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a review of the literature and an extensive medline search revealed that this is the first case report of the use of guaifenesin to increase sperm motility . he reported an inability to conceive with his wife after 18 months of unprotected intercourse . a semen analysis was performed that included spermatozoa count , liquefaction , morphology , motility , viscosity and volume . two months after guaifenesin therapy the semen analysis was repeated that demonstrated marked improvement in both total sperm count and motility . evidence for the effectiveness of guaifenesin is almost entirely anecdotal . given the mechanism of action of guaifenesin , it is not clear from this case why the patient demonstrated such a large improvement in both sperm count and motility . additional studies of the effects of guaifenesin on male fertility could yield information of the medication s effect on men with normal or decreased total sperm counts . there are currently anecdotal reports and popular news media stories on the use of guaifenesin , particularly the brand name product robitussin ( pfizer , inc . , new york , ny ) , for use in treating both male and female infertility.14 guaifenesin is an expectorant medication sold over the counter and usually taken by mouth to assist expectoration of phlegm from the airways in acute respiratory tract infections . its mode of action in treating infertility is not well understood , but it appears to decrease mucus viscosity . a 32-year - old male patient presented to his primary care provider for an infertility evaluation . the patient is a nonsmoker , who consumes little or no alcohol with no known allergies . a recent screening exam for pulmonary tuberculosis was negative and the patient had recently undergone a required military service physical exam . he reported an inability to conceive with his wife after 18 months of unprotected , regular intercourse . as part of a routine infertility evaluation a semen analysis was performed that included spermatozoa count , liquefaction , morphology , motility , viscosity and volume ( cpt code 89320 ) . initial results of the semen analysis demonstrated low sperm count and motility ( table 1 ) . this sample , as well as the follow - up sample , were obtained through masturbation and provided to the lab within 30 minutes of collection . the patient s primary care provider offered treatment with guaifenesin 600 mg extended release tablets twice daily . the repeat semen analysis demonstrated marked improvement in both total sperm count and motility ( table 1 ) . the patient made no other significant lifestyle changes during the treatment course with guaifenesin . at the time of writing this case report describes the semen analysis laboratory results in a male patient who was given guaifenesin . guaifenesin is a mucolytic agent usually taken orally to assist the expectoration of phlegm from the airways in acute respiratory tract infections . scientific evidence for the effectiveness of guaifenesin is almost entirely anecdotal ; a review of medical literature revealed very limited data on use of guaifenesin for infertility.5,6 there appeared to be some improvement in a small study without controls of female infertility related to hostile cervical mucus.5 check regards guaifenesin as the simplest but least effective method of improving cervical mucus.7 given the proposed mechanism of action of guaifenesin , it is not clear from this case why the patient demonstrated such a large improvement in both sperm count and motility . additional study of the effects of guaifenesin on male fertility suggests the need to conduct a more rigorous placebo - controlled clinical trial that could yield information of the medication s effects on men with normal or decreased total sperm counts .

backgrounda review of the literature and an extensive medline search revealed that this is the first case report of the use of guaifenesin to increase sperm motility.casea 32-year - old male presented for an infertility evaluation . he reported an inability to conceive with his wife after 18 months of unprotected intercourse . a semen analysis was performed that included spermatozoa count , liquefaction , morphology , motility , viscosity and volume . initial results of the semen analysis demonstrated low sperm count and motility . the provider offered treatment with guaifenesin 600 mg extended release tablets twice daily . two months after guaifenesin therapy the semen analysis was repeated that demonstrated marked improvement in both total sperm count and motility.conclusionevidence for the effectiveness of guaifenesin is almost entirely anecdotal . given the mechanism of action of guaifenesin , it is not clear from this case why the patient demonstrated such a large improvement in both sperm count and motility . additional studies of the effects of guaifenesin on male fertility could yield information of the medication s effect on men with normal or decreased total sperm counts .

the following section describes the treatment procedure for patients with deep infection following tka using modified static spacers . the original prosthesis was removed , followed by intensive irrigation and wide debridement of the infected soft tissue . a 36 fr - diameter straight thoracic catheter ( mallinckrodt medical , athlone , ireland ) and a steinmann pin measuring 3.0 mm in diameter and 22 cm in length vancomycin ( 2 g ) was then added to the gentamicin bone cement ( depuy , warsaw , in , usa ) . at the late liquid stage of the cement , the steinmann pin was inserted into the tube , and the prepared cement was delivered through the tube . during this procedure , the tube was removed from the cement rod using a surgical knife . finally , a cement rod measuring 9 mm in diameter and 22 cm in length was formed ( fig . an entry hole was created at the center of the distal femur and proximal tibia for the insertion of the cement rod . the rod was then inserted into the femur and tibia through this hole . during insertion , it was important to place the center of the cement rod on an imaginary joint line . the proximal medullary canal of the tibia was filled with antibiotic - impregnated cement up to the surface of the proximal tibia , while the surgical assistant maintained proper anatomic alignment and joint space . the space between the cement of the distal femur and the proximal tibia was filled with more antibiotic - impregnated cement . finally , the suprapatellar pouch and medial and lateral gutter space were filled with antibiotic - impregnated cement to reduce soft tissue adhesion ( fig . cylinder splint immobilization was required for three days after the operation , after which a fixed - angle knee brace was used and toe - touching ambulation was allowed until the reimplantation surgery . from april to november 2007 , the authors performed the static technique in four patients using the novel antibiotic - impregnated cement rod for the treatment of infected tka ( culture : staphylococcus in three cases and no bacteria in one case ) . follow - up laboratory studies , including erythrocyte sedimentation rate and c - reactive protein , culture study via knee aspiration and a frozen biopsy from the second - stage operation ( < 5 polymorpho - leukocytes / high power field ) were performed to confirm successful eradication of the infection . the second - stage reimplantation was performed when all the criteria for the validation of infection control were met ( fig . the second - stage reimplantation was performed using the rectus snipping approach , and more than 90 of flexion was obtained intra - operatively . in all four patients , no re - infection was evident after two and a half years of follow - up . the range of motion of the knee joints were respectively improved from 50 to 80 , 95 , and 100 , and the knee society scores were 70 , 86 , 65 , and 84 , respectively , in the last follow - up evaluation . fehring et al.8 ) emphasized the importance of resting the joint in septic joint conditions . others also reported that the static spacer technique provides more stability than the mobile spacer technique in patients with severe bone loss.5,8 ) the main advantage of this technique is the maintenance of a normally aligned lower limb during the interval period . this maintains knee stability in combination with early muscle strengthening exercises , including quadriceps setting exercise , and enables the patient to comfortably dress and manage him / herself during the intervening period . the cement rod and static spacer provide a stable gap between the femur and tibia , thereby minimizing soft tissue contracture and shortening of the lower limb . in addition , symmetric maintenance of the soft tissue of both medial and lateral gutters requires no additional soft tissue balancing at the second - stage reimplantation . the additional cost of a metal nail , however , and the difficulty in infection control due to biofilm formation around the metal nail can be troublesome . in addition , a metal nail can not be removed easily at the second stage reimplantation due to its hardness , and soft tissue adhesion of the femoral or tibial medullary canals . on the other hand , an antibiotic - impregnated cement rod enjoys advantages , such as inexpensive antibiotic delivery to the marrow spaces and easy removal by using a hercules cutter . in addition , a static spacer is anchored to the cement rod , which can prevent spacer migration and bone erosion . this feature is believed to generate less cement wear debris than with the conventional static spacer or mobile articulating spacer technique . during the conduct of the antibiotic - impregnated cement rod technique , antibiotic - impregnated cement was applied to the proximal tibia , distal femur , joint gap space , suprapatellar pouch , and both gutters in a stepwise manner . this technique enables easy removal of the cement and reduced soft tissue adhesion at second - stage reimplantation .

the two - stage exchange arthroplasty ( one- or two - stage ) is believed to be the gold standard for the management of infections following total knee arthroplasty . we herein report a novel two - stage exchange arthroplasty technique using an antibiotic - impregnated cement intramedullary nail , which can be easily prepared during surgery using a straight thoracic tube and a steinmann pin , and may provide additional stability to the knee to maintain normal mechanical axis . in addition , there is less pain between the period of prosthesis removal and subsequent reimplantation . less soft tissue contracture , less scar adhesion , easy removal of the cement intramedullary nail , and successful infection control are the advantages of this technique .

nathan , as an oncology fellow , knew well that white blood cells fought infections . this was an experiment repeated in front of us all the time , he says : chemotherapy lowered his patients ' white blood cells and increased their risk of infections . mackaness had shown that macrophage activation did not depend on direct contact with t cells ( 1 ) , suggesting the possibility of a secreted factor . when nathan tested the supernatant from activated t cells , he saw that it did indeed induce macrophage activation ( 2 ) . nathan got a rough idea of the molecular weight ( 3 ) , but that was the best anyone could do , he says . protein separation methods were primitive , and cloned proteins and monoclonal antibodies would only become available a decade later . henry murray , one of nathan 's collaborators , sums up the feeling of frustration : we were all nibbling at the edges of the same problem . nathan therefore changed tack to take a closer look at the activated macrophages . short - lived neutrophils were known to produce hydrogen peroxide , and nathan found the same was true of longer - lived activated macrophages ( 4 ) . unlike previous signs of macrophage activation increased spreading , phagocytosis , and glucose metabolism this so - called respiratory burst ifn had been on the cover of time magazine , and recombinant murine ifn was found to induce macrophages to kill tumor cells ( 5 ) . nathan , now a faculty member in zanvil cohn 's macrophage factory at rockefeller university ( new york , ny ) , thought ifn might also activate macrophages to kill intracellular parasites . consistent with this idea , ifn was made by antigen - stimulated t cells and was associated with defense from infection . now the respiratory burst gave nathan an assay , berish rubin ( down the street at the new york blood center ) supplied an ifn monoclonal antibody , and a phone call to genentech yielded recombinant ifn. in a seminal paper published in the journal of experimental medicine in 1983 , nathan was thus able to show that depleting ifn from unpurified t cell supernatants decreased the respiratory burst activity and the killing of intracellular protozoa in human macrophages . adding back recombinant ifn into this mix restored macrophage activation ( 6 ) . i had an assay , a hunch , a history of purifying proteins that did this , and the serendipity of meeting with people nearby who had the antibody . nathan next showed that ifn worked in people . injecting recombinant ifn directly into cutaneous lesions of lepromatous leprosy patients induced macrophage infiltration , hydrogen peroxide production , and killing of the causative pathogen , mycobacterium leprae ( 7 ) . in the 1990s , the macrophages of children with ifn receptor deficiencies were shown to be defective in killing mycobacteria ( 8) . tracing the pathway from t cells to macrophages to bacteria started , for nathan , in 1967 , and he says we still haven't finished making the molecular links .

t cells tell macrophages when to start making the toxic soup of lysosomal enzymes , reactive oxygen species , and nitric oxide that destroys intracellular pathogens . in 1983 , carl nathan proved that this start signal comes in the form of the secreted cytokine ifn.

temporary henna tattoos or pseudotattoo have become increasingly widespread among children and adolescent , as a safe and economic alternative to permanent tattoos . it is well - known that allergic skin reactions to natural henna are rare , due to its extremely low rate of sensitization . in india , north of africa , china , and egypt , it is used in weddings and religious ceremonies ; in occident , it is used to dye hair and cosmetics . paraphenylenediamine ( ppd ) , a powerful allergen , is added to the henna tattoo mixtures ( black henna tattoo ) to decrease application time and intensify the color . we describe the case of a 7-year - old boy who reported erythematous papular bulls - eye shaped lesions and consolidated edema primarily in the upper and lower extremities [ figure 1 ] . he also showed an erythematous - eczematous lesion on his leg , shaped like a dolphin [ figure 2 ] , and lesions compatible with erythema multiforme - like reaction . erythematous papular lesions contact eczema in the tattoo area dolphin shaped patch tests were performed , and we observed a high sensitivity after 48 h and moderate after 96 h. we reported a positive reaction to ppd . henna has been used to paint the skin for adornment and religious reasons for 9000 years and in over 60 countries . christians , jews , muslims , hindus , and buddhists have used henna as part of their religious customs . the henna is a flowering plant native to northern africa , western and southern asia in semi - arid zones , used since antiquity to dye skin . it has a great affinity for keratinocytes , and it is used to create temporary tattoos , without it being necessary to puncture the skin . black henna contains an ingredient in addition to pure henna to achieve its ebony color . in most cases , this added ingredient is ppd , a powerful sensitizer that should not be directly applied to the skin as it may cause mild contact dermatitis . one of the most dangerous applications of this chemical is when it is added to henna because the dye is applied while the ppd is in its oxidation process , and its potential as allergen is increased . when added to henna , the concentration of ppd is often much higher than what is approved for use in hair dyes . the cause of the sensitivity to ppd is unknown ; it is believed that the mechanism involved in the pathogenesis may be a reaction mediated by type iii immune complexes and associated with type iv retarded hypersensitivity . various topicals allergens cause erythema multiforme , including topical drugs such as corticosteroids , nonsteroidal anti - inflammatory drugs , iodine povidone , imiquimod ; rubber gloves ; nickel and herbicides . three possible causes of the residual hypopigmentation have been described : a reduction in melanin synthesis , selective destruction of the melanocytes , or photoleukomelanodermitis due to pigment blocking . as henna tattoos are becoming increasingly popular , prevention requires the provision of information to consumers , especially young people and their parents . it is important for the population to be aware of this circumstance and the risk entailed by sensitization to ppd . to conclude , we believe that temporary black henna tattooing should be controlled by health authority legislation to minimize the appearance of new cases of reaction to ppd and the serious and permanent consequences we have presented . it is important for the population to be aware of the risk entailed by sensitization to ppd due to popular henna tattoos .

temporary henna tattoos or pseudotattoos have become increasingly widespread among children and adolescent . a generalized skin reaction , type erythema multiforme - like reaction is unusual , and rarely reported . we describe the case of a 7-year - old boy who reported erythematous papular bulls - eye shaped lesions and consolidated edema primarily in the upper and lower extremities . these lesions were compatibles with erythema multiforme - like reaction . he also showed an erythematous - eczematous lesion on his leg , shaped like a dolphin . in this area , a temporary henna tattoo was painted 1-month earlier . patch test was positive for paraphenylenediamine ( ppd ) . skin reactions due to henna are rare . most of the reactions are due to additives , especially ppd , an aniline derivative , which is added to speed up the process of skin dyeing and to give a darker brown to black color ( black henna ) . as henna tattoos are becoming increasingly popular , prevention requires the annual provision of information to consumers , especially young people and their parents .

