilated vascular bed5 ) . existence in the epidural space without bone involvement is rare1,10 ) , and only 4% of all chs ( 0.22/1.000.000 ) are purely epidural1,10 ) . clinical symptoms are usually seen as slowly progressive paraparesis , myelopathy and localized pain1,5 ) . although magnetic resonance imaging ( mri ) is the best diagnostic method for this lesion , it is not a definitive one8 ) . we felt it appropriate to present this case because chs in the epidural space have rarely been encountered . a 55-year - old male patient was admitted to our clinic with complaints of back pain beginning two years previously . additionally , he had progressive spastic paraparesis in both lower extremities , and an inability to stand without support for the previous 3 months . upon neurological examination , the motor power in both lower extremities was ii - iii / v , deep tendon reflexes were hyperactive , and hypesthesia was present under the t10 - 11 level . the patient had no history ofurinary or fecal incontinence , and the laboratory tests were within normal limits . however , inthe thoracic , lumbar , and cervical mris performed for further investigation , a mass lesion was seen along the t7 - 8 vertebral body levels . 1a ) , with a slightly lower signal than the cerebrospinal fluid ( csf ) on the t2-weighted images ( fig . 1b ) , and slight heterogeneous staining on the gadolinium - enhanced t1-weighted images ( fig . additionally , it was observed that the spinal cord was displaced to the right side due to the mass ( fig . a t8 - 9 total laminectomy was performed and an approximately 31.5 cm sized ( fig . 3a ) dark - colored vascular mass with soft consistency was found in the epidural space without invasion of the dura ( fig . 3b ) , which was completely excised microsurgically . the histopathological examination revealed a cavernous hemangioma , composed of large dilated blood - filled vessels lined with flattened endothelium ( fig . ten days postoperatively , the patient could walk independently and reported reduction in the localized back pain . chs are collections of small capillaries covered with a single layer of endothelium , characterized by lobules , separated by fibrous connective tissue septa , and composed of irregular and dilated vascular channels6 ) . however , they create clinical signs with mass effects , fluid movement within vascular structure , hemorrhages , thromboses , and the formation of cysts or caverns6 ) . these lesions can occur in every region of the body ; however , the most common area of occurrence in the cranial region of the central nervous system is the supratentorial area8 ) . chs have rarely been seen in the spinal canal1,6,10 ) , while only 4% of all cavernous hemangiomas ( 0.22/1.000.000 ) are purely epidural chs1,10 ) . spinal chs appear at an average age of 40 ( 30 - 60 ) and are more common in women ( 70% ) . according to frequency , the localization in the spinal vertebrae can be listed in order of occurrence as in the thoracic ( 54 - 60% ) , cervical ( 30% ) , and lumbar ( 10% ) vertebral regions1,7,9 ) ; they are seen most commonly in the posterior part of the spinal canal1,9 ) . there are two currently accepted hypotheses in the literature with regard to the frequent occurrence in the thoracic vertebrae ; the first is that the thoracic epidural space is wider3,6 ) , while the second is that the resistance in the posterior part of the thoracic spinal canal is lower3,6 ) . besides the sizes are very diverse3,6,7 ) the localization of the ch in our fifty - five - year - old male patient was consistent with the literature . although clinical symptoms may vary according to the localization , size and biological behavior , slow progressive paraparesis ( 71% ) and radiculopathy ( 19% ) are seen most commonly1,6,7,8,9,10 ) . acute presentation may occur due to either extradural hemorrhageor thrombotic occlusion within the cavernoma , by causing rapid increase in the bulk of the lesion6,8 ) . in our case , , the demarcated lobular lesion appears isointensein the t1-weighted images , hyperintense in the t2-weighted images , and intensely homogeneous with contrast enhancement in the contrast - enhanced t1-weighted images3,9 ) . in case of intramedullary chs , a hypointense ring due to peripheral hemosiderin deposition and heterogeneous intensity in the center although differential diagnosis is most commonly required with schwannoma in mris , it may be confused with other neurogenic tumors , metastasis , lymphoma , meningioma , multiple myeloma , extraosseous ewing 's sarcoma , disc fragments or epidural angiolipoma6,8 ) . in our case , the absence of a hemosiderin ring , as well as the displacement of the spinal cord , slightly lower signal than the csf signal in the t2-weighted images , and slightly heterogeneous significant contrast involvement suggested epidural hemangioma6 ) . aim of the surgery should be total removal at first operation6 ) ; however , intraoperative bleeding and intramedullary placement may impede the total removal . although hemorrhage is rare in intramedullary chs , massive bleeding may be seen in epidural chs1,2,6,8,10 ) . in cases of incomplete removal due to bleeding and its localization , adjuvant radiotherapy may be required6,8 ) . in our case , the bleeding in the perioperative period could be controlled surgically and adjuvant radiotheraphy was not needed . chs are non - neoplastic vascular malformations rarely seen in the spinal region , leading to a variety of clinical symptoms . in mris , it is very difficult to distinguish these from schwannomas . in this case with this kind of spinal epidural ch , despite wrong diagnosis is likely to occur , the author could perform complete reomval of this vascular malformation microsurgically .

cavernous hemangiomas were first reported in 1929 by globus and doshay , and are defined as benign vascular structures developed between the neural tissues occurring in the central nervous system , consisting of a dilated vascular bed . cavernous hemangiomas comprise nearly 5 - 12% of all spinal vascular malformations ; however , existence in the epidural space without bone involvement is rare . only 4% of all cavernous hemangiomas ( 0.22/1.000.000 ) are purely epidural cavernous hemangiomas . in this case report , we removed a hemorrhagic thoracic mass presenting with progressive neurological deficits in a 55-year - old male patient . we found this case to be appropriate for presentation due to the rare occurrence of this type of cavernous hemangioma .

lirraggiamento degli alimenti una tecnologia utilizzata nellindustria che ha la potenzialit di prevenire il deterioramento delle derrate prolungandone cos la shelf - life e migliorandone la salubrit . gli alimenti vengono sottoposti a dosi ben definite di radiazioni ad alta energia , generalmente raggi gamma , raggi x o fasci di elettroni , in grado di alterare lattivit degli enzimi degradativi presenti negli alimenti , di inattivare il materiale genetico delle cellule microbiche , inibendone la suddivisione , e di devitalizzare eventuali parassiti presenti , ad esempio , in pesci , molluschi e crostacei . il trattamento con radiazioni ionizzanti disciplinato dalle direttive quadro 1999/2/ce e 1999/3/ce ( commissione europea , 1999 ) . la legislazione comunitaria prevede che ciascun alimento e / o ingrediente alimentare trattato con radiazioni ionizzanti , debba riportare in etichetta la dicitura irradiato o trattato con radiazioni ionizzanti . ciascuno stato membro , inoltre , tenuto ad effettuare controlli , mediante metodi analitici validati e / o standardizzati a livello europeo , sugli impianti di irraggiamento e sugli alimenti presenti sul mercato al fine di verificare la corretta etichettatura . lobiettivo del presente lavoro stato quello di mettere a punto e validare il metodo fisico di screening in luminescenza otticamente stimolata ( photostimulated luminescence , psl ) per la rivelazione di molluschi e crostacei trattati con radiazioni ionizzanti presso listituto zooprofilattico sperimentale delle regioni lazio e toscana , roma . il metodo psl ( en 13751:2009 ) ( uni , 2009 ) si basa sulla misura della luce emessa dai particolati minerali presenti naturalmente nel campione che , se precedentemente irradiati , emettono luce in seguito a stimolazione ottica . si misura lintensit dellemissione luminosa in termini di conteggi per unit di tempo ( conteggi/60 secondi ) . il risultato viene confrontato con due soglie di riferimento , t1 ( soglia minore ) e t2 ( soglia maggiore ) . per segnali superiori alla soglia t2 il campione viene definito irradiato , ma deve essere comunque classificato correttamente attraverso uno dei metodi di conferma comitato europeo di normazione . segnali inferiori alla soglia t1 suggeriscono che il campione non ha subito un trattamento con radiazioni ionizzanti ed perci classificato come non irradiato . valori intermedi alle due soglie esprimono un risultato incerto che deve essere correttamente classificato mediante un ulteriore metodo standardizzato . sono stati acquistati , presso punti vendita al dettaglio , n.8 campioni : mitili ( mytilus chilensis ) , vongole ( paphia undulata ) , capesante ( argopecten purpuratus ) , gamberi rosa ( parapenaeus longirostris ) , gamberi argentini ( hymenopenaeus muelleri ) , scampi ( nephrops norvegicus ) , mazzancolle ( penaeus vannamei ) e granchio ( cancer magister ) . essi sono stati dapprima analizzati in psl per verificarne la negativit e , in seguito , inviati allizs della puglia e della basilicata per essere irraggiati ciascuno a tre dosi distinte : 0,5 , 3 e 5 kgy . solo nel caso del granchio lirraggiamento avvenuto ad una dose singola di 1 kgy . i n.22 campioni irraggiati sono stati , quindi , sottoposti allanalisi in psl per rilevare lavvenuto trattamento . lanalisi stata condotta mediante analizzatore con sistema di luminescenza pulsata stimolata ( scottish universities environmental research centre pulsed photostimulated luminescence , suerc ppsl ) sui campioni sgusciati . le soglie di riferimento sono state impostate a 1000c/60s ( t1 ) e 4000c/60s ( t2 ) , in accordo con la norma di riferimento . la conferma analitica dei campioni risultati irradiati alla misura in psl stata eseguita mediante metodo fisico di termoluminescenza ( en 1788:2001 ; commissione europea , 2001 ) . la validazione del metodo stata eseguita determinandone la sensibilit e la specificit ; stata valutata la compatibilit del metodo con la norma di riferimento uni en 13751:2009 ( uni , 2009 ) . i risultati delle prove si sono dimostrati in accordo con leffettivo stato di irraggiamento dei campioni ; sono stati ottenuti valori di sensibilit e specificit del 100% . i risultati ottenuti presso il nostro laboratorio si sono dimostrati perfettamente compatibili con quelli contenuti nella citata norma di riferimento . per tale motivo

the irradiation of food is a technology used in the industry to prevent the deterioration of foodstuff in some countries . the european community legislation states that each member state must carry out annual checks on the products during commercialisation . the istituto zooprofilattico sperimentale delle regioni lazio e toscana ( rome , italy ) has developed and validated the screening method of photostimulated luminescence uni en 13751:2009 to identify irradiated shellfish . a total of 30 tests of shellfish samples , consisting of 22 certified as irradiated and 8 not - irradiated samples , were performed . the validation procedure was based on sensitivity and specificity ; the compatibility between the screening method and the reference standard en 13751:2009 was evaluated . data were processed : 100% sensitivity and 100% specificity were obtained . results obtained in our laboratory were perfectly compatible with the reference standard . for this reason , the method has been validated and proved to be suitable for its intended use .

ibs represents one of the most common causes of abdominal pain , and it affects around 11% of the population around the world ( 1 , 2 ) . hae is a rare cause of abdominal pain , and sometimes can be misdiagnosed as ibs . hae is a rare autosomal dominant disorder with an estimated prevalence of 1 in 50,000 worldwide with no racial or sex differences , although women tend to have more severe disease ( 3 , 4 ) . in 1888 , william osler comprehensively described the clinical manifestation of hae ( 5 ) , and in 1963 , donaldson and evans subsequently discovered that hae was caused by a mutation of the c1-inh gene ( 6 ) . this c1-inh gene , serping1 , is located on chromosome 11q11-q13.1 ( 4 , 7 ) . hae accounts for about 75% of cases , with the remaining 2025% of cases being sporadic ( 4 , 7 ) . c1-inh , a protein synthesized mainly by hepatocytes , belongs to the serine protease inhibitor family . its deficiency or dysfunction leads to elevated levels of bradykinin , believed to account for most of the disease manifestations ( 4 ) . the disease is divided into three different types , depending on the level and function of c1-inh : type 1 accounts for approximately 85% of patients and is characterized by decreased production of c1-inh , caused by deletions or insertions of single or multiple nucleotides into the c1-inh gene . type 2 accounts for about 15% of patients , with normal or elevated levels of dysfunctional c1-inh due to point mutations in serping1 ( 4 , 7 ) . it is further divided into hae with normal c1-inh and fxii mutation and hae of unknown origin ( u - hae ) ( 4 , 8 , 9 ) . hae typically presents in the first or second decades of life ( 4 , 10 ) . the average time between the onset of symptoms and diagnosis is 810 years ( 3 , 8) . the skin is the most commonly involved organ , followed by the gastrointestinal and respiratory systems ( 10 ) . the cutaneous presentation is characterized by non - pitting edema of the face , extremities , and genitalia . in one retrospective study of 221 patients with hae by bork et al . , 93.3% of patients had recurrent abdominal symptoms ( 10 ) . gastrointestinal symptoms included abdominal pain , nausea , vomiting , constipation , or diarrhea . , the fluid loss ( third spacing ) can lead to hypovolemic shock ( 7 ) . abdominal sonogram often shows mucosal thickening and free peritoneal fluid ( 11 , 12 ) . abdominal symptoms may be the only presenting symptoms of hae , and these symptoms may precede the skin manifestation by many years ( 8) . ct scans of the abdomen show small bowel or colonic wall thickening with increased contrast enhancement , prominent mesenteric vessels , and mild to moderate ascites , which resolve after an acute attack ( 11 , 13 ) . endoscopy is relatively contraindicated when acute hae is a possible differential because of the risk of inducing life - threatening laryngeal edema . however , endoscopic findings , if performed , have included diffuse erythema and mucosal edema , with bulging masses of gastric mucosa resembling a submucosal tumor ( 14 ) . diagnosis of hae is often challenging if skin manifestations are absent . a positive family history can help , as was the case in our patient . if hae is suspected , the c4 complement level can serve as a screening test due to its high sensitivity and high negative predictive value ( 9 , 15 , 16 ) . the c4 level is typically less than 30% of the mean normal level in untreated hae ( 15 , 16 ) . if the c4 level is low , c1-inh level and function should be checked ( 16 ) . the three tests should be repeated in 13 months to minimize diagnostic error , given the low prevalence of hae ( 9 , 15 , 16 ) . the diagnosis of the third type of hae with normal c1-inh function is either genetic ( in the case of fxii mutation ) or clinical ( for unknown origin ) . these criteria are : presence of clinical symptomsone or more family member with similar symptoms the exclusion of familial and hereditary chronic urticaria with urticaria - associated angioedemanormal c1-inh activity and protein in plasma , and no hae - associated mutation in fxii gene ( 9).the c1q level can be used to distinguish between hae and acquired angioedema . presence of clinical symptoms one or more family member with similar symptoms the exclusion of familial and hereditary chronic urticaria with urticaria - associated angioedema normal c1-inh activity and protein in plasma , and no hae - associated mutation in fxii gene ( 9 ) . there are currently three approved medications for the treatment of acute attacks : plasma - derived c1-inh , the bradykinin b2 receptor antagonist icatibant , and kallikrein inhibitor ecallantide . all have been shown to be safe and efficacious for the treatment of acute hae attacks ( 8 , 18 , 19 ) . ibs is a diagnosis of exclusion , and it should be considered after excluding other causes . clinicians should keep hae in mind in patients suspected of having ibs or in those who present with recurrent unexplained abdominal symptoms , as early diagnosis can lead to prompt treatment and relief of symptoms . the authors have not received any funding or benefits from industry or elsewhere to conduct this study .

abdominal pain is one of the most common reasons for outpatient and emergency department visits . we present one such case of early closure in a 32-year - old male with recurrent abdominal pain who was diagnosed with irritable bowel syndrome ( ibs ) . family history was suspicious for hereditary angioedema ( hae ) . the hae workup came back positive , and the patient was started on prophylactic therapy , which led to an improvement in symptoms and quality of life . the purpose of this case is to create awareness among physicians to test for hae in patients diagnosed with ibs who , based on their history or physical examination , have clinical suspicion for hae .

leishmaniasis is endemic in 98 regions and countries in the world with the annual incidence and prevalence of about 2 and 12 million people , respectively ( 1 ) . as a major global health , it includes a group of diseases caused by protozoan parasites of the genus leishmania transmitted to mammals through female phlebotomine sandfly bites ( 2 ) . visceral leishmaniasis ( vl ) is caused by l. infantum in the mediterranean and middle east countries like iran ( 3 , 4 ) . its most common clinical manifestations are fever and splenomegaly identified in 80% of patients . besides , its most common laboratory abnormalities include elevated esr , anemia , neutropenia , thrombocytopenia , and hypergammaglobulinemia ( 5 ) . a 5-yr - old boy presented with enlarged multiple posterior cervical lymph nodes on the right side in sep 2014 . all lymph nodes were mobile without tenderness ; the largest node measured about 1 cm . results of laboratory tests including ldh , esr , cbc , and crp were within normal range . no changes occurred during that time , and the same lab tests were repeated and reported within normal range . an excisional lymph node biopsy was performed in mar 2015 ( fig . 5-year - old boy who had multiple enlarged posterior cervical lymph nodes on his right side for several months and was finally diagnosed with leishmaniasis granulomatous lymphadenitis with focal necrosis and leishmania parasites were histologically detected ( fig . lymph node biopsy of a 5-year - old boy showing amastigotes of leishman - donovan bodies ( arrow ) informed consent was taken from patient s parents . vl diagnosis is commonly delayed due to a microscopically difficult identification of rare amastigotes in bone marrow smears , varied incubation times , nonspecific symptoms , and negative serological test results , especially in immuno - compromised patients ( 4 ) . vl clinical manifestations in iran and mediterranean countries are of a similar type except that significant lymphadenopathy is lacking in the former country ( 5 ) . spleen nodules ( 4 ) , fever - free vl ( 5 ) , isolated cervical leishmanial lymphadenopathy in apparently vl - cured patients ( 6 ) , cutaneous leishmaniasis associated with pleural effusion ( 7 ) or an extensive ulcer in the left arm s entire lateral side ( 8) , and isolated mediastinal lymphadenopathy in hiv patients ( 9 ) are some unusual forms of leishmaniasis reported in the literature . moreover , sharma ( 10 ) and ignatius ( 11 ) reported an isolated lymphadenopathy in immunocompetent individuals as a rare manifestation of leishmaniasis . the case reported herein is unique , because isolated lymphadenopathy was the only manifestation of leishmaniasis and results of general and specific tests for leishmania were normal in an immunocompetent patient . leishmaniasis should be included in the differential diagnosis of isolated lymphadenitis in immunocompetent patients , even if the k39 and ifa for kala - azar are reported as negative . ethical issues ( including plagiarism , informed consent , misconduct , data fabrication and/or falsification , double publication and/or submission , redundancy , etc . ) have been completely observed by the authors .

leishmaniasis is an endemic parasitic disease in iran . this paper reports the case of a 5-yr - old boy who presented with multiple isolated cervical lymphadenopathy for several months with no history of fever and no signs or symptoms . in an excisional lymph node biopsy , leishmania parasites were histologically detected . thus , leishmaniasis should be included in the differential diagnosis of isolated lymphadenitis in immunocompetent patients , even if the k39 and ifa for kala - azar are reported as negative .

nocardiosis is caused by a group of aerobic , gram positive , weakly acid fast species of the genus nocardia . more than 80 species of nocardia causing different types of human infections have been identified . pulmonary nocardiosis is the more common clinical type ; primary cutaneous nocardiosis is rare and is always seen in patients with underlying risk . cutaneous nocardiosis can be seen in immunocompetent persons as an occupational disease among gardeners and agriculturists . because nocardiosis is not a notifiable disease and is not aids defined illness the global rate of nocardiosis is not known . a rare case of primary cutaneous nocardiosis occurring in the facial region in an adult immunocompromised patient is reported and cutaneous nocardiosis in india is reviewed . 35 years old immunocompromised lady on art for 9 years noticed a small blackish patch on the zygomatic arch 3 months back , associated with mild pain , increased in size gradually and developed into an abscess , which ruptured 30 days later . pus oozed from the ruptured abscess [ figures 1 and 2 ] . on examination a discharging sinus in the infraauricular area white to cream colored friable rough colonies grew on blood agar after 48 hrs incubation at 37 degrees [ figure 3 ] . a positive urease test , growth at 42 degrees and negative hydrolysis of proteins confirmed the growth as n. asteroides . reproducibility of the isolate was established by collection of a repeat pus sample and bacteriological examination . blood culture was done to detect the disseminating nature , but it did not yield growth of any bacteria after 10 days incubation . extensive nature of the disease and non compliance of the treatment are associated with poor prognosis . it can appear as multiple ascending subcutaneous abscesses appearing sequentially after healing of original lesion . long term usage of corticosteroids and anti - inflmmatory drugs induces suppression of cmi , release of cytokines and other chemokines including tnf - alpha , resulting in decreased macrophage activity and poor intracellular killing . hence nocardiosis is more commonly seen in immunocompromised patients[79 ] , in whom it can be fatal . primary cutaneous nocardiosis can also occur as an associated complication of other systemic diseases like crohn 's disease . it may also disseminate to distant organs like extension to craniocerebral region , epidural space leading to abscess formation in immunocompetent persons the indolent nature and slow progression of the lesion may lead to dissemination to distant organs which may be detected months or years later . such unusual and rare presentations reemphasizes the need to consider nocardiosis as one of the differential diagnosis , especially in a patient giving a previous history of discharging sinus . appropriate cultures and stains are required to reveal the true nature of the organism and ensure that appropriate therapy is instituted . a case of nocardiosis causing thyroid abscess in an immunocompromised patient presenting as puo has been reported . cases of bilateral conjunctivitis and of endophthalmitis due to n. asteroides have been reported from india . an unusual presentation of nocardiosis causing corneal ulcer in a leprosy patient has been detected . review of nocardiosis in india emphasizes the varied and unusual presentation of primary cutaneous [ table 1 ] nocardiosis can also present as spinal osteomyelitis . nocardia species is recognized as an opportunistic pathogen in patients with impaired host defense mechanisms . lymphoreticular malignancies , organ transplantation , corticosteroid or other immunosuppressive therapy , and underlying pulmonary disease are important predisposing factors.infection with human immunodeficiency virus type i ( hiv i ) is associated with profound dysfunction of cmi that results in life threatening opportunistic infections . although nocardiosis in patients with aids has been described , it is considered to be an uncommon complication of hiv i infection . further national level detailed studies in all hiv seropositives will help in better understanding of nocardiosis and also will help in the management . this case report emphasizes the importance of proper and detailed identification of all gram positive non sporing bacilli seen in gram smear or grown in culture . cutaneous nocardiosis reports patients with hiv infection and severe nocardiosis seem to have a worse prognosis and should be treated aggressively . the effectiveness of prophylactic trimethoprim - sulfamethaxazole as a potent prophylactic agent is not very clear . this collection of reviews emphasizes the importance of considering nocardia in the differential diagnosis of any immunosuppressed patient presenting with fever , especially those with signs or symptoms localizing to the lungs , skin , or cns .

nocardiosis is an acute , subacute or chronic bacterial infection caused by several species of geophilic aerobic bacteria of the genus nocardia . cutaneous nocardiosis is an uncommon infectious disease that presents as primary cutaneous infection or as a sequale of disseminated pulmonary nocardiosis . its rarity and as nocardiosis is not an aids defined disease it is often underreported . the global incidence of cutaneous nocardiosis is not exactly known . the frequency of nocardiosis in hiv patients has increased from 0.3 to1.85% . in immunocompetent persons primary cutaneous nocardiosis is more commonly seen among gardeners and agriculturists . we report a case of extensive primary facial cutaneous nocardiosis due to nocardia asteroides , in an adult immunocompromised lady who had no pulmonary focus . the lesions were seen as sinus tracts on the zygomatic arch , preauricular and infraauricular regions . bacteriological examination of the pus confirmed the presence of n. asteroides . the rarity of the presentation and cutaneous nocardiosis in india is reviewed .