a 55 year - old man visited our emergency department because of increasing frequency of chest pain . he had undergone off - pump coronary artery bypass grafting ( cabg ) 10 years ago because of unstable angina associated with three vessel coronary artery disease . at the initial operation , the in situ right internal thoracic artery ( ita ) , in situ left ita and in situ right gastroepiploic artery ( rgea ) grafts were used to revascularize the left anterior descending coronary artery , two obtuse marginal coronary branches , and posterior descending coronary artery , respectively . an excess segment of the distal right ita was connected to the side of left ita as a y - composite graft and anastomosed to the first diagonal coronary artery . coronary angiography and myocardial single photon emission computed tomography ( spect ) were performed at 5 years after surgery as a follow - up study . the 5-year angiography showed all patent grafts and the myocardial spect demonstrated no perfusion decrease . exertional chest pain recurred at 7 years after surgery , and a repeated coronary angiography showed patent previous grafts including faint visualization of the in situ rgea graft associated with significant stenosis at the os of the celiac axis . the computed tomographic angiogram also demonstrated a 90% stenosis at the celiac os , which had been without stenosis on abdominal angiography taken before the surgery ( fig . redo off - pump cabg was performed 10 years after the initial surgery because of an increasing frequency of angina and an aggravated finding of the follow - up myocardial spect , which was a newly developed reversible perfusion decrease in the inferior wall ( fig . , the great saphenous vein was harvested from the lower leg and interposed between the middle part of in situ right ita and distal part of in situ rgea grafts used previously , to supply blood flow from the right ita graft to the posterior descending coronary artery . one year after redo surgery , the patient had no symptoms of angina and coronary angiogram was performed and revealed patent grafts , including an interposed saphenous vein graft ( fig . 3a ) . the myocardial spect test was also performed and demonstrated that there was no perfusion decrease including the inferior wall ( fig . reoperations for coronary artery disease have been increased due to the increased number of isolated cabg . the society of thoracic surgeons statistics indicated that nearly 5% of the current cabg procedures done in the us were repeat surgical revascularization . angiographic indications for reoperation are progression of native coronary atherosclerosis , previous graft failure or a combination of both . one previous study demonstrated that 4 out of 400 patients who underwent cabg using the rgea graft needed percutaneous interventions due to the rgea graft failure during postoperative follow - up of 2211 months . one of those 4 patients required an angioplasty for a newly developed stenosis of the celiac trunk . in the present case , an indication for reoperation the patient had been free of angina , and the angiographic and myocardial spect follow - up studies revealed no abnormal findings at postoperative 5 years . when the patient suffered from recurred angina at postoperative 7 years , coronary angiography showed a faint visualization of the in situ rgea graft associated with significant stenosis at the os of the celiac axis . the 10-year follow - up myocardial spect test demonstrated a newly developed reversible perfusion decrease in the inferior wall . the prevalence of celiac axis stenosis was 7.3% in a korean population although it was lower than the previously reported incidence of celiac axis stenosis in western populations ranged from 12.5% to 24% . in the present case , celiac artery stenting could be an alternative option in such a case . however , we performed a redo operation because celiac axis stenting was associated with a high incidence of late restenosis . the aorta or another in situ arterial graft could be chosen as a blood source . alternatively , patent in situ grafts used previously may be re - used as an inflow conduit . with regards to our patient , the 3 in situ arterial grafts had already been used . the saphenous vein graft was interposed between the middle part of right ita and distal part of in situ rgea grafts used previously .

we report a redo coronary artery bypass grafting ( cabg ) in a 55-year - old man . angina recurred 7 years after the initial surgery . coronary angiography showed all patent grafts except a faint visualization of the in situ right gastroepiploic artery ( rgea ) graft , which was anastomosed to the posterior descending coronary artery , associated with celiac axis stenosis . redo - cabg was performed at postoperative 10 years because of aggravated angina and decreased perfusion of the inferior wall in the myocardial single photon emission computed tomography . the saphenous vein graft was interposed between the 2 in situ grafts used previously ; the right internal thoracic artery and rgea grafts . angina was relieved and myocardial perfusion was improved .

since the introduction of extra - oral implants in reconstruction of craniofacial defects , achieving proper prosthesis retention has become more promising . these problems include ulceration of hard and/or soft tissues used for retention , lack of retention due to prosthesis movement , and tissue irritation caused by adhesives . the ideal position and number of implants for restoring orbital defects would be three non - linear implants in lateral , supraorbital , and infra - orbital rims . however , such implant arrangement is not always conceivable considering the extension of the defect , and bone quality and quantity of defect s walls . two of the most common retention systems used in reconstruction of orbital defects include freestanding abutments with magnetic retention and bar - clip retention . magnetic abutments are more common because they resolve the potential problems associated with bar - clip attachment including difficulty in insertion and removal of prosthesis by the patient , difficulty in regular hygiene measurements , and rigidity of the attachment resulting in implant overloading . however , magnetic attachment might not provide sufficient retention if implants have been placed adjacently . the presence of implant in the defective area might complicate the usual impression - taking procedures used in fabrication of conventional craniofacial prostheses . accuracy of the impression is affected by defect shape , retention system , number , and divergence of the implants . moreover , anatomical undercuts in the defect , and proximity or remoteness of the implants could complicate the impression - taking procedure . use of multiple trays , elastomeric impression materials , and dual impression technique have been suggested to overcome such problems [ 2,1214 ] . the purpose of this article was to present a case treated with an implant - supported prosthesis to reconstruct a relatively large orbital defect using three adjacent implants in the lateral orbital rim . a 60-year - old woman with a left orbital defect due to removal of periocular basal cell tumor was referred to the implant department of tehran university of medical sciences , school of dentistry , for prosthetic reconstruction of the eye . three implants ( superline , dentium , seoul , south korea ) , 8 mm in length and 3.6 mm in diameter were placed in the lateral rim of the orbit . although the most suitable sites for orbital implants are the superior and lateral rims , in the present case the implants have been placed adjacently , due to insufficient bone thickness in superior and inferior orbital rims . the defect was relatively deep with undercuts in the medial wall which could complicate impression making . the preferred prosthesis design was an implant - supported prosthesis with a custom bar containing properly distributed magnetic components . the healing abutments were unscrewed and three hexed direct - casting abutments ( implantium , dentium , seoul , south korea ) with 4.5 mm diameter were directly secured to the implants . the medial undercuts were blocked out , using a gauze pack to avoid the penetration of acrylic resin . an auto - polymerizing acrylic resin ( pattern resin , gc , tokyo , japan ) pattern was formed directly on the abutments in a manner that cobalt samarium ( co5sm ) magnets ( implantium , dentium , seoul , south korea ) , with 5.5 mm diameter and retention force of 700 gram could be placed at proper distances in the superior , inferior and lateral segments of the acrylic bar ( fig . the acrylic resin bar was casted using base metal alloy ( aalba dent inc . ; cordelia , c.a , usa ) and the magnet keepers were cemented in corresponding sites with panavia f 2.0 resin cement ( kurary medical inc , japan ) . acrylic resin pattern of bar containing indentations for magnets ( a ) , try - in of metal bar on the implants with magnet keepers in place ( b ) . the space beneath the superstructure and also the undercuts in defect walls were blocked out with gauze packs . the final impression was made in order to pick up the magnets and simultaneously record the rest of the orbital defect . light viscosity addition silicone ( panasil , kettenbach , germany ) was used as the first layer to cover the entire defect as well as the intact side of the midface . afterwards , regular viscosity addition silicone ( panasil , kettenbach , germany ) was used over the light viscosity material to create mechanical retention projections for the gypsum layer ( herostone vigodent inc . the wax pattern of the orbit was formed containing an ocular prosthesis which simulated the properties of a healthy eye . the pattern was tried on the patient and some modifications were made to improve its esthetic and adaptation . the prosthesis was made of a combination of heat - cured acrylic resin for holding the magnets , and high - temperature vulcanizing silicone with internal / external staining and other characterizations of the skin , such as wrinkles , eye brow and eye lashes . the final prosthesis was delivered to the patient and necessary home care instructions were provided such as removing the prosthesis during night , cleaning the eye defect with damp gauze , and the need for regular biannual follow - ups [ 69 ] . tissue side of the prosthesis with three magnets ( a ) , delivery of the prosthesis ( b ) the patient presented here has been treated with an implant - supported orbital prosthesis with bar - magnetic attachment . this retention mechanism might minimize the risk of mechanical overload on the implants compared to a conventional bar - clip attachment with cantilever arms . despite the proximity of implants , the mentioned distribution of magnetic attachments has increased the retention through creating a tripod . furthermore , since the acrylic resin pattern of the bar was made directly in the defective area , no implant or abutment analogues were used in final impression procedure . prolonged chair - side time is a disadvantage of the stated method which could be justified considering the mentioned advantages .

implant - supported craniofacial prostheses are made to restore defective areas in the face and cranium . this clinical report describes a technique for fabrication of an orbital prosthesis with three adjacent implants in the left lateral orbital rim of a 60-year - old woman . selection of appropriate attachment system ( individual magnetic abutments versus bar - clip attachment ) for implant - supported orbital prostheses depends upon the position of implants . bar - magnetic attachment has been selected as the retention mechanism in the present case .

the laparoscopic removal of a cervical stump following a supra cervical ( subtotal ) hysterectomy was first described by nezhat et al , and they concluded that the cervical stump could be removed laparoscopically by an experienced surgeon . the advantages of the laparoscopic approach included possible stump adhesiolysis , providing adequate postoperative vault support , and assessment of the pelvic lymph nodes . the 43-year - old , presented with a history of persistent p v discharge and occasional post - coital bleeding . she had undergone subtotal hysterectomy in 1994 , due to postpartum hemorrhage following a normal delivery . a colposcopic biopsy done in january 2009 , reported severe dysplasia of the cervix , with a human papillomavirus ( hpv ) effect and crypt extension . there was a strong family history of cancer of the cervix , as her mother had succumbed to the disease . on general examination she was in fair general condition , well - built and well - nourished , with adequate hydration . the hemoglobin was 13.3 g / dl , blood sugar was 5.3 mmols / l , urea and electrolytes were normal . an initial diagnosis of abnormal pap smear was entertained and the patient opted for a laparoscopic trachelectomy , with the option of a laparotomy , after discussing all her options . there were dense adhesions in the pouch of douglas involving the bowel and the cervical stump . the pelvic lymph nodes were clearly visualized ( after intracervical methylene blue injection ) and did not appear to be enlarged . gentle adhesiolysis was undertaken using sharp dissection , bipolar cautery , and a harmonic scalpel . the vaginal vault was subsequently opened over the ceramic cup of a clermont ferrand elevator . a cystoscopy with retrograde ureteral catheterization , to confirm the integrity of the bladder and ureters , was undertaken . the cervical stump after laparoscopic trachelectomy at one week of follow - up the patient was well . a postoperative intravenous urogram ( ivu ) confirmed that both the ureters and bladder were intact . subtotal hysterectomy was developed as a procedure in the 1990s , and is regarded as a safe option to total abdominal hysterectomy in the management of benign uterine conditions and in obstetrics , due to severe postpartum hemorrhage . okaro et al , in an assessment of the long - term outcomes of laparoscopic supracervical hysterectomy analyzed the case records of 70 consecutive women undergoing the procedure . of these , 24.3% ( 17 cases ) reported symptoms related to the cervical stump , within 14 months of the original surgery . in his series 14 of these patients underwent laparoscopic trachelectomy , one had only laparoscopic adhesiolysis and two underwent a laparotomy with trachelectomy due to dense bowel adhesions on the cervical stump . histologically the stumps showed endometriosis ( 23.5% ) and mild dysplasia in 7.6% of the patients . in this case our patient presented with persistent p v discharge and occasional post - coital bleeding . the subsequent pap smears were abnormal . in a retrospective of 41 patients undergoing laparoscopic subtotal hysterectomy , van der stege et al , noted that 98% of the patients were satisfied with their procedure , with 10% of them having monthly spotting . they concluded that although laparoscopic hysterectomy for benign diseases was a satisfactory procedure , special attention should be paid to careful management of the cervical stump . hilger et al , reviewed the indications of 310 trachelectomies performed at the mayo clinic from 1974 to 2003 . they included stump prolapse ( 4% ) , fibroid mass ( 1% ) , cervical dysplasia ( 6% ) , carcinoma in situ ( 5% ) , irregular bleeding ( 2% ) , and cervicitis ( 53% ) . the complications following vaginal trachelectomies were encountered in 80% of the procedures against 37% in the abdominal procedure . in our report the cervical stump confirmed carcinoma in situ .

a 43-year - old , who underwent a subtotal hysterectomy for postpartum hemorrhage following a normal delivery , 10 years ago , presented with a history of persistent vaginal discharge and post - coital bleeding . a pap smear reported moderate dysplasia , and a subsequent colposcopic biopsy reported severe dysplasia with crypt extension . the patient underwent a laparoscopic trachelectomy , and histology of the stump reported cervical squamous carcinoma in situ , with no microinvasion .

acute generalized exanthematous pustulosis ( agep ) is a rare acute reaction that is drug - induced in 90% of the cases , characterized by a widespread , sterile pustular rash . cefepime is a fourth generation cephalosporin antibiotic used to treat febrile neutropenia , severe infections related to the urinary tract , skin , nosocomial pneumonia , brain abscess , and intra - abdominal and septic lateral / cavernous sinus thrombosis . a 67-year - old man with renal failure who had been on dialysis during the last 2 years and with an 8-year history of cardiac insufficiency was admitted to the hospital complaining of 6 days of diarrhea . the patient was taken to the semi - intensive care unit and treated with ciprofloxacin . as a consequence , his long - term medications had not been changed and consisted of acetylsalicylic acid , furosemide , captopril , carvedilol and clonazepam . on the seventh day , the patient became dyspneic and his chest radiograph showed a left lower lobe opacity . treatment for nosocomial pneumonia was promptly initiated with cefepime ( 1 g / day ) . five days later , he presented with a pruritic , erythematous , maculopapular eruption affecting the abdomen , neck and skin folds . one day later , he developed disseminated pustular lesions ( fig . 1 ) and his temperature was 37c . laboratory exams evidenced c - reactive protein 136 mg / l , white blood cells 14,700 cells/l ( normal 3,50010,500 cells/l ) with 11,995 cells/l neutrophils ( normal 1,7008,000 cells/l ) . histology showed a toxic pustuloderma with spongiform subcorneal pustules , edema in the papillary dermis and perivascular inflammatory infiltrate consisting of neutrophils ( fig . after withdrawal of cefepime and introduction of imipenem , the disseminated skin nonfollicular pustules cleared within 4 days following a desquamation . the patient denied previous adverse reaction to other drugs and no personal or family history of psoriasis was evident . agep is a disease characterized by the rapid onset of many sterile , nonfollicular pustules usually arising on an edematous erythema and frequently accompanied by leukocytosis and fever . skin symptoms usually arise rapidly after an insult and resolve spontaneously ( within a few days ) . agep often starts predominantly in intertriginous areas or on the face , spreading rapidly to the trunk and lower limbs . the mean duration of the pustules is 9.7 days , and an annular desquamation typically follows for a few days . complications are rare [ 1 , 3 ] . the agep validation score of the euroscar study group has been used to establish the diagnosis . a score between 8 and 12 for agep is a definitive diagnosis ( table 1 ) . the case score was 11 , according to the validation score of the euroscar study group ( table 2 ) . the main differential diagnosis of agep is pustular psoriasis . because the pustules clinically and histologically resemble the lesions of pustular psoriasis and because in a number of reports patients had a history of plaque psoriasis , some authors assume that agep is nothing more than an acute exacerbation of psoriasis caused by a variety of exogenous triggers however , many studies strongly suggest that agep is not associated with psoriasis [ 1 , 5 ] . up to now agep has been attributed to a variety of causes such as viral infections , chlamydia pneumoniae infection or hypersensitivity to mercury , but the skin reaction is primarily an adverse response to drugs . antibiotics , other than cefepime , have been implicated as the causative agents in 80% of individuals . in this group , the present case of agep has well defined criteria , and because correct diagnosis generally leads to spontaneous resolution once the causative drug is withdrawn , clinicians should keep the possibility of this cutaneous drug reaction in mind .