spontaneous coronary artery dissection ( scad ) is a rare and fatal cause of acute coronary syndrome ( acs ) that has been reported by autopsy in many cases historically.1 ) the clinical diagnosis of scad has increased because coronary angiography ( cag ) and intravascular ultrasound ( ivus ) available for providing detailed morphological information of vessel layers is frequently performed for evaluation of acs . although several modalities including percutaneous coronary intervention ( pci ) , coronary artery bypass graft surgery ( cabg ) and medical therapy have been performed to manage patients with scad , no treatment guideline has yet been established . we report a case of scad which was presented as st - segment elevation myocardial infarction ( stemi ) and treated successfully with medical treatment . a 53 year - old woman was transferred to the emergency department due to chest pain via a district hospital . she denied any prior history of pregnancy , cocaine or amphetamine medication , chest trauma , connective tissue disease and family history of premature coronary artery disease . on arrival , her vital signs were stable except for blood pressure reading of 140/84 mmhg . the physical examination revealed no evidence of tenderness on the anterior chest and no sign of joint swelling or tenderness . the levels of total cholesterol , low density lipoprotein - cholesterol ( ldl - c ) and cardiac enzymes were elevated . the patient 's total cholesterol , triglyceride , high density lipoprotein - cholesterol , and ldl results were 236 mg / dl ( 0 - 200 mg / dl ) , 98 mg / dl ( 0 - 150 mg / dl ) , 41 mg / dl ( 35 - 55 mg / dl ) , 169 mg / dl ( 55 - 155 mg / dl ) , respectively . creatine kinase - mb , and troponine - i levels were 113 ng / ml ( 0 - 2.8 ng / ml ) , and 26 ng / ml ( 0 - 0.045 ng / ml ) . glucose was 95 mg / dl ( 70 - 110 mg / dl ) , and creatinine was 0.81 mg / dl ( 0.7 - 1.4 mg / dl ) . suspecting myocardial infarction , we performed emergent cag . in the examination , a long and smooth lesion from the mid to distal left anterior descending artery ( lad ) ivus confirmed the dissecting flap with intramural hematoma compressing the true lumen at the distal lad ( fig . 1c ) , and ectatic dilatation of the proximal lad ( internal diameter : approximately 6 mm ) . , the patient did not complain of chest pain and all vital signs were stable . because the intramural hematoma was located at distal lad and the thrombolysis in myocardial infarction flow grade was three , we did not conduct any additional interventional treatments for the patient . multi - detector computed tomography ( mdct ) of coronary artery was undertaken three days later using a siemens 64-slice scanner . we observed a luminal narrowing of the distal lad with a perivascular low attenuation corresponding to hematoma and ectatic change of the left coronary artery ( fig . the patient was treated with aspirin , clopidogrel , bisoprolol , valsartan , and diltiazem , and did not suffer from any discomfort after discharge . follow - up mdct of the coronary artery demonstrated dilatation of lumen size at the distal lad with resolution of perivascular hematoma ( fig . 2c and d ) . it separates coronary arterial layers and formed hematoma between the layers which compress the true lumen of the coronary artery and induce ischemia . the incidence of scad is reported from 0.1% up to 1.1% of patients referred for cag.2 ) the etiology is not fully known , but atherosclerosis is considered to be the most common causal factor for scad.3 ) hormonal changes in women who are in peripartum period or taking oral pills , iatrogenic , secondary to chest trauma , connective tissue disease and vasculitis , seem to be related to scad.4 - 6 ) in cases of scad with obscure cag findings , ivus can be helpful by detecting the presence of an intramural hematoma in the outer layer of the media compressing the true lumen.5 ) the detection of intimal tearing flap by ivus is not always available maybe due to spontaneous clotting at the tearing point.7 ) in addition to ivus , according to development of ct spatial resolution , mdct of the coronary artery can visualize the extent and thickness of hematoma in the assessment of scad.5 ) the therapeutic strategy is generally determined by the clinical condition and image findings.3)5 ) if vital conditions are stable and ischemia is not ongoing , scad may be treated medically similar to medical treatment of acs . thrombolytic therapy in scad is not recommended due to the extension of dissection resulting in poor prognosis . cabg can be considered in cases of dissection of left main coronary artery or multivessel involvement . although our patient was presented with stemi , the initial findings of cag and ivus were compatible with scad , and vital signs were stable . we were able to avoid invasive procedures like coronary stenting , and short - term follow - up with mdct resulted in more confidence in the treatment . in addition to follow - up cag , serial check - up using ivus and mdct could clearly assess the resolution of hematoma and the acquisition of the correct true lumen . therefore , we think that ivus and mdct can be useful to diagnose , decide the optimal treatment and identify the progress of disease in the case of scad presented with stemi .

spontaneous coronary artery dissection ( scad ) is an uncommon cause of acute coronary syndrome which may be related to lethal condition . although several modalities including medical therapy have been suggested , agreement on optimal treatment has not yet been determined . we describe a case of scad which was presented as st - segment elevation myocardial infarction , and treated successfully with medical treatment . coronary angiography , intravascular ultrasound and multi - detector computed tomography showed the serial changes of this disease entity .

although a number of tumors may arise from the adrenal gland , surgical intervention is always warranted in the setting of functional tumors and in the likelihood of malignancy . many criteria have been established that guide our approach to the adrenal incidentaloma . the association between acquired immunodeficiency syndrome ( aids ) , epstein - bar virus ( ebv ) , and leiomyomas has been described . we report the successful laparoscopic excision of an enlarging left adrenal leiomyoma in a 49-year - old woman with aids . the patient is a 49-year - old female with aids who presented to her primary physician in 2001 with the complaint of vague abdominal discomfort . a computed tomographic ( ct ) scan at the time revealed gallstones and an incidental 1.9x2.1-cm left adrenal mass . surveillance ct and magnetic resonance imaging ( mri ) revealed a significant growth in the mass to 4.1x2.7 cm over a 1-year period . the core of the mass had a high signal in the t2 fat suppressed sequence suggestive of central necrosis . no drop occurred in the signal in the in - phase / opposed - phase sequence . computed tomographic scan of the left adrenal leiomyoma measuring 4.1x2.7 cm ( anterior to kidney ) . t2 weighted magnetic resonance imaging of the left adrenal leiomyoma with an enhancing central core . her 24-hour urine catecholamine tests were also normal . a thyroid function test confirmed that she was euthyroid . the patient was hypokalemic , but biochemical test results were not consistent with an aldosterone - producing adenoma . given the rapid rate of growth over the surveillance period and the patient 's underlying medical status , it was recommended that she undergo a laparoscopic left adrenalectomy . with the patient in a lateral transperitoneal position , we explored her laparoscopically and were able to resect the medially located left adrenal mass without complications . the patient 's postoperative course was uneventful , and she was discharged on the second postoperative day . the specimen consisted of a roughly spherical - shaped , tan - white , well - encapsulated , firm mass . it measured 3.0x3.5x3.0 cm and weighed 17.8 g. a small rim of compressed adrenal cortex was also present . it confirmed the diagnosis and outlined numerous veins at the center of the tumor , consistent with its origin from vascular smooth muscle . these include the transabdominal lateral flank approach , posterior retroperitoneal approach , and the anterior abdominal approach . we have a preference for the lateral flank approach and will briefly describe our technique for the left adrenalectomy . the patient is initially placed in a supine position for the induction of general anaesthesia . once successfully anesthetized , the patient is turned to the right lateral decubitus position ( left side up ) . the table is flexed to allow for the opening up of the space between the costal margin and the iliac crest . pressure points are addressed at this time , the patient is secured to the table , and the left arm is secured on an elevated armrest . it is placed in the anterior axillary line approximately 2 cm below the costal margin . after insufflation to approximately 15 mm hg , a 5-mm port is placed at the same site . a 5-mm/45-degree scope is placed inside , and the peritoneal cavity is inspected . a 10-mm to 12-mm optiview trocar another 5-mm port is then placed below the costal margin approaching the xiphoid . at times , a 5-mm port is also placed laterally between the costal margin and the iliac crest . the dissection begins with the mobilization of the splenic flexure of the colon , moving the colon inferiorly . once this is accomplished , it generally creates a valley with the spleen and pancreas towards the left ( of the screen ) and the kidney and adrenal on the right . the plane between the adrenal and the kidney can generally be identified and the space opened up with an ultrasonic scalpel . medium titanium clips are applied proximally and distally , and the adrenal vein is then transected . although it is not essential to dissect out the left renal vein , at times this can be helpful in identifying the left adrenal vein . it is essential to follow the vein to the adrenal gland to ensure that it is not an accessory renal vein . although not always possible , we believe that early identification of the adrenal vein is helpful in maintaining hemostasis throughout the procedure . once the adrenal vein is transected , the adrenal gland can be retracted superiorly and complete mobilization of the gland accomplished . of note , no good handle for the adrenal gland exists , and it is best to grasp the fatty tissue surrounding the adrenal gland rather than the gland itself as this will lead to tearing of the gland and subsequent bleeding . once the gland is mobilized , it is placed in a sterile retrieval bag and removed via the 10-mm port site . this site may need to be enlarged for removal of the gland . once hemostasis is assured , the ports can be removed under direct vision and the enlarged port site closed . the finding of an adrenal incidentaloma requires concurrent testing to determine the tumor 's functional status , as well as its potential for malignancy . initial biochemical testing begins routinely with a 24-hour urine collection for catecholamines , metanephrines , and cortisol to exclude a pheochromocytoma or cushing 's syndrome . current guidelines require the surgical management of tumors found to be hormonally active or suspicious for carcinoma . although somewhat variable , patients with lesions > 4 cm are also candidates for resection . advances in imaging technology have proven to be particularly useful in the evaluation of adrenal masses . the mri is advantageous in that it does not expose the patient to ionizing radiation ; however , it is more expensive . although leiomyomas of the gastrointestinal tract are quite common , adrenal leiomyomas are rare tumors . the link between the immune system and smooth muscle tumors of the adrenal gland is not clear . it has been postulated that infection with the human immunodeficiency virus ( hiv ) may promote smooth muscle tumors . previous studies have documented an association between ebv and aids - related smooth muscle tumors . the ebv genome has been detected by polymerase chain reaction ( pcr ) . in this patient , although it is well known that patients with aids most commonly develop lymphoma or kaposi sarcoma , we must also be cognizant of the growing association with the rare adrenal leiomyoma . hence , the possibility of a smooth muscle tumor should be included in the differential diagnosis in the aids population . given the rare nature of this tumor , we believe this to be the first report of a laparoscopically resected adrenal leiomyoma . in the setting of the immunocompromised population ,

objectives : laparoscopic management of adrenal masses has been well described . immunologically compromised patients can obtain significant benefit from these minimally invasive procedures . we describe a case of an enlarging smooth muscle tumor of the adrenal gland in an acquired immunodeficiency syndrome ( aids ) patient and review the sparse literature available on this subject.case report : a 49-year - old female with aids complaining of vague abdominal discomfort was found to have a left adrenal mass . significant enlargement of the mass was noted during routine follow - up . the patient underwent an elective laparoscopic left adrenalectomy without complications . pathological review found the mass to be a rare adrenal leiomyoma.discussion:benign , smooth muscle tumors arising from the adrenal glands are rare . a review of the literature does reveal a propensity for these tumors to occur in the immunocompromised population.conclusion:the ability to manage these tumors laparoscopically is of significant benefit to patients .

we have previously identified the lack of continuity between the ventricular septum and the aortic annulus as the salient pathological feature of the syndrome of prolapsing right coronary cusp , dilatation of the sinus of valsalva , and ventricular septal defect ( vsd ) . in keeping with this salient pathological feature , we devised a simple technique of anatomic correction that addressed all the components of the pathology . this consists of using a transaortic approach , closing the vsd with interrupted pledgeted sutures that elevate the crest of the septum to the aortic media , thus restoring the position of the aortic annulus and plicate the excessive tissue of the unsupported sinus of valsalva with the same sutures . management of patients whose vsd is located under the non coronary sinus has generally been ignored in literature . characterisation of the cusp prolapsing into the vsd is important to determine the type of correction because prolapse of the non - coronary cusp is not amenable to anatomical correction . we present the case of a male child in heart failure with nyha class ii symptoms , who weighed only 21 kilograms at 9 years of age . echocardiography showed that he had a vsd located underneath the non - coronary aortic cusp with left - to - right shunt . he had significant prolapse of the non - coronary cusp , dilation of the corresponding sinus of valsalva , and severe aortic regurgitation . his mitral , tricuspid and pulmonary valves were normal and his right ventricular outflow tract was widely patent . at operation non - coronary aortic sinus was significantly dilated and its corresponding leaflet had extensive secondary changes in the form of thickening , and a significantly redundant free margin . the commissure between the non - coronary cusp and the right coronary cusp was displaced down into the non - coronary aortic sinus . a ventricular septal defect , shaped like a transverse oval , was located underneath the non - coronary cusp . we attempted aortic valve repair by performing commissuroplasty that resuspended the non - right coronary commissure at its proper level and eliminated part of the redundant free margin of the non - coronary cusp . we performed additional plication of the free margin to accurately match the length of the free margins of the non coronary cusp with the other two cusps . the vsd was closed with a goretex patch using continuous prolene suture , taking care to safeguard the atrioventricular node . on removing the aortic cross clamp the left ventricle immediately dilated indicating severe aortic regurgitation . cardioplegia was immediately re - administered directly into coronary ostia , and cardiac standstill was achieved . we replaced the aortic valve by performing a ross procedure using the root replacement technique . the child made an uneventful recovery and was discharged home on the seventh post - operative day . preoperative characterisation of the prolapsing cusp is important to plan repair in patients with vsd , aortic valve prolapse and aortic regurgitation . in patients whose vsd is located underneath the non coronary sinus , the atrioventricular node is in close proximity to the non - coronary cusp and is therefore extremely vulnerable to damage if direct closure of the vsd is undertaken . also , the non - coronary cusp is extensively involved by secondary pathological changes which diminish the chances of a successful repair . in our patient , patch closure of the vsd and failure to simultaneously plicate the non coronary sinus added to the redundancy of tissues of the non - coronary sinus . this resulted in failure to restore the normal position of the aortic annulus and caused severe aortic regurgitation . early diagnosis of this disease and clear delineation of aortic valve prolapse and aortic regurgitation can be easily achieved with transthoracic echocardiography . as soon as the aortic valve shows signs of prolapse the patient should be referred for repair before the onset of significant aortic regurgitation . finally , a ross procedure can easily be performed in this group of patients in spite of the presence of significant pathology in the region of the right ventricular outflow tract and pulmonary valve .

ventricular septal defect ( vsd ) with prolapse of the right coronary cusp and aortic regurgitation can be managed surgically with the anatomical correction technique . however when the vsd is located underneath the non coronary cusp surgical management differs due to anatomical constraints and secondary pathological changes seen in the non coronary cusp . it is therefore important that the location of the vsd and the morphology of prolapsing cusp be characterised preoperatively in order to plan appropriate surgical repair . we present a case study in which we discuss the salient differences in the surgical management of the prolapsing right and the prolapsing non coronary cusps .

patients presenting with recent onset of low back pain and dermatomal sensory loss are often evaluated for common entities including disc herniation , degenerative lateral recess stenosis , nerve sheath tumor , and meningioma . described herein is a patient presenting with such symptoms who was found to have an extradural soft tissue chondroma in the lumbar spine , which was successfully treated with surgical excision . when found in an intraosseous location , if associated with the cortical surface , they are termed periosteal chondromas , and when located at a site distant from the bone , they are referred to as soft tissue chondromas . true soft tissue chondromas are uncommon , and the identification of this tumor within the spinal canal represents an extreme rarity . a 46-year - old female presented with a 3-week history of lower back pain with decreased sensation and paresthesias of the left lower extremity . plain x - ray films of the lumbar spine were noted to be unremarkable with no boney erosion or reactive bone growth visualized [ figure 1 ] . the magnetic resonance imaging of the lumbar spine with and without contrast demonstrated an extradural soft tissue mass within the spinal canal at the l3 level with extension into the left l3/4 neural foramen [ figure 2 ] . ( a ) anteroposterior and ( b ) lateral x - ray films of the lumbar spine with attention to the l3/4 intervertebral space show no signs of boney erosion or reactive bone growth to suggest invasive tumor axial noncontrast t1 ( a ) and postgadolinium t1 with fat saturation ( b ) magnetic resonance imaging of the lumbar spine show a homogeneously enhancing soft tissue mass within the left l3 lateral recess extending into l3/4 neural foramen the patient initially refused surgery and noted moderate improvement of symptoms following administration of dexamethasone . as symptoms did not completely resolve , she agreed to proceed with an l3 laminectomy with wide left l3/4 foraminotomy for excision of the lesion . intraoperative electromyography was utilized for the monitoring of motor potentials during tumor removal . during the operation , the thecal sac was noted to have a normal appearance , with moderate amounts of abnormal grey tissue , found both ventrally and dorsally to the ligamentum flavum . at the site of the nerve root axilla , excess soft tissue was encountered which was firm in consistency and noted to be compressing the nerve . while the tissue was resected clear of the dura , transient self - resolving irritation was noted on electromyogram . postoperatively the patient did well and had exhibited complete resolution of symptoms at 5-month follow - up . pathologic examination revealed benign cartilaginous tissue organized in a lobulated pattern of loose clusters of chondrocytes surrounded by abundant chondroid stroma . findings suggestive of aggressive chondrosarcoma such as mitotic figures , double - nucleated chondrocytes , and a significant spindle cell component were notably absent [ figure 3 ] . hematoxylin and eosin stain at 10 magnification ( a ) shows benign cartilaginous tissue organized in a lobulated pattern . at 40 magnification ( b ) chondrocytes surrounded by abundant chondroid stroma without mitosis it is rare for these tumors to arise in an extradural location but when such tumors have been encountered they are frequently located within the cranium . these cranial chondromas typically represent the periosteal variant which is common at the spheno - petrosal , spheno - occipital , or petro - occipital synchondroses . the soft tissue variant of chondroma such as described above is rare and is thought to arise from cartilaginous cell rests of mesenchymal origin that are thought to be displaced during development . these ectopic masses are typically asymptomatic and often noted as incidental findings on radiographic evaluation . this variant of chondroma is a rarity at any location particularly along the central nervous system and exceptionally rare in the lumbar spine . cho et al . described a case of lumbar extradural chondroma in a patient with ipsilateral lower extremity paresthesias . in their report , cho et al . cetinkal et al . have reported a single case of extradural chondroma at the l2 level . this patient presented with femoral numbness and l2 hypesthesia and was treated with complete excision through a partial hemilaminectomy . it is of note that in this rare case , the intradural compartment was explored , and no gross infiltration of tumor was observed . recently , ogata et al . described a periosteal chondroma in the lumbar region presenting with lower extremity weakness and radiculopathy . these periosteal chondromas are distinct in their origination from within the periosteal tissue plane and are frequently nestled partly within the underlying cortical bone . it is of note that the present case was characterized by localization outside of the periosteal tissues and contained partially by the epidural fat pad . while the majority of chondromas of the lumbar spine are likely to remain asymptomatic or present merely as a palpable paravertebral mass , many may mimic disc herniation or nerve sheath tumors . for this patient , our differential diagnosis upon presentation included nerve sheath tumor , meningioma , or possibly lymphoma . while the majority of vertebral chondromas represent benign tumors , long - term follow - up is recommended for lesions of unusual pathology , such as the presented case as the potential for malignant transformation is unknown . cells may reside in small nests referred to as isogenous groups and occupy lucent spaces within their myxoid matrix called lacunae . immunohistochemical staining will typically be positive for s-100 protein , and negative for epithelial markers such as ae1/ae3 and epithelial membrane antigen . additional research will be helpful in further characterizing the genetic makeup of similar ectopic lesions as this may provide insight into their formation .

the identification of a soft tissue chondroma within the spine represents a rarity and is typically not included within the differential diagnosis for patients with sensory complaints of the leg . the authors describe 46-year - old female presenting with 3-week history of decreased sensation and paresthesias of the left leg . magnetic resonance imaging of the lumbar spine demonstrated an l3 extradural soft tissue mass . she underwent an uncomplicated excision through an l3 laminectomy and exhibited complete resolution of symptoms . pathologic examination revealed benign cartilaginous tissue ; however , the authors recommend long - term follow - up for such lesions as the potential for malignant transformation is unknown .

lymphoproliferative disorder ( lpd ) in association with the reactivation of epstein - barr virus ( ebv ) has frequently been reported in immunocompromised patients following antithymocyte globulin ( atg ) therapy . ebv commonly remains latent in nave b cells ; however , in rare circumstances , it has also been shown to infect t cells and natural killer ( nk ) cells . ebv is often reactivated in patients with immune dysfunction , leading to lpd and lymphoma . lpd associated with ebv - reactivation is often characterized by the proliferation of ebv - infected lymphocytes . the rationale for use of the anti - cd20 monoclonal antibody rituximab in ebv - associated lpd rests on the frequent expression of the cd20 b - cell antigen . indeed , patients with ebv - associated b - lpd have been treated with rituximab with variable efficacy . however , patients with a large tumor burden of the b - lpd or following atg therapy for idiopathic aplastic anemia ( aa ) and stem cell transplantation have had a particularly bad response to antibody therapy including rituximab and a poor survival . bone marrow failure and therapy - induced immunocompromized conditions are also occasionally life - threatening due to severe infection including ebv - reactivation , hemorrhage , or delayed transformation and major causes of death . we herein described a patient with aa who developed ebv - negative oligoclonal b - lpd in association with both reactivated clonal ebv and clonal t cells following atg therapy . the findings of this study may shed new light on the pathophysiology of intractable lpd . a 69-year - old woman with acquired aa was admitted for atg - based immunosuppressive therapy . on admission she had undergone total gastrectomy , partial pancreas head resection , and splenectomy for gastric cancer four years previously , and had been diagnosed with idiopathic aa based on findings such as hypoplastic fatty marrow ( figure 1a ) with a normal karyotype in the absence of an abnormal infiltrate including lymphoid neoplasms , myelodysplasia , infections , or rheumatic diseases six months prior to her admission . she was treated initially with cicrosporin ( csa ) and metenolone acetate , and subsequently with rabbit atg , csa , and prednisolone . the t - cell population of lymphocytes disappeared after the therapy ( figure 1b ) . she developed fever , hypoglycemia , and marked lymphocytosis with the reactivation of ebv and cytomegalovirus on day 54 after this treatment ( figure 1b ) . ebv - reactivation was confirmed by an increase in serum ebv - dna ( 30010 copies / ml ) and the results of serological tests ( positive for both igg to the ebv capsid antigen and antibody to the ebv nuclear antigen ) . she also exhibited rapidly fatal complications associated with hepatomegaly , renal dysfunction , and an infection with stenotrophomonas maltophilia prior to initiating treatment with rituximab ( table 1 ) . the present study gives a new insight into ebv - associated lpd through a rare aa patient undergoing atg therapy and subsequently developing fatal lpd with autopsy analysis . histological examinations revealed that lymphocytes densely infiltrated into the para - aortic lymph nodes ( figure 2a ) , liver , kidney , pancreas , and thyroid . flow cytometry showed that most lymphocytes expressed pre - b - cell markers such as cd3 , cd7 , cd19 , cd20 , cd38 , and -chain ( data not shown ) . however , of interest , the elaborate analyses showed that lymphocytes in the lpd lesions were oligoclonal when assessed by southern blotting ( figure 2b ) and the detection of two serum m - proteins ( igg and igm ) . predominant lymphocytes within the lpd lesions were also negative for eber when limited by the presence of cd3 cd20 b cells ( inset right below for each panel in figure 2a ) and no major chromosomal abnormalities were detected ( data not shown ) . moreover , it did not affect the quantity of the two digested bands in southern blotting for the igh rearrangement ( figure 2b , lanes 2 and 3 of the patient ) in spite of only a small minority of clonal ebv - positive cells . thus , these results suggest that oligoclonally expanding ebv - negative b cells virtually occupied the lpd lesions . ebv potentially infects lymphocytes such as nave b cells , t cells , and nk cells . lpd lesions were occupied mostly by ebv - negative b cells and by a small population of cd3 lymphocytes ( figure 2a ) . the sparse t cells of lpd lesions ( figure 2a ) showed clonal proliferation when analyzed by southern blotting ( figure 2d ) and the pcr - based gene clonality assay of tcr genes ( figure 2e ) , suggesting the clonal expansion of t cells infected with ebv . atg for aa may not allow the predominant proliferation of clonal t cells and the immune surveillance of t cells , being partly supported by outbreak of serious infections ( figure 1b ) . moreover , to determine the association between clonal t cells with oligoclonal b - lpd , we measured various cytokines that promote b - cell proliferation . interferon g , il-6 , il-10 , and tumor necrosis factor were markedly increased in the serum ( table 1 ) and were also detected in lpd lesions ( figure 2f ) . therefore , it is conceivable that atg suppressed cytotoxic t cells and allowed the development of b - lpd . the predominant b - cell proliferation may be associated with b - cell selection by the cytokine and cytotoxicity responses . based on our results , we consider that ebv - infected clonal t cells were critically involved in the development of ebv - negative oligoclonal b - lpd . the molecular autopsy study revealed that the sparse ebv - infected clonal t cells could be critically involved in the pathogenesis of ebv - negative oligoclonal b - lpd through cytokine amplification and escape from t - cell surveillances attributable to atg - based immunosuppressive therapy , leading to an extremely rare b - cell - rich t - cell lymphoma . this report may be helpful in elucidating the complex pathophysiology of intractable b - lpd refractory to rituximab , although further studies are needed to draw a conclusion .

b - cell lymphoproliferative disorder ( b - lpd ) is generally characterized by the proliferation of epstein - barr virus ( ebv)-infected b lymphocytes . we here report the development of ebv - negative b - lpd associated with ebv - reactivation following antithymocyte globulin ( atg ) therapy in a patient with aplastic anemia . the molecular autopsy study showed the sparse ebv - infected clonal t cells could be critically involved in the pathogenesis of ebv - negative oligoclonal b - lpd through cytokine amplification and escape from t - cell surveillances attributable to atg - based immunosuppressive therapy , leading to an extremely rare b - cell - rich t - cell lymphoma . this report helps in elucidating the complex pathophysiology of intractable b - lpd refractory to rituximab .