acute generalized exanthematous pustulosis ( agep ) is a rare cutaneous rash characterized by widespread sterile nonfollicular pustules . cefepime is a fourth generation cephalosporin , used to treat severe infections . a 67-year - old man was admitted with acute gastroenterocolitis . on the seventh day , the patient developed a nosocomial pneumonia and cefepime was initiated . on the fourth day of cephalosporin treatment , he presented with a maculopapular , pruritic eruption affecting the face , neck , abdomen and limbs . one day later he developed disseminated pustular lesions and his temperature was 37c . laboratory analysis evidenced leukocytosis and skin biopsy showed subcorneal pustule , edema in the papillary dermis , perivascular inflammatory infiltrate consisting of neutrophils , leukocytoclasia and red cell extravasation in the epidermis . cefepime was suspended and within 4 days the non - follicular pustules cleared following a desquamation . agep is a disease attributed to a variety of causes , but in 90% of the cases it is due to an adverse drug reaction . antibiotics are implicated in 80% of these cases , mostly penicillins and macrolides . there are few cases associated with cephalosporins . it is very important to consider agep in cases of acute pustular rashes and drugs should be investigated as causative agents .

canaliculitis is a common encounter in ophthalmic practice but supernumerary puncta and canaliculi ( spc ) are rare congenital disorders . in a large series a 59-year - old gentleman presented with painful swelling of the left lower lid for a week , which was associated with epiphora . the swelling was confined to the nasal aspect of the left lower lid ( 0.50.5 mm ) with inflamed overlying skin ( figure 1a ) . eversion of the lower eyelid revealed two puncta , 0.5 mm apart ( figure 1b ) . the outer punctum was situated at the normal anatomical position ; whereas the inner punctum in the caruncle . gentle pressure did not result in any regurgitation from the both puncta . the patient was treated with oral cloxacillin 500 mg , 6 hourly for 5 days . the outer punctum had a soft stop with regurgitation of fluid from the same punctum . the outer punctum - canaliculus system was a cul - de - sac ( figure 1c ) . c ) dacryocystography showed pooling of dye in the cul - de - sac ( white arrow ) . c ) dacryocystography showed pooling of dye in the cul - de - sac ( white arrow ) . most spcs ( 78% ) present with epiphora . among the 23 patients reported by satchi et al . , none presented with canaliculitis . sequestration of tear and debris in the cul - de - sac served as nidus for infection . the resultant canaliculitis with its surrounding edema caused obstruction of the lacrimal drainage ; hence epiphora . epiphora however , may develop despite patent lacrimal drainage system . the 2-compartment model for lacrimal canalicular drainage of kakizaki et al . , suggested that the muscle of duverney - horner may deviate normal flow within the accessory canaliculus and thence transport tears back to the lacrimal tear lake , leading to epiphora . a solid epithelial cord forms in the region of the medial lower eyelid ( figure 2a ) and sends projections to form the canaliculi and the nasolacrimal duct ( figure 2b ) . spc is due to extra out - budding of the solid epithelial cord ( figure 2c ) . canalization begins at 4 months of gestation with disintegration of the central ectodermal core , forming lacrimal drainage outflow system . in this case , the extra inner canalicular epithelial bud ( nearer to the main epithelial cord ) underwent complete canalization and remained connected to the main epithelial cord . the outer canalicular epithelial bud , although its punctum is located at the normal anatomical position , was separated from the main epithelial cord ; forming a cul - de - sac ( figure 2d ) . c ) extra out - budding of the solid epithelial cord in supernumerary puncta and canaliculi . d ) the outer canalicular epithelial cord was separated from the main epithelial cord , forming a cul - de - sac . c ) extra out - budding of the solid epithelial cord in supernumerary puncta and canaliculi . d ) the outer canalicular epithelial cord was separated from the main epithelial cord , forming a cul - de - sac .

we report the first case of supernumerary puncta and canaliculi presented with canaliculitis . a-59 year - old gentleman presented with painful swelling of the left lower lid for a week , which was associated with epiphora . the swelling was confined to the nasal aspect of the left lower lid ( 0.50.5 mm ) with inflamed overlying skin . two puncta ( 0.5 mm apart ) were noted . the outer punctum at the normal anatomical position was a cul - de - sac while the inner punctum it the caruncle was patent . we described the embryology leading to supernumerary puncta and canaliculi to explain the paradoxical patency of the abnormally located punctum as well as the pathomechanism leading to canaliculitis . the patient was treated with oral cloxacillin 500 mg , 6 hourly for 5 days ; the cellulitis subsided after three days .

often , a new physics faculty member is faced with the duty of renovating the introductory physics labs . we will provide a list of experiments and equipment needed to convert about half of the traditional labs on a 1-year introductory physics lab into microcomputer - based laboratories ( mbls ) . our student body consists mostly of science majors that take the algebra - based course . but , the lab renovation described here could be used for the calculus - based group as well . we would suggest adjusting the lab manuals . nowadays , mbls are usually the choice when thinking of a renovation . they have effectively demonstrated an advantage to the learning process over the years.[14 ] moreover , for our science students , the labs are important in reinforcing the concepts learned in class . it is very common to hear , during the lab sections , students commenting on their grasp of the concept learned in class due to the experiment being performed . the overall 1-year lab experience follows the guidelines provided by the american association of physics teachers . it contains a brief theoretical description and the procedures to be followed on the day of the lab . on the lab day , the students should come prepared and ready to start without additional instructions . the instructor circles around the stations to guide and answer appropriate questions if needed . on the lab day , the students are handed the lab report . it contains a data analysis part , some discovery questions , and ends with a summary and conclusion part . the report is completed by the student during the session . we did not find an appropriate version for the other half to meet our overall goal . therefore , we kept a few traditional labs . the list of experiments is chosen based on the lecture material . one of the concerns was to always be able to cover the theory before the lab was performed by the student . one - year introductory microcomputer - based laboratory experiment list understanding motion , free fall , projectile motion , atwood 's machine , boyle 's law , electrical equivalent of heat , heat transfer , electrostatic charge , ohm 's law , rc circuit , and magnetic induction . a suggestion for the beginner is to try all the experiments before hand until you get really familiar with the sensors and software and how they work . most of the time , it is a lack of understanding of the use of the apparatus , assuming it is not defective of course . we will list here the total equipment needed per station to implement the 1-year lab described above . it is expected that the laboratory will have a printer that can be shared among all groups . each station consists of a laptop and the science workshop 750 interface ( ci-7650 ) with the datastudio software ( ci-6870 g ) . lab station : science workshop interface , laptop and motion sensor sensors to be used with the interface for data measurement : motion sensor ( ci-6742a ) , photogate and pulley system ( me-6838 ) , accessory photogate ( me-9204b ) , time - of - flight accessory ( me-6810 ) , pressure sensor ( ci-6532a ) , temperature sensor ( ci6605a ) , power amplifier ( ci-6552a ) , charge sensor ( ci-6555 ) , voltage sensor ( ci-6503 ) , photogate head ( me-9498a ) . figure 2 displays a few sensors . from left to right : pressure sensor , charge sensor , and photogate head the datastudio software collects and analyzes the data . it has an easy - to - use interface , allowing the students to explore the data . for instance , the left screenshot in ure 3 displays a graph of voltage versus time . the data are collected using a voltage sensor when a magnet is dropped through a coil . the students can select a region on the graph and the software calculates the area under the curve . the screenshot on the right in figure 3 displays the curve - fitting feature of datastudio . left screenshot : induction lab using graph and area under the curve calculation . the pressure column will be filled as the measurements are taken using the pressure sensor . boyle 's law lab using a table display the additional equipment needed from pasco to perform the experiments are : picket fence ( me-9377a ) , projectile mini launcher ( me-6825a ) , photogate mounting bracket ( me-6821a ) , extension cable ( pi-8117 ) , thermodynamics kit ( ci-6514a ) , charge producers ( ci-6555 ) , faraday ice pail ( es-9057b ) , ac / dc electronics lab ( em-8656 ) , and bar magnet ( em-8620 ) . general lab supplies needed include a pair of scissors and goggles , one digital balance ohaus ( sp-601 ) , one meterstick , one thermometer , tongs ( handling hot bottles ) , gloves ( handle hot containers ) , braided physics string ( se-8050 ) , 500 ml glass container ( 90c water ) , banana plug cord red and black ( 5 on set ) ( se-9750 ) or ( se-975 ) , masses and hanger set ( me-8979 ) , universal table clamp ( me-9376b ) , calorimetry cups ( td-8825a ) , and hot plates ( se-8830 ) . oftentimes , this task is hard to accomplish for a solo faculty in a small institution . we provided here a list of the experiments and equipments needed to upgrade about half the experiments to mbls on a 1-year introductory physics lab . we would like to add that although we used pasco , there are other comparable systems in the market . the intention of this paper is to help others with their own lab renovation . in order to better fulfill this purpose ,

nowadays , data acquisition software and sensors are being widely used in introductory physics laboratories . this allows the student to spend more time exploring the data that is collected by the computer hence focusing more on the physical concept . very often , a faculty is faced with the challenge of updating or introducing a microcomputer - based laboratory ( mbl ) at his or her institution . this article will provide a list of experiments and equipment needed to convert about half of the traditional labs on a 1-year introductory physics lab into mbls .

the potential relevance of endothelial activation biomarkers to sepsis has been raised in both this journal and others [ 1 - 3 ] . biomarkers for sepsis associated with the endothelial glycocalyx remain relatively unknown , however , and this commentary attempts to reverse this omission . the term glycocalyx ( sweet husk ) was introduced 50 years ago to describe an extracellular polysaccharide coating of cells . whilst electron microscopy revealed that the luminal surface of the endothelium expressed this structure , it was thought to be of little consequence or functional significance . what has become increasingly evident , however , is that the glycocalyx - now estimated to extend up to 1 m from the endothelial cell membrane - represents a substantial intravascular compartment contributing significantly to vascular wall homeostasis . specifically , roles of the glycocalyx include maintenance of the vascular permeability barrier , mediation of shear - stress - dependent nitric oxide production , and housing vascular protective enzymes ( for example , superoxide dismutase ) and a wide array of coagulation inhibition factors such as antithrombin , the protein c system and tissue factor pathway inhibitor . the glycocalyx also modulates the inflammatory response by preventing leukocyte adhesion and binding numerous ligands , including chemokines , cytokines and growth factors [ 4 - 6 ] . negatively charged and with a mesh - like structure , the endothelial glycocalyx is comprised of glycoproteins , proteoglycans , glycosaminoglycans ( gags ) and associated plasma proteins including albumin . proteoglycans consisting of a core membrane - bound protein of the syndecan or glypican families with attached heparan or chondroitin sulphate gag side chains are a prominent feature . hyaluronan - a nonsulphated , uncharged gag with water - retaining properties - is attached or adsorbed onto other cell - surface anchored proteins ( for example , cd44 ) and helps to stabilise the glycocalyx structure . alteration in the composition of the glycocalyx following exposure to an inflammatory insult is one of the earliest features of endothelial activation . it is now accepted that tnf , oxidised lipoproteins , lipopolysaccharide , thrombin , ischaemia / reperfusion , hyperglycaemia and growth factors all cause glycocalyx disruption via the action of proteases - leading either to partial degradation with release of gag side chains , or to more severe damage characterised by shedding of core proteins . several studies have evaluated circulating levels of syndecan-1 and gags in patients with sepsis [ 10 - 13 ] . plasma gag levels were higher in patients with septic shock than in matched controls , and were significantly higher in nonsurvivors . in the same study , syndecan-1 levels were also increased and correlated with the sequential organ failure assessment score . in an additional study of 150 patients either with severe sepsis or septic shock or post - abdominal surgery without the systemic inflammatory response syndrome and healthy volunteers , significant increases in plasma syndecan-1 and heparan sulphate were observed in the sepsis and surgery groups . the highest syndecan-1 levels were detected in patients with sepsis and correlated with those of il-6 . a further study showed greater syndecan-1 levels in patients with septic shock compared with healthy controls , together with a positive correlation with vascular adhesion protein-1 and with day 1 sequential organ failure assessment scores . finally , hyaluronan levels , in addition to those of syndecan-1 and heparan sulphate , have been shown to increase with severity of sepsis . whilst the care of patients with sepsis has improved over the last decade the failure of two promising drugs , eritoran tetrasodium and drotrecogin alfa , to confer significant reduction in mortality suggests that novel approaches to sepsis research are required . given the fundamental , but perhaps relatively overlooked , role of the endothelial glycocalyx in regulating vascular integrity and functions central to the pathophysiology of sepsis , identifying interventions aimed at protecting or repairing it might prove a promising therapeutic target . some clinically established therapies used for the treatment of sepsis ( such as glucose control and steroid administration ) and also approaches used in experimental studies ( such as tnf inhibition , antithrombin iii , infusion of albumin and avoidance of natriuretic peptide release ) are known to reduce glycocalyx disruption . however , drugs that might specifically increase the synthesis of glycocalyx components , refurbish the glycocalyx or selectively prevent protease degradation are not currently available . future endeavours in the field of sepsis research , which are urgently required , should not only include components of the endothelial glycocalyx in the list of biomarkers , but also consider their potential as therapeutic targets for the development of new therapies .

sepsis is the third largest cause of death in industrialised countries , but treatment remains largely supportive and effective therapeutic interventions are urgently needed . disruption and dysfunction of the microvascular endothelium leading directly or indirectly to multiple organ failure are now recognised to underpin the pathophysiology of sepsis . biomarkers of endothelial activation may therefore assume an important role in guiding future research efforts . we suggest that integral to this approach is the investigation and evaluation of endothelial glycocalyx biomarkers , not only as indicators of the pathogenic process but also to inform the development of pharmacological and other therapies .

the adenoma is solitary in 8590% of patients , while others have multiple adenomas or parathyroid hyperplasia . accurate preoperative localization is essential for good surgical outcome , and inability to locate the adenoma in an ectopic gland may delay the diagnosis . nuclear imaging accurately localizes the tumor in more than 90% of cases , obviating the need for advanced imaging modalities . rarely , patients present with localization failure posing a great challenge to the treating endocrinologist and operating surgeon . we report the use of a novel imaging method leading to successful outcome in a patient of primary hyperparathyroidism with failed first surgery . a 54-year - old lady presented with body pains and muscle aches for 1-year duration to a peripheral hospital . investigations revealed high serum calcium ( 11.6 mg / dl ) , low phosphorus ( 2.6 mg / dl ) , elevated alkaline phosphatase ( 677 u / l ) and intact parathyroid hormone ( ipth ) of 116 pg / ml ( normal 10 - 65 pg / ml ) . sestamibi scan revealed right inferior parathyroid adenoma , and she was diagnosed as a case of primary hyperparathyroidism . she underwent adenomectomy along with thyroidectomy and showed no features of hungry bone syndrome postoperatively . there was no confirmation of parathyroid adenomectomy by using intraoperative pth levels or by frozen section of the removed tissue . her clinical symptoms persisted after surgery and histopathological examination of the specimen removed showed thyroid tissue with no evidence of parathyroid adenoma . she reported to us after 6 months of initial surgery with persisting complaints of body aches and myalgia . her clinical examination was unremarkable , with a normotensive blood pressure , and well - healed scar in the neck . serum biochemistry revealed elevated calcium ( 10.8 mg / dl ) , low phosphorus ( 2.8 mg / dl ) and elevated alkaline phosphatase ( 280 bone mineral density estimation revealed a t - score of -2.2 at hip joint and z - score of -2.3 . serum 25 hydroxy vitamin d level was 22 ng / l and parathyroid hormone was elevated ( ipth-140 pg / ml ) . localization with sestamibi scan revealed right inferior parathyroid adenoma with no tracer uptake in thyroid bed [ figure 1 ] . abdominal sonography showed normal renal parenchyma and ultrasonography neck and plain ct neck did not show parathyroid adenoma . tc 99 m sestamibi scan showing right inferior parathyroid adenoma in view of past history of failed surgery , tc 99 m sestamibi single photon emission computed tomography ct ( spect ) was done for precise localization of the adenoma prior to re - exploration . it revealed an ectopic parathyroid adenoma , located suprasternally in the pretracheal region on right side [ figure 2 ] . histopathological examination of the specimen confirmed the parathyroid adenoma . during last follow - up , 1 year after second surgery the patient is free of all symptoms and had normal serum calcium , phosphorus and alkaline phosphatase values . sestamibi emission computed tomography ct showing parathyroid adenoma pretracheal in location ( coronal and sagittal views ) the disease is detected during asymptomatic stage in developed countries , while we encounter the advanced spectrum of the disease with severe metabolic bone disease . precise localization is important to prevent further delay in definitive therapy after biochemical confirmation of the diagnosis . parathyroid glands are derived from pharyngeal pouches ( superior parathyroid glands from 4 and inferior from 3 pouch ) with subsequent caudal migration . the modalities available for precise localization of a parathyroid adenoma are palpation , ultrasonography ( usg ) , ct , mri , nuclear scintigraphy , and combination of these tests . ultrasonography is useful for its wide availability , convenience , cost and a guiding tool for the surgeon before surgery . however , the sensitivity and specificity of usg reported was 73% and 100% , respectively . ct and mri scans provide excellent spatial resolution but often miss a small parathyroid adenoma . this is recommended mostly in cases of failed surgery , recurrent disease and when planned for a limited surgical exploration . immediate imaging reveals the tracer uptake in both thyroid and parathyroid gland along with adenoma but the adenomatous tissue shows retention of the tracer in delayed images . spect scan is an advance in radionuclide studies with a three - dimensional ( 3-d ) reconstruction , further increasing the sensitivity for adenoma localization . spect scan , with its 3-d capability , combined with ct images , is very helpful in directing the surgeon particularly in recurrent or residual hyperparathyroidism . recent reports suggest that spect / ct is superior to spect scan alone for localization of parathyroid adenoma with nodular goiter , distorted neck anatomy and those with ectopic parathyroid glands . to conclude , our patient had an ectopic parathyroid adenoma resulting in failed initial surgery . use of a novel imaging modality like spect helped in accurate localization of the adenoma prior to repeat surgical exploration .

primary hyperparathyroidism often presents with protean manifestations , resulting in delayed diagnosis . at times , aberrant development and migration of the gland leads to ectopic location leading to problems in localization . judicious use of combination methods of localization is recommended in treatment failure or recurrent disease . we report the use of single photon emission computed tomography - ct in precise localization of parathyroid adenoma in a patient with failed initial surgery .

fixed drug eruption ( fde ) is a distinctive variant of drug induced dermatoses characterized by sharply demarcated , erythematous patches with / without blistering that develop within hours of administration of the causative drug and heals with postinflammatory residual hyperpigmentation . it usually recurs at the same site of the skin or mucous membrane upon subsequent exposure to the same / similar group of drugs . fluoroquinolones are widely used antimicrobials , which cause cutaneous adverse drug reactions in about 1 - 2% of patients . however , bullous fde is rarely reported . herein we report a rare case of fde induced by ciprofloxacin followed by ofloxacin administration . a 37-year - old male presented to the outpatient dermatology department of our hospital , puducherry with a history of multiple fluid filled blisters over both hands and feet [ figures 1 and 2 ] . he stated that the lesions appeared within 5 h of taking a single dose of oral ofloxacin , which was obtained as over the counter drug for fever from a local private medical shop . history of itching over both hands and feet followed by a burning sensation and the subsequent development of multiple fluid filled lesions were present . there was no previous history of any medical conditions such as allergy or atopic dermatitis . on further inquiry , he recalled a history of a similar episode about 1 year back for ciprofloxacin , which has been prescribed for fever . at that time physical examination revealed multiple flaccid bullous lesions with intact roof of the blister in an erythematous base were seen over proximal metacarpophalangeal joint of left thumb , left instep of sole , right dorsal big toe and little toe of left foot . diagnosis of fde caused by ofloxacin was made taking into account of previous history of fde induced by ciprofloxacin and clinical signs . patch test was not done as the patient did not give consent for the same . the causative drug ofloxacin was discontinued and the patient was treated with antihistaminics and topical emollients . the lesions and symptoms improved gradually within a week leaving behind residual hyperpigmentation and the patient was advised not to take fluoroquinolones in future . well - defined bullous lesion in the instep of left foot bullous lesions in the right dorsal toe fluoroquinolones are commonly used antimicrobials ( effective for both gram negative and gram positive bacteria ) in the treatment of various bacterial infections and are generally well tolerated . common side - effects include gastrointestinal effects ( nausea , vomiting and diarrhea ) and neuropsychiatric symptoms ( headache and insomnia ) . photosensitivity and morbilliform rash have been reported with fluoroquinolones , but fde is quite uncommon . a large number of drugs have been reported to elicit fdes such as trimethoprim - sulfamethoxazole , tetracyclines , penicillin , erythromycin , nonsteroidal antiinflammatory drugs , barbiturates , valproate , phenytoin , phenolphthalein , and nitroimidazoles . even though , the pathogenesis of fde is not known , certain serum factors , antibodies , and cell mediated immunity have been attributed as causative factors . localized tissue damage results when intra - epidermal cd t - cells are activated to kill surrounding keratinocytes and release cytokines such as interferon - gamma into the microenvironment . quinolones can cause both delayed type and ige - mediated hypersensitivity reactions . in this case , the following criteria were considered : there were previous conclusion reports on this reaction ( + 1 ) ; the adverse event appeared after ofloxacin was administered ( + 2 ) ; adverse event improved when ofloxacin was discontinued ( + 1 ) ; adverse event reappeared when ofloxacin was re - administered ( 0 ) ; alternate causes that could solely have caused the reaction ( + 2 ) ; the reaction reappeared when a placebo was given ( 0 ) ; drug detected in the blood ( or other fluids ) in a concentration known to be toxic ( 0 ) ; the reaction was more severe when the dose was increased or less severe when the dose was decreased ( 0 ) ; the patient had a similar reaction to ciprofloxacin in the previous exposure ( + 1 ) ; the adverse event confirmed by objective evidence ( + 1 ) . probable reaction to ofloxacin administration . according to who - uppsala monitoring centre causality assessment system patient had fde to ciprofloxacin 1 year back followed by similar reaction to ofloxacin in the current admission . cross - reaction between quinolone families , clinically manifested as fde , has been rarely reported in the literature . to the best of our knowledge , only one case of cross reactivity between ciprofloxacin and ofloxacin has been reported so far which proposed the probable mechanism would be a complex of quinolone and piperazine residue as the antigenic determinant for both ciprofloxacin and ofloxacin . bullous fde due to fluoroquinolones should be included in the differential diagnosis when fde is suspected . our case described the cross sensitivity between two fluoroquinolones ciprofloxacin and ofloxacin used within 1 year interval time . hence , health care providers should be aware of the diagnosis and proper management of fde . patients should be warned against the use of anti - microbials without the physician 's advice .

fixed drug eruptions ( fde ) are the common dermatological adverse drug reaction accounts for 1621% of all cutaneous drug reactions in india . drugs most frequently implicated in fde are antimicrobials , anticonvulsants , and nonsteroidal antiinflammatory drugs . here , we report a rare case of bullous fde due to ciprofloxacin followed by ofloxacin administration .

though both minor and major spontaneous or post - operative bleeding is the most common presentation of this rare disorder , there are several case reports of thrombotic complications also . there are few reports of myocardial infarction ( mi ) in the literature in patients of afibrinogenemia . a 33-year - old man , who was a confirmed case of congenital afibrinogenemia and was diagnosed six years back when he had excessive bleeding following trauma over face and persisted even after suturing that area , presenting to us with severe retro sternal chest pain of 10 h duration . he had a past history of myocardial infarction ( mi ) two years back and was advised dual antiplatelet therapy . he was born of second degree consanguineous marriage with history of sibling death after birth . on admission , electrocardiogram showed 2 mm st segment elevation in leads ii , iii , avf and st depression in leads i and avl [ figure 1 ] . troponin t obtained at admission was strongly positive with 1.24 ng / ml ( normal- < 0.1 ng / ml ) . coagulation profile was sent after admission and tests revealed absent fibrinogen using the clauss method , markedly reduced fibrinogen antigen level , normal platelet count and bleeding time , infinitely prolonged activated partial thromboplastin time ( aptt ) , prothrombin time ( pt ) and thrombin time . prominent q wave , st segment elevation and t wave inversion in lead ii , iii and avf with st segment depression seen in lead i and avl . right sided chest leads ( v4r - v6r ) showed < 1 mm st segment elevation as this patient had high risk for bleeding , thrombolysis or primary percutaneous transluminal coronary angioplasty ( ptca ) was not advised though he had ongoing chest pain . he was treated with dual antiplatelet therapy ( aspirin plus clopidogrel ) , statins , betablocker , angiotensin converting enzyme inhibitors and injection nitroglycerin ( ntg ) . after few hours of treatment , the chest pain subsided and st segment showed evolving changes . his admission lipid profile was normal ( low density lipoprotein 112 mg / dl , triglyceride 128 mg / dl , high density lipoprotein 40 mg / dl ) . the patient did not experience a recurrence of angina and was discharged three days after admission with dual antiplatelet therapy . fibrinogen is the major coagulation protein in blood by mass : normal fibrinogen levels vary between 1.5 and 3.5 bleeding , which usually manifests already in the neonatal period ( 85% of cases presenting umbilical cord bleeding ) , is the main complication of afibrinogenemia . paradoxically , both arterial and venous thromboembolic complications have also been reported in afibrinogenemic patients . these complications can occur in the presence of concomitant risk factors such as a co - inherited thrombophilic risk factor or after replacement therapy . first , even in the absence of fibrinogen , platelet aggregation is possible due to the action of von willebrand factor and , in contrast to patients with hemophilia , afibrinogenemic patients are able to generate thrombin , both in the initial phase of limited production and also in the secondary burst of thrombin generation . second , the increase of prothrombin activation fragments or thrombin - antithrombin complexes have been observed , reflecting enhanced thrombin generation . so , antithrombin role has also been attributed to fibrinogen because in its absence , clearance of thrombin is impaired . though there are several reports of both arterial and venous thrombosis in afibrinogenemia , only a few cases have been reported where these patients developed mi . with recurrent mi , treatment of mi in the presence of a bleeding disorder like afibrinogenemia is difficult as administration of thrombolysis and anticoagulant will increase bleeding . so , we treated with both aspirin and clopidogrel in our case . as patient stopped taking dual antiplatelet therapy he had recurrence of mi . chest pain subsided after starting injection of ntg and the area of myocardial involvement was also small , we managed the patient conservatively , and discharged him on dual antiplatelet therapy . further study is needed on this aspect to determine the best treatment that we can provide to them . until then dual antiplatelet therapyshould be recommended to all these patient with hereditary bleeding disorder with close supervision of bleeding diathesis since without this treatment they may have recurrences .

afibrinogenemia is a rare autosomal recessive bleeding disorder with an estimated prevalence of 1:1,000,000 . usual presentation of this disorder is spontaneous bleeding , bleeding after minor trauma and excessive bleeding during interventional procedures . paradoxically , few patients with afibrinogenemia may also suffer from severe thromboembolic complications . the management of these patients is particularly challenging because they are not only at risk of thrombosis but also of bleeding . we are presenting a case of 33-year - old male patient of congenital afibrinogenemia who had two episodes myocardial infarction in a span of two years . the patient was managed conservatively with antiplatelet therapy and thrombolytic therapy was not given due to high risk for bleeding .