it is well known that acute coronary syndrome ( acs ) is the most common cause of cardiac arrest . however , spontaneous subarachnoid hemorrhage ( sah ) is also a common neurological disorder that leads to out - of - hospital cardiac arrest . typical electrocardiogram ( ecg ) changes , such as st - segment elevation or depression and abnormal t wave morphologies , may mimic myocardial infarction or ischemia . furthermore , sah patients also have elevated troponin levels and myocardial regional wall motion abnormalities due to neurogenic stunned myocardium . these nonspecific findings can lead to misdiagnosis and incorrect therapeutic decisions in these cardiac arrest patients , such as thrombolytic therapy and percutaneous coronary intervention . in this article , we report a case of an out - of - hospital cardiac arrest survivor whose initial ecg indicated a st - segment elevation myocardial infarction ( stemi ) ; however , she was finally diagnosed with sah . compared with previous reports of cardiac arrest survivors with sah mimicking acute myocardial infarction ( ami ) , the ecg of this case was more distinct because of its st - segment elevations in the lateral leads and the reciprocal st - segment depression in the inferior leads indicating a typical stemi . we suggest that , even with signs of ami , clinicians should consider the possibility of sah as a cause of cardiac arrest in comatose resuscitated patients . a 48-year - old woman without any known history of disease suddenly collapsed and lost consciousness . she had no palpable pulse , and the initial ecg rhythm , determined by an automated external defibrillator , was asystole . ems providers continues cardiopulmonary resuscitation ( cpr ) and arrived at the emergency department about 30 minutes after the sudden collapse . in ed , cpr was performed in accordance with the current advanced cardiac life support guidelines of 2010 . after 4 minutes of resuscitation with a total of 2 mg epinephrine , she recovered spontaneous circulation . her vitals were as follows : blood pressure , 122/99 mmhg ; pulse rate , 144/min ; respiratory rate , 20/min . her glasgow coma scale score was 3 ; endotracheal intubation was performed for airway protection by an emergency physician . the initial 12-lead ecg showed sinus tachycardia and st - segment elevation in leads i , avl , v5 , and v6 with reciprocal st - segment depression in leads iii , avf , and v1 to v3 ( fig . results of the initial biochemical tests revealed followings : sodium 142 mmol / l , potassium 3.7 mmol / l , glucose 321 mg / dl , serum creatine kinase mb 4.5 u / l , and troponin - i 0.63 g / l . within 10 minutes after recovery of spontaneous circulation , a low blood pressure was documented ( 83/43 mmhg ) , and norepinephrine infusion was started in the mean time a cardiologist performed an emergent bedside echocardiography and decided to do an emergent coronary angiography because of regional wall abnormalities that suggested an ischemic insult of the left circumflex artery . at 30 minutes after recovery of spontaneous circulation , she underwent coronary angiography , which revealed normal coronary arteries without any evidence of stenosis . after admission into the cardiac care unit , a computed tomography scan of the brain was performed . twenty hours after the onset of the symptoms , the st - segment abnormalities disappeared and t - wave inversion was noted ( fig . serial values of the serum cardiac enzymes increased within 24 hours , and the peak values of creatine kinase mb and troponin - i were 28.3 u / l and 7.25 g / l , respectively . on the third day of hospitalization , the echocardiography showed akinesia of the left ventricle ( lv ) mid - walls with moderate to severe lv dysfunction ( ejection fraction , 36% ) , which implied a variant form of stress - induced cardiomyopathy . despite the administration of a vasopressor the shock progressed gradually , and on the 13th day of hospitalization , she was pronounced dead . many cases have been reported with cardiac manifestations following sah including ecg changes such as st - segment deviations , t - wave inversion , and qtc prolongation ; cardiac enzyme elevations ; and echocardiographic abnormalities . despite many reports , it is still a challenge for clinicians to distinguish intracranial hemorrhage from acs , especially among post - cardiac arrest survivors . a previous studies on cardiac manifestations of sah showed that cardiac abnormalities were found in 14.1% of patients with non - traumatic sah . the most common ecg finding was t - wave inversion and st - segment depression , suggesting subendocardial ischemia . they reported that 8 out of 10 patients had st - segment elevation in avr with st - segment depression in widespread leads , and three of these patients showed takotsubo - like regional lv dysfunction . to our knowledge , this is the first report describing an out - of - hospital cardiac arrest survivor whose initial ecg changes and echocardiographic findings strongly suggested stemi , but who was finally diagnosed with sah after the emergent coronary angiography revealed entirely normal coronary arteries . the ecg changes of lateral wall myocardial infarction typically present as st - segment elevation in leads i , avl , v5 , and v6 with reciprocal st - segment depression in leads ii , avf , v1 , and v2 . however , lateral wall infarction usually occurs in other territories of the myocardium such as the anterolateral and inferolateral areas . in our case , the st - segment elevation in the lateral leads was obvious , but the reciprocal changes of the st - segment depression were relatively obscure . in addition , there was no contiguous st - segment depression in the precordial leads and the upsloping st - segment depression was an unusual finding for ischemic myocardial injury . many interventions have been emphasized for improving post - cardiac arrest outcomes , including immediate thrombolysis and percutaneous coronary intervention . according to the current guidelines , regardless of the level of consciousness in cardiac arrest survivors , aggressive treatment such as percutaneous coronary intervention emergency physicians may also feel pressured to promptly initiate revascularization treatment due to the importance of door - to - balloon interval . thus , further studies will be needed to clarify the differences in the ecg findings of acs and sah . we believe that observations reported here have potentially significant implications for physicians making decisions of post - arrest care , for once successfully resuscitated patients . clinicians should consider an immediate brain computed tomography to exclude sah as a cause of cardiac arrest , even with st - segment elevation .

electrocardiogram changes in subarachnoid hemorrhage ( sah ) have been described as st - t changes that mimic acute coronary syndrome and even acute st - segment elevation myocardial infarction . elevation of cardiac enzymes and abnormality of regional myocardial wall motion have been reported frequently for sah . we report a case of an out - of - hospital cardiac arrest survivor with high suspicion of st - segment elevation myocardial infarction based on the electrocardiogram and bedside echocardiography , who had normal coronary arteries on emergent coronary angiography . the patient was ultimately diagnosed with sah as a cause of out - of - hospital cardiac arrest .

schwannomas ( also known as neurilemmomas ) are rare neoplasms that originate from schwann cells . they can arise from any peripheral , autonomic , or cranial nerves ( with the exception of the olfactory and optic nerves which lack schwann cells ) ( 1 ) . between 25 - 45% of extra cranial schwannomas occur in the head and neck ; the majority are benign . we present a case report of the unexpected finding of a schwannoma of the ansa cervicalis in a patient where clinical examination and preoperative imaging suggested a primary thyroid pathology . a 25-year - old man presented to the otolaryngology department with a one - year history of a asymptomatic , anterior triangle neck swelling which he had incidentally noticed . on examination , there was a 32 cm swelling just right of the midline which moved with swallowing . the general practitioner had organised an ultrasound that showed a 3326x19 mm complex cyst in the right lobe of the thyroid gland . a fine needle aspiration ( fna ) was performed and a non - contrast ct scan was requested . the fna was reported as thy1 ; a subsequent ultrasound guided fna also was reported as thy1 . the ct scan showed a cystic lesion ( figure 1 ) which seemed to be arising from the right lobe of the thyroid gland . ct scan of schwannoma of ansa cervicalis intra - operatively , a cystic lesion was found between the right sternohyoid and thyrohoid muscles . macroscopic findings showed a dull grey fluctuant nodule which on sectioning had a blood filled cavity . microscopic findings showed fascicles of spindle shaped cells with verocay bodies consistent with a diagnosis of a schwannoma . schwannoma of the ansa cervicalis is extremely rare and there have only been four reported cases in the literature . they are notoriously difficult to diagnose as history and clinical examination are non specific . in the head and neck , these tumours are often mistaken for other lesions such as enlarged lymph nodes , carotid body tumours , branchial cysts , or thyroid lesions ( 2,3 ) . imaging in the form of ct scan and mri are helpful in providing some suspicion of a schwannoma ( 4 ) . on ct , schwannomas appear as well - defined homogeneous masses which show cystic change with contrast enhancement that become more prominent as the lesion enlarges ( 5 ) . on mri scans they are well - circumscribed homogenous masses that exhibit high - signal intensity on t2-weighted images and a relatively homogenous low - signal intensity on t1-weighted images . however , diagnosis is only definitively established by histopathological examination of the tumour . this classically shows the pattern of antoni a and antoni b cells in addition to verocay bodies ( 6 ) . complete surgical excision is the treatment of choice as tumours are benign and radio resistant . incomplete excision may result in slow recurrence over months to years ( 7 ) . in our case , the preoperative ct did not have contrast enhancement as thyroid malignancy was a differential diagnosis . the blood filled cavity of the lesion was presumably due to the previous fnas . the position of the schwannoma between the strap muscles was consistent of the nerve of origin being a branch of the ansa cervicalis . in summary , schwannoma of the ansa cervicalis is rare and is difficult to diagnose preoperatively ; our report adds another case to the sparse literature on this pathology .

schwannomas are rare neoplasms that originate from schwann cells . we present a case report of schwannoma of the ansa cervicalis in a patient where preoperative imaging suggested thyroid pathology.a 25-year - old man presented to the otolaryngology department with a one - year history of an asymptomatic , anterior triangle neck swelling . imaging and fna suggested a cystic lesion of the thyroid . however , intraoperatively , the lesion was found between the right sternohyoid and thyrohoid and histology showed findings consistent with a diagnosis of schwannoma , determined to originate from the ansa cervicalis based on its anatomical position.schwannoma of the ansa cervicalis is extremely rare and there have only been four reported cases in the literature . schwannomas are often misdiagnosed and confused for other lesions . in our case report we add to the sparse literature on this pathology and highlight common pitfalls in diagnosis and discuss the principles of management of this rare condition .

alopecia areata ( aa ) is a common , usually , nonscarring type of hair loss affecting 0.10.2% of the general population . typically , it presents as circumscribed patches of alopecia ; the skin of the affected area remain normal and smooth . here , we report an unusual case of aa showing a linear band - like form of alopecia traversing over the center of the scalp . a 35-year - old male patient presented with a linear bald patch on the scalp which was persisting for the past 3 years . hair loss was initially noted in the vertex area of the scalp which then gradually progressed in a linear pattern toward the temporal region on either side in the period of 2 weeks . there was no associated itching or swelling in the alopecic area . at around 2 cm in front of the helix of pinna , a linear patch of alopecia measuring 22 cm long and 2 cm wide was seen , traversing the center of the scalp [ figure 1 ] . the underlying skin was smooth and normal in color without any evidence of scaling , atrophy , or induration . a trichoscopic evaluation revealed short vellus hair in center and hairs with the tapering base at the periphery . histopathological examination revealed lymphocytic infiltrate in peribulbar area [ figure 2a ] with an increase in telogen hair units along with the formation of a fibrous stellae [ figure 2b ] . a diagnosis of aa was considered and he was treated with monthly intralesional triamcinolone acetonide ( 5 mg / ml ) injections along with topical minoxidil 5% solution . ( a and b ) linear band of alopecia traversing center of scalp histopathology ( h and e , 100 ) ( a ) peribulbar lymphoid infiltrate ( b ) follicular stellae and telogen unit hairs aa over scalp is known to present in various shapes and extents of hair loss . aa has been classified into different types based on the pattern ( e.g. , alopecia reticularis , ophiasis , and sisiapho type ) and extent of alopecia ( e.g. , aa circumscripta , aa totalis , and aa universalis ) . however , aa presenting in linear band - like form traversing center of the scalp is very rare . four cases of histologically proven , lupus erythematosus profundus ( lep ) presenting with linear alopecias have been reported in medical literature . histopathologically , a peribulbar lymphocytic infiltrate , a so - called swarm of bees , is considered as the diagnostic histopathologic feature of aa in early active stage and it may be subtle or even absent in the chronic stage of aa . increased hairs in the catagen or telogen phase , follicular miniaturization , and pigmentary incontinence around the hair follicles are also frequently found in aa , and the former two findings are more significant in long - standing lesions of aa . lep demonstrates lobular lymphohistiocytic infiltrate often with plasma cells in adipose tissue . in well - established lesions hyalinization of adipose lobules with stromal mucin deposition is prominent . in the present case , scant peribulbar infiltrate , increase in catagen hair and pigmentary incontinence around hair follicle are consistent with features of a long - standing case of aa and absence of mucin deposition along with normal adipose tissue rules out lep . in terms of linear lesions in dermatology , quite a few dermatoses can occur over the scalp such as linear scleroderma , linear lichen planus , linear psoriasis , and linear epidermal nevus . all of these dermatoses show visible cutaneous changes and often they may extend to the adjoining smooth skin over the hairlines or they may involve other parts of the body simultaneously . it is difficult to explain the reason why aa occurred in a linear pattern here . aa is known for its unpredictability , and this is probably the first report in the medical literature describing the linear band - like form of aa .

alopecia areata ( aa ) over scalp is known to present in various shapes and extents of hair loss . typically it presents as circumscribed patches of alopecia with underlying skin remaining normal . we describe a rare variant of aa presenting in linear band - like form . only four cases of linear alopecia have been reported in medical literature till today , all four being diagnosed as lupus erythematosus profundus .

history of applying light as a therapeutic remedy dates back to ancient egypt . in dermatologic field , ultraviolet a ( uva : 320 - 400 nm ) and ultraviolet b ( uvb : 280 - 320 nm ) has been mainly focused . many phototherapeutic and photochemical modalities using uva and uvb have been developed and used effectively in many inflammatory skin diseases such as psoriasis and atopic dermatitis ( 1 , 2 ) . low level laser or light was introduced by mester and colleagues in the late 1960s and has been mostly used in rheumatoid arthritis , wound healing , postherpetic neuralgia and recovery following nerve injury ( 3 ) . to our best knowledge , there has been no report about clinical effect of low level polarized polychromatic non - coherent light ( lppl ) on inflammatory skin condition . this report concerns a successful lppl treatment in a pregnant patient suffering from recalcitrant acrodermatits continua . in october 2009 , a 40-yr - old woman presented with severe erythematous pustular eruption and exfoliation on all fingertips and on the paraonychia of her nails ( fig . when she delivered her first child twenty months ago , erythema and pustules developed on one of the fingertips and extended on to every fingertip . she was diagnosed as an acrodermatitis continua by skin biopsy at the other clinic when the initial skin lesion developed . she had been treated with the topical steroid and narrow band ultraviolet b ( nbuvb ) phototherapy , which produced a partial response . her skin lesion worsened a lot after her second conception and did not respond at all to any topical agents ( including 0.05% clobetasol propionate ointment ) , or nbuvb phototherapy when she was referred to our clinic . she has a 10-yr history of plaque psoriasis on her knees and elbows and it has been controlled well with the topical calcipotriol ointment alone . however , she refused it after the previous ineffective treatment of nbuvb . therefore , we designed the treatment with the exposure of lppl ( bioptron , bioptron 2 , bioptron ag , swiss , 480 - 3,400 nm , 95% polarization , exposure dose 10 j / cm ) and topical steroid application ( much less potent than the topical preparation she had used before ) twice a week . in two weeks ( after only 4 treatments ) , the clinical resolution was impressive and no pustules were found ( fig . topical methylprednisolone aceponate 0.1% cream was switched to a ceramide - containing moisturizer and she has been treated twice or once a week with lppl exposure ( 10 j / cm ) and her improved skin condition sustained during the rest of the whole pregnancy . over 10 months of follow - up , no recurrence or flare - ups of skin lesion was noticed . acrodermatitis continua is considered as a variant of pustular psoriasis but some authors classify this dermatosis as a separate entity based on its clinical features ( 1 ) . interestingly , her psoriatic plaques were well controlled using topical calcipotriol ointment alone , while newly developed sterile pustules on her fingertips were refractory to any conventional treatment . four times of topical steroid application and the co - exposure to lppl showed an excellent clinical result and this effect maintained for several months without any further topical steroid application . it can not be said that lppl alone produced a rapid clinical resolution in this patient . topical steroid might play a certain role to suppress the disease activity at the beginning of the treatment . however , she had used the most potent topical steroid ( 0.05% clobetasol propionate ointment ) before visiting our clinic and it was ineffective , though . lppl with the topical steroid application appeared to provide outstanding clinical improvement in this patient . even after the topical steroid was changed to the topical moisturizer instead , there was no recurrence or aggravation of the skin lesion . the clinical disease process of acrodermatitis continua can spontaneously wax and wane ( 1 ) . however , natural clinical course can not fully explain the rapid improvement in this patient and sustaining result . therefore , we could say that lppl could work successfully on the inflammatory skin disease . low level light treatment on various clinical conditions is getting considerable attention now ( 4 - 7 ) . its use was generally limited in wound healing , relieving various rheumatic condition and pain control before ( 3 , 8) . the mechanisms of action is not clear , although it was explained in terms of photobiomodulation ( 5 - 10 ) . biomodulation is the process of changing the natural biochemical response of a cell or tissue within the normal range of its function to stimulate the cell 's innate metabolic capacity to respond to a stimulus ( 3 - 6 ) . when biomodulation occurs from a photon transferring its energy to a chromophore , it is referred to as photobiomodulation ( 3 , 8) . the photobiomodulation has been found to normalize the jeopardized cellular milieu in various disease condition and promote spontaneous healing ( 4 - 9 ) . recent studies showed that photobiomodulation could regulate the inflammatory responses , too ( 5 , 7 , 9 , 10 ) . lppl was proven to have anti - inflammatory effect on chronic tendonitis and gingivitis in several reports ( 5 , 7 ) . others demonstrated that the exposure of a small area of the human body to lppl ( 480 - 3,400 nm , 12 j / cm ) decreased in the elevated pro - inflammatory cytokine levels and increased in the anti - inflammatory factor concentration ( 10 ) . the decrease of proinflammatory cytokine such as tnf- , ifn- , and il-2 and anti - inflammatory effect after lppl exposure may pose a suitable explanation of the clinical result of lppl in the inflammatory skin disease . this case gives intimation that lppl could be a possible treatment modality producing substantial clinical result in inflammatory skin condition .

low level laser or light treatment on the various clinical condition is getting considerable attention now . however , there has been no report about the clinical effect of low level polarized polychromatic noncoherent light ( lppl ) on the inflammatory skin disease . we experienced a case of acrodermatitis continua in a pregnant woman refractory to any conventional treatment including the most potent topical steroid . she was successfully treated with lppl . lppl could be a possible treatment modality producing substantial clinical result in inflammatory skin condition without any side - effect .

cementoblastoma is a relatively uncommon benign odontogenic neoplasm of the jaws and was first described by dewey in 1927 . the benign cementoblastoma is recognized in the world health organization 's ( who 's ) classification ( 1971 ) of periapical odontogenic tumors as one of the four types of cementum - producing disorders . the other three are periapical cemental dysplasia , cementifying fibroma , and gigantiform familial cementoma.[57 ] the who defines benign cementoblastoma as a neoplasm characterized by the formation of sheets of cementum- like tissue containing a large number of reversal lines and a lack of mineralization at the periphery of the mass or in the more active growth area . the who has classified benign cementoblastoma and cementifying fibroma as the only true cemental neoplasm . the most commonly affected tooth is mandibular first molar.[61113 ] however , other teeth involved have included mandibular second and third molars , mandibular bicuspids and maxillary bicuspids , and first , second and third molars . true cementoblastoma can be associated with deciduous molars , although this is an uncommon occurrence . lesions generally are discovered in patients younger than 30 years of age , often on a routine radiograph although the range has been 1072 years . symptoms may be totally absent or when they do occur , they tend to be minor . radiographically , cementoblastoma typically consists of well - defined radiopacity with a cortical border and then a well - defined radiolucent band just inside the cortical border . the outline of the affected root is generally obliterated because of the resorption of the root and fusion of the mass to the tooth . most teeth affected by the cementoblastoma respond normally to the vitality tests during early stages of the lesion , but necrotic pulp can occur with this entity , usually in later stages . a 55-year - old female reported to the department of oral and maxillofacial surgery , with complaints of swelling in the right mandibular angle since 1 year and pus discharge in the same region since 2 months . history revealed that the patient had mild swelling with respect to the right mandibular angle since 6 years which underwent a sudden increase in size since a year . no history of fever , paresthesia , and numbness of the lower lip was reported . an extraoral examination revealed facial asymmetry due to the presence of diffuse swelling and draining sinus with respect to the inferior border of the right mandibular angle . a hard mass was palpable beneath the buccal mucosa and also on the lingual mucosa with respect to the mandibular angle . provisional diagnosis of cementoblastoma , cement - ossifying fibroma , and complex odontoma was made . a panoramic radiograph revealed a dense radiopaque mass surrounded by a well - defined radiolucent band with respect to the mandibular angle . the outline of the roots of the third molar was obliterated and the radiopaque mass seemed to be attached to the roots of third molar [ figures 15 ] . axial view of lesion on ct scan three dimensional view of lesion on ct scan a ct examination of the mandible revealed a large expansile radiopaque mass measuring 22 cm in size . the patient was treated for the copd first by the physician and simultaneously the patient was put on antibiotics to eradicate the infection from the lesion . after the patient was medically fit , the lesion was surgically excised along with the tooth and the sinus lining was excised . histopathologically , the tumor consisted of a calcified mass fused with the roots of third molar with a resultant obliteration of the periodontal ligament . the tumor comprised sheets of calcified tissue with multiple reversal lines and prominent cementoblasts and multinucleated cementoclasts . the peripheral columns showed characteristic radiating columns of the cementum perpendicular to the surface of the lesion . the cementoblastoma or true cementoma is a slow - growing , benign odontogenic tumor arising from ectomesenchyme . although statistical data suggest that benign cementoblastomas are uncommon , many believe that they occur more often than published account indicates . cementoblastomas have an unlimited growth potential and endodontic therapy does not eliminate or arrest them . . lesions commonly occur in the younger age group with people less than 30 years of age . more than 50% of the lesions occur under 20 years of age and the lesion is located in the mandible in more than 70% of cases ( with a predominant location at the first molar and second premolar ) . the expansion of the cortical plates of the bone is the typical feature of cementoblastoma . the internal structure of the mass may possess a mixed radiolucent radiopaque quality with a radiating pattern . a radiolucent band around the benign cementoblastoma is usually better defined and more uniform than with cemental dysplasia . periapical cemental dysplasia is small in size and shows a progressive change in radiographs from radiolucent to mixed to radiopaque over time . the cementoblastoma is distinguished from the osteoblastoma by its location in an intimate association with the tooth root . the odontome is usually not fused with the tooth root and appears as a more heterogenous radiopacity . hypercementosis is a small lesion and does not associate with pain or jaw swelling . due to benign but a locally aggressive nature of the lesion , the treatment of choice is a complete removal of the lesion along with the associated tooth . a more conservative approach to retain the associated tooth and removal of the lesion using a surgical endodontic technique has been reported . it can be used for small lesions in strategic teeth in which the lesion can be excised without injuring adjacent teeth and if a sufficient crown - to - root ratio remains after apicoectomy . recurrence after the excision is rare ; if it recurs , it is because of an inadequate excision of the lesion .

cementoblastoma is a relatively uncommon , benign odontogenic neoplasm of jaws . mandible is affected more than the maxilla . the lesions are generally diagnosed on a routine radiograph . the localized expansion of cortical plates is observed . radiographically , it consists of well - defined radiopacity with a radiolucent band . here is a case report of a female aged 55 years having swelling in the right mandibular angle with an extraoral draining sinus . a panoramic radiograph shows a dense radiopaque mass along the roots of the third molar surrounded by a radiolucent band . surgical excision was carried out and a histopathological examination was carried out which was suggestive of cementoblastoma .