mesenteric pseudocyst is a term used to describe abdominal cystic mass without the origin of abdominal organ.(1 ) this has been classified according to embryologic , ehiologic , histologic , and ther data , causing considerable confusion . it was considered the term mesenteric cyst as merely descriptive , and apply a histologic classification such as lymphangioma , pseudocyst , enteric duplication cyst , enteric cyst , and mesothelial cyst.(2 ) we presented a case of mesenteric pseudocyst of the small bowel in a 70-year - old man . a 70-year - old man was referred to our hospital for operation of gastric cancer with a 1-month history of progressively worsening epigastric and intermittent peri - umbilical discomfort . he had no specific previous medical or surgical history including cancer . on physical examination , esophago - gastro - duodenoscopy ( egd ) showed a 3.5 cm sized excavated lesion on the posterior wall of angle . endocopic biopsy confirmed a histologic diagnosis of poorly differentiated adenocarcinoma including signet ring cell component . endoscopic ultrasonography revealed invasion of caner to the proper muscle layer . abdominal computed tomography ( ct ) scan showed a focal mucosal enhancement in posterior wall of angle of stomach , a 2.4 cm sized enhancing mass on distal small bowel loop without distant metastases or ascites in rectovesical pouch , and multiple gallbladder stones ( fig . 1 ) . these physical , laboratory , and radiological findings prompted us to diagnose early gastric cancer , and gastrointestinal stromal tumor of small bowel . laboratory testing revealed alfa - fetoprotein level of 2.88 ( normal range , 0 to 9 ng / ml ) , carcino - embryonic antigen level of 1.45 ng / ml ( normal range , 0 to 5 ng / ml ) , carbohydrate antigen ( ca ) 19 - 9 level of 6.5 u / ml ( normal range , 1 to 35 u / ml ) , and ca 72 - 4 level of 4.8 u / ml ( normal range , 0 to 4 u / ml ) . other laboratory test results were within normal limit . the patient underwent subtotal gastrectomy with gastroduodenostomy , segmental resection of small bowel , and cholecystectomy . mesenteric mass was adhered severely with greater omentum at the mesenteric side of small bowel , and mesenteric fat tissues . small bowel , mesentery , and mesenteric mass were resected en - bloc methods , and end to end anastomosis was performed . after fixation of the surgical specimen , macroscopic examination revealed a uni - locular cyst measuring 332 cm in size . pathological examination revealed 3 cm sized fibrous cystic wall without endothelial or epithelial lining and foam cell collection ( fig . 2 , 3 ) . pathologic stage of gastric cancer was t1bn1m0 ( 6th international union against cancer tnm staging system ) ; invasion to submusosa , metastases to 4 perigastric lymph nodes out of 16 retrieved nodes , and negative resection margin . mesenteric pseudocysts are very rare intraabdominal mass with an incidence of about 1 case per 100,000 hospital admissions.(3 ) ros et al.(2 ) first used the term " pseudocyst " in the classification of mesenteric cyst . mesenteric pseudocyst could be located in the small bowel , large bowel mesentery and even retroperitoneum.(1,4 ) most reports were pseudocyst of large bowel or retroperitoneum.(1 ) although most mesenteric pseudocysts are asymptomatic , symptomatic mesenteric cysts could be associated with cyst size , cyst location , and complications , including infection , rupture , hemorrhage , and intestinal obstruction.(5 ) in our patient , there was no specific symptom associated with mesenteric pseudocyst except for intermittent vague periumbilical discomfort . if egd and ct scan were not performed in this patient presenting non - specific abdominal pain , the diagnosis of mesenteric pseudocyst would be delayed . to the best of our knowledge , this is the first case report describing incidentally detected mesenteric pseudocyst of small bowel in gastric cancer patients . when clinician performed staging work up for gastric cancer , should be aware the possibility of associated intraabdominal lesions .

mesenteric pseudocyst is rare . this term is used to describe the abdominal cystic mass , without the origin of abdominal organ . we presented a case of mesenteric pseudocyst of the small bowel in a 70-year - old man . esophago - gastro - duodenoscopy showed a 3.5 cm sized excavated lesion on the posterior wall of angle . endocopic biopsy confirmed a histologic diagnosis of the poorly differentiated adenocarcinoma , which includes the signet ring cell component . abdominal computed tomography scan showed a focal mucosal enhancement in the posterior wall of angle of the stomach , a 2.4 cm sized enhancing mass on the distal small bowel loop , without distant metastases or ascites in rectal shelf , and multiple gallbladder stones . the patient underwent subtotal gastrectomy with gastroduodenostomy , segmental resection of the small bowel , and cholecystectomy . the final pathological diagnosis was mesenteric pseudocyst . this is the first case report describing incidentally detected mesenteric pseudocyst of the small bowel in gastric cancer patients .

we used the lrn as a conduit to maintain the confidentiality and anonymity of the variola testing sites . a convenience sample of 45 laboratory workers completed an online survey developed by researchers at the university of nebraska medical center ( omaha , ne , usa ) . nonidentifying demographic information was collected , in addition to any adverse effects after vaccination and perceived barriers to revaccination . to determine a significant difference existed regarding the success ( presence or absence of a take after vaccination ) of the vaccine based on intervals between vaccines , we measured the mean interval ( in years ) between vaccinations . respondents mean age was 46 years ; they had worked a mean of 20.5 years in the laboratory setting . eighty - four percent of respondents reported that the only adverse events from vaccination were related to the skin irritation caused by the occlusive dressings worn over the vaccination lesion . sixty - seven percent listed a medical condition in themselves or a close household contact as the barrier to revaccination . the mean interval from first to second vaccination was 4.8 years for vaccinees who had a successful vaccine and 6.0 for those who did not . statistical analysis demonstrated no significant difference ( p = 0.149 ) between the number of years between first and second vaccinations and the take rates . sixty - two percent of respondents indicated they did not work with non highly attenuated orthopoxviruses . ( i.e. , developed lesions ) regardless of number of years since previous vaccination , suggesting that immunity might have waned . therefore , our data do not provide evidence to suggest that the acip recommended interval for revaccination be prolonged . although most respondents reported having no adverse effects from the vaccine , for some this vaccination caused discomfort . many reported symptoms related to the occlusive dressing worn as a precautionary measure to ensure that the lesion site was properly covered during work hours . other measures to ensure the lesion is covered appropriately , such as nonocclusive dressings and long sleeves , may be considered given that laboratory workers do not have direct contact with patients . although the lrn asks this small group of laboratory workers to comply with the acip recommendations , the question remains whether this requirement should include laboratory workers who do not handle orthopoxviruses . revaccination of most laboratory workers at variola testing sites every 3 years would be expected to be sufficient to provide an initial immunologic response , whereas laboratory workers who do not handle orthopoxviruses could be vaccinated in the same fashion as other health care and public health workers who have at least 1 recent ( since 2003 ) documented successful vaccination ( 5 ) . this recommendation is based on the same premise as using the vaccine as prophylaxis for documented exposure to a smallpox - infected person . this practice was used regularly during the smallpox eradication program . because the average incubation period for vaccinia is 34 days shorter than the incubation period for smallpox , a person exposed to smallpox would have a 34 day window in which to be vaccinated with and immunologically respond to vaccinia , which also confers immunity to smallpox ( 6 ) compromised immune systems or cardiac risk factors that make vaccinees ineligible for vaccination are more likely to develop as they age ( 7 ) . most barriers to revaccination were related to medical conditions ( compromised immunity and/or exfoliative skin disorders ) that place vaccinees at high risk for adverse events to the currently licensed smallpox vaccine . the conditions are an added challenge for the aging pool of laboratory workers assigned to national variola testing sites ( 8) . currently unlicensed third - generation smallpox vaccines may be considered ( pending licensure ) as replacements to acam2000 ( sanofi pasteur biologics , lyon , france ) , the currently licensed vaccinia vaccine , for laboratory workers at national variola testing sites or perhaps an even broader population of laboratory workers throughout the united states . third - generation vaccines are nonreplicating and safer in populations that might have contraindications to traditional vaccines ( 911 ) . the risk to the us population from a release of smallpox this reduced risk stems not from a lower threat from terrorism but from the existence of a stockpile of the new acam2000 smallpox vaccine , in addition to a cadre of health care and public health professionals who could be revaccinated quickly and mobilized accordingly ( 12 ) . more research on the immunogenicity of smallpox vaccine is needed but is challenged by the absence of smallpox disease to test the efficacy of vaccination . researchers now appreciate that the complex mechanism of the immune response to vaccinia and/or smallpox infection might lead to better treatment options for infectious and autoimmune diseases ( 7 ) . future opportunities may arise to challenge the vaccine with the actual virus to measure vaccine efficacy and provide sound recommendations to protect all public health and health care responders against smallpox ( 13 ) . in the meantime , ensuring that recommendations created to protect some populations are properly interpreted and applied is important to protecting the most vulnerable persons without exposing others to unnecessary harm .

to evaluate the need to revaccinate laboratory workers against smallpox , we assessed regular revaccination at the us laboratory response network s variola testing sites by examining barriers to revaccination and the potential for persistence of immunity . our data do not provide evidence to suggest prolonging the recommended interval for revaccination .

compromised renal functions and previous central nervous system ( cns ) disease have been shown to predispose to this neurotoxicity . we describe a case of acute transient encephalopathy in a patient treated with ceftriaxonefor enteric fever infection . the present case illustrates the diagnostic challenges and management of this rare but potentially severe side effect of one of the most commonly prescribed parenteral antibiotics . an eight - year - old male child presented with a history of diarrhea and high - grade fever . the child was conscious , cooperative , well oriented to time , place and persons . the patient was hospitalized and started on ceftriaxone ( 1 g iv daily ) and intravenous fluids . after three days of treatment with iv ceftriaxone , child became afebrile but showed altered mental status with progressive apathy and somnolence . the patient was referred to the dyanand medical college , ludhiana ( punjab ) . in the emergency department , the patient was not in acute distress , had no fever , was hemodynamically stable , but dehydrated . hb 12 g / dl [ normal range 12 to 15 g / dl ] , hct 38% [ normal range 35.0 to 49.0% ] , tlc 6 10/l l [ normal range 5 to 12 10/l l ] , dlc - n 62 [ normal range 6070% ] , l 27% [ normal range 2040% ] , plt 274 10/l l [ normal range 100 to 300 10/l ] , urea 14 mg / dl [ normal range 825 mg / dl ] , cr 0.6 mg / dl [ normal range 0.51.7 mg / dl ] , na / k 139/4 [ normal range 135147/ 3.55 meq / dl ] , urinalysis revealed no bacteriuria and pyuria , tsb / dsb 0.77/0 [ normal range 0.11.0/ < 0.2 mg / dl ] , sgot / pt 44/23 [ normal range 1147/ 753 iu / l ] , stoolr / e , 2d mri scan of brain did not reveal acute stroke . the patient 's neurological status improved and three days later he was again alert and oriented . the proposed mechanisms include a decrease in -amino butyric acid ( gaba)-mediated inhibition and cephalosporin - mediated release of cytokines . in fact , cephalosporins may decrease gaba release from nerve terminals , increase excitatory amino acid release , and exert a competitive antagonism with gaba . alternatively , cephalosporin treatment has been proposed to induce endotoxin release , which generates cytokines liberation , such as tumor necrosis factor- , a proinflammatory cytokine implicated in septic encephalopathy . pre - existing cns abnormalities have been indicated as a risk factor for -lactams encephalopathy . in this was not the case in our patient , who presented with enteric fever and dehydration corrected with intravenous fluids . in fact , the temporal association of the encephalopathy induction and resolution with ceftriaxone administration and withdrawal makes this antibiotic highly likely to be responsible for the encephalopathy . moreover , the temporal pattern is in accordance with previous publications reporting cephalosporin neurotoxicity , with a latency of one to ten days after drug initiation and regression of all neurological symptoms within two to seven days following ceftriaxone treatment suspension . we could establish a probable causal relationship between ceftriaxone and the encephalopathy ( naranjo score 6 ) . the severity assessment revealed the adr to be moderate , suggesting that required therapeutic intervention and hospitalization prolonged by 1 day but resolved in 24 h or change in drug therapy or specific treatment to prevent a further outcome . since this patient did not have a history of any such reaction due to ceftriaxone , this adverse drug reaction was unpreventable . we describe a case of ceftriaxone - induced acute reversible encephalopathy in a patient treated for enteric fever infection . early recognition of this complication is particularly relevant as discontinuation of ceftriaxone reverts the neurological syndrome .

ceftriaxone is a commonly used , third - generation cephalosporin . encephalopathy is a rare side effect of third- and fourth - generation cephalosporins . renal failure and previous disease of the central nervous system predispose to this neurotoxicity . we describe a case of acute transient encephalopathy in a patient treated with ceftriaxone for enteric fever infection . early detection of this complication is relevant given that stopping the drug usually reverts the neurological syndrome .

a 2-year - old asian indian female presented to us with mild fever and swelling of the right upper lid of 10 days duration . there was no history of preceding viral illness or significant medical history necessitating treatment with antibiotics . cutaneous anthrax was unlikely as there was no history of unexplained cattle death in her environment . on examination , the child had low - grade fever and there were no other skin lesions . ophthalmological examination revealed right upper lid edema with a large black necrotic area of the lid which was adherent to the underlying tissues . the child was examined by a pediatrician to rule out any other focus of infection . microscopic examination of the skin biopsy revealed staphylococci and hence cutaneous anthrax was ruled out . the child was started on intravenous cefotaxime for a week with resolution of fever and the necrotic area turned to a well - defined eschar with no edema and induration . after 2 weeks , the child underwent escharotomy with wound debridement and full thickness skin graft from the groin [ fig . 2 ] . under general anesthesia , the groin area was cleaned and draped . the eschar on the lid was found to be partial thickness , was excised in toto , and the wound margins were debrided . the harvested skin was placed over the lid defect and sutured with 6 - 0 prolene . clinical photograph of the child showing large black necrotic area of the right upper lid adherent to the underlying tissues with surrounding erythema and edema and no discharge immediate postoperative clinical photograph showing full thickness skin graft from the groin postoperative photograph at 1 week showing healthy well - taken graft bacterial invasion of the arteries in the dermis and subcutaneous tissues produces a necrotizing vasculitis . the characteristic clinical appearance of eg is a red macule that progresses to a nodular or ulcerative lesion with central area of necrosis surrounded by erythema . bullae develop subsequently and become filled with mucopurulent or serosanguinous fluid . in the end stage , the lesions become hemorrhagic and slough off , leading to a necrotic eschar . progression through these stages is rapid , typically occurring within 1224 h. there are few reports of this condition developing in healthy individuals without any predisposing factors . usually , eg is associated with bacteremia , but can also occur in the absence of it . classic eg rarely involves the periocular tissues and to our knowledge , only a few such cases have been described in the literature . maccheron et al . presented a case of eg that led to orbital cellulitis and panophthalmitis . inamadar et al . described a diabetic individual who developed severe periorbital eg after suffering a laceration to the forehead . ghosheh and kathuria reported a case of bilateral periorbital eg in a diabetic male with renal failure . the mortality rate in nonsepticemic cases varies between 0% and 15% compared with 2096% for those associated with septicemia . the closest differential diagnosis in our case was necrotizing fasciitis , but on the basis of clinical features and negative blood cultures , a diagnosis of eg was entertained in this case . the diagnosis of necrotizing fasciitis depends on clinical features , blood cultures , and gram stain to identify causative organisms and these patients usually have septicemia with positive blood cultures . the eschar formed following antibiotic administration was a full thickness eschar adherent to surrounding tissues and the lesion caused ectropion and mechanical ptosis , which blocked the pupil . considering the possible complications of scarring including entropion or ectropion , trichiasis , corneal exposure , and amblyopia in the child , surgical intervention was indicated . to the best of our knowledge , there are no reports of skin grafting being done as a treatment modality for eg . our patient was atypical in that eg was due to methicillin - resistant staphylococcal infection in contrast to all the four reports where there was pseudomonas infection . the case also highlights the need of early surgical intervention in such circumstances so as the probable sequelae of scarring of upper eye lid , resulting in mechanical ptosis which can result in stimulus deprivation amblyopia can be prevented . 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 .