to study working condition of beedi rollers in the urban slumsto find out health hazards among study subjects to study working condition of beedi rollers in the urban slums to find out health hazards among study subjects descriptive , cross - sectional , community based study was carried in the urban slums of mumbai . considering the feasibility factors , the study was purposively carried out in the field practice area of the urban health training centre from april 2011 to june 2011 . snow balling sampling technique was used to identify beedi roller . here , after interviewing with semi - structured questionnaire and examining the initial subject , the subject was asked to nominate another beedi roller currently involved in this occupation . all the beedi workers who were currently involved in the beedi rolling were included in the study . the beedi rollers were interviewed regarding their socio - economic status , working conditions and health problems . age distribution of study subjects around 48.08% had started beedi rolling at the age of 11 to 15 years . two women had chosen this occupation after neighbours advice . around 26.92% of the study subjects were in this occupation for last 21 to 30 years . the women sit in the awkward working postures for many hours for rolling beedis . out of 52 beedi rollers , 29 had children less than 14 years , but none of them had involved their children in this occupation . most of the respondents replied that their children go to school . regarding safety measures , only 43 women ( 82.7% ) wash hand after beedi making . adequate lighting and ventilation was observed in only 17.31% and 25% of the houses respectively . out of 52 women , 10 had given birth to low birth weight baby , two of them were taking treatment for infertility and four had premature menopause . regarding past history , three women had suffered from tuberculosis , two had asthma and one had hemiparesis . other findings were otitis externa and media , finger tip thickening , pharyngitis , lower respiratory tract infection , dental caries and cataract . only 4 women were partially aware of health hazards of beedi rolling such as it causes cancer , tuberculosis , weight loss and backache . rest were totally ignorant about the ill effects of their occupation . around 67.3% of the women nineteen women ( 37% ) were addicted to masheri which is smokeless form of tobacco . the home - based nature of the industry makes it difficult to determine actual numbers of people engaged in manufacturing bidis , most of who work part - time or seasonally . however , according to the best government estimates , there were 4.4 million beedi workers in india in 1997 . in our study , beedi factories are situated in large numbers in the telangana area and perhaps due to this reason generally the telugu people are found as beedi workers . even in the factories situated in maharashtra area , the telugu speaking persons make beedis . thus , many beedi rollers in urban slums started alternate occupation such as tailoring , handkerchief making , mobile cover making etc . most of them live in one small room where they do the beedi work as also cook , and sleep . . the union should actively raise awareness regarding the benefits available for beedi rollers and safety measures that should be practice by them . the international labor organization cites ailments such as exacerbation of tuberculosis , asthma , anemia , giddiness , postural and eye problems , and gynaecological difficulties among beedi workers . our study also showed similar findings . in a study conducted by gopal m , 65 and 9.7% of the beedi workers reported aches and cough respectively . in our study , thus in the urban area , the prevalence of morbidity in beedi rollers is high . moreover , it was observed that in spite of there being easy availability of health care facilities , health care seeking behaviour was very poor . many women suffered from aches for last 8 to 10 years , but still they ignored their suffering . beedi rollers handle tobacco flakes and inhale tobacco dust and volatile components of tobacco in their work environment ( often their homes ) and are at risk for genotoxic hazards . these workers during their home visits can sensitize the pregnant women who are beedi rollers about the harmful effects of the tobacco . they can also raise awareness about safety measures such as washing hands , wearing mask and gloves , cleaning floor and storing tendu leaves in dry area . awareness of the beedi rollers regarding adverse effects of their occupation and safety measures that has to be taken is very poor .

background : beedi rollers are exposed to unburnt tobacco dust through cutaneous and pharyngeal route . they are not aware of their rights . studies have been conducted on beedi workers but not many studies are carried out in urban areas . thus , study was carried out to understand working condition and health hazards in beedi workers residing in the urban slums of mumbai and to know whether beedi roller are in better condition in urban areas.aim:to study working condition and health hazard in beedi rollers in the urban slums.materials and methods : descriptive , cross - sectional , community based study was carried in the urban slums of mumbai with population of 8985 from april 2011 to june 2011 . with snow balling sampling technique , 52 beedi workers were interviewed regarding their socio - economic status , working conditions and health problems after informed consent . data entry and statistical analysis were performed using the spss windows version 14.0 software.results:the mean age was 45 years with sd of 12 years . all were hindu females . around 42.31% were illiterate . mean years of service were 30 years and they work on an average for eight hours . children were not involved in beedi rolling . most common morbidity was fatigue . none were aware of the benefits provided for them . awareness regarding health hazard and safety measures was poor.conclusions:the working condition of beedi rollers in the urban areas is not favourable .

the ras has an important role in the control of body fluid , electrolyte balance and arterial pressure . estrogen activates the synthesis of the rennin substrate angiotensinogen and it inhibits plasma renin activity . it is reported that estrogen administration in ovarectomised rats is caused upregulation of angiotensin type 2 receptor ( at2r ) , and angiotensin ii ( angii ) is caused a stronger vasoconstriction in ovarectomised rats . nitric oxide ( no ) is an endogenous mediator in different biological actions including vasodilation . it also was reported that no releasing was significantly higher in ovarectomised rats treated with estradiol ( ove ) and estrogen induces augmentation of no production through vascular endothelium . so , with attention to role of estrogen in at2r expression and no releasing , in this study we attempt to find the role of estrogen on no releasing in response to angii in presence and absence of at2r in female rats . the rats were housed at a temperature of 23 - 25c with a 12 h light / dark cycle and they had free access to water rat chow . the experimental groups were as ( 1 ) intact animals ; ( 2 ) ovariectomised rats treated with placebo for 2 weeks ( ovx ) , and ( 3 ) ove valerate ( 0.5 mg / kg body weight , i.m ) for 2 week ( ove ) . louis usa ) , trachea was isolated to insert air ventilation tube and catheters were implanted into the carotid artery and jugular vein . blood pressure was monitor through carotid artery and after the equilibration period , rats from each group were divided into two subgroups . one subgroup received saline vehicle ( 0.9% saline ) and the other subgroup received at2r antagonist ; pd123319 ( sigma , st . louis , mo , usa , 1 mg / kg as bolus plus continuous infusion of 1 mg / kg / h during the experiment ) . at 30 min after commencing vehicle or antagonists treatments , intravenous infusions angii ( 20 g / kg / h ) for period of 60 min commenced . the blood samples also were obtained before and after the angii infusion for nitrite concentration determination . the level of nitrite was measured using a colorimetric assay kit ( promega corporation , usa ) that involves the griess reaction . the serum level of nitrite before ( control ) and after ( treat ) angii infusion between the groups were compared via repeated measures anova with factors group ( intact , ovx and ove ) and time ( before and after angii infusion ) and their interaction . the serum level of nitrite before ( control ) and after ( treat ) angii infusion between the groups were compared via repeated measures anova with factors group ( intact , ovx and ove ) and time ( before and after angii infusion ) and their interaction . the results are presented in figure 1a and b. at control phase ( before angii administration ) , no significant differences were observed between the subgroups neither treated with vehicle nor pd123319 . after angii administration when at2r antagonist ( pd123319 ) was not infused , the serum level of nitrite in response to angii administration in ove groups increased significantly [ figure 1a ] ( p < 0.05 ) . however , this increase was abolished by at2r antagonist [ figure 1b ] . the serum level of nitrite in three groups of experiments before ( control ) and after ( treat ) angiotensin ii administration without ( a ) and with ( b ) antagonist ; pd123319 . significant difference was observed between estradiol and other groups when angiotensin type 2 receptor was present . star ( * ) indicate significant difference from others group ( p < 0.05 ) . ovx ; ovariectomised rats treated with placebo , ove ; ovariectomised rats treated with estradiol , and n in the top legend shows the number of animal in each subgroups the results are presented in figure 1a and b. at control phase ( before angii administration ) , no significant differences were observed between the subgroups neither treated with vehicle nor pd123319 . after angii administration when at2r antagonist ( pd123319 ) was not infused , the serum level of nitrite in response to angii administration in ove groups increased significantly [ figure 1a ] ( p < 0.05 ) . however , this increase was abolished by at2r antagonist [ figure 1b ] . the serum level of nitrite in three groups of experiments before ( control ) and after ( treat ) angiotensin ii administration without ( a ) and with ( b ) antagonist ; pd123319 . significant difference was observed between estradiol and other groups when angiotensin type 2 receptor was present . star ( * ) indicate significant difference from others group ( p < 0.05 ) . ovx ; ovariectomised rats treated with placebo , ove ; ovariectomised rats treated with estradiol , and n in the top legend shows the number of animal in each subgroups in this short study , we found that the serum level of nitrite increased significantly after angii administration in ove group when at2r is present , and this increase was abolished by at2r antagonist . estrogen is responsible of complex effects on ras components and there is interaction between estrogen and at2r . at2r activation opposes with at1r actions and estrogen decreases at1r / at2r ratio . confirmed with our result other studies have reported that ovariectomised rats treated with estrogen is caused enhancing endothelium derived relaxing factor level due to increasing of endothelial no synthase . the vasodilatory effect of estrogen response to angii administration may mediate by at2r to increase the serum level of no metabolite in female rats . due to gender difference of angii receptors activities , the role of at2r in no formation response to angii infusion may be different in male .

background : renin - angiotensin system activity is gender related . the vasodilatory response of angiotensin ii ( angii ) angiotensin type 2 receptor ( at2r ) may involve nitric oxide ( no ) production . we attempted to find the role of at2r on no formation response to angii administration in ovariectomised rats treated with estradiol ( ove).methods : a total of 33 female wistar rats were divided into 3 groups ; intact animals , ovariectomised treated with placebo ( ovx ) and ove . at 2 weeks later , all animals were subjected to anesthetize and catheterize and each group was divided into two subgroups that received at2r antagonist ( pd123319 ) or vehicle . each animal was subjected to 1 h continuous infusion of angii ( ~20 g / kg / h ) and the level of no metabolite ( nitrite ) was measured before and after angii infusion.results:at the presence of at2r , the serum level of nitrite in response to angii administration in ove groups increased significantly ( p < 0.05).conclusions : however , this increase was abolished by at2r antagonist . it seems that at2r involves nitrite production response to angii in ove .

there are reports of de novo production or exacerbation of obsessive - compulsive symptoms ( ocs ) in patients with schizophrenia treated with atypical antipsychotics.[13 ] this issue has been debated owing to the lack of clarity about the causality of ocs . since ocs occurs in a proportion of schizophrenia patients without the influence of any drug , it becomes difficult to substantiate the drug - induced causality of ocs . to establish directionality of causation , one needs to demonstrate in a longitudinal manner the occurrence of ocs after initiation of an atypical antipsychotic . we report one such case where a patient with a primary diagnosis of schizophrenia treated with olanzapine , developed de novo obsessive - compulsive disorder ( ocd ) , with convincing evidence for its causality due to the drug . a 30-year - old married woman presented with symptoms such as suspiciousness , fearfulness , and significant hallucinatory behavior , which impaired her daily functioning , persisting for 3 years . a diagnosis of paranoid schizophrenia was made and she was started on olanzapine with 10 mg initially , later increased to 15 mg . after 3 weeks of therapy , significant improvement was noted in her symptoms [ hallucinations and suspiciousness ( bprs score : 10 ) ] . at this point of time , she started having recurrent sexual thoughts and pathological doubts . she reported significant anxiety associated with these thoughts and felt them to be irrational and uncontrollable . she fulfilled a diagnosis of ocd with predominant obsessions . due to the de novo emergence of severe obsessions after 2 weeks of treatment with aripiprazole , patient 's psychotic symptoms worsened within 5 weeks and the bprs score reached 51 . however , the ocd symptoms improved drastically with the ybocs score reaching 4 . considering the worsening of psychotic symptoms , it was decided to restart olanzapine . while the patient 's psychotic symptoms improved dramatically within 2 weeks of treatment , the obsessive symptoms reemerged with the same intensity as earlier . we started the patient on a trial of fluoxetine to 60 mg for ocd . at the end of 8 weeks after starting fluoxetine , ocd remitted and the ybocs score reached zero . the patient is currently being followed - up for 2 years . there are no psychotic or ocd symptoms and her socio - occupational functioning is normal . given the emergence of de novo obsessive - compulsive symptoms after starting olanzapine , their resolution after stopping the drug and re - emergence of the symptoms on re - challenge with olanzapine , it was concurred that ocd in this patient was induced by olanzapine . the use of naranjo et al . adverse drug reaction probability scale ( score = 8) indicated that the adverse effects were probably related to olanzapine itself . antiserotonergic properties of atypical antipsychotics have been implicated as the underlying mechanism causing obsessions , with an emphasis on their 5-ht2a and 5-ht2c receptor antagonism . in the case reported here , the obsessive thoughts emerged only after an optimal clinical dosage ( 15 mg/ day ) was reached , suggesting a clear cut relationship between ocd symptom production and drug institution . compared with the earlier reported cases , the use of a structured and validated scale to ascertain the causal relationship is an advantage in this report . also this case follows a removal - rechallenge strategy to establish the same unlike the earlier reports . since it is known that ocd may cooccur in a substantial proportion of schizophrenia patients , this aspect must be considered in differentiation of drug - induced ocd symptoms due to the fact the treatment of schizophrenia is primarily with atypical antipsychotics . close monitoring needs be exercised while starting atypical antipsychotics in schizophrenia since occurrence of ocs as a comorbid condition would affect the prognosis .

there are reports of de novo development or exacerbation of obsessive - compulsive symptoms in patients with schizophrenia treated with atypical antipsychotics , although this is widely debated . we report one such case where a patient with a primary diagnosis of schizophrenia , treated with olanzapine , developed de novo obsessive - compulsive disorder , with convincing evidence for its causality due to the drug .

a 23-year - old male reported to the department of oral medicine and radiology , jkkn dental college and hospital , with the complaint of pain in the right lower back tooth for past 1 month which was mild , intermittent , dull aching , that aggravated during mastication . intraoral examination revealed partially erupted 47 [ figure 1 ] with asymptomatic pericoronal flap and enamel caries in 46 with tenderness on vertical and horizontal percussion . oval - shaped , nonhomogenous radiopaque mass of 1.51 cm , overlying distal root of 46 and coronal portion of 47 , interrupting with its eruption . mesially , the radiopaque mass was surrounded by diffuse radiolucent image extending to furcation area and periapical region of distal root of 46 . differential diagnosis included cementoblastoma , osteoid osteoma , cement - ossifying fibroma , and focal sclerosing osteomyelitis . intraoral photograph showing partially erupted 47 intraoral periapical radiograph showing dense radiopaque mass associated with impacted 47 orthopantamograph showing radiopaque mass associated with 46 and 47 surgical removal [ figure 4 ] of calcified mass and 46 was done under local anesthesia to facilitate the eruption of 47 . histopathologic examination of the excised mass [ figure 5 ] revealed encapsulated lesion with irregularly arranged dental hard tissue with areas of cell rich pulpal tissue . the adjacent tissue showed chronic inflammatory cell infiltrate , suggestive of the lesion being secondarily infected . the term odontome , first described by paul broca in 1867 , was originally used as a general descriptive term for any tumor of odontogenic origin . however , owing to their complication , slow - growing , and non - aggressive behavior , they are referred to as hamartoma ( not a true tumor ) . etiology of odontomas is unknown ; suggested theories include either inherited or local trauma during primary dentition , a positive family history , genetic mutation , and hereditary anomalies such as gardner syndrome , hermann 's syndrome , odontoblastic hyperactivity , and alterations of genetic components responsible for controlling tooth development.[46 ] they are classified as complex , when the calcified tissue presents simply as an irregular mass composed mainly of mature tubular dentin , or compound , if there is superficial anatomic similarity to even rudimentary teeth . complex odontomes are less common in men . they are found in the mandibular first and second molar area ( 70% ) . they occur more frequently on right side of the jaw ( 68% ) . they are usually small and produce few clinical signs and symptoms which include retention of deciduous or permanent teeth that accounts for 1044% of complex odontomes , pain , expansion of cortical bone , tooth displacement , and paresthesia in the lower lip . in the present case , complex odontomas present as solid radiopaque masses surrounded by radiolucent borders corresponding to connective tissue capsule . the increase in the size of odontome over time produces a force sufficient to cause bone resorption . in our case , we found periapical radiolucency in relation to distal root and furcation bone loss in 46 . odontomas exhibit considerable growth , cyst formation , and bone destruction due to odontogenic nature . most often , they are associated with impacted maxillary central incisor , maxillary canine , followed by mandibular canine and maxillary third molar . here , we report a rare case of complex odontome fused with permanent mandibular first molar , causing impaction of permanent mandibular second molar and diagnosis was established while investigating for its delayed eruption . occasionally , in the presence of odontome , missing tooth from the arch has been reported ; however , in our case , it was not associated with missing tooth but as a rare variant found fused with the permanent tooth .

odontomas are malformation of the dental tissue , arising during normal tooth development . they are usually asymptomatic , but often associated with tooth eruption disturbance . this article reports a case of complex odontome in a 23-year - male , which hampered the eruption of mandibular right second molar as well devitalization of first molar .

we report the case of a 14-year - old teen girl who presented with a skin lesion on the inner side of the left arm , approximately at the level of the elbow [ figure 1 ] . the lesion was initially observed 5 months before and was continuously increasing in size during that period . the history and the clinical examination of the patient did not reveal any other pathological background . skin lesion of the left forea upon examination , the lesion had a cystic , semi - transparent , fluid - filled , pedunculated appearance . at its inside , multiple , stony - hard , nodule - like structures were observed . , the patient did not refer any discomfort or pain . the magnetic resonance imaging with and without the use of contrast media demonstrated a well - demarcated , broadly based mass with centrally solid and peripherally cystic structures [ figure 2 ] . the differential diagnosis based on the clinical finding of rapid growth included a subcutaneous sarcoma ( fibroma - like or pseudogranulomatous ) , but the radiologic findings were more suggestive of a benign subcutaneous ring - like granuloma or a subcutaneous fibroma . well - demarcated mass with centrally solid and peripherally cystic structures the lesion was surgically excised , and surgical exploration of the underlying tissue did not reveal any local infiltration or spread . histopathology showed a tumorous formation ( diameter ~ 3 cm ) of subcutaneous origin consistent with the morphology of calcified malherbe 's epithelioma . pilomatrixoma is located in the lower , whereas epidermal inclusion cyst is found in the upper right part of the histology slide histologic appearance of the central lesion suggestive of pilomatrixoma cutaneous hybrid tumor composed of epidermal cyst and cystic pilomatricoma as in our case is very rare . pilomatricoma ( pilomatrixoma ) , or calcifying epithelioma of malherbe , is a tumor with differentiation toward hair cells , particularly hair cortex cells . the face and the upper extremities are the most common sites . in general , the tumor varies in diameter from 0.5 to 3.0 cm , but it may be as large as 5 cm . the tumors may arise in persons of any age , but about 40% of them arise in children younger than 10 years of age , and about 60% in persons in the first two decades of life .

we report a rare case of cutaneous hybrid tumor composed of epidermal cyst and cystic pilomatricoma that presented in an unusual way in a child . a 14-year - old teen girl presented with a skin lesion on the inner side of the left arm , approximately at the level of the elbow . the lesion was initially observed 5 months before and was continuously increasing in size during that time resembling other benign or malignant cutaneous tumors .

although several literature mentioned this before , in 1976 , tessier published a detailed description with the classification of the condition . the defect may range from the involvement of soft tissue of the lower lip , teeth , mandible , and neck . some authors have opined that the early repair of this condition should be done to avoid feeding problem . we are reporting a case of midline facial cleft that was repaired in the neonatal period with good functional outcome . a 5-day - old female was admitted with a midline cleft of the lower lip , mandible , and tongue along with midline deficiency of the muscles and skin of the neck region [ figure 1 ] . the initial appearance of the patient computed tomography scan with three - dimensional reconstruction and magnetic resonance imaging scan of the face and neck region was done . the soft tissue gap was from tip of the tongue to its base along with the submandibular region . the mandible was separated wide at symphysis , but there was no bony deficiency . to prevent respiratory distress nasogastric tube feeding started from the 2 postoperative day and after 5 day breastfeeding was initiated . the patient gradually learnt the sucking and swallowing and was out of tube feeding from the 10 postoperative day . tip of the tongue was released from the floor of mouth , both halves of the mandible were united by stainless steel wire suturing and the soft tissue over the mandible was repaired in a straight line [ figure 2 ] . nasogastric tube feeding was started from the 2 postoperative day and the baby was able to drink milk by spoon from the 7 postoperative day . after repair of the defect the patient was discharged 14 days after the second operation . at that time , the baby was on breastfeeding . at 3 weeks follow - up , the patient was thriving well and was on exclusive breastfeeding . couronne in 1819 first reported a case of midline mandibular cleft and till 2012 , a total of 67 cases were reported . in 2014 , guttikonda et al . association of thinned - out strap muscles of the neck , split hyoid , split sternum , split tracheal cartilages , thyroglossal cyst , dermoid cyst , etc . reported a case of the median cleft of the mandible and lower lip with ankyloglossia and ectopic minor salivary gland on the tongue . almeida et al . reported a case with fusion defect with deficiency of the mandible . in their case tongue , they repaired the mandible at 10 years of age with bone graft and plate fixation . so far , there is only one case report of tessier 30 cleft with complete duplication of the tongue . the case reported here had midline cleft of the lower lip , mandible , and floor of the mouth with the involvement of skin and superficial muscles of the neck . there was a complete duplication of the tongue but without the involvement of trachea and sternum . they suggested that in the first stage , soft tissue correction including z - plasty in chin skin , lip , and neck is to be performed . mandible reconstruction was advised at 10 years of age to minimize the damage to the developing tooth buds . however , they advocated earlier fixation of mandible when the segments are hypermobile causing respiratory or feeding difficulty . the present case had mobile halves of the mandible , and it caused a feeding problem . as there was the least bone handling it is expected that there will be no defect in the dentition . in conclusion , a rare case of tessier 30 cleft is reported , and the literature is reviewed . in this case , there was cleft of the tongue , mandible and the soft tissue of the neck long - term follow - up regarding dentition and scar contracture is to be observed . the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s ) has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal . the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed . the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s ) has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal . the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed . the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s ) has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal . the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed .

a case of midline cleft of the lower lip , mandible , and the neck with complete duplication of the tongue repaired at neonatal period is reported here . median cleft of the lower lip , mandible , and bifid tongue with ankyloglossia is reported in the literature , but cleft of the neck with complete duplication of the tongue as a part of the tessier 30 cleft is very rare . we could not find such report in the available english literature .

restorative proctocolectomy with ileal pouch - anal anastomosis has become a standard procedure for patients with familial adenomatous polyposis ( fap ) and chronic ulcerative colitis . a good long - term pouch function is to be expected in > 90% of patients . pelvic sepsis following this procedure has been reported in up to 25% of cases and has been shown to have a negative impact on pouch function and late failure rate [ 1 , 2 ] . the incidence of pouch - related fistula is reported in 416% of cases with the most common being pouch - vaginal [ 3 , 4 ] . on the other hand , pouch - sacral fistula is a rare event [ 1 , 5 , 6 ] . treatment of a pouch - sacral fistula includes pouch revision and curettage of the sacrum . we describe the use of a human acellular dermal matrix ( alloderm ) mesh to patch a large sacral defect in conjunction with pouch revision . a 20-year - old man was admitted with pelvic and hip pain , anorexia and loss of weight . his past surgical history revealed a proctocolectomy with ileo - pouch anal anastomosis for familial adenomatous polyposis ( fap ) carried out in another institution 3 years previously . this had been complicated by an anastomotic leak treated with a loop ileostomy that was taken down 6 months later . subsequently , he developed a new pelvic collection and persistent pouch - presacral space fistula that was treated with a laparoscopic drainage and repeat loop ileostomy . a follow - up magnetic resonance imaging ( mri ) showed improvement but persistence of pelvic phlegmon . cultures of presacral fluid revealed a polymicrobial flora including escherichia coli , enterococcus , bacillus species and eikenella corrodens . at the time of evaluation at our institution , he was afebrile and the laboratory tests , including inflammatory markers , were unremarkable . a computed tomography ( ct ) scan of the abdomen and pelvis showed a presacral fluid collection with a fistula between the pouch and the sacrum ( fig . 1 ) . an mri of the pelvis was performed and this revealed signs of osteomyelitis involving the s2s4 vertebrae ( fig . 2 ) . a laparotomy was performed and the ileal - anal pouch anastomosis was taken down , the sacrum was debrided leaving a large anterior bony defect . no omentum was available , so a 10 cm 10 cm piece of alloderm was used to cover the defect . the pouch fistula was excised and closed and the revised pouch re - anastomosed to the anus . presacral air - fluid collection with a pouch - sacral fistula ( arrow ) . nuclear scans are often non - specific and do not provide adequate details to guide resection margins . ct - guided aspiration and culture of pelvic collections are helpful to guide antibiotic treatment . although percutaneous drainage may offer a temporizing approach , it is not a definitive therapy for cases of suspected osteomyelitis . the most successful treatment involves aggressive surgical debridement , removal of the offending agent , long - term antibiotics and dead - space management . the development of a fistulous tract between the pouch and the sacrum is rarely reported . one patient underwent pouch excision in another institution and presented with pelvic sepsis associated with sacral and l5 vertebral destruction that required bony resection and decompression . bursics et al . reported a case where the fistula originated from the efferent blind loop of the pouch . the sacrum was debrided and a gentamycin sponge was left in the cavity . in our case , pelvic sepsis was likely exacerbated by actinomycosis that is known to cause chronic infection that is difficult to treat . the sacral defect was covered with alloderm that has been shown to be a suitable material following sacral resection . in fact , it has similar tensile strength to polypropylene , and it is non - allergenic and possibly less likely than the synthetic mesh to cause inflammation leading to small bowel adherence . we believe that part of our patient 's successful outcome was due to our ability to separate the inflamed sacral defect from the revised pouch .

fistula formation after restorative proctocolectomy poses a challenge to the surgeon and sometimes can lead to the excision of the pouch . while pouch - vaginal fistulas are more common , pouch - sacral fistulas are a rare event and treatment is still controversial . the authors report a case of pouch - sacral fistula which was treated successfully with a novel approach comprising pouch revision , debridement of sacrum and placement of a human acellular dermal matrix ( alloderm ) mesh to patch the residual large sacral defect . this is the first report of the use of alloderm under this rare condition .

mesenteric intra - abdominal cystic lesions have been recently classified on the basis of histopathological features . cysts of mesothelial origin are rare lesions seen more frequently in young and middle - aged women , mostly benign and located in the mesenteries or omentum . what makes our particular case interesting is that it arose within the round ligament of the liver in a male patient . owing to the low incidence , etiology remains unclear although true simple mesothelial cysts are mainly congenital . a 34-year - old man was admitted in our department complaining for the last 3 months of epigastric pain , abdominal distension and tenderness . physical examination revealed mild abdominal distension with a sense of fullness in the epigastric region . blood tests were negative , and serum tumor markers ( carcinoembryonic antigen , carbohydrate antigen [ ca ] 199 , ca 72 - 4 , -fetoprotein ) levels were within the normal range . helical computed tomography ( ct ) scan [ figure 1a ] and magnetic resonance imaging ( mri ) [ figure 1b ] showed a 10 cm low - density fluid - filled polilobate cystic lesion with internal septations and calcifications located between the left lobe of the liver , shorter gastric curvature , pancreas and mesocolon . the cyst appeared located within the round ligament extending from the dorsal free margin of the falciform ligament to the anterior abdominal wall [ figure 2 ] . it was completely aspirated , dissected form the surrounding structures with ultracision harmonic scalpel and then removed with endobag . histopathology revealed a thin fibrous wall with a single layer of flattened to cuboidal mesothelial cell lining lacking any cellular atypia [ figure 3 ] . post - operative course was uneventful , and the patient was discharged 2 days after the operation . magnetic resonance imaging ( a ) and computed tomography scan ( b ) showed a low - density fluid - filled polilobate cystic lesion with internal septations and calcifications located between the liver , stomach and pancreas intraoperative view of the cyst before aspiration histopathologic examination showing a thin fibrous cyst wall lined by a single layer of flattened to cuboidal mesothelial cell most of the cysts of mesothelial origin are asymptomatic and represent incidental findings during the course of investigations for other reasons . however , the growth may produce non - specific symptoms depending on size and location . diagnosis is usually based on clinical examination and radiographic imaging , including ct scan or mri but precise site , and origin can not always be determined . moreover , precise pre - operative differential diagnosis with other intra - abdominal cystic lesions remains challenging . immunohistochemistry is used to differentiate histologic type , with simple mesothelial cysts being positive for cytokeratins and calretinin and negative for cd31 . if symptoms or complications occur , complete surgical excision with clear margins in order to avoid the risk of recurrence is recommended , and prognosis is excellent . different entities of the cystic lesions within the round ligament of the liver were described . the laparoscopic approach has been reported only in sparse cases of true simple mesothelial cyst , with different locations comparing to ours . to the best of our knowledge , this is the first case reported treated with a laparoscopic approach . laparoscopy appears safe , feasible and less invasive without compromising surgical principles and today should be considered the gold standard in most cases . in the presence of a voluminous mass , complete aspiration before excision may allow to achieve adequate space for dissection .

a 34-year - old man was admitted in our department with a 3 months history of epigastric pain , abdominal distension and tenderness . helical computed tomography scan and magnetic resonance imaging showed a 10 cm low - density fluid - filled polilobate cystic lesion with internal septations and calcifications located between the left lobe of the liver , shorter gastric curvature , pancreas and mesocolon . laparoscopic exploration was performed . macroscopically the lesion was a unilocular serous cyst with a thick fibrous wall . histopathology revealed a thin fibrous wall with a single layer of flattened to cuboidal mesothelial cell lining lacking any cellular atypia . the patient is currently alive without evidence of recurrence at 6 months . cysts of mesothelial origin are rare lesions seen more frequently in young and middle - aged women , mostly benign and located in the mesenteries or omentum . diagnosis is usually based on clinical examination and radiographic imaging . immunohistochemistry is used to differentiate histologic type , with simple mesothelial cysts being positive for cytokeratins and calretinin and negative for cd31 . the laparoscopic approach appears safe , feasible and less - invasive without compromising surgical principles and today should be considered the gold standard in most cases .

, the hemoglobin mainly distributes in the red blood cell ( kundu et al 2003 ; weber and fago 2004 ) . structurally , each molecule of hemoglobin contains four globin chains and heme ( kundu et al 2003 ; weber and fago 2004 ) . the four globin chains ( two alpha chains and two beta chains ) are depicted as a tetramer looking like folded worms ( kundu et al 2003 ; weber and fago 2004 ) . in the case of structurally abnormal hemoglobins , the following mechanisms can be possible : single nucleotide base substitutions leading to amino acid replacement or chain termination variants ; nucleotide deletions or additions leading to deletion and frameshift variants ; and nonhomologous crossing over , leading to the production of fused globin chains ( forget et al 1979 ) . the molecular basis of the hemoglobinopathies , disorders characterized by absent or decreased synthesis of alpha- or beta - globin chains , is quite heterogeneous ( forget et al 1979 ) . luckily , the new development in molecular bioinformatics can be applied in nanoscale genomics and proteomics research . here , the author used a new gene ontology technology to predict the molecular function and biological process of four important hemoglobin disorders with single substitution . the database , unitprot ( bairoch et al 2008 ) , was used for data mining of the amino acid sequence for normal hemoglobin . the author performed a prediction of molecular function and biological process of normal and each abnormal hemoglobin using a novel gene ontology prediction tool namely gofigure by department of computer and information sciences , university of delaware , newark , usa ( khan et al 2008 ) . gofigure is a computational algorithm tool which is recently developed for gene ontology study ( khan et al 2008 ) . the tool accepts an input dna or protein sequence , and uses the basic local alignment search tool ( blast ) to identify homologous sequences in gene ontology annotated databases ( khan et al 2008 ) . the purpose is to use a blast search to identify homologs in public databases that have been annotated with gene ontology terms ( khan et al 2008 ) . these terms include : swissprot , flybase ( drosophila ) , the saccharomyces genome database ( sgd ) , mouse genome informatics ( mgi ) , and wormbase ( nematode ) ( khan et al 2008 ) . the contents of the results include molecular function as well as biological process of the studied protein ( khan et al 2008 ) . the database , unitprot ( bairoch et al 2008 ) , was used for data mining of the amino acid sequence for normal hemoglobin . the author performed a prediction of molecular function and biological process of normal and each abnormal hemoglobin using a novel gene ontology prediction tool namely gofigure by department of computer and information sciences , university of delaware , newark , usa ( khan et al 2008 ) . gofigure is a computational algorithm tool which is recently developed for gene ontology study ( khan et al 2008 ) . the tool accepts an input dna or protein sequence , and uses the basic local alignment search tool ( blast ) to identify homologous sequences in gene ontology annotated databases ( khan et al 2008 ) . the purpose is to use a blast search to identify homologs in public databases that have been annotated with gene ontology terms ( khan et al 2008 ) . these terms include : swissprot , flybase ( drosophila ) , the saccharomyces genome database ( sgd ) , mouse genome informatics ( mgi ) , and wormbase ( nematode ) ( khan et al 2008 ) . the contents of the results include molecular function as well as biological process of the studied protein ( khan et al 2008 ) . the four studied important abnormal hemoglobins with single substitution included hb s , hb e , hb c , and hb j - baltimore . summary of the mutation of each abnormal hemoglobin using gofigure server , the molecular function and biological process in normal and abnormal hemoglobin were predicted . the molecular function and biological processes of normal hemoglobin and abnormal hemoglobin are similar , as presented in figure 1 . the summary of the comparison of the molecular function and biological processes between normal and abnormal hemoglobin is presented in table 2 . the four studied important abnormal hemoglobins with single substitution included hb s , hb e , hb c , and hb j - baltimore . using gofigure server , the molecular function and biological process in normal and abnormal hemoglobin were predicted . the molecular function and biological processes of normal hemoglobin and abnormal hemoglobin are similar , as presented in figure 1 . the summary of the comparison of the molecular function and biological processes between normal and abnormal hemoglobin is presented in table 2 . hemoglobin research reached a renaissance in recent few years due to the discovery of globins or their genes in all living organisms and in all tissues of higher animals ( kundu et al 2003 ; weber and fago 2004 ) . new developments brought to a re - evaluation of our understanding of the structure and function of hemoglobins ( kundu et al 2003 ; weber and fago 2004 ) . until now , the functional aberration due to the mutation in hemoglobin was not well demonstrated , and there is a need for improvement of our understanding on those mutated proteins function . based on the recent advances in the genomics , current technologies can permit the examination of gene expression patterns of tens of thousands of genes ( bairoch et al 2008 ) . a challenge for the biologist to interprete such data is recognizing the function of many of the hits identified in a single experiment ( khan et al 2008 ) . while one can classically search the literature , a more rapid mean of developing some idea of potential function of a gene product is via the ontology terms that describe the gene ( khan et al 2008 ) . many genes ontology tools have been constructed and launched for public usage . in this study , the author used a gene ontology tool to predict the function of normal and four important hemoglobin disorders with underlying single amino acid substitution . compared with normal hemoglobin , all studied abnormal hemoglobins have the same function and biological process . this indicates that the overall function of oxygen transportation is not disturbed in the studied hemoglobin disorders . this result is similar to another report by wiwanitkit ( 2006 ) on four rare hemoglobinopathies , hb agrino ( 29leu-->pro ) , hb siam ( 15gly - > arg ) , hb amsterdam ( 32met-->ile ) and hb evanston ( 14 try-- > arg ) . clinical findings of oxygen depletion in abnormal hemoglobins should be due to the other processes rather than genomics , proteomics and expression levels .

hemoglobin is an important protein found in the red cells of many animals . in humans , the hemoglobin is mainly distributed in the red blood cell . single amino acid substitution is the main pathogenesis of most hemoglobin disorders . here , the author used a new gene ontology technology to predict the molecular function and biological process of four important hemoglobin disorders with single substitution . the four studied important abnormal hemoglobins ( hb ) with single substitution included hb s , hb e , hb c , and hb j - baltimore . using the gofigure server , the molecular function and biological process in normal and abnormal hemoglobins was predicted . compared with normal hemoglobin , all studied abnormal hemoglobins had the same function and biological process . this indicated that the overall function of oxygen transportation is not disturbed in the studied hemoglobin disorders . clinical findings of oxygen depletion in abnormal hemoglobin should therefore be due to the other processes rather than genomics , proteomics , and expression levels .

pregnancy after renal transplantation is associated with an increased risk for both mother and fetus . higher rates of stillbirth , preterm delivery , low birth weight , pre - eclampsia , neonatal death and transplant dysfunction are reported . spontaneous twin pregnancy is uncommon in renal transplant recipients and potentially presents an even greater risk to the mother , the transplant and the fetuses . we present a case of a successful outcome for both mother and babies and describe the effects of the pregnancy on transplant function and haemodynamics within the transplant kidney . a 27-year - old woman received a deceased donor kidney transplant in december 1995 from a 10-year - old donor , human leucocyte antigen 3/6 mismatch ( a , b and dr 111 ) . she had a past history of recurrent urinary infections and hypertension and presented initially to the nephrologists with bilateral dysplastic kidneys requiring peritoneal dialysis prior to transplantation . immunosuppression at induction was cyclosporin 200 mg bd , azathioprine 75 mg daily and prednisone 20 mg daily . at the time of spontaneous conception ( march 2007 ) , she was taking cyclosporin 100 mg bd , azathioprine 50 mg daily and prednisolone 5 mg daily , with no other medications or anti - hypertensive agents . the course of the diamniotic dichorionic pregnancy was largely uneventful apart from a modest increase in proteinuria and blood pressure ( bp ) . proteinuria ( 0.3 g/24 h ) increased to 0.5 g/24 h by 28-week and 1 g/24 h by 30-week gestation . blood pressure increased significantly after 31 weeks , just before delivery ( figure 1a ) . at 31 weeks , corticosteroid therapy was introduced to enhance fetal lung maturity , in anticipation of preterm delivery . cardiotocograph of both fetuses demonstrated heart rates of 140 and 135 beats per minute , respectively , with good variability , presence of accelerations and no significant decelerations . ( b ) biochemical changes ( serum creatinine , serum albumin and egfr ) during twin pregnancy . at 32 weeks , a semi - elective caesarean section was performed , due to bp increasing to 155/98 mmhg despite nifedipine therapy and increased proteinuria ( not quantified but dipstick positivity increased ) . delivery required a minimal medical input initially , with both fetuses having normal apgar scores of 9 and 10 at 1 min and 5 min , respectively . both suffered respiratory distress syndrome ( oxygen saturations of 92% on room air , and tachypnoea with an initial respiratory rate of 6070 breaths per minute ) , requiring oxygenation with non - invasive continuous positive airway pressure ventilation . at the time of discharge from hospital their weights were 2.3 and 2.22 kg , and by 5 months post - delivery 7.91 kg ( 5075th percentile ) and 8.73 kg ( 91st percentile ) , respectively . during the pregnancy , cyclosporin trough levels , despite the changes exhibited in metabolic activity and volume distribution during the pregnancy , remained stable from preconception levels of 3630 ng/ ml pre - delivery and 48 ng / ml 2 weeks post - delivery . serial transplant ultrasound scans by a single operator revealed a 21% increase in the cross - sectional area of the kidney ( figure 2a ) with a 10% increase in main renal artery peak flow and a 21% reduction in the resistive index ( ri ) ( figure 2b can be seen online in colour as supplementary information ) . following pregnancy , the creatinine increased to 129 mol / l , urea 8.1 mmol / l and albumin 38 g / l , and these remained stable . the ri remained unaltered , main renal artery peak flow fell by 50% , while the kidney cross - sectional area returned to baseline post - delivery . currently , more than 2 years post - partum , mother and babies are healthy and transplant function stable . ( figure 2b can also be seen online in colour as supplementary information online . ) our patient was young , had excellent allograft function 12 years post - transplantation from a young donor and had minimal pre - conception proteinuria and normal bp with no other comorbidities . pregnancy rates in patients with moderate - to - severe chronic kidney disease ( ckd ) are significantly reduced compared to the general population , due to the effects of ckd on gonadal function . renal transplantation often restores fertility via improvements in the hypothalamic pituitary axis , which leads to a restoration of the ovulatory cycle in women and improved sperm motility in men . according to registry data the degree of pre - existing renal impairment correlates with the risk of poor pregnancy outcome , including pre - eclampsia , preterm birth , small for gestational age and neonatal mortality . recent guidelines suggest that it is safe to proceed with pregnancy as early as 6 months following transplantation if graft function is optimal ( creatinine < 132 mmol / l ) , urinary protein excretion is minimal ( < 500 mg/24 h ) and immunosuppression dosing is stable . changes in renal haemodynamics during pregnancy are thought to be similar in renal transplant recipients compared to non - transplant patients , with up to a 70% rise in renal blood flow ( rbf ) , 50% increase in glomerular filtration rate ( gfr ) and 50% fall in urea and creatinine . however , physiological adaptations seen in normal pregnancy may not occur in patients with ckd or renal transplantation , especially if the creatinine is > 200 mol / l , leading to a potential blunted rise in gfr . in our twin pregnancy case , we demonstrated a 40% fall in creatinine with a concomitant 10% increase in the velocity of rbf . normally , resistance to flow across the arterioles constitutes most ( 85% ) of the renal vascular resistance ( the remaining from the peri - tubular capillaries and renal veins ) . as rpf is inversely related to renal vascular resistance , one can conclude that in our case there was an increase rbf of 18% . most of this increase in renal perfusion could be accounted for by the volume expansion and hence lead to the increased gfr . it should be acknowledged that given beneficial circumstances , there may be no increased risk in comparison to non - transplant females . without these , pregnancy may be high risk leading to poor transplant and fetal outcomes . we confirm that neither the manuscript nor any significant part of it has appeared elsewhere in a manner that could be construed as a prior or duplicate publication of the same , or very similar , work . has previously been on the advisory board for roche and astellas and has received honorarium for lectures and funds for assistance in travel to medical conferences from a number of pharmaceutical companies , including pfizer , roche , novartis and amgen .

spontaneous twin pregnancy is rare in renal transplant recipients , and confers a significant risk , in terms of both transplant dysfunction and fetal complications . physiological changes in renal haemodynamics may assist in predicting a favourable outcome , but have not been previously reported in these circumstances . we present a case of a successful outcome for both mother and babies , and detail the effects of the pregnancy on transplant function and haemodynamics within the transplant kidney . without beneficial circumstances , twin pregnancy may be a high risk in renal transplant recipients and may lead to a poor outcome for both transplant and fetuses .

the study was conducted in 2 health care and demographic surveillance sites in hanoi province , vietnam : ba vi district ( rural ) and dong da district ( urban ) . each site contained 11,000 households that were selected by cluster sampling to represent the district population ( 12 ) . this study was approved by ethical committees at the university of oxford and hanoi medical university . a quantitative survey on tiet canh consumption was administered to household members at health care and demographic surveillance sites ( ba vi : may june 2012 ; dong da : december 2012january 2013 ) . field surveyors visited households as part of their routine survey schedules and interviewed 1 member per household individually . a total of 6,993 participants in ba vi and 3,991 participants in dong da were interviewed ( no households refused ) . after persons for whom no data were available regarding age and sex were excluded , 6,943 ( 99.3% ) persons in ba vi and 3,921 ( 98.2% ) in dong da were included in the analysis ( mean age [ range ] : 47.0 [ 897 ] years in ba vi and 48.3 [ 9102 ] years in dong da ) . rural and urban respondents differed significantly by sex ( 24.6% vs. 34.5% male participants , respectively ) , education ( 21.9% vs. 74.3% with 10 years of education ) , and occupation ( 2.4% vs. 29.6% office workers ) . subsequently , 10 focus groups that involved 81 participants in the 2 districts were formed ( april june 2013 ) . participants in focus groups were selected on the basis of reported consumption of tiet canh in the previous survey and were stratified by district , sex , and consumption status . for each district , 1 focus group was also conducted for local government workers . details on data collection , characteristics of participants , and data analysis are described in the technical appendix . a total of 35% ( 95% ci 33.8%36.1% ) of persons in the rural area vs. 8.6% ( 95% ci 7.7%9.5% ) in the urban area reported eating porcine tiet canh in the past year . duck blood was the second most common source of tiet canh ( technical appendix table 3 ) . sex , age , level of education , occupation , economic status , and marital status were associated with consumption patterns by univariate analysis ( table 1 ) . however , level of education was not associated by multivariable regression ( table 2 ) . , odds ratio ; he s , household economic status . or was adjusted for sex and age . includes construction , factory work , casual manual work on call , handicraft work , and mining . each variable that was not significant ( p 0.10 ) was removed step by step until all remaining variables were significant ( p<0.10 ) in the model . more men than women reported consumption , and this difference was greater in the urban setting than the rural setting . given that more women than men participated in the survey , the estimated frequency of persons consuming tiet canh will likely be higher than reported in this study . the practice was more common in persons 4049 years of age than in other groups . persons who reported highest consumption included farmers , manual laborers , persons working in service and sales . in the urban district , household economic status was negatively associated with consumption levels ( odds ratio > 2.0 for 2 lowest quintiles compared with the highest quintile ) . this finding was further confirmed in focus groups because tiet canh is relatively inexpensive and available in most markets . therefore low - income workers are more likely to eat this dish ( technical appendix table 5 ) . several male participants expressed pride and fond memories of their experience in participating in slaughtering events . tiet canh is sometimes served at family celebrations expressly to demonstrate that slaughtered pigs are healthy . cultural contributions of tiet canh must be understood to develop effective communication messages to reduce health risks associated with this practice . participants articulated strong confidence in the safety of raw pig products when the source of the pig was known to the consumer and the pig appeared healthy . sources of pigs considered relatively safe were home - raised pigs , wild boars , or pig breeds locally known as ln mn and ln mng ( typically free - range , scavenging pigs raised by ethnic minorities ) . these perceptions contrast with findings of prevalence studies that showed high carriage rates of s. suis , even in apparently healthy pigs and pig products ( 13 ) , and with reports of transmission of neurocystercercosis ( 14 ) and trichinellosis ( 6,15 ) , which suggested increased transmission risks associated with scavenging pigs . beliefs about potential health benefits of eating tiet canh , such as preventing anemia or a general cooling effect , were widespread . however , participants did not fully understand the health risks posed by infectious agents or contaminants , and risks were dismissed or overlooked . although concerns regarding the risk for diseases associated with tiet canh were raised in all focus groups , few participants knew what specific diseases are transmissible to humans through tiet canh consumption . in contrast , risk underestimation through optimistic bias was common , and fatalistic attitudes were shared in the group setting ( online technical appendix ) . 18 bnn / c , may 21 , 2009 ) that requested coordinated actions in controlling transportation , slaughtering , selling , and consumption of animals and animal products in response to recent disease reemergence . however , this proposed ban was considered to be unenforceable and ineffective among participants in all focus groups . the profit from selling tiet canh and consumer demand furthermore , trade in raw pig products is too widespread and decentralized , and the food chain from pig producers to pork consumers is too complex to enable regulation or enforcement of trade bans . this study showed that consumption of tiet canh was more common among adult working - age men , outdoor workers , low - income urban inhabitants , and married persons in rural areas . children rarely eat tiet canh , which may partly explain why s. suis meningitis is mainly a disease of adults and more common in men . disease surveillance and reporting should be improved to better estimate the incidence of s. suis infections and clarify the relative role of the foodborne transmission route . given the traditions of consumption of tiet canh during family celebrations , interventions such bans on consumption or simple education messages on health risks without accounting for associated cultural values are unlikely to be effective . however , changes in education , urbanization , and increasing income levels will affect social and behavioral attitudes toward consumption of tiet canh in the future . food safety research could benefit consumers by exploring methods of preparation of tiet canh designed to reduce infectivity of any pathogens in raw blood and preserve desired texture or taste characteristics of this traditional cuisine . details on data collection , characteristics of participants , questionnaire , and data analysis for raw pig blood consumption and potential risk for streptococcus suis infection , vietnam .

we assessed consumption of raw pig blood , which is a risk factor for streptococcus suis infection in vietnam , by using a mix - method design . factors associated with consumption included rural residency , age , sex , occupation , income , and marital status . we identified risk groups and practices and perceptions that should be targeted by communication programs .

a 60-year - old man visited the oral medicine and radiology department , complaining of a mild intermittent pain associated with sudden ulcerated growth on the right maxillary edentulous alveolar ridge since 1 month earlier . the patient gave a history of extraction of teeth in the same region one year before . on examination , a diffuse mild extra oral swelling was present on the right cheek , with proptosis and watery discharge from the right eye ( fig . extraorally the swelling was mildly tender and discontinuity was felt on the right infra orbital margin . intraoral examination revealed a soft well defined ulcerated growth on the right maxillary edentulous alveolar ridge , extending from the right maxillary first molar region to the maxillary tuberosity region posteriorly . the clinical differential diagnosis included the most common malignancies in the oral cavity such as squamous cell carcinoma ( scc ) , minor salivary gland tumor , and carcinoma of the maxillary sinus . computed tomography ( ct ) scan was performed and sections were taken in the axial , coronal , and sagittal planes . coronal section revealed a large soft tissue density lesion with its epicentre in the maxillary sinus , causing destruction of all walls of the maxillary sinus , extending medially into the lateral wall of the nasal septum , left nasal cavity involving the inferior and middle turbinates , laterally into the pterygopalatine fossa , superiorly into the orbit , inferiorly causing destruction of the hard palate and alveolar processes of the right maxilla in the molar region . three dimensional ct reconstructions using the bone and soft tissue settings demonstrated a large lytic lesion in the right maxillary sinus destroying all walls of the maxillary sinus , hard palate , and alveolar process in the molar region ( figs . 4 and 5 ) . the patient was advised to undergo routine haematological examination , and an incisional biopsy was performed which revealed a cellular connective tissue stroma predominantly made up of lymphocytes , the majority being large cells and a few small cells showing vesicular nuclei with prominent nucleoli . scattering the patient was referred to the oncology department , who started chemotherapy ; unfortunately , the patient passed away after two cycles of chemotherapy . malignant lymphoma can appear in all parts of the body , and may have varied radiographic manifestations.3 24 - 84% of nhls arise from extra nodal sites . the head and neck is the second most common region for extra nodal lymphoma after the gastro intestinal tract.4 nhl is the second most common neoplasm of the head and neck region after scc and the third most common group of malignant lesions of the oral region after scc and salivary gland neoplasm.5,6 nhl commonly involves oropharyngeal lymphoid tissue comprising waldeyer 's ring , but occasionally involves other oral tissues.6 nhl occurs more frequently in the head and neck region in the pediatric age group,7 however our patient was a 60-year - old male . sinuses are the primary site of nhl in 90% of the cases , most commonly invaded by diffuse large b cell lymphoma.7 in our case , the epicentre of the lesion seemed to be in the right maxillary sinus on the ct images . . a few cases of oral lymphomas were reported in association with acquired immune deficiency syndrome ( aids ) , and it might even be the first presentation of aids in certain individuals.8 in our case , the patient was human immunodeficiency virus ( hiv ) negative . primary oral and para - oral lymphoma most commonly presents as a painless local mass that gradually increases in size with superficial ulceration.9 diagnosis of nhl in oral cavity may result from mucosal tissue / gingival swelling / masses . when oral soft tissue lesions first appear , they are relatively soft and often have an overlying ulceration , and are often characterized by absence of other symptoms . if bone is the primary site , tooth mobility and alveolar bone loss are often noted . pain , swelling , numbness of the lip , and pathologically related fractures may be associated with the bone lesion.5 in our case , the patient presented with a slightly painful ulcerated growth on the maxillary edentulous alveolar ridge resembling scc . clinical signs and symptoms of lymphomas of the paranasal sinuses include a mass in the nasal cavity , facial pain , paresthesia , recurrent sinusitis , nasal discharge , eyelid swelling , and proptosis if orbital invasion has occurred.10 our patient showed an extraoral swelling in the right maxillary sinus region and also proptosis of the eye suggestive of extension of the lesion into the sinus and orbit . radiological imaging is vital for many reasons , including assessment of tumor extension , assessment of bony destruction , evidence of mucosal thickening , and choice of biopsy site and route . ct is the best imaging modality for demonstrating fine bony detail.10 lymphoma can cause nonspecific bony destruction at and around the paranasal sinuses . the maxillary sinuses are most frequently affected , followed by the ethmoidal and frontal sinuses . as the process of destruction continues , the bony margins of the maxillary sinuses can become eroded , especially the medial and posterior walls . erosion of the anterior wall of the maxillary sinus was also reported.11 the epicentre was found to be in the right maxillary sinus on ct images in our case also . lymphomas are usually submucosal , and on gross appearance , differ from scc which is usually ulcerative.12 our case clinically manifested as an ulcerated growth closely resembling scc , and it was very difficult to differentiate both of the lesions clinically . paranasal lymphomas have a poor prognosis , which is usually worse than that associated with lymphomas in other sites in the body.10 in conclusion , this report focused on the importance of ct in assessing the exact tumor extent and staging for large , clinically doubtful lesions , which was essential for diagnosis and treatment planning .