ecthyma gangrenosum ( eg ) is a cutaneous infection which usually occurs in immunocompromised patients . we report a case of eg of the eyelid treated with escharotomy and skin grafting , highlighting the importance of surgical management . a 2-year - old asian indian female presented to us with right upper lid edema with a large necrotic area . the child received intravenous cefotaxime for a week and the necrotic area turned to a well - defined eschar . escharotomy with wound debridement and skin grafting was done . the present case highlights the importance of surgical intervention to prevent the sequelae of scarring of upper lid .

recent times have witnessed much turmoil regarding the ' life is sacred at any cost ' maxim . current technology is capable of indiscriminately maintaining some of the vital functions of the body , but the same technology does not necessarily allow us to heal underlying disease processes . an unintended side effect of modern technological advances has been the plausibility of maintaining moribund patients in a state of suspended animation for prolonged and sometimes indefinite periods . also , advanced resuscitation techniques make it possible to convert death into life - in - death . patients may be stalled in suspended animation ; they are not alive in the sense the we enjoy life but neither are they able to die as long as nutrition , hydration , ventilation , and perfusion are assured . in many cases reanimation of such patients this conundrum is created because we must be prepared to apply life - sustaining technology to patients when the benefit appears to outweigh the risk and when there is a reasonable chance for an outcome that the patient would desire . it frequently seems reasonable to buy sufficient time to see whether the disease will respond to aggressive treatment by instituting the most invasive life support technology . however , if organ system failure is not reversible , then the reasoning behind life support technology becomes moot . we must then be prepared to remove supportive technology when it appears that inevitable death is being delayed , rather than meaningful life prolonged . the courts have repeatedly affirmed competent a patient 's authority to regulate their medical treatment , regardless of their reasoning . however , when the patient becomes incapacitated , family surrogates are granted authority to make decisions regarding treatment options because of their proximate knowledge of what the patient would have wanted before they became incompetent . this position is based on the postulate that any attempt to interject physician paternalism into the surrogate decision - making equation is ethically unacceptable . most rational surrogates are unwilling to continue life support after a reasonable trial has demonstrated that its benefit has passed the point of diminishing returns . however , there is a continuing trend of surrogates demanding that moribund patients be kept on life support after prevailing medical opinions concur that there is no meaningful chance of reanimation . some reasons why this occurs are as follows : 1 . physicians tell surrogates that they can make any decision they want as an open - ended ideal . this puts them in the position of being buyers in a consumer 's market . by asking them to make a choice an observer 's primal reaction to the vibrant external appearance of a body supported in an intensive care unit ( icu ) is radically different from that to a corpse on a morgue slab . as long as the patient ' looks viable , it is emotionally easier to accept the pie in the sky bye and bye long shot cure ' . if the patient can just be maintained comfortably for long enough , then a cure may eventually become possible . 3 . surrogates dislike being in a position of making decisions that directly result in the death of a loved one . once life - supporting care is instituted , the patient has options for ' survival ' that they did not have before , even though they are dependent on ' life support ' . there are now variables that decision makers control , and it is much easier to avoid decisions that may hasten death . instead of yielding to inevitable death , the potential now exists to manipulate it . physicians do not have an exceptional track record in explaining end - of - life issues to patients and their families . it is not uncommon for physicians to ask loaded questions in their quest for end - of - life decisions . for example , ' this is your grandmother 's 17th transfer from a skilled nursing facility in 3 months for sepsis and respiratory failure , and now she 's in kidney failure as well . what do you want to do : everything or let her die ? ' given that choice , most surrogates would opt for doing something rather than nothing , even if ' something ' perpetuated open - ended pain and discomfort . the popular media , especially the tabloids , frequently feature anecdotal articles describing patients who have awakened after years of coma . most if not all of these patients ' conditions have been embellished to generate public interest , and frequently subsequent investigators can not find these patients . accordingly , some families feel that if life support systems can maintain vital signs for a day or a week , then ' suspended animation ' should be possible indefinitely , until a cure is found . the notion of ' medical futility ' as an end - stage process in which vital signs can not be supported further is poorly understood by both physicians and surrogates . in fact , any medical treatment capable of sustaining hemodynamics , ventilation , and metabolism is not technically futile if it achieves that limited goal . therefore , if a patient in a progressive , inevitable death spiral is placed on mechanical ventilation , it is not technically futile if vital signs are sustained , however briefly . it is medically inappropriate but not technically futile . under the current rules , the only test of futility is that embodied by the question , ' will this treatment result in sustained life ? ' if the answer is ' yes ' , then virtually any treatment is fair game , even if it will do nothing to revitalize the patient . perhaps the most effective way of dealing with strong familial incentives to tread the path of least resistance in end - of - life care is twofold . first , in end - of - life issue discussions , we must strive for ' consensus without consent ' . discussions with surrogates should strive for concordance and understanding but not extend to soliciting their consent for medically inappropriate care . second , we should strive to emphasize what streat and coworkers termed , ' the large risk of unacceptable badness ' , rather than a vanishingly small potential for benefit . there are far worse things than death , and many of them occur in icus when futility maxims are circumvented . there is a population of icu patients who will die no matter what treatment is rendered them . medically inappropriate care causes pain , suffering , and discomfort . the fundamental maxim for these patients should be comfort .

when patients or their families rarely request inappropriate end of life care in the icu for capricious reasons . end of life treatment decisions that only prolong discomfort and death are usually emotional and based on unrealistic expectations . i explore some of those reasons in this paper .

oral infections of geotrichum candidum are clinically similar to candidiasis and commonly associated with diabetes mellitus and hiv infection , . cases of dissemination and fungemia are reported in patients with chronic and acute myeloid leukemia , , , , , , . old women post - partum with isolated renal calculi and renal fungal bezoar attributed to geotrichum candidum and to illustrate the diagnostic dilemmas . old women presented with history of left flank pain and intermittent fever since 15 days . she was evaluated elsewhere with contrast enhanced computerized tomography ( ct ) scan which revealed contracted left kidney with 2 calculi in the lower and middle calyx of 89 mm each with intrapelvic mass and multiple air pockets in the renal pelvis ( fig . 2 ) . she had undergone cytoscopy and left dj stenting elsewhere but continued to have fever and flank pain when she was presented to us . after routine investigation , patient was started on 3rd generation cephalosporin and she underwent left percutaneous nephrolithotripsy ( pcnl ) which revealed brownish gray material with 2 calculi . gross specimen consists of multiple irregular gray brown tissue bits , largest measuring 0.5 cm0.5 cm and cut portion showed gray brown areas . section showed fungal ball containing aggregates of macerated , distorted fungal hyphae with some showing acute angle branching surrounded by cell debris and neutrophils . both urine and biopsy material sent to mycology laboratory for culture investigation were inoculated on sabourauds dextrose agar ( hi - media laboratories ltd . , mumbai ) and incubated at 37 c and 28 c which grew a rapidly growing fungus with flat , white to creamy having a smooth texture later becoming hairy consistent with geotrichum candidum ( fig . geotrichum candidum was morphologically identified by the presence of true hyphae , hyaline smooth , one - celled , subglobose to cylindrical , slimy arthroconidia and the lack of blastoconidia . the arthroconidia vary in size and germinate at one end giving a hockey stick appearance ( fig . 4 ) . biochemical identification was carried out in the mycology laboratory , kasturba medical college , manipal using both conventional and api 20c yeast identification system ( biomerieux inc . ) . it was further differentiated from trichosporon by the absence of urea utilization and inability to assimilate carbohydrate ; maltose , sucrose , lactose , cellobiose , inositol raffinose and trehalose . antifungal susceptibility testing for the isolate was performed according to the clinical and laboratory standards institute ( clsi ) document m38-a2 . the mic90 ( minimum inhibitory concentration ) for amphotericin , fluconazole , itraconazole and voriconazole were found to be 0.125 g / ml , 16 g / ml , 4 g / ml and 0.25 g / ml respectively . patient continued to have fever in the post - operative period and responded only after starting intravenous itraconazole 200 mg bd for 2 days followed by oral itraconazole 200 mg bd and continued for 6 weeks . during the follow up , a repeat ct done showed complete clearance of the fungal material from the left kidney . the saprophytic colonization of a preformed cavity by conglomerate of fungal mycelia without invasion of adjacent tissue is termed as fungal ball or fungal bezoar . renal colic can be caused by passage of fungal ball that obstruct the collecting system . genitourinary tract is rarely a site of primary fungal infection with exception of candida species , however it may be involved as a result or part of systemic infection . candidal infection can cause pyelonephritis , abscess , papillary necrosis and obstruction with fever and flank pain , . genitourinary fungal infections are usually encountered as a part of disseminated disease in immunocompromised host ( aids , corticosteroids , malignancy , neutropenia ) , , , , , , . fungal balls also called and fungal bezoars or accretions are known to cause ureteral and uretro - pelvic junction obstruction . diagnosis is established by identification the of fungi in urine and imaging studies using ( computerized tomography , ultra sonography , intravenous urography ) that document obstructive uropathy and soft tissue density with in renal collecting system . have successfully managed the removal of bilateral renal pelvis mycotic bezoars using a mechanical thrombectomy device followed by antifungal renal pelvis irrigation . percutaneous nephrostomy , tract dilation and fluoroscopically guided extraction of renal fungal ball under epidural anesthesia is described by doemeny et al . . the outcome of geotrichum infections depend on the degree of tissue invasion by the organism and the immune status of the host . sheehy et al . suggested that geotrichum lack virulence and ability to colonize renal tubules based on the rarity of disseminated disease , lack of tissue invasion and their rapid clearance in most of the case reported . its incidence may be under reported since it can be misdiagnosed histopathologically as candida , aspergillus or trichosporon . this possibility of misinterpretation highlights the importance of obtaining repeated fungal cultures in addition to histopathological examination . we hereby reiterate the pathogenic potential of geotrichum candidum and report its role in causing renal fungal ball .

geotrichum candidum is yeast like fungi that cause infections in immunocompromised patients . we report a case of renal fungal ball with geotrichum candidum in a 27 yr . old women post - partum . this case to our knowledge is the first case of renal fungal bezoar due to geotrichum candidum reported in india .

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

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

in 2009 , a 52-year - old woman presented with a single lesion on her nose , which started as a papule , referred to sedighe tahereh clinic , isfahan , iran . the lesion had existed for a period of 14 months and was slowly increasing in size , enlarging to a plaque . the diagnosis of leishmaniasis was confirmed with a positive smear of the lesion showing leishmania bodies about 1 year before . all five members of her family had had a history of proven leishmaniasis . in the past medical history , the patient was a renal failure case since 11 years before and received a renal transplant 4 years after the diagnosis of renal failure . she was receiving oral mycophenolate mofetil ( 2 g daily ) and cyclosporine ( 100 mg daily ) . a 33 cm indurated ulcer with elevated borders was present on the tip of her nose ( figure 1 ) . her therapeutic plan was intralesional glucantime injection ( approximately 1 ml of 1.5 g vial per week , intralesional injection ) . after completing a therapeutic course of 20 sessions receiving intralesional glucantime injections , she was considered as glucantime therapy resistant . the occurrence of malignant neoplasms in sites of scars is an infrequent but well - known phenomenon.5 although the coexistence of cutaneous leishmaniasis and bcc may have been coincidental , some studies suggest that an association between these two entities does exist.6 leishmaniasis can directly or indirectly alter the diagnosis and course of different malignancies.7 there are reports of bcc in chronic leg ulcers.8 cases of bcc developing in a leishmania scar have also been documented,9 but to our knowledge , cases of both leishmaniasis and bcc in the same site and the same lesion are rare.10 however , in this case , solid organ transplantation and long term immuno suppressive therapy should be considered as risk factors for malignancy . advances in effective immuno suppression after organ transplantation have led to increased risk of malignancies , particularly skin cancers11 including squamous cell carcinoma , basal bcc and malignant melanoma.12 thus , malignancies should be considered in the differential diagnosis of leishmaniasis lesions difficult to treat . the possible role of cutaneous leishmaniasis , as a predisposing factor for skin cancer , should also be kept in mind . aa was the main therapeutic physician and helped write the manuscript . i m and pk contributed in writing the manuscript .

leishmaniasis is a protozoan infection due to organisms of the genus leishmania . the differential diagnosis of cutaneous leishmaniasis includes arthropod bites , basal cell carcinoma ( bcc ) and other malignancies . bcc is the most common form of skin cancer . we present a case of cutaneous leishmaniasis resistant to standard intralesional glucantime injection in an immunocompromised patient , which was proved to be bcc after surgical excision .

in the previous issue of critical care , chase and coworkers reported on their implementation into clinical practice and evaluation of the specialized relative insulin nutrition table ( sprint ) . this is an improved protocol in the form of a wheel - based system to control blood glucose levels and nutritional intakes in intensive care patients , which was developed a few years ago . blood glucose has become a key biological parameter in critical care since publication of the study conducted by van den berghe and colleagues , who demonstrated decreased mortality in surgical intensive care patients in association with tight glycaemic control ( tgc ) , based on intensive insulin therapy . however , two negative studies were recently reported , which were interrupted early because of high rates of severe hypoglycaemia , namely the visep study and the as yet unpublished glucontrol trial . hence , there is currently much debate regarding the actual benefits of such a strategy in intensive care patients in terms of outcomes . it is also uncertain whether the results of the ongoing multicentre , open label , randomized controlled trial nice sugar of the effects of blood glucose management on 90-day all - cause mortality in a heterogeneous population of intensive care unit ( icu ) patients will resolve remaining concerns about tgc in the icu . included among these concerns is the key issue of what is the most appropriate algorithm to achieve the desired blood glucose range . the major focus of the study conducted by chase and colleagues was on the method to achieve a predetermined blood glucose range by modulating both insulin infusion rate and nutritional inputs . as with the other reported studies comparing protocols , efficacy was evaluated by comparison with historical control patients . however , although the study reported by chase and coworkers was conducted with great care and rigour , it is but another case - control retrospective comparative study . nevertheless , there is a clear need to introduce efficient tools that will help clinicians and nursing staff to control blood glucose levels in icu patients , because hyperglycaemia superior to 10 mmol studies are required to provide clinicians with recommendations on the evaluation and comparison of the various protocols currently in use or that are soon to become available . benchmarking of tgc protocols must take in account all the dimensions of efficiency : performance , risk for severe hypoglycaemia , practical aspects ( ease of use , training time and required materials prior to implementation , error rate ) , integrated continuous monitoring , nursing workload ( evaluated on the mean time between controls ) . furthermore the best way to compare performance is controversial : is it the time with glucose within a common target range , the hyperglycaemia index , the recently described glycaemic penalty index , or the variability that would be associated with outcome ? this raises the question of whether the efficacy results from instructions regarding nutritional intake , allowing insulin infusion rates to be limited to a level lower than usual , or from the intrinsic quality of the algorithm used , which is based on the glucose - insulin regulatory system model ( capturing insulin utilization rate , insulin losses and saturation dynamics ) . also , sprint is apparently associated with few severe hypoglycemia events , which contrasts with the high rate of severe hypoglycaemic episodes reported in the second leuven study . finally , sprint should be relatively simple to implement in numerous icus as a paper - based protocol , presented in an original form using a wheel , without need for computational resources . weaknesses of sprint rest in its inability to monitor parameters related to the quality of glucose control as sprint is a paper - based protocol . most importantly , despite the favourable subjective opinions of care givers , sprint may not reduce workload because it requires measurements every hour or 2 hours . ultimately , evaluation of any tgc protocol must also include an assessment of its ability to be implemented easily and safely in another icu that did not participate in its development . the monocentric study of chase and coworkers may not ensure the ' exportability ' of their tgc protocol . the debate continues about the real benefits of tgc , with numerous questions being asked . what is the optimal target range ? which patients will benefit the most ? when during the icu stay should tgc be applied and to derive which benefits ? which is the best method to control glucose level intensive insulin therapy , and/or limitation of nutritional intakes during acute phase , and/or antidiabetic drugs ? however , the competition to develop the ideal tool with which to control blood glucose levels in the icu and perhaps throughout the hospital stay has begun , involving multidisciplinary teams of physicians and engineers who have specialized in control systems ( feedback control or model predictive control ) . icu = intensive care unit ; sprint = specialized relative insulin nutrition table ; tgc = tight glycaemic control . pk declares that he holds shares of lk2 ( saint - avertin , france ) .