non - hodgkin 's lymphomas are a group of highly diverse malignancies and have a strong tendency to affect organs and tissues that do not ordinarily contain lymphoid cells . primary extra nodal lymphoma of the hard palate is rare . here , we present a case of diffuse large b cell lymphoma in a 60-year - old male patient that manifested as slightly painful ulcerated growth on the edentulous right maxillary alveolar ridge extending onto the palate , closely resembling carcinoma of the alveolar ridge . computed tomography images showed the involvement of the maxillary sinus and right nasal cavity , along with destruction of hard palate , superiorly extending into the orbit . this case report highlights the importance of imaging to evaluate the exact extent of such large malignant lesions , which is essential for treatment planning .

a 38-year - old woman visited our hospital complaining of progressive hypesthesia in the right lower limb and weakness in the left lower limb . she had noticed decreased sensation in the right lower limb 3 years previously when she took a hot bath , and had felt motor weakness in the left lower limb on walking or climbing 3 months previously . she had no trauma , surgery history , or previous medical history such as diabetes , hypertension , tuberculosis , or hepatitis . on neurological examination , she was alert and well - oriented . both upper extremities were intact , but her left lower extremity showed weakness measured grade iv+ on the medical research council ( mrc ) scale . her left knee and ankle jerks were increased as grade 3 + compared with the right side , but babinski reflex was not present . sensory examination disclosed a decreased sensation in her right side for pinprick and temperature below the 5 thoracic dermatome , but her position , vibration , and tactile sensations were symmetric and intact on both sides . she showed a mild limping gait in the left side , and her neck was supple . with an impression of a lesion involving the cervicothoracic hemi - spinal cord , we performed imaging studies . thoracic spinal mri with enhancement revealed anterior displacement of the spinal cord at the level of the t4 - 5 intervertebral disc ( fig . 1 ) . there was no mass lesion or congenital abnormality involving the spinal cord or column . with an impression of spinal cord herniation , surgical management was performed . during the operation , ovoid shaped ventral dural defect was confirmed in the left paracentral area and spinal cord was herniated through it . after restoring the herniated spinal cord , postoperative spinal mri showed a revised dural alignment and spinal cord contour without unusual finding ( fig . she was discharged without postoperative complications , and her weakness and hypesthesia were almost completely resolved at the 6-month follow - up . the absence of the position and vibration sensation impairments suggested that the posterior column of the spinal cord was not involved , but the other findings were consistent with typical brown - sequard syndrome . she had no history of trauma , and spinal mri revealed no combined structural abnormalities that could potentially induce a dural tear . the most common clinical presentation of isch is brown - sequard syndrome , but spastic paraparesis and monoparesis have also been reported depending on the extent of the involved spinal cord.4 the thoracic segment is most commonly affected . since the symptoms are commonly progressive and the outcome is usually good after surgical management,3 an early diagnosis is of particular importance . the symptoms can also evolve in a stepwise manner.3 the pathogenesis has not been clearly established yet , and there have been several hypotheses to explain the nature of dural defect . an intradural arachnoid cyst or herniated disc may increase pressure and dural erosion , resulting dural tear and cord herniation.4 however , contrast myelographic studies did not show a block or evidence of raised pressure.1 some authors postulated the presence of a congenital structural anomaly , such as duplicated dura mater or disturbance of dural texture.4 pulsation of cerebrospinal fluid ( csf ) caused by cardiac or respiratory intrathoracic pressure fluctuation may cause adhesion and dural leak , causing dural defect.4 the diagnosis in a suspected patient is now easy with mri , which shows ventral displacement of the spinal cord . the surgery is generally approached via a posterior laminectomy , although in some cases an anterior approach is adopted.3 the aim of surgery is to replace the herniated spinal cord and repair the dural defect to avoid relapse . the prognosis is generally good for early surgical treatment , but treatment delay can prevent recovery in some patients.3 since the surgical management deals with dural alignment , csf leakage or collection may happen , causing positional headache or the formation of a csf collection sac . no definitive prognostic factor has been proposed , but initial paraparesis appears to be related to a poor response to surgical treatment.3 to date , there have been two case reports of isch in korea.5,6 the first5 was a 42-year - old man with a 2-year history of brown - sequard syndrome , in whom the neurological deficits recovered slowly over 9 months following surgical management . the other patient6 was a 55-year - old woman who also presented with a 3-month history of brown - sequard syndrome . no surgical management was performed , and hence a definite diagnosis could not be confirmed in that case . there was no combined structural abnormality such as arachnoid cyst or duplicated dura that could be regarded as a potential cause of spinal cord herniation in either case . in our patient , weakness and hypesthesia were significantly improved after surgical management , which emphasizes the importance of early diagnosis and surgical intervention . further studies are needed to disclose the underlying pathomechanism and prognostic factors of isch . in conclusion , since isch is treatable , it should always be included in the potential causes of myelopathy especially when a patient presents with brown - sequard syndrome .

idiopathic spinal cord herniation is a rare spinal cord disorder caused by spinal cord prolapse through a adural defect . it is a curable disease , so early detection is of particular importance . we report a 38-year - old woman with brown - sequard syndrome which was caused by the thoracic spinal cord herniation . her weakness was almost completely resolved after surgical management , which emphasizes the importance of early diagnosis and surgical management in this rare disease entity .

all glycerol dehydration experiments catalyzed by hzsm5 in scco2 were conducted at 8 mpa and 320 c ( see figure si1 for details ) . a measured amount of catalyst ( 5 ml , 3.08 g ) was diluted with the same volume of quartz sand and packed into a downflow stainless steel reactor ( 9.4 mm i.d . , quartz sand and quartz wool were put on top of the catalyst bed to serve as a preheating zone . the temperature of the catalyst bed was monitored by a ktype thermocouple and controlled by a pid controller . before reaction , liquid co2 ( industrial grade , 99.97 % purity , airgas , knoxville , tn ) was metered into the system by a liquid co2 pump ( 1 ml min at 4 c ) and preheated to 300 c . after stabilization of temperature and pressure for roughly 1 h , a 20 wt % aqueous solution of glycerol ( 99.5 % , sigma aldrich ) was injected into the reactor by a high pressure pump at a flow rate of 0.1 ml min to obtain a molar ratio of glycerol / h2o / co2=0.008:0.170:0.822 . after depressurization through a back pressure regulator , the reaction effluent flew through a condenser with circulating coolant at 0 c and the condensed liquid product was collected . the noncondensable gaseous product was sampled by using a gas syringe through the sampling port . the gasphase glycerol dehydration was conducted on the same reaction system with modification so that co2 gas at atmospheric pressure was metered in at 120 ml min through a rotameter ; all other conditions , including temperatures of preheating and reaction , catalyst loading and packing , and flow rate of 20 wt % aqueous solution of glycerol , were all kept the same . as a service to our authors and readers , this journal provides supporting information supplied by the authors . such materials are peer reviewed and may be reorganized for online delivery , but are not copyedited or typeset . technical support issues arising from supporting information ( other than missing files ) should be addressed to the authors .

abstractsupercritical carbon dioxide ( scco2 ) has been used for the first time as a reaction medium for the dehydration of glycerol to acrolein catalyzed by a solid acid . unprecedented catalyst stability over 528 hours of timeonstream was achieved and the rate of coke deposition on the zeolite catalyst was the lowest among extensive previous studies , showing potential for industrial application . coking pathways in scco2 were also elucidated for future development . the results have potential implications for other dehydration reactions catalyzed by solid acids .

high - frequency oscillation ventilators were initially designed for neonatal application . with the recognition of the role of ventilator - induced lung injury in the morbidity and mortality of patients with acute lung injury , there has also been increasing interest in the use of high - frequency oscillatory ventilation ( hfov ) in adult patients , since it theoretically offers , by design , an ideal mode for lung protection . the need to suppress patients ' spontaneous breathing activity with heavy sedation and muscle paralysis because of patient discomfort , due to a significantly increased level of imposed work of breathing ( wob ) , however , has so far limited the use of hfov in larger pediatric patients and in adult patients . in the present issue of critical care , van heerde and colleagues describe a new flow - demand system that significantly allows for reducing wob during hfov . this new concept , so far tested in a bench test , gives the potential for adult intensive care physicians to more often use hfov and to further investigate hfov . high - frequency oscillatory ventilators can be seen as continuous positive airway pressure ( cpap ) devices that allow generation of pressure oscillations around a continuous distending pressure , which will facilitate elimination co2 mainly by accelerating the molecular diffusion processes . accepting hfov as such a ' super - cpap ' allows one to realize that maintaining spontaneous breathing during hfov should be nothing other than natural . this maintenance is possible and well tolerated in newborns , and was probably a significant contributor to improved pulmonary outcome in this patient group . as previously shown by van heerde and colleagues , the imposed wob for a neonate or an infant ( up to a bodyweight of 10 kg ) on hfov is considerably low ( < 0.5 j / l or < 1.0 j / l , respectively ) during spontaneous tidal breathing with physiologic or smaller tidal volumes between 7 ml / kg to 5 ml / kg and this is independent of endotracheal tube size . with increasing patient size and weight , increasing the fresh gas flow rate allows one to reduce the imposed wob , but not to an acceptable level in the large child or in the adult necessitating heavy sedation , analgesia and often neuromuscular blockade . using the new flow - demand system , the imposed wob can be considerably reduced to a maximum of 0.5 j / l during shallow or normal breathing . on the basis of currently available data from the experience with airway pressure release ventilation or biphasic positive pressure both methods allowing for unrestricted spontaneous breathing at any phase of the ventilatory cycle because of an integrated high - flow or demand valve cpap system it might be postulated that a new high - frequency oscillation ventilator equipped with a flow - demand system allowing for unrestricted spontaneous breathing should allow for less sedation , and should therefore decrease the duration of mechanical support , decrease the length of stay in the intensive care unit , and , ultimately , decrease the overall costs of hospitalization . the application of hfov was mainly reported as a rescue ventilatory mode in adult patients with acute respiratory distress syndrome who were thought to have failed conventional ventilation . outcome results from such studies can not reflect the real potential of hfov as a lung protective ventilatory mode . with the possibility of maintaining spontaneous breathing , hfov could now be used in patients with mild and/or early forms of acute lung injury . with the neonatal experience demonstrating that a lung - protective effect with hfov requires an early initiation of hfov before the lung is damaged , continuing until the lung is no longer vulnerable to ventilator - induced injury , an early transition to hfov should now be considered in adult acute lung injury / acute respiratory distress syndrome patients , but this will need proper clinical testing . weaning concepts from hfov to any form of assisted ventilation or to extubation ( as is already possible in newborns and infants ) will also need re - evaluation . in patients with acute respiratory distress syndrome , perfusion matching , intrapulmonary shunting , and arterial oxygenation , indicating recruitment of previously nonventilated lung areas . hfov at high lung volumes ( i.e. recruited lung ) , which is classically achieved by a stepwise increase in continuous distending pressure to oxygenation and chest x - ray targets , has been shown superior to hfov at low lung volumes . this high - volume approach during hfov is often associated with relatively high airway pressures , which can cause hemodynamic compromise necessitating intravascular volume load ; the airway pressure might not , however , be sufficient to optimally expand the lungs . in the heavily sedated and paralyzed patient , the continuous distending pressure can be titrated up the inflation limb ( to recruit ) and down the deflation limb ( to find the least pressure required to keep the lungs open ) of the static pressure volume curve , which often allows substantial reduction of mean airway pressures while reducing hemo - dynamic side effects to a maximum . with the possibility of benefiting from spontaneous breathing for better recruitment of the dependent lung areas close to the diaphragm , it might become possible to use lower continuous distending pressures to achieve the same oxygenation goals . this may result , together with the effects of the periodic reduction of intrathoracic pressure resulting from spontaneous breathing , in better venous return to the heart , in improved ventricular filling , and therefore in increased cardiac output and oxygen delivery . converting hfov from a ventilation mode that often requires suppression of spontaneous breathing in larger children and adults to a ' super - cpap ' system that allows for unrestricted spontaneous breathing at any phase of the ventilatory cycle because of an integrated high - flow or demand valve system will give hfov the ultimate chance to prove its real potential for optimal lung protection . cpap = continuous positive airway pressure ; hfov = high - frequency oscillatory ventilation ; wob = work of breathing .

in the present issue of critical care , van heerde and colleagues describe a new technical development ( a flow - demand system during high - frequency oscillation ) that may have an important impact on the future use of high - frequency ventilation in children and adults . flow compensation on patient demand seems to reduce the imposed work of breathing , may therefore increase patient comfort , and should theoretically allow for maintaining spontaneous breathing while heavy sedation and muscular paralysis could be avoided . with further technical development of this concept , high - frequency oscillation can finally be added to the techniques of mechanical ventilatory support that maintain , rather than suppress , spontaneous breathing efforts . furthermore , this concept will give high - frequency oscillation the chance to prove its potential role as primary therapy in patients with acute lung injury / acute respiratory distress syndrome , the chance to reduce the incidence of high - frequency oscillation failure for patient or physician discomfort as reported in so many clinical trials in the past , the chance to most probably allow successful weaning from high - frequency oscillation to extubation , and , ultimately , in analogy to what has been reported from the experience with other ventilator modes that allow for maintaining spontaneous breathing , the chance to decrease ventilator days in patients with acute lung injury / acute respiratory distress syndrome .

we focused on the geographic range of denvs in latin america and the caribbean , where dengue is widespread and expanding in range . we attempted to identify areas contiguous with previously known dengue - endemic zones where new denv transmission is occurring by using reports of recent outbreaks . known dengue - endemic areas were defined as dengue risk areas identified by the us centers for disease control and prevention ( atlanta , ga , usa ) health information for international travel ( commonly referred to as the yellow book ) , 2010 ( 7 ) and 2012 ( 8) editions . each edition of this book reflects the known distribution of dengue risk in the prior 2 years . to characterize spread according to the yellow book , we identified areas that were classified as no known dengue risk in 2010 but were changed to risk areas in the 2012 edition ( hereafter referred to as new dengue - endemic areas ) . outbreak data for december 1 , 2009march 18 , 2011 , were collected from healthmap ( http://www.healthmap.org/en/an ) , an open access online infectious disease outbreak monitoring system ( 9,10 ) . healthmap integrates outbreak - related data from > 30,000 electronic sources , including the news media , promed - mail , and other electronic public health reporting sources , by using algorithms to classify the diseases and locations associated with each report . because we wanted to identify spread into new dengue - endemic zones , we limited our analyses to areas that were identified as having no known dengue risk in the 2010 yellow book but that were contiguous with > 1 risk areas in the 2010 yellow book . we fitted a bivariate gaussian mixture model to the extracted healthmap alerts to model a continuous surface of outbreak density ( technical appendix ) . this modeled outbreak probability density surface represents a risk map of recent denv spread into areas of previously unknown dengue endemicity according to the 2010 yellow book ( figure 1 ) . we compared our map with the geographic distribution of new dengue - endemic areas identified in the 2012 yellow book . details of the datasets , models , and statistical methods are available in the technical appendix . b ) central mexico ; c ) central south america ; d ) eastern amazonas , brazil . . areas to which dengue was identified in the 2010 yellow book are shaded in gray . new dengue - endemic areas identified in the 2012 yellow book are outlined in blue . modeled healthmap alert probability density surface is shown in a gradient from yellow to red with yellow areas predicted as having lower alert densities and red areas predicted as having higher alert densities according to the model . areas outlined with heavy black solid lines were classified as high healthmap alert density but were not identified in either yellow book edition as dengue risk areas . areas outlined with heavy black dashed lines were classified as low healthmap alert density but were identified in the 2012 yellow book as areas at risk for dengue . figure 1 shows that high dengue outbreak activity occurred adjacent to previously recognized dengue - endemic zones in 6 states in central mexico and in parts of northern argentina , southern brazil , bolivia , and paraguay . we used receiver - operating characteristic analysis with cross - validation ( figure 2 ) to set a threshold dengue report density that best identifies new dengue - endemic areas ( figure 1 ; technical appendix ) . of the 19 new dengue - endemic areas reported in the 2012 yellow book , this threshold identified 14 ( 74% ) as being at elevated risk of endemicity , according to the dengue outbreak probability density estimated by our model . of the 41 areas that remained unidentified as dengue - endemic areas in the 2012 yellow book , our model classified 35 ( 85% ) as having reduced risk of endemicity . receiver - operating characteristic plot of 5-fold cross - validated healthmap alert density - based classification with new dengue - endemic areas identified by the 2012 yellow book as the standard . when compared with the yellow book , our model incorrectly classified 6 areas as at elevated risk ( figure 1 ) . all alerts in these areas described outbreaks of cases acquired in a nearby known dengue - endemic region of the country . one alert also warned of the recent discovery of dengue vector mosquito larvae by the local surveillance program . the model also classified 5 yellow book dengue - endemic areas as at reduced risk ( figure 1 ) . although other explanations likely exist , the low observed sensitivity in these areas illustrates certain limits of any system that relies on internet - based information flow for monitoring disease spread . electronic event based surveillance systems such as healthmap and others are frequently used by public health authorities , travelers , physicians and patients , to gain a real - time understanding of global outbreak activity . the healthmap dengue feed , denguemap , is currently part of the online dengue information resource of the centers for disease control and prevention ( http://www.cdc.gov/dengue/ ) . used in combination with traditional case reporting , healthmap and other electronic surveillance systems have proven value for enhancing the timeliness of outbreak discovery and information dissemination ( 11 ) . however , these information sources may also provide added value for monitoring ongoing spread . although the signal of denv activity detected by healthmap is relatively robust , it has certain limitations . first , the signal tends to be sparse in areas with limited reporting because of low population density or incomplete coverage by the news or social media . second , the signal can be surrounded by background noise because separating reports caused by cases in travelers from true autochthonous transmission is difficult with automated methods . by limiting our analysis to areas contiguous with known dengue - endemic areas and smoothing outbreak alerts into an outbreak - density surface although this analysis was performed retrospectively , the timeliness of this signal far outperforms any traditional surveillance data stream . passive case report - based surveillance systems typically operate at a delay of weeks to months , which limits their value for providing a picture of geographic spread , especially on an international scale where surveillance delays may be even more prolonged . we have demonstrated a novel approach to real - time monitoring of recent expansion of denv activity in latin america . using outbreak reports captured by healthmap , we identified a signal of geographic expansion of dengue activity that would precede official reports of the geographic distribution of dengue - endemic areas . currently , no reliable surveillance system is in widespread use that reports the distribution of denv activity on an ongoing basis and enables near real - time monitoring of trends in geographic expansion . such a system should enhance the ability of regional and global public health authorities to dynamically allocate resources within a time frame that might effectively avert a full - blown epidemic . like other large - scale surveillance data sources , our results must be interpreted cautiously . however , when used in conjunction with traditional surveillance methods , our approach has the potential to provide a timely estimate of changes in the geographic distribution of dengue , a critical component of targeted prevention and control efforts . bivariate gaussian mixture model applied to extracted healthmap alerts to model a continuous surface of outbreak density .

dengue , a potentially fatal disease , is spreading around the world . an estimated 2.5 billion people in tropical and subtropical regions are at risk . early detection of outbreaks is crucial to prevention and control of dengue virus and other viruses . case reporting may often take weeks or months . therefore , researchers explored whether electronic sources of real - time information ( such as internet news outlets , health expert mailing lists , social media sites , and queries to online search engines ) might be faster , and they were . although information from unofficial sources should be interpreted with caution , when used in conjunction with traditional case reporting , real - time electronic surveillance can help public health authorities allocate resources in time to avert full - blown epidemics .

several randomized trials have demonstrated that breast - conserving surgery followed by radiation therapy , which is called breast - conserving therapy ( bct ) , is as effective as mastectomy and should be a standard treatment for early - stage breast cancer . recently , there has been an increase in reports of angiosarcoma ( as ) after bct [ 2 , 3 , 4 ] . lymphedema - associated cutaneous as , so - called stewart - treves syndrome , was first described in 1948 by stewart and treves . herein , we report a case of as which developed after bct and a case of stewart - treves syndrome with a focus on lymphedema . in 1997 , a 62-year - old woman underwent bct with 50 gy radiation for left - sided breast cancer , categorized as stage ia . she was started on weekly intravenous paclitaxel at a dose of 100 mg / m . in may 2009 , she presented with an erythematous purplish palpable mass on the right breast ( fig . a punch biopsy revealed the invasion of spindle - shaped cells with vascular differentiation into the subcutaneous tissue ( fig . each time , further wide excisions were performed . due to these local recurrences , at 85 cycles after the administration of weekly paclitaxel therapy , the patient was switched to monthly docetaxel at a dose of 70 mg / m . since then a 64-year - old woman was diagnosed with right - sided breast cancer that was categorized as stage ia . she received no adjuvant radiotherapy because she had already been treated with chemotherapy using a combination of paclitaxel and carboplatin for ovarian cancer . in november 2011 , the patient was admitted to our hospital for evaluation of purplish ecchymosed cutaneous lesions without a palpable mass on the right breast in the setting of chronic lymphedema ( fig . a punch biopsy revealed pleomorphic spindle - shaped cells with little vascular differentiation infiltrated into the dermis ( fig . the patient was started on monthly docetaxel at a dose of 75 mg / m . in 1997 , a 62-year - old woman underwent bct with 50 gy radiation for left - sided breast cancer , categorized as stage ia . she was started on weekly intravenous paclitaxel at a dose of 100 mg / m . in may 2009 , she presented with an erythematous purplish palpable mass on the right breast ( fig . a punch biopsy revealed the invasion of spindle - shaped cells with vascular differentiation into the subcutaneous tissue ( fig . each time , further wide excisions were performed . due to these local recurrences , at 85 cycles after the administration of weekly paclitaxel therapy , the patient was switched to monthly docetaxel at a dose of 70 mg / m . since then a 64-year - old woman was diagnosed with right - sided breast cancer that was categorized as stage ia . she received no adjuvant radiotherapy because she had already been treated with chemotherapy using a combination of paclitaxel and carboplatin for ovarian cancer . in november 2011 , the patient was admitted to our hospital for evaluation of purplish ecchymosed cutaneous lesions without a palpable mass on the right breast in the setting of chronic lymphedema ( fig . a punch biopsy revealed pleomorphic spindle - shaped cells with little vascular differentiation infiltrated into the dermis ( fig . the patient was started on monthly docetaxel at a dose of 75 mg / m . many studies have demonstrated that radiation may be a major risk factor in the development of as [ 2 , 3 , 4 ] . on the other hand , case 2 suggests that chronic lymphedema is the primary risk factor for as , which was first described in 1948 by stewart and treves . radiation therapy secondarily tends to induce the development of as , since radiation therapy induces fibrosis and proliferation of lymphatic vessels via cytokines such as vascular endothelial growth factor , which is followed by subclinical chronic edema . it is suggested that axillary lymph node dissection predisposes patients to the development of as , since it is closely associated with lymphedema . the increased use of bct is likely to lead to an increase in the number of patients with as . the prognosis of as after bct is poor , with a low 5-year overall survival ( 55% ) and a low disease - free survival at 5 years ( 35% ) . therefore , breast surgeons and radiologists should be aware of skin changes in order to improve the early detection of as during the follow - up of patients who have undergone bct , and especially those treated with axillary lymph node dissection .

several randomized trials have shown that breast - conserving therapy ( bct ) is as effective as mastectomy and should be a standard treatment for early - stage breast cancer . recently , there has been an increase in reports of angiosarcoma ( as ) after bct . herein , we report a case of as which developed after bct and a case of stewart - treves syndrome with a focus on lymphedema . chronic lymphedema is the primary risk factor for as , which was first described in 1948 by stewart and treves [ cancer 1948;1:6481 ] . radiation therapy secondarily tends to induce the development of as , since radiation therapy induces fibrosis and proliferation of lymphatic vessels via cytokines such as vascular endothelial growth factor , which is followed by subclinical chronic edema . it is suggested that axillary lymph node dissection predisposes patients to the development of as , since it is closely associated with lymphedema . breast surgeons and radiologists should be aware of skin changes in order to improve the early detection of as during the follow - up of patients who have undergone bct , and especially those treated with axillary lymph node dissection .

this study was a controlled clinical trial aiming to compare the outcomes of open reduction and rigid internal fixation of displaced calcaneal fractures with that of non operative treatment . the research proposal of this study was approved by research department of isfahan university of medical sciences . from december 1998 until january 2009 , 72 patients with displaced intra - articular calcaneal fractures admitted in kashani university hospital and were randomly allocated to surgical and non surgical groups . first group underwent open reduction and internal fixation with reconstruction plate and screws fixation and the other group were treated with closed reduction and cast immobilization.13 data were collected by clinical observation and a questionnaire six months following surgery . some reasons that patients were not selected for surgery were as follows : patient disagreement with surgery , open fractures ( not suitable for open reduction internal fixation ) , combined injuries ( head trauma , cardiovascular disorders , severe osteoporosis ... ) also were not suitable for surgery179 and severe comminution . post - operative exam after two weeks , one month , three months , six months and one year was recorded . roentgenography was obtained and physical examination including pain scoring , swelling , limitation of activities , shoe wearing difficulties , range of motion and osteoarthritis in ankle and subtalar joints as well as patient satisfaction were also scored and recorded . functional scoring based on kerr 's meta - analysis and pain scoring was used.1121 data were analyzed by spss 18 software . seventy two patients with mean age 49 years ( 21 - 84 years old ) were included . eleven patients were excluded from the study ( unable to follow up after hospital discharge ) . eventually , 61 cases of calcaneal fractures enrolled and were also followed - up for averagely 3 years . patients in operation group sub - classified in two categories : first group comprised of 17 cases with essex - lopresti technique ( under fluoroscopy - x - ray control , closed reduction , internally fixed with pin fixation , and cast immobilization).22 second group consisted of 14 cases with open reduction with lateral calcaneal approach and fixation with reconstruction plate ( figure 4 ) . ambulation with crutch walking and non - weight bearing continued for 6 - 10 weeks after surgery . lateral calcaneal approach with exostosectomy thirty cases had non - surgical treatment , with splinting , ice pack , elevation the limb , then short leg cast and ambulation with crutch walking and non weight bearing . in non - surgery group ambulation with crutches started 3 days after casting and cast was removed after 6 weeks and physical therapy , home exercises and partial weight bearing was recommended . the findings regarding the comparison between two groups for different variables are shown in table 1 . fracture classification ( sander s ) in post operation examinations , range of motion of ankle in both groups were good ( more than 50% of r.o.m ) but in subtalar joints decreased range of motion in non - operative group compared to operative group was obtained ( odds ratio : 6.75 , p = 0.002 ) . last x - ray examinations showed that traumatic osteoarthritis ( degenerative joint disease ) in non - operative group was a major problem ( 26% compared to 9% in operative group ) . shoe fitting difficulties was also a major problem ( 50% in non - operative compared with 12% in operative group).18 pain in walking was 63% in conservative group compared to 29% in operative group ( odds ratio : 6.72 , p = 0.001).2122 swelling in ankle and foot , reflex sympathetic dystrophy including focal osteoporosis and or spotty osteoporosis in non operative group was twice more than operative group ( 6 cases versus 3 cases ; odds ratio : 6.80 , p = 0.001 ) ( table 2 ) . our findings showed that open reduction and internal fixation of displaced calcaneal fractures in absence of open fracture , severe osteoporosis , or comminution and poor general condition may be the preferred method of treatment . although surgical treatment of calcaneal fractures has recently received attention owing to good results and less morbidities,13911 most of orthopaedic surgeons prefer to treat them conservatively , probably because of many complications including post operative infections , wound dehiscence , malreductions and long term osteoarthritis . most of calcaneal fractures are intra - articular and displaced . on the other hand , many of these fractures have ecchymosis , swelling , and blister which increase risk of open reduction and internal fixations ( fracture- blister).14 thornes et al.15 showed that surgically treated calcaneal fractures have better prognosis compared with those conservatively treated . burdeaux 's work also showed that shoe fitting and weight bearing difficulties were less in those underwent operation.16 pain in daily living activities were dramatically less in patients with open reduction and internal fixation , and range of motion in ankle and subtalar joints were desirable.1720 open reduction and internal fixation of displaced calcaneal fractures in absence of open fracture , severe osteoporosis , or comminution , poor general condition may be the preferred method of treatment . young and middle aged patients with calcaneal fracture who are in sander 's type ii and iii with mild comminution due to minor trauma , without soft tissue injuries may be the best candidates for open reduction and internal fixation . mhn and fmm participated in the design study , conduct the study and prepared the manuscript .

background : the aim of this study was to compare outcomes of open reduction and rigid internal fixation of displaced calcaneal fractures with that of non operative treatment.methods:seventy two consecutive patients with displaced intra - articular calcaneal fractures were selected regarding inclusive and exclusive criteria and then were randomly allocated to surgical and non surgical groups . first group underwent open reduction and internal fixation with reconstruction plate and screws fixation and the other group were treated with closed reduction and cast immobilization . data were collected by clinical observation and a check list . data was analyzed by chi - square and student 's t-test.results:the results showed significant difference between outcomes of surgical treatment and nonsurgical method ( p = 0.001 ) . there were some differences between two methods in terms of decreasing pain [ odd ratio ( or ) : 6.72 , p = 0.001 ] , swelling ( or : 6.80 , p = 0.001 ) , increased range of motion of the joints ( p = 0.001 ) , decreased late osteoarthritis ( or : 2.33 , p = 0.22 ) in favor of surgical group.conclusions:open reduction and internal fixation of displaced calcaneal fractures in absence of open fracture , severe osteoporosis , or comminution , poor general condition may be the preferred method of treatment .

we present a case of multiple cutaneous metastases from prostate carcinoma in the chest region . a 78-year - old man with an 8-year history of prostate cancer metastatic to the bone presented with a 6-month history of several asymptomatic skin nodules that appeared in the chest . despite repeated urging by his physician the nodules in the chest were up to 0.51 cm in size , pinkish , firm and dome - shaped with a smooth surface ( fig . pertinent laboratory studies included a prostate - specific antigen ( psa ) serum level of 180 ng / l ( normal range 04 ng / ml ) , which had risen by 70 ng / ml in the 8 months preceding his presentation with the skin lesion . a skin biopsy of an isolated nodule on the chest stained with hematoxylin and eosin showed monotonous sheets and small clusters of basophilic neoplastic cells filling the papillary dermis and diffusely permeating the reticular and deep dermis ( fig . microscopically , the lesion is characterized by some abortive glandular lumina and by tall columnar cells with abundant cytoplasm , which form a single or pseudostratified layer . the primary antibodies used in this study were : monoclonal antibody to cytokeratin clones ae1/ae3 , isotype igg1 ( dako ) , anti - human prostatic acid phosphatase clone pase/4lj isotype igg1 ( dako ) , monoclonal psa clone er / pr8 , and isotype igg1 ( dako ) . immunophenotypic studies for metastatic lesions showed the tumor cells staining positively for ae1:ae3 cytokeratin cocktail ( fig . cells labeled by the antibody displayed a cytoplasmic staining pattern , confirming the diagnosis of cutaneous metastases from prostate cancer . it is known that the progression of the disease is highly associated with metastasis to the bone , lung , liver and adrenal glands , and the lymph nodes , whereas skin metastasis is considered exceptional and accounts for fewer than 1% of cutaneous metastases , with less than 80 cases published in the literature [ 3 , 4 ] . when prostate carcinoma metastasizes to the skin , the metastases usually appear as multiple or solitary asymptomatic nodules or papules in the suprapubic region , lower abdominal area , genitalia , and the anterior aspect of the thigh [ 2 , 5 , 6 ] . less frequently , other sites of distant metastasis include the chest , abdomen , face , and scalp [ 7 , 8 ] , and may not have the typical nodular morphology . methods of spread to the subcutaneous tissues include direct extension , dissemination through the lymphatic system , and embolization of blood vessels . in prostate cancer , skin metastases from prostate cancer are an ominous finding and most patients die within 6 months . only a few cases with distant metastasis to areas such as the scalp or chest wall have been reported . in conclusion , we reported this case because of the rarity of cutaneous metastasis from prostatic adenocarcinoma in the chest region . urologic skin metastases are most common from renal tumors , followed by those of the bladder and then the prostate .

we report a case of multiple cutaneous metastases from prostate cancer . a 78-year - old man with an 8-year history of prostate cancer had multiple nodular lesions in the chest . histologically , the lesion showed an abortive glandular lumina and tall columnar cells with abundant cytoplasm . immunohistochemical staining for ae1:ae3 cytokeratin cocktail , prostate - specific antigen , and prostate - specific acid phosphatase was positive in tumor cells , confirming the diagnosis of cutaneous metastases from prostate cancer . we report this case because of the rarity of cutaneous metastases from prostatic adenocarcinoma in the chest region .

a 21-year - old male reported to the department of conservative dentistry and endodontics , with a complaint of the fractured crown in the right maxillary central incisor . the clinical and radiographic examinations revealed a loss of tooth structure extending to the cervical third , as well as an exposure of the root canal , with necrosis of pulp [ figure 1 ] . conventional root canal treatment with lateral condensation of gutta - percha , followed by post placement and full crown rehabilitation for replenishing the lost tooth structure . a post has to be placed to compensate for the amount of tooth been lost . hence , we decided to use an intraradicular biological post made from cutting the root of extracted and properly sterilized canine and subsequent adaptation of post to the maxillary central incisor . the patient received instructions regarding the advantages and disadvantages of biological restoration , as well as information on other treatment options . after agreeing upon the proposed treatment , a consent form was duly signed . in addition , it was made clear to the patient that the post would be obtained from extracted teeth that had been previously sterilized by autoclaving in accordance with standards . first , all carious tissue were removed conventional access cavity was prepared , working length determined , cleaning and shaping done , and calcium hydroxide closed dressing given for 2 weeks . the restoration technique initially consisted of the preparation of the root canals for post space and direct molding of prepared space using addition silicon impression material [ figure 2 ] . after having established the master cast from the impression , the extracted , donated canines , were autoclaved at 121c for 15 min . using a diamond disk , the crown portion was separated from the root , the root was sectioned mesiodistally along the long axis of the tooth . the cementum was removed by abrasion , using diamond drills , and each part of the root was cut in such a way as to form biological post after the intraradicular post had been shaped and suitably adapted to the master cast [ figure 4 ] ; they were then conditioned with 37% phosphoric acid for 30 s [ figure 5 ] , followed by washing , drying , and application of the adhesive system ( adper single bond 2 , 3 m espe , ca , usa ) [ figure 6 ] . post were adapted to the master cast application of 37% phosphoric acid in the post application of the adhesive system in the post the inner portion of the canal was conditioned with 37% phosphoric acid for 15 s [ figure 7 ] . next , the adhesive system was applied to the post and polymerized [ figure 8 ] . application of 37% phosphoric acid in the canal application of the adhesive system in the canal dual cured resin cement ( varolink ii , ivoclar ) was applied to the inner portion of the canal with the help of a paste carrier [ figure 9 ] and also to the surface of the post . the post was then inserted into the canal under constant digital pressure [ figure 10 ] . core buildup of the tooth structure was done using dual cure core buildup material ( fluorocore dentsply ) [ figure 11 ] . tooth preparation was done , and an impression taken using addition silicone impression material metal free ceramic crown was fabricated and luted using same dual cure resin cement [ figure 12 ] . application of the dual cure resin into the canal post were then inserted into the canals under constant pressure until the end of the cement polymerization core build up , radiograph , crown preparation postoperative , postoperative radiograph the use of a dentin post provides biocompatibility , a resilience that is comparable to the original tooth , excellent adhesion to the dental structure and composite resin , at a low cost , as dentin posts are made from donated extracted natural teeth . furthermore , the formation of a sole biomechanical system ( monoblock ) adhesive joining of dental structures , the cement agent , and the dentin post allow for a better distribution of stress along the root , minimizing the rate of adhesive and cohesive failure . steel and titanium posts have higher elastic modulus than dentin , causing a concentration of stress at the tooth restoration interface with an increased risk of tooth fracture when subjected to occlusal loads . when a fiber post , which has lower elastic modulus , is subjected to the same loads , debonding of the post - restoration joint occurs . lower elastic modulus may raise the risk of spontaneous debonding of the post , instead of vertical fracture of the root . concerning the ethical aspect , it is necessary to clarify to the patient and/or his parents or guardian that the post is made from duly donated and properly sterilized extracted teeth , thus preventing biosecurity risks .

anterior tooth fracture as a result of traumatic injuries , is frequently encountered in endodontic practice . proper reconstruction of extensively damaged teeth can be achieved through the fragment reattachment procedure known as biological restoration . this case report refers to the esthetics and functional recovery of extensively damaged maxillary central incisor through the preparation and adhesive cementation of biological post in a young patient . biological post obtained through extracted teeth from another individual represent a low - cost option and alternative technique for the morphofunctional recovery of extensively damaged anterior teeth .

are located in the ovaries and sacral lesions , 7% are seen in head and neck region , only approximate 1.6% of these tumours are found in oral region . only a few number of cases have been reported in the literature so far ( 1 ) . examination revealed a firm , rubbery , non - tender 3x2x2 cm sessile swelling with no induration or ulceration ( fig 1 ) . swelling on surface of tongue lately , she experienced difficulty in moving tongue , resulting in globbus sensation and dysphagia . general examination of the patient revealed average built , pulse rate 80 beats / min with regular rhythm , bp 130/90 mm hg , rr 24 breaths / min . computed tomography revealed a 3x2 cm cystic anterior lingual structure , the wall of which was thin and regular with a content consisting of homogenous fluid . there was no bone involvement . with a clinical diagnosis of dermoid cyst an excision biopsy histopathological findings consisted of cyst wall lining of stratified squamous epithelium with sebaceous glands , blood vessels , muscle and cartilage in the underlying connective tissue , and a diagnosis of teratoma was made ( fig 2 ) . one year after surgical removal of the lesion , there was no sign of recurrence . the anterior two thirds is derived from ectoderm and posterior one third is from endoderm . the anterior two third s originate from paired lateral lingual swellings , which are contributed by first branchial arch . the posterior one third of the tongue arises from the hypobranchial eminence , which is made up of mesoderm of the second , third and a portion of the fourth pharyngeal arches . congenital dermoid cysts arise from epithelial rests trapped during midline fusion of these branchial arches whereas acquired dermoid cyst arise from epithelium implanted during trauma and they occur at the sites away from midline . the terms teratoma , teratoid cyst and dermoid cyst have been used interchangeably to describe a wide variety of lesions by some authors . dermoid type cysts contain skin appendages whereas teratoids contain epithelium lined mesodermal or endodermal elements such as bone , teeth , muscle , mucous membrane ( 2 ) . the other differentials which are encountered at these sites are ranula , lymphangioma , angioma and lipoma ( 1 ) . there is an epithelial lined cavity containing mesodermal as well as endodermal derivatives like muscle , intestinal mucosa , respiratory mucosa , fibres , bone and blood vessels etc . teratoma of tongue may exhibit skin , hair , bone , cartilage or mucous membrane on the surface ( 7 ) . the rarity of teratoma has been stemmed from the fact that it is not located along embryonic fusion line and it does not involve the floor of the mouth ( 4 ) . teratoma in the head and neck region are rare , comprising 1 - 10% of cases . they probably arise from totiopotent embryonic tissue that has been displaced during ontogeny ( 8) . a good patho - radiological correlation is required to confirm the diagnosis . ultrasonography establishes the presence of solid and cystic components and can differentiate cyst from surrounding tissue . by far mri has been proven to be superior among imaging modalities , as it can locate exact position , extention and demarcations of the lesion ( 1 ) . because of their avascular character , teratoma do not enhance with administration of contrast material and thus can cause diagnostic confusion with choriostoma , endodermal sinus tumours and granular cell tumours . because oral teratomas are well defined , complete excision is usually possible . most of the times , these tumours are benign but may result in high degree of mortality and morbidity due to variations in their size and location . if large enough , they may cause airway obstruction , respiratory distress , dysphagia , difficult in eating and pain due mostly to infection in the lesion . in malignant teratoma radio - chemotherapy alphafetoprotein ( afp ) has been shown to be reliable indicator of disease activity and some authors advocate investigating teratoma recurrence by doing serial serum afp levels . though teratoma has been reported in infants so far it is unusual with the site not being the midline .

teratomas are the benign tumours , which may occur anywhere in the body . development of these lesions in the oral cavity is extremely rare . in the oral cavity , they usually arise in the midline , in the floor of mouth . infrequently , they may be seen in the tongue proper . we hereby , present a case of swelling tongue in 56 years female diagnosed as teratoma .

desmoplastic fibroma ( df ) is an intra - osseous tumor that frequently occurs in long bones and the mandible15 ) . these tumors are histologically benign but show locally aggressive behavior9 ) . without complete resection , frequent local recurrence occurs12 ) . df in the cranium is extremely rare . since the first report by gardini et al.7 ) in 1978 , fewer than 20 cases have been described in the literature5,11,14 ) . in this report , we present a case of df in the cranium . a 20-year - old man visited our clinic with a 1-year history of worsening headache and swelling of the right frontal region . a computed tomographic ( ct ) scan demonstrated a 33.5-cm focal calvarial thickening and expansion of the diploic space by a hypo - attenuated mass with a sclerotic margin and ground - glass appearance . magnetic resonance imaging showed heterogeneous signal intensity on t2-weighted images and intermediate signal intensity on t1-weighted images with multifocal enhancement ( fig . the lesion was completely excised with sufficient safety margins by inspection under guidance of intra - operative navigation . the gross specimen was bulging with a pinkish color at the lesion site , which contained a round dark - brownish area with a sclerotic margin in the diploic space , slightly expanded and thicker compared to normal bone flaps . the lesion was accompanied by yellow necrotic foci and exhibited fibroblastic proliferation within a collagenous background , with extensive hemorrhage and fat necrosis . other markers such as ema , cd34 , cd68 , vimentin , and desmin were negative . first described by jaffe in 1958 , desmoplastic fibroma is recognized as a separate entity from bone tumors . df is a rare benign bone tumor composed of spindle cells accounting for 0.3% of benign bone tumors13 ) . the world health organization describes df as exhibiting " minimal cytological atypia and abundant collagen production"6 ) . df can occur at any age , but most cases occur before age 301 ) . df may involve any bone , but commonly occurs in the metaphyses of the long bones , mandible , and pelvis , and cranial dfs are exceedingly rare . dfs affect both genders , although a female preference has been suggested for cranial df12 ) . despite benign histological appearance and slow growth , frequent local recurrence puts df in a category between benign and malignant bone tumors3 ) . intracranial involvement was reported in one case , but brain parenchymal invasion has not been reported17 ) . radiographically , cranial dfs are often solitary , honeycomb , or trabeculated lytic lesions , with expansion of the diploic space with or without marginal sclerosis8 ) . dense connective tissue and hypocellularity yields heterogeneous signal intensity on t2 and iso - signal intensity on t1-weighted magnetic resonance images with heterogeneous enhancement9,16 ) . these findings are not distinctive compared to other skull lesions such as fibrous dysplasia , hemangioma , eosinophilic granuloma , low - grade osteosarcoma , or metastasis . given its rarity and nonspecific radiographic findings , it is very difficult to diagnose cranial dfs . differential histopathological diagnosis includes benign and malignant spindle cell bone tumors , including fibrous dysplasia , fibrosarcoma , low - grade intra - osseous osteosarcoma , and non - ossifying fibroma10 ) . typical fibrosarcoma is more cellular with a herringbone pattern that shows more pleomorphism and higher mitotic activity4 ) . in fibrous dysplasia , recognition of c - shaped , woven bone formation within a fibrous background is an important diagnostic feature . non - ossifying fibroma consists of cellular masses of fibrous tissue often arranged in a storiform pattern . immunohistochemistry of df may be positive for sma , vimentin , and desmin , while cytokeratin , s-100 , ema , and cd16 are negative18 ) . despite some reports that endocrine therapy with tamoxifen can be effective , chemo- and radiotherapeutic approaches in df have not been established2 ) . so far , there are no reports of recurrence in cranial df , which may be due to feasibility of wide excision in skull lesions . since cranial df remains poorly understood , radiographic follow - up is warranted , especially in incomplete resection cases . df is uncommon , but should be considered in differential diagnosis of any expansile cranial mass . because df may be locally aggressive , en bloc resection with adequate margin is the treatment of choice .

desmoplastic fibroma , which develops predominantly in long bones and the mandible , is a rare and benign but locally aggressive tumor . desmoplastic fibroma of the cranium is extremely rare . we report a case of desmoplastic fibroma of the frontal bone in a young man . because of its locally aggressive behavior , complete surgical excision with a safety margin is essential .

reported complications after pbt are radiation - induced cataract and raised intraocular pressure ( iop ) . filtering glaucoma surgery has generally been avoided because of fears of seeding . a 37-year - old man presented with a self - discovered , pigmented lesion on his right iris . four years later , the pigmented lesion was diagnosed as an iris melanoma , because of documented growth . the iop could not be controlled despite maximal medical therapy and selective laser trabeculoplasty ( slt ) . finally , baerveldt implant surgery was performed , resulting in an iop lowering to 10 mmhg and stabilization of the glaucomatous visual field loss . our case demonstrates that baerveldt implant surgery is a reasonable therapy for glaucoma following successful radiotherapy of iris melanoma . iris melanoma comprises 3% to 10% of all uveal melanomas and is the most common primary malignancy of the iris.1,2 it tends to have a ten - year metastasis rate of 3% to 6%.13 possible therapies for iris melanoma include iridectomy , iridocyclectomy , plaque brachytherapy , proton beam therapy ( pbt ) , and enucleation . pbt is generally selected if the tumor is too extensive for surgical excision or if such surgery is rejected because the surgical iris coloboma is expected to cause unacceptable photophobia or cosmetic deficit . trabecular scarring may play a role in the latter.4 secondary glaucoma occurs in 7% of eyes with untreated iris melanoma and in 30% of patients with microscopically - confirmed iris melanoma , occurring mostly because of tumor infiltration of the trabecular meshwork with outflow obstruction.5,6 traditionally , filtering glaucoma surgery has been avoided in patients with iris melanoma because of fears that such aqueous drainage might encourage subconjunctival or intraorbital tumor seeding.2,3 nevertheless , insights into the biology of uveal melanomas and outcome studies after pbt encouraged us to treat a patient with a baerveldt tube implantation because of rapidly deteriorating vision and uncontrollable glaucoma . a 37-year - old man discovered a pigmented iris lesion in his right eye . the best - corrected visual acuity ( bcva ) was 6/6 . ophthalmologic examination showed a pigmented iris lesion between the 5.30 and 6.30 oclock meridians with a basal diameter of 3.5 mm and a thickness of 1.4 mm . initially , the tumor showed no growth ; however , four years after presentation , the iris lesion had changed to a diffuse tumor , extending from the 4.30 to 6.30 oclock meridians with seeding onto the iris surface from the 3.30 to 7.00 oclock meridians . gonioscopy showed pigment deposition in the iridocorneal angle between the 1.00 and 10.00 oclock meridians . the entire anterior segment was treated with pbt ( 53.1 gy , administered in four fractions over four days ) . one month later ( figures 1b and 1c ) the patient developed secondary glaucoma with iop levels fluctuating between 20 and 43 mmhg , despite maximal medical therapy . slt was performed , placing 25 shots with a total energy of 15 mj in the nasal quadrant . meanwhile , the optic disc cupping had become pathological and glaucomatous visual field loss had progressed from mild loss to very extensive loss within two months . since the patient was keen to preserve the remaining vision in this eye , despite advice about a possible risk of extraocular spread , we finally placed a baerveldt tube in the anterior chamber ( figure 1d and figure 2 ) . after one year of follow - up , the iop was stable at 10 mmhg with the additional use of dorzolamide and timolol . the patient declined systemic screening for metastasis ; however , he remains under intensive ophthalmic surveillance . secondary glaucoma after pbt for iris melanoma can be difficult to control with medical therapy.7 we report successful lowering of the iop in such a case by using a baerveldt glaucoma implant . , drainage surgery is avoided after treatment of iris melanoma , probably because of concerns that tumor cells might seed through the drainage fistula and metastasize to other parts of the body . insights from genetic studies on uveal melanomas suggest , however , that these tumors metastasize almost exclusively if they show loss of chromosome 38 or class ii gene expression profile.9 there is growing evidence that metastasis starts at a very early stage , before the patient even presents to the ophthalmologist.10 for these reasons , there are now considerable doubts that glaucoma drainage surgery would enhance risks of metastasis spread to the rest of the body by providing an exit route from the eye . another concern is that the iris melanoma can recur and seed through the tube into the subconjunctival and orbital tissues . we consider these risks to be small , firstly , because local tumor recurrence is rare after pbt and , secondly , because the tumor was located far from the internal opening of the tube ( figure 1d ) . in any case , the patient is being monitored closely so that appropriate treatment can be administered without delay in case of re - growth of the tumor . further studies with more patients and long - term follow - up are indicated to evaluate the safety and efficacy of the baerveldt glaucoma implant for the treatment of secondary glaucoma after pbt for iris melanoma .