the report by chase and coworkers in the previous issue of critical care describes the implementation into clinical practice of the specialized relative insulin nutrition table ( sprint ) for tight glycaemic control in critically ill patients . sprint is a simple , wheel - based system that modulates both insulin rate and nutritional inputs . it achieved a better glycaemic control in a severely ill critical cohort than their previous method for glycaemic control in a matched historical cohort . reductions in mortality were also observed .

group a included patients of arm with ru fistula who had undergone posterior sagittal anorectoplasty ( psarp ) without closure of ru fistula , from february 2006 to january 2010 . the rest of the psarp procedure was the same as conventionally done , the only difference being that we did not close the ru fistula after separating it from the rectum . we just separated the rectum from the urethra and left the urethral fistula as it is without closing it . group b included 34 previous successive patients who had undergone psarp before january 2006 in whom the ru fistula was closed using interrupted sutures . all the patients in both the groups had undergone staged repair of arm and not primary psarp . micturating cystourethrogram ( mcu ) and distal colostogram was done in all these patients prior to psarp . all the patients were evaluated during follow - up both clinically and with investigations like mcu and cystoscopy . the patients were studied for parameters like urinary stream , urinary dribbling , urinary tract infections , and recurrent ru fistula . moreover , all patients had undergone urethrocystoscopy three months after psarp to check for the status of the urethra and bladder . patients who had sacral agenesis were excluded from the study group because such congenital sacral defects can lead to a neurogenic bladder . the following were the observations in group a ( a ) in the immediate postoperative period , there was no urinary leakage , urinary retention , or any other complication ; thus all these patients had an uneventful recovery . ( b ) urinary stream was normal ; there was no evidence of urinary dribbling or retention , urinary tract infection , and recurrent rectourinary fistula during follow - up . mcu showed normal urethra , without any evidence of stenosis or stricture , urethro - ejaculatory duct / vasal reflux , or diverticulum in any of the cases . however , in group b , complications like urethral stenosis , urethral diverticulum , and neurogenic dysfunction were seen . a comparative analysis of the two groups was done and overall complications were listed [ table 1 ] . during psarp , urological injuries in male patients are known complications.[13 ] excessive traction on the urethra during dissection leads to transection or injury to the urethra . it is extremely important for the surgeon to bear in mind that in arm with ru fistula , the rectum is intimately attached to the urethra and that meticulous dissection and separation are necessary . urethral stenosis can occur due to traction on the ru fistula , that is , indirect traction on the urethra during separation and closure of fistula . urethral stenosis can be avoided by applying less traction on the fistula during separation and avoiding the closure of fistula ; we have seen in our series that urethral stenosis was not seen in any of the cases of group a , where the ru fistula was not closed . closing another point to note is that if we separate the rectum from the urethra very near the urethral wall and use interrupted sutures for its closure , it also increases the chances for urethral stenosis . urethral stenosis due to ligation or closure of the ru fistula may result in recurrent epididymo - orchitis . urethral diverticulum is the result of a segment of the rectum left attached to the urethra and the separated end closed . such patients usually present with recurrent urinary tract infections , stone formations in diverticulum again leading to dysuria , urinary tract infections , and so on . this complication can be avoided by separating the rectum away from the urethra without leaving any segment of the rectum attached and leaving the fistula as it is without closing it , so that nothing like a pouch / diverticulum is formed . neurogenic dysfunction after psarp has been reported in the form of neurogenic bladder , impotence , or loss of ejaculation . postoperatively , a neurogenic bladder may reflect a poor surgical technique with denervation of bladder and bladder neck during repair . by avoiding the closure of the ru fistula , we can avoid excessive traction on the fistula and hence on the urethra , and also prevent the excessive dissection during fistula closure and minimize the chance of neurogenic dysfunction . damage to the external vesical sphincter has also been reported during ligation or closure of the fistula . thus by avoiding closure of the fistula , we avoid this complication also and , hence , neurovesical dysfunction . thus we have seen that by not doing something , that is , by not closing the ru fistula during psarp , we can avoid many complications ; so , not doing something is preferable here .

aim : to study the effect of nonclosure of rectourethral ( ru ) fistula and to do a comparative analysis of the complications with and without nonclosure of ru fistula during posterior sagittal anorectoplasty ( psarp ) in anorectal malformation cases ( arm).materials and methods : a total of 68 cases of arm were included in the study group , of which 34 cases were those in whom ru fistula was not closed ( group a ) during psarp . another 34 successive cases were included in study group b in whom the ru fistula was closed as is conventionally done by using interrupted sutures.results:comparatively , group a had none or minimum urological complications as compared to group b.conclusion:ru fistula closure is not mandatory during psarp and nonclosure avoids urological complications . it especially avoids urethral complications , which are 100% preventable .

organic foreign bodies are generally associated with severe inflammatory reaction and infection , while the nature of reaction elicited by inorganic foreign bodies depends on the material of the foreign body . graphite , which is the major constituent of pencil lead , has been reported to remain inert in the eye for a long time . however , it has also been reported to cause severe endophthalmitis - like reaction in the eye . we report a rare case of retained graphite pencil tip in the anterior chamber of a six - year - old girl . a six - year - old girl presented to us with history of mild pain in the left eye of two days duration . the child s mother gave a history of trauma with a graphite lead pencil about four months ago at school when she was accidentally poked in the left eye by another child . the child had not been examined by an ophthalmologist after the incident as she was apparently asymptomatic at the time . on examination , the best corrected visual acuity was 20/20 in the right eye and 20/40 in the left eye . there was a full thickness corneal scar ( figure 1 ) in the left eye . a small area of iris atrophy with a sphincter tear was noted at the edge of the pupil at the 6 o clock position . there was a black foreign body resembling a graphite pencil lead tip , measuring about 1.5 mm in size , on the iris at the 7 o clock position ( figure 1 ) . ocular ultrasonography of the left eye did not reveal any abnormality in the posterior segment . figure 1slit lamp photograph of the left eye showing the corneal scar and the graphite pencil lead tip on the iris . slit lamp photograph of the left eye showing the corneal scar and the graphite pencil lead tip on the iris . a corneal incision was made at 5 o clock position with a 2.8 mm keratome . the anterior chamber was filled with 2% methyl cellulose and the foreign body ( figure 2 ) was removed in toto with a bechert - mcpherson forceps . the remaining graphite particles were aspirated out with a simcoe cortex aspiration cannula using an anterior chamber maintainer . post - operatively , the patient was put on tapering doses of topical steroids and cycloplegics . on follow up , one month later , the best corrected visual acuity in the left eye was 20/40 . there was no inflammation ; the lens was clear and the fundus was normal . the reaction of the eye to a retained intraocular foreign body varies depending on its composition . foreign bodies comprised of materials like gold , silver and platinum have been reported to remain inert in the intraocular environment . there are only a few reports of ocular trauma with retention of graphite pencil lead in the eye . retained graphite has been described in the conjunctiva , cornea , angle of the anterior chamber and the posterior segment . a case of pencil - tip injury to the orbit with retained graphite foreign body associated with delayed orbital infection has also been described . however , the potential toxicity of the other constituents of pencil lead like animal fats and clay is not clearly known . there has been a report of severe endophthalmitis - like reaction incited by retained graphite foreign bodies in the vitreous . in this case , it is unclear whether the reaction was induced by the other constituents of pencil lead like the aluminium in the kaolinite or if there was an associated infection . in our case , we decided to surgically remove the intraocular foreign body in spite of the fact that it had obviously remained in the eye for some time ( as evidenced by the healed corneal scar and presence of iris atrophy ) without inciting an inflammatory response or causing much damage to the intraocular structures . there was a distinct possibility of causing damage to the lens and inciting an inflammatory reaction during surgical removal of the foreign body . this risk had to be weighed against that of the damage the foreign body might cause if it was left in the eye . there was a chance that the foreign body would get dislodged into the angle at a later stage and cause progressive damage to the angle structures and the cornea as in the case reported by han et al . honda et al . have reported a case of a five - year - old child with a graphite foreign body lodged in the peripheral retina , whom they followed up for six years with serial electroretinograms , fundus photographs and fundus fluorescein angiography . there was no evidence of any damage to the eye caused by the foreign body at the end of their follow up . however , in our case , such meticulous follow - up would have been quite impossible as the child s family belonged to a poor socio - economic background and the parents would not have been able to afford the cost of repeated hospital visits and investigations . our case also differed from honda et al.s case in that the foreign body was in the anterior segment and therefore , was at a more accessible site . there was a higher chance of removal of the foreign body without causing damage to the intraocular structures in our case . in conclusion , graphite foreign bodies may be retained in the eye without causing any inflammation or damage to the intraocular structures . on the other hand , there is also the possibility of progressive damage to intraocular structures by these foreign bodies due to various mechanisms . therefore , the decision about surgical removal of the foreign body has to be made on an individual basis after taking multiple factors into consideration and estimating the risk - benefit ratio in each patient .

retained intraocular graphite foreign bodies are uncommon . although they are generally inert , they have been reported to cause severe inflammatory reaction and progressive damage to intraocular structures . we report a case of a six - year - old girl with a retained intraocular graphite pencil lead foreign body in the anterior chamber of the eye and discuss the various considerations in the management of such cases .

ductal adenocarcinoma of the prostate was first reported by melicow and pachter in 1967 as an endometrial carcinoma prostatic utricle . since then , ductal adenocarcinoma of the prostate has been found to account for 0.27.5% of all prostate carcinomas . a 73-year - old man was referred to our hospital due to an elevated prostate - specific antigen ( psa ) level of 23.4 ng / ml . he had no remarkable medical history . the hematological and biochemical data showed no abnormal findings aside from the elevated psa levels . in february 2016 , a prostate needle biopsy detected gleason score 4 + 4 adenocarcinoma in his left prostate . computed tomography ( ct ) and magnetic resonance imaging ( mri ) showed a higher density on his left peripheral zone ( fig 1a , b ) . in may 2016 , radical prostatectomy with lymph node resection histologically , there were many large , clear - edged cells and cancer cells with low differentiation forming a circular shape . based on these findings , ductal adenocarcinoma and gleason score 4 + 4 = 8 acinar adenocarcinoma with positive surgical margin were diagnosed . the patient has not experienced recurrence or biochemical recurrence in the 10 months since radical prostatectomy . histologically , there were many large , clear - edged cells and cancer cells with low differentiation forming a circular shape . based on these findings , ductal adenocarcinoma and gleason score 4 + 4 = 8 acinar adenocarcinoma with positive surgical margin were diagnosed . no adverse perioperative events were observed . the patient has not experienced recurrence or biochemical recurrence in the 10 months since radical prostatectomy . ductal adenocarcinoma of the prostate was first reported as endometrial carcinoma of the prostatic utricle in 1967 . recent studies have suggested that ductal adenocarcinoma of the prostate developed from the ductal epithelium , based on findings from immunohistochemical and electron microscope analyses . histologically , ductal adenocarcinoma of the prostate is characterized by high cylindrical epithelium collate papillary or etat cribriform . the histological differences between ductal adenocarcinoma and acinar adenocarcinoma are thought to be clear . in this case , although the prostate needle biopsy showed acinar adenocarcinoma , the surgical specimens showed ductal adenocarcinoma . the first is a mixed type with acinar adenocarcinoma and accounts for < 75% of ductal prostate specimens . mixed - type ductal prostate adenocarcinomas account for 5.06.6% of all prostate cancer cases , and pure - type ductal prostate adenocarcinomas account for 0.40.8% of all prostate cancer cases . because ductal carcinomas account for 90% of all prostatic carcinoma cases , our case was assumed to be pure type . because of its extension toward the urethra , the tumor was not palpable on a digital rectal examination and showed a low psa level . ductal adenocarcinoma of the prostate usually extends toward the urethra and shows macrohematuria and urinary symptoms at an early stage . reported that ductal adenocarcinoma of the prostate showed a significantly poorer prognosis than acinar prostate adenocarcinoma in nonmetastatic cases . however , in metastatic cases , there were no prognostic differences between these 2 groups . other reports have found no marked differences in the 5-year survival rate between ductal adenocarcinoma and gleason score 810 acinar adenocarcinoma . reported therapies of ductal adenocarcinoma of the prostate are also the same as for acinar adenocarcinoma , including radical prostatectomy , androgen deprivation therapy , and radiation therapy or a combination of these therapies . reported that pure ductal adenocarcinoma tended to extend into the submucosal urethra ; as such , pure ductal adenocarcinoma carries a higher risk of a positive surgical margin in the urethra . although we are not performing adjuvant therapy in this patient at present , careful observation including ct , mri , or positron emission tomography - ct should be performed , as psa does not always accurately represent cancer progression .

ductal adenocarcinoma is an unusual variant of adenocarcinoma of the prostate . a 73-year - old male was referred to our hospital for the further examination of an elevated prostate - specific antigen level of 23.4 ng / ml . radical prostatectomy ( rp ) was performed based on the diagnosis obtained by a prostate needle biopsy . the rp specimen revealed ductal adenocarcinoma of the prostate with positive capsular penetration . we herein report a rare case of ductal adenocarcinoma of the prostate .

incidental detection of small renal masses is increasing . this has led to an increase in biopsy of small renal masses , a proportion of which needle biopsy of small renal masses is controversial owing to the risk of seeding malignant cells along the needle tract . needle tract seeding is a rare event ; the incidence is estimated to be less than 1 in 10,000 cases of all biopsies . eight other cases of needle tract seeding in a renal mass biopsy have been described in the medical literature , two as recently as 2013 ( table 1 ) . we report our experience of a man with renal cell carcinoma ( rcc ) seeding along a biopsy tract and compare the circumstances and biopsy techniques with reported cases in the literature . a 66-year - old man was incidentally found to have a 32-mm right lower pole renal mass on a computed tomography ( ct ) scan ( fig . two samples were obtained by use of a 16-gauge temno core biopsy needle ( carefusion , san diego , ca , usa ) and a 22-gauge francine needle . histopathology revealed a well - circumscribed 30-mm clear cell rcc , predominantly fuhrman grade 2 with focal areas of grade 3 . there was an area where the capsule was interrupted that corresponded to a hemorrhagic area on the cortical surface ( fig . a tumor deposit was also noted in the perinephric fat . these features suggested that the tumor deposit in the fat was likely due to tumor seeding rather than a metastasis and that the tumor seeding could have resulted from the needle biopsy . his tnm staging was pt3a nx mx , at least stage 3 disease ( american joint committee on cancer , 7th edition , 2010 ) and his leibovich score was 5 ( intermediate risk ) . six months after the operation , there was no radiological evidence of tumour recurrence on a ct scan . aside from the potential for false - negative results , a key risk of renal mass biopsy is seeding of the biopsy tract with malignant cells . several factors in theory could affect the risk of biopsy tract seeding , such as needle size , the number of needle passes , and the use of a coaxial needle . biopsy tract seeding has been reported in renal mass biopsies using needles as fine as 23-gauge and as large as 14-gauge . theoretically , a larger - bore needle would increase the risk of seeding owing to an increased area of defect on the surface of the tumor and an increased circumference or surface area of the needle . however , because of the scarcity of cases , it is difficult at this stage to accurately determine a relationship between needle size and the risk of seeding . it is also difficult because of underreporting to associate the risk of needle tract seeding with the number of needle passes through a tumor . use of a coaxial needle allows multiple passes through the renal mass with only one pass through the surrounding normal tissue . this theoretically reduces the risk of needle tract seeding into normal tissue and potentially reduces patient discomfort as well . although it is interesting to note that a coaxial needle was not used in any of the currently reported cases of needle tract seeding after renal mass biopsy ( table 1 ) , there are just too few cases to establish a firm relationship between the risk of biopsy tract seeding and the use of a coaxial needle . visualization of larger coaxial needles on ultrasound or ct may be easier than with smaller biopsy needles , and this may improve accuracy . histological evidence of biopsy tract seeding may not always be found after definitive surgery to remove the renal mass . seeding into excised perinephric tissues can be found soon after surgery but seeding into surrounding muscle , fascia , and skin may only be apparent months , or even years , after surgery . as was seen with this case , the biopsy needle traversed skin , subcutaneous tissue , multiple muscle and fascia layers , and perinephric fat before reaching the renal lesion ( fig . thus , the tumor could theoretically seed into one or more of these tissues ; seeding as superficial as the subcutaneous tissue has been reported ( table 1 ) . this delayed presentation may increase the risk of adverse outcomes such as further metastasis and poorer prognosis . time to presentation or diagnosis of tumor seeding after renal mass biopsy has ranged from 24 days to 84 months in previously reported cases where tumor seeding was not found on the initial histopathological analysis ( table 1 ) . in conclusion , a common feature in all reported cases of needle tract seeding from a renal mass biopsy is that a coaxial needle was not used . however , because of the paucity of cases , there is currently no satisfactory association between the risk of needle tract seeding and needle size or the number of needle passes . it is important to consider that histopathological evidence of needle tract seeding may not be apparent in all cases , especially if seeding occurred beyond the excised tissues .

a 66-year - old man underwent computed tomography - guided needle biopsy of a suspicious renal mass . two months later he underwent partial nephrectomy . histology revealed a 30-mm clear cell renal cell carcinoma , up to fuhrman grade 3 . an area of the capsule was interrupted , which corresponded to a hemorrhagic area on the cortical surface . under microscopy , this area showed a tongue of tumor tissue protruding through the renal capsule . a tumor deposit was found in the perinephric fat . these features suggest that tumor seeding may have occurred during the needle biopsy .

a male neonate born to g2 p1l1 mother at term by spontaneous vaginal delivery to iii degree consanguineous marriage was found to have proximal shortening of both upper and lower limbs [ figure 1 ] . the antenatal period was uneventful and antenatal ultrasound was reportedly not done during pregnancy and the mother was referred to our hospital after the onset of labor . apart from rhizomelic shortening , the neonate also had coronal clefts of thoracic vertebrae and stippled epiphysis of femur tibia and humerus on skeletal survey radiograph [ figure 2 ] . based on the above features a provisional diagnosis of rhizomelic chondro - dysplasia punctata ( rcdp ) was made and the prognosis was explained to the parents . the baby developed progressively severe respiratory distress and was discharged at request on day 3 of life as the parents were unable to come to terms with the diagnosis . rhizomelic shortening of upper limb punctate calcification and epiphyseal abnormalities chondrodysplasia punctata is a radiological diagnosis characterized by punctate or stippled calcifications in epiphyseal cartilage and seen in peroxisomal disorders such as zellweger syndrome , neonatal adrenoleukodystrophy , and infantile refsum disease . it may also be inherited as x - linked dominant , x - linked recessive , and autosomal recessive forms . it is classically associated with pex7 gene ( peroxin family of genes ) mutation and has been reported in indian patients too . rcdp is characterized by proximal shortening of the humerus and to a lesser degree the femur , punctate calcifications in cartilage with epiphyseal and metaphyseal abnormalities , radiolucent defects ( coronal clefts ) of the vertebral bodies which represents cartilage that are not ossified , cataracts , contractures , microcephaly , characteristic skin changes of icthyosis , facial dysmorphism ( depressed nasal bridge , hypertelorism , hypoplastic midface , anteverted nostrils , full cheeks ) , and developmental impairment . this condition is considered to be lethal and most of the affected fetuses die in utero or soon after birth . only few of them survive beyond infancy with severe physical disability and profound mental retardation in whom , death usually occurs in the first decade of life . diagnosis of rcdp is based on clinical findings and confirmed by clinically available biochemical or molecular genetic testing which includes biochemical tests of peroxisomal function like red cell plasmologen concentration , plasma phytanic acid , and very long chain fatty acid estimation . this case is presented due to its rarity and failure to detect such an abnormality in utero resulting in a wasted pregnancy . the lack of resources ( both money and manpower ) is probably responsible for this tragedy to the parents which could have been prevented by early diagnosis and appropriate counseling . establishing regional genetic labs which are connected with district level hospitals can be of immense help in reducing the burden of genetic diseases by appropriate prenatal diagnosis and counseling .

a male neonate was born with rhizomelic shortening of limbs . skeletal radiograph showed punctate calcification of epiphysis of humerus , femur , and tibia . the diagnosis and a brief review of literature pertaining to the condition with emphasis on antenatal diagnosis and counseling are being reported .

a 56-year - old female presented with best corrected visual acuity ( bcva ) of 20/120 and nuclear sclerosis ( nuclear opacity 3 , nuclear color 2 using lens opacification classification system iii ) in the left eye ( le ) . the surgery was performed using proparacaine drops ( paracain ophthalmic solution 0.5% , sunways pvt . ltd . , a foldable iol of + 22.5 d of the sensar ar40e variety [ abbott medical optics inc ( amo ) , 1700 e. st . andrew place , santa ana , ca 92705 usa ] was loaded into the emerald c cartridge ( lot ch00841 of amo inc . , usa ) by the first assistant outside the field of the operating microscope to save the surgical time . the cartridge was inserted in the injector and the loaded injector was handed to the surgeon . the tip of the cartridge was just inserted snugly by slight rotatory motion into the anterior chamber through the 2.8-mm incision . however , while removing the injector system , it was noticed that there was a gross downward beaking of the bevelled anterior end of the cartridge [ fig . immediately , the incision site was inspected under the operating microscope and a descemet 's tear was detected with a rolled out flap of about 2 mm in length . the viscoelastic was meticulously washed out and the main incision wound and the two side port entries were carefully hydrated and an air bubble was injected into the anterior chamber . downward beaking of the beveled anterior end of the emerald c cartridge ( lot ch00841 of advanced medical optics , inc . , usa ) on the first postoperative day , the patient 's le had an uncorrected va of 20/60 with a small rolled out descemet 's flap and adjacent descemet 's striae at the site of the main clear corneal incision ( temporally ) [ fig . a corneal opacity remained at the deeper corneal layers with mild surrounding edema , even at the time of last check - up at 4 weeks post - op , with a bcva of 20/30 [ fig . a small rolled out descemet 's flap and adjacent descemet 's striae ( left eye of the reported case on the first postoperative day ) corneal opacity at the deeper corneal layers with mild surrounding edema ( left eye of the reported case at 4 weeks post - op ) damage to iols as a consequence of passage through various injector systems includes marks or scratches , stress fractures , cracks and tear lines . damage to descemet 's membrane can occur due to various factors during cataract surgery , including engaging of descemet 's membrane by the leading haptic during iol implantation or with the irrigation / aspiration device ( when mistaken as an anterior capsular remnant ) or due to inadvertent injection of viscoelastic between descemet 's membrane and corneal stroma . repair techniques include manual repositioning , repositioning with viscoelastic or air , suturing of descemet 's membrane to the peripheral cornea or use of sf6 or c3f8 . our case report describes injury to the corneal endothelium and descemet 's membrane intraoperatively due to frayed and beaked tip of the amo emerald c cartridge . the case has been followed up for a period of about 4 weeks as on the day of reporting , and as the visual axis was not completely involved , the vision is maintained , although the descemet 's stria and mild surrounding edema remains . we have reported only a single case ; however , a damaged amo emerald c cartridge has been found in a few subsequent cases in our institute . in cases where a back - up cartridge was not available , the size of the clear corneal incision was increased to 3.2 mm at least to protect the entry wound architecture and the corneal endothelium , while injecting the iol using the damaged cartridge . the cause of the damaged nature of the amo emerald c cartridges appears to be a manufacturer 's oversight which has been duly informed to the concerned authorities , who have assured speedy correction of the defect . these cartridges are delivered in sterile transparent cases and the tip can be easily examined under the slit lamp beforehand without opening the casing . this should be made a routine practice as this will allow any damaged cartridge to be replaced before starting the surgery by ordering a fresh one from the manufacturer . we suggest loading of the foldable iol should be done by the surgeon himself under the operating microscope . the speed of the surgery should never compromise the quality of the surgery and/or the final visual outcome . with the advent of newer techniques like the microincision cataract surgery ( mics ) , surgeons also can not compromise on the incision size or wound integrity and architecture . the onus is on the various manufacturing companies to provide surgeons with precision instruments that are both safe and durable for the patient 's eyes . and more importantly , every instrument entering the patient 's eye should undergo careful preoperative microscopic inspection by the operating surgeon himself so that a microscopic manufacturing defect can be identified and immediate rectification of the situation can be done .

foldable intraocular lens ( iol ) implantation using an injector system through 2.8-mm clear corneal incision following phacoemulsification provides excellent speedy postoperative recovery . in our reported case , a sensar ar40e iol ( abbott medical optics , usa ) was loaded into emerald c cartridge , outside the view of the operating microscope , by the first assistant . the surgeon proceeded with the iol injection through a 2.8-mm clear corneal incision after uneventful phacoemulsification , immediately following which he noted a descemet 's tear with a rolled out flap of about 2 mm near the incision site . gross downward beaking of the bevelled anterior end of the cartridge was subsequently noticed upon examination under the microscope . we suggest careful preoperative microscopic inspection of all instruments and devices entering the patient 's eyes to ensure maximum safety to the patient .

when the gallbladder is not visualized in its normal location , the possibility of its ectopic location should be considered . a case of incidentally detected anomalous position of gall bladder causing confounding problem in interpretation of pet - ct is described . a 70-year - old man , with h / o chronic liver disease and suspected of hepatocellular carcinoma [ serum alpha - fetoprotein ( afp ) 5024 ng / ml ] was subjected to fluorine-18 fluorodeoxyglucose positron emission tomography ( f-18 fdg pet)/computed tomography ( ct ) imaging . rest of the liver revealed non - fdg avid lesions in segments iii and viii . on viewing the fused pet / ct images , the radiotracer accumulation was localized to the anomalously placed suprahepatic gallbladder . magnetic resonance ( mr ) images of the same patient confirmed the presence of the suprahepatic gallbladder [ figure 1 ] . ( a ) transaxial view of pet image showing suprahepatic subdiaphragmatic gallbladder with tracer uptake ; ( b ) coronal view of pet image ; ( c ) sagittal view of pet image ; ( d ) transaxial view of ct image ; ( e ) coronal view of ct image ; ( f ) sagittal view of ct image ; ( g ) transaxial view of post - contrast t1-weighted mri image ; ( h ) coronal view of post - contrast t1-weighted mri image ; ( i ) transaxial view of t2 fat saturated mri image shows gallbladder as a bright structure routine imaging of the gallbladder demonstrates a wide array of imaging variants , including anomalies in location , number , and configuration . an awareness of these normal variants would prevent misdiagnosis and aid in the assessment of differential diagnostic possibilities . normally , the gallbladder is situated adjacent to the inferior surface of the liver , in the plane of the interlobar fissure , with the gallbladder neck maintaining a constant relationship to porta hepatis . the gallbladder is generally found in the right upper quadrant , but may be seen in other parts of the abdomen . while anomalous positions are rare , the most common of these are ( 1 ) under the left hepatic lobe , ( 2 ) intrahepatic , ( 3 ) transverse , and ( 4 ) retroplaced ( retrohepatic or retroperitoneal ) . the lesser common of these are ( 1 ) supradiaphragmatic and ( 2 ) suprahepatic . gallbladder is intrahepatic during the embryonic period and becomes extrahepatic only later . an intrahepatic gallbladder ( usually a congenital anomaly ) this poses a problem for scintigraphy , as an intrahepatic gallbladder can cause a focal defect ( pseudo space - occupying lesion ) ; ultrasonography can be helpful in these cases . the suprahepatic region is among the rarest sites , and very few reports have appeared in either the surgical or radiological literature.[35 ] of the very few reports on the suprahepatic gallbladder , one refers to a normally inserted organ that rotated 180 upward to an intrathoracic position after eventration of the diaphragm . in two other cases , an abnormally mobile gallbladder was found trapped between the chest wall and the upper border of the liver ; this became symptomatic and caught the attention of the clinician and the imageologist . faintuch et al . reported three cases of suprahepatic gallbladder with hypoplasia of the right hepatic lobe and upward migration of the gallbladder