background : proton beam therapy ( pbt ) is effective in the treatment of iris melanoma . reported complications after pbt are radiation - induced cataract and raised intraocular pressure ( iop ) . filtering glaucoma surgery has generally been avoided because of fears of seeding.case report : a 37-year - old man presented with a self - discovered , pigmented lesion on his right iris . four years later , the pigmented lesion was diagnosed as an iris melanoma , because of documented growth . the patient was treated with pbt but developed secondary glaucoma one month later . the iop could not be controlled despite maximal medical therapy and selective laser trabeculoplasty ( slt ) . finally , baerveldt implant surgery was performed , resulting in an iop lowering to 10 mmhg and stabilization of the glaucomatous visual field loss.conclusion:our case demonstrates that baerveldt implant surgery is a reasonable therapy for glaucoma following successful radiotherapy of iris melanoma .

spindle cell lipoma is a benign lipomatous tumor which constitutes about 1.5% of all adipocyte tumors . similar to other kinds of lipomas , 75% of spindle cell lipomas are found in the subcutaneous tissue of back , shoulder , and neck . a 45-year - old lady presented to our outpatient department with a swelling in the right side of the nose since two years [ figure 1 ] . , there was a swelling 32 cm , 1 cm below medial canthus of the right eye extending to the right nasoalar crease . ct of the facial skeleton revealed a soft tissue mass over anterior surface of the right maxilla and right nasal bone with mild sclerosis of the right nasal bone . excision was done under general anesthesia through lateral rhinotomy incision [ figure 2 ] . on gross examination , specimen was sent for histopathological examination which revealed a mixture of mature adipocytes bland spindle cells in fibrous background with thick collagen bundles , consistent with spindle cell lipoma which is very rare in the region of head and face [ figure 3 ] . the patient was asymptomatic during the follow up . a 45-year - old lady with swelling on right side of nose lateral rhinotomy incision hpe of spindle cell lipoma spindle cell lipoma is a benign lipomatous tumor which usually arises on the back of the neck , shoulder , or upper back of males . angiolipoma , myelolipoma , spindle cell lipoma , chondrolipoma and myxolipoma are histological variants of lipomas arising from fat tissue . men are affected significantly more commonly than women ( 9:1 ) at a mean age in the sixth to seventh decade of life . our case is unusual because our patient was a female in fourth decade of her life . it is a subcutaneous tumor of back and shoulder usually solitary , subcutaneous , and well circumscribed . it is relatively superficial with a mixture of mature adipocytes and bland spindle cells ( pale eosinophilic cytoplasm with uniform wavy nuclei similar to neurofibroma ) and multinucleated giant cells in mucinous or myxoid or fibrous background with thick collagen bundles . they may contain variable mast cell lymphocytes and characterized by abscence of storiform pattern , abscence of lipoblasts with no or rare mitotic activity . the spindle cells stain positive for cd34 with androgen receptors in men and usually adipocytes stain positive for s-100 . the variable proportion of fibrous and myxoid elements among different example of these tumors confers to spindle cell lipoma a variable microscopic appearance that can make the diagnosis difficult . spindle cell lipomas constitute only 7.5% of all adipocyte tumors , common in males in 6 to 7 decade of life in shoulder and upper back region . our case report is mixture of mature adipocytes and bland spindle cells ( pale eosinophilic cytoplasm with uniform wavy nuclei similar to neurofibroma ) and multinucleated giant cells in mucinous or myxoid or fibrous background with thick collagen bundles . spindle cells are arranged in short fascicles with occasional nuclear palisading unique in terms of rarity of its occurrence in a female of 45 years of age .

we present a case report of a 45-year - old lady with history of swelling on right side of the nose since two years . on clinical examination , there was a firm swelling , 3 2 cm in size , just above the right nasoalar crease , nontender and mobile . computed tomography revealed fibrous tissue over anterior surface of the right maxilla and nasal bone with mild sclerosis of the right nasal bone . excision was done through lateral rhinotomy incision . histopathological examination of the excised specimen revealed spindle cell lipoma which is very rare . very few cases have been reported in the literature so far .

arginine vasopressin ( avp ) is increasingly used in the management of refractory vasodilatory shock . indeed , it was recently incorporated into the recommendations ( grade iib ) proposed by the american heart association for treatment of refractory septic shock and the guidelines of the surviving sepsis campaign ( grade e ) . however , although the global haemodynamic effects of avp are relatively well described , its effects on the microcirculation are still largely unknown . in this issue of critical care , luckner and coworkers present an original study in which they evaluated skin micro - vascular blood flow , using laser doppler fluxmetry , before and after avp infusion in patients with refractory septic shock . they report that avp infusion did not impair forearm skin perfusion compared with norepinephrine alone . the authors intended to explore further the results of two of their previous studies : a retrospective analysis , in which they reported a 30.2% rate of ischaemic skin lesions with avp infusion ; and a prospective controlled trial that found no difference in the incidence of such lesions between a group of patients treated with avp plus norepinephrine and patients treated with norepinephrine alone . of note , it is difficult to draw conclusions regarding the safety of avp administration on the basis of the latter study because the dose of norepinephrine received by the patients in the avp / norepinephrine group was half that in the other group . as mentioned by the authors , their results presented in this issue are in striking contrast to those of several published physiological experiments on the topic . indeed , animal and human studies [ 6 - 9 ] have revealed significant dose - dependant impairment in skin blood flow with avp . indeed , the skin microvasculature is considered to be a vascular bed that is rather sensitive to avp . accordingly , the results of the study presented by luckner and coworkers are somewhat unexpected , and some methodological issues might account for the discrepancies . laser doppler fluxmetry only provides an estimate of the average blood flow in a given volume of tissue ; this volume can vary according to its intrinsic refractive properties . multiple individual and environmental factors , including haemoglobin level and temperature , can also influence the results of laser doppler fluxmetry . moreover , laser doppler fluxmetry does not take into account the type of microvessels under study , their morphology , the direction of flow and , more importantly , the heterogeneity of perfusion ; the latter is a key component in the study of microcirculation , especially in sepsis . more specifically , the biological zero , which can represent up to 80% of the total laser doppler fluxmetry signal , can be modified during ischaemia / reperfusion procedures because it is influenced by vasodilatation . therefore , various authors have suggested that the biological zero should always be taken into account when red blood cell flux is measured in the skin using laser doppler fluxmetry . finally , measurement of differential perfusion is impeded by the rather small signal and oscillatory pattern of basal cutaneous microcirculation . in addition , it is worth noting that vasomotion patterns are highly dependant on probe location relative to the tissue of interest . this could explain , to some extent , the considerable difference reported in baseline vasomotion between groups . these technical issues account for the substantial short - term variability in laser doppler fluxmetry measurements . hence , it is apparent that relatively large observed changes or large sample sizes are needed to detect statistically significant differences between groups . the power of a study is a measure of its ability to detect a statistical difference when it truly exists ; it is particularly important to bear this in mind when interpreting studies that return negative findings . the calculated power of the study reported by luckner and coworkers is approximately 40% , considering the observed difference in primary outcome ( area under the curve of the laser doppler fluxmetry signal ) between the two groups . this means that there is a 60% chance that a true difference will remained undetected . with only three additional patients in each group ( assuming the same difference in variance between groups ) the study would identify a significant difference in microvascular blood flow perfusion and lead to the conclusion that avp has , in fact , a considerable deleterious impact on skin microcirculation . finally , the important variance in avp response ( 8.56 in the avp group versus 3.25 in the norepinephrine group ; data provided by luckner and coworkers ) suggests that avp had rather heterogeneous effects from patient to patient and that other factors ( e.g. interindividual variability in sensitivity to avp stimulation , endogenous avp level , relative adrenal insufficiency , among others ) could have played a role . luckner and colleagues are to be commended for their pioneering work on the microcirculatory effects of avp . such studies are essential if we are to understand better the micro - circulatory consequences of our resuscitation strategies . however , this work should be duplicated , and we should exercise caution interpreting these results as reassurance that avp is devoid of adverse microcirculatory side effects . further work examining different microcirculatory beds and using different measurement tools to assess microcirculation will improve our knowledge of the role of avp in resuscitation .

use of arginine vasopressin in the management of refractory vasodilatory shock has been associated with development of ischaemic skin lesions . because of the increasing popularity of arginine vasopressin , it is important to evaluate its effects on microcirculatory blood flow . such studies are crucial if we are to appreciate the microcirculatory consequences of our various resuscitation strategies . however , methodological issues must always be considered because they can significantly influence interpretation of the results . some aspects of use of laser doppler to evaluate the microcirculation are reviewed within the context of recent findings presented by luckner and coworkers in this issue of critical care .

birth injuries are common phenomenon . but commonly encountered birth injuries are clavicle fracture , humerus fractures and uncommonly femur fracture . as the first secondary centre around elbow - capitellum appears at 3 - 9 months , its radilological assessment of alignment with elbow or the radius shaft is not possible in neonates . here we are reporting a case of lower end humerus epiphyseal injury , as birth injury , detected in early neonatal period . this injury is unique for the reasons that detection by conventional radiography is difficult as it mimics elbow dislocation and on reduction it is unstable injury to treat by just closed reduction . till date few such cases are reported in english literature but only two in last 10 years . though all the previously reported cases have been treated with just closed reduction , none have reported grossly unstable reduction . here we are reporting the lower end humerus epiphyseal injury in early neonatal period and use of thin k wire for stability for gross instability after reduction . common among them are fractures of humerus , clavicle and femur . injuries around the joint , and epiphyseal injuries are uncommon and are difficult to diagnose in view of late appearance of epiphyseal centres . for the diagnosis of these injuries , one has to have high level of suspicion , when the x ray is normal but clinical findings suggest otherwise . as the first secondary centre around elbow - capitellum appears at 3 - 9 months , its radilological assessment of alignment with elbow or the radius shaft is not possible in neonates . a three days old male baby presented to the outpatient department with h / o excessive crying on movement of right upper limb . mother noticed decreased movements of right upper limb on second day of birth . on examination , there was localized gross swelling in right elbow . movements of right elbow were grossly painful with excessive crying of baby on attempt to move elbow joint . patient was investigated with antero - posterior and lateral x - rays of right elbow ( fig 1 & 2 ) , routine haemogram including esr , c - reactive protein were done . x - ray showed loss of normal anatomical alignment between humerus and radius and ulna in the elbow region on right side , similar to elbow dislocation ( fig 1 & 2 ) . pre - op , elbow ap view pre - op , elbow lateral view in view of rarity of elbow dislocation during this age group , patient was advised for ultra - sonography of elbow . baby was subjected for high resolution ultrasonography ( 5 - 9mhz ) examination . on ultrasound examination ( fig3 ) , it was found that injury was distal humerus epiphyseal separation rather than the elbow dislocation , which was suspected before the scan . usg of elbow showing epiphyseal separation patient was posted for closed reduction under anaesthesia . on reduction , there was gross instability of physis , as evident on image intensifier as loss of humero - ulnar alignment . hence , closed k - wiring ( 0.5 mm diameter ) was done ( fig 4 & 5 ) . stability was achieved with wire , which was confirmed on image intensifier ( fig 4 & 5 ) i.e , reduction was maintained on leaving pressure . post op x - rays were taken on same day ( fig 6 ) , at 1 wk ( fig 7 ) , 2 wks ( fig 8) and at 2 % months(fig 9 ) . x - ray at two and half months showed complete remodelling without deformity . functionally , baby had full range of movements at 1 month follow up . intra - op iitv(c - arm ) image - ap intra - op iitv image birth injuries are commonly seen in day to day orthopaedic practice . but distal humerus epiphyseal separation , as the birth injury is not commonly described injury . the challenge in such injury is proper diagnosis , because other common possibilities like septic arthritis of the elbow especially in premature children , where classical symptoms associated with septic arthritis are not obvious in premature children . also , because of the swelling clinical findings of three point relationship of the elbow may not be readily appreciated in neonates . the x - ray image of such injury , may be misdiagnosed as elbow dislocation , as the ossification centre is not visible . elbow dislocation is not common birth injury or injury in neonates . in this case , high resolution ultra sonography [ 10 , 11 ] was very helpful tool to confirm diagnosis and plan treatment . ultra sonography is simple investigation and this can be done in nicu facility as well . in such uncommon birth injuries , unbiased clinical examination , where ever possible , is very essential . other differential diagnosis like ostegenesis imperfecta , child abuse should also be considered . some case reports have indicated - no treatment for such injuries with supposed good results without any treatment . but closed reduction alone in unstable injuries has not been explained . in such cases , rather than leaving the injury unreduced ( grossly mal - aligned ) and hoping for the re - modelling to correct all the deformity , a thin ( o.5 mm ) k wire for stability can be used . since these injuries are very fast to heal in neonates , removal of wire at two weeks can be planned . when x ray as imaging modality is inconclusive , ultrasonography is simple and useful tool in diagnosis . in grossly unstable epiphyseal injury of distal humerus , it is better to stabilize the injury with thin k wire than hoping nature to correct the deformity completely . utilization of ultrasonography is an useful tool in neonatal as well as , epiphyseal injuries . proper diagnosis and simple procedure like k wiring will go a long way getting acceptable results in case of neonatal epiphyseal injuries .

introduction : birth injuries are common phenomenon . but commonly encountered birth injuries are clavicle fracture , humerus fractures and uncommonly femur fracture . incidence of distal humerus epiphyseal injuries as birth injury are rare . as the first secondary centre around elbow - capitellum appears at 3 - 9 months , its radilological assessment of alignment with elbow or the radius shaft is not possible in neonates . it is difficult to differentiate elbow dislocation from epiphyseal injury in neonates.case report : here we are reporting a case of lower end humerus epiphyseal injury , as birth injury , detected in early neonatal period . this injury is unique for the reasons that detection by conventional radiography is difficult as it mimics elbow dislocation and on reduction it is unstable injury to treat by just closed reduction . the fine resolution sonography differentiates the epiphyseal separation from elbow dislocation . till date few such cases are reported in english literature but only two in last 10 years . though all the previously reported cases have been treated with just closed reduction , none have reported grossly unstable reduction . here we are reporting the lower end humerus epiphyseal injury in early neonatal period and use of thin k wire for stability for gross instability after reduction.conclusion:epiphyseal injuries , though rare , are very deceptive . they have to be diagnosed properly and appropriately managed .

it is a rare complication with a frequency that is under reported as well as underestimated . therefore , physicians as well as surgeons need to be aware of this clinical entity and not assume that previous appendectomy precludes recurrent / stump appendicitis . failure to recognize this possibility may lead to delay in treatment and may result in complications such as perforation , abscess formation , and sepsis . we report a case of stump appendicitis in an 18-year - old boy , 2 years following laparoscopic appendectomy . an 18-year - old boy was admitted by a physician with a 1 day history of severe periumbilical pain radiating to the right iliac fossa with loss of appetite . there was no history of vomiting , fever , altered bowel habits or urinary symptoms . patient had undergone laparoscopic appendectomy 2 years back and had an uneventful recovery , but the details of the operative findings and histopathology were unavailable . positive clinical findings included a right lower quadrant tenderness and leukocytosis i.e. 15,000 cells / mm ( reference normal range 4 - 11,000 cells / mm ) . a computed tomogram of abdomen showed only small collection in right iliac fossa [ figure 1 ] and initial conservative management was planned by the treating physician . ct scan of abdomen showing localized fluid collection suggestive of abscess in right iliac fossa surgical consultation was sought after two days as the clinical condition of the patient deteriorated . there was a 3 cm long inflamed perforated appendicular stump with abscess formation ( ~ 30 - 40 ml pus ) [ figures 2 and 3 ] . the appendicular stump was defined and divided at the base with an endo stapler [ figure 4 ] . patient had port site wound infection in post operative period and was discharged on 4 post operative day . intra operative view of abscess in right iliac fossa intra operative view of residual perforated appendicular stump intra operative view of completion appendicectomy with endoscopic linear stapler claudius amyand in 1735 , performed the first appendectomy and reginald fitz in 1886 , described the clinical features and pathological abnormalities of appendicitis . in 1945 , rose was the first to describe stump appendicitis in two patients who had undergone appendectomy for acute appendicitis in past . the appendix arises from the postero - medial wall of cecum about 3 cm below the ileocecal valve . its variable position and subserous length , combined with acute inflammation , may result in misidentification of the appendicio - cecal junction . dissecting the recurrent branch of the appendiceal artery and following generally , an appendix stump shorter than 5 mm reduces the risk of stump appendicitis . stump appendicitis is one of the rare delayed complications after appendectomy with the reported incidence of 1 in 50,000 cases . prompt recognition is important to lead to an early treatment , thus avoiding serious complications like wound infection , intra abdominal abscess , and intestinal perforation with peritonitis , bleeding , and adhesions with sub acute intestinal obstructions . stump appendicitis can represent a diagnostic dilemma if the treating physician is unfamiliar with this uncommon clinical entity . clinically , patients present with sign and symptoms mimicking appendicitis or acute abdomen along with a previous history of appendectomy as seen in our case . the presence of an appendectomy scar does not rule out the possibility of stump appendicitis . the time interval for onset of symptoms could range from 2 weeks to years after appendectomy . it has been reported following both open and laparoscopic appendectomy . whether the laparoscopic technique plays any role in the increased incidence of stump appendicitis is yet to be ascertained . the potential limitation of laparoscopy such as lack of 3d vision and absence of tactile feedback has been suggested by some authors to increase the chance of leaving behind a longer stump . further advancement in the techniques of laparoscopy and especially the use of angled scopes and high definition cameras provide good visualization of the surgical field . accurate visualization of the base of the appendix either in open or laparoscopic appendectomy is a must to minimize the incidence of stump appendicitis . leaving a longer stump may result in chronic inflammation or serve as a reservoir for fecoliths , become ischemic and eventually perforate and / or suppurate . it has been suggested that no appendicular stump longer than 3 mm should be left behind . the common conditions leading to stump appendicitis have been broadly classified under the anatomical and surgically related factors . one common denominator is the inappropriate indentification of the appendicular base i.e appendicular - cecal junction . the anatomically related factors may be a retrocecal or subserous appendix or a duplicated appendix , a rare developmental abnormality seen in about 0.004% in appendectomy patients . the surgical factors predisposing for stump appendicitis may be inadequate indentification of the appendicular base because of severe local inflammation , leaving long stump due to fear of cecal injury or difficult dissection and local ulcerations due to fecoliths . the stump appendicitis has been reported following open appendectomy with stump ligation , open appendectomy with stump inversion , and laparoscopic appendectomy where appendiceal stump is either closed with an endoloop or by stapling . both the surgical techniques i.e. inversion of stump or simple ligation of stump can not prevent the possibility of stump appendicitis . radiological evaluation by ultrasound and computed tomography ( ct scan ) aids in the preoperative diagnosis of stump appendicitis . ct scan of the abdomen is more specific than ultrasound for the accurate pre operative diagnosis of stump appendicitis because it excludes other etiologies of acute abdomen . they include pericecal inflammatory changes , abscess formation , fluid in the right paracolic gutter , cecal wall thickening , and an ileocecal mass . in the era of laparoscopy a diagnostic laparoscopy may prove to be the next diagnostic and therapeutic option in case of ambiguity . completion appendectomy either by open or by laparoscopic intervention is the treatment of choice for stump appendicitis . very rarely , extensive surgery such as ileocolic resection may be necessary if there is significant inflammation around the ileocecal region . it is imperative to adequately visualize the appendicular base and the ileocecal region to ensure that a stump not more than 5 mm remains after appendix removed . the prevalence and incidence of stump appendicitis has been increasing in the recent years . clinical presentation of stump appendicitis mimics symptoms and signs of acute appendicitis or acute abdomen and with a previous appendectomy . henceforth , it merits consideration in the differential diagnosis of acute abdomen . the diagnosis is often missed or delayed if the clinician is unaware of this rare clinical entity . clinical awareness and a high level of suspicion would prevent unnecessary delay in initiating treatment thus avoiding serious complications . intra - operatively meticulous dissection , proper indentification of the appendicular base i.e. appendicio - cecal junction and leaving the appendix stump shorter than 5 mm minimizes the incidence of stump appendicitis .

stump appendicitis is one of the rare delayed complications after appendectomy with reported incidence of 1 in 50,000 cases . stump appendicitis can present as a diagnostic dilemma if the treating clinician is unfamiliar with this rare clinical entity . we report an 18-year - old patient with stump appendicitis , who underwent completion appendectomy laparoscopically .

3 full factorial design was used for the optimization . the levels for the selected independent variables y = b0 + b1x1 + b2x2 + b12x1x2 + b11x12 + b22 x22 on the basis of the preliminary trials a 3 full factorial design was employed to study the effect of independent variables i.e. drug - to - polymer - to - polymer ( x1 ) and the stirring speed ( x2 ) on dependent variables like particle size , drug entrapment efficiency , the time required for 50% drug release ( t50 ) and drug released up to 5 hr ( y5 ) and 12 hr ( y12 ) . the expected in vitro release pattern selected for the colonic delivery was not more than 10% of the drug release up to the end of small intestine ( 5 hr ) and more than 85% of drug release up to 12 hrs . in factorial design batches microspheres thus obtained were recovered from the medium and dried subsequently and stored properly for the further studies . the concentration of cross linking agent and stirring speed were varied in batches c1 to c9 . potential variables such as concentration of chitosan solution , polymers to drug ratio ( 2:1 ) and amount of dispersion medium ( 500 ml ) were kept constant . in vitro drug release studies in simulated gastro intestinal fluids showed a burst release pattern in the initial hour necessitating microencapsulation with eudragit s100 by solvent evaporation technique . the effect of different coat / core ratio on particle size , drug entrapment efficiency and in vitro drug release were studied . the microspheres of all the batches of the factorial design were spherical and free flowing . the average particle size of different chitosan microsphere formulations was found to be in the range of 9.93 m- 18.48 m and showed good correlation co - efficient ( 0.9932 ) . results indicate that the effect of x1 ( stirring speed ) is more significant than x2 ( amount of cross linking agent ) . when higher level of glutaraldehyde was used cross linking favoured and hence slower drug release was observed compared to the other batches . the entrapment efficiency of different formulations was found to be between 66.65 to 92.07% and showed good correlation co - efficient ( 0.9293 ) . the effect of stirring speed on entrapment efficiency showed that optimum speed should be 1000 rpm . in vitro dissolution of all the batches indicates that the burst release pattern in the initial hour . within 5 hr 70 to 90% of drug cumulative in vitro drug release of carvedilol from formulations c1 to c9 thus , only biodegradable polymers were not satisfactory for colonic delivery . the burst release may be due to solubility of chitosan in the acidic ph . in order to prevent the drug release in stomach and small intestine these chitosan microspheres were encapsulated with eudragit s100 , which shows solubility at a ph 7 . since formulation c4 showed high drug loading and drug release pattern , it is selected for microencapsulation process . chitosan microspheres ( c4 ) were microencapsulated with eudragit s100 to achieve colonic delivery of carvedilol . the effect of core - coat ratio on eudragit s100 microencapsulated chitosan microspheres was studied and found that the particle size was increased from 137.87 to 154.33 m with increasing the core - coat ratio from 1:8 to 1:12 . the entrapment efficiency of microencapsulated formulations varied between 90 - 95% with increasing core - coat ratio . the in vitro drug release studies of various eudragit coated chitosan microspheres were performed in simulated gastro intestinal fluids . results showed that 8 - 12% of drug was released within initial 4 hrs and increased thereafter when the formulations were exposed to ph which is above solubility of eudragit s100 . the best formulation then subjected to in vitro drug release in presence of rat ceacal contents . a result of release studies indicates that eudragit s100 coating offers a high degree of protection from premature drug release in the stomach and small intestine . eudragit coated chitosan microspheres deliver most of the drug load in the colon , an environment rich in bacterial enzyme that degrade the chitosan and allow drug release to occur at the desired site after proper transit time . thus , the designed formulation is potential systems as multiparticulate for the chronotherapy of hypertension .

the purpose of this research was to design , and evaluate multiparticulate systems for chronotherapeutic delivery of beta blocker containing biodegradable polymers coated with ph sensitive polymers in hypertension . chitosan was used as a carrier for drug delivery and eudragit s100 was used as an enteric coating polymer . 32 full factorial design was employed to optimize the proper formulation for chronotherapeutic drug delivery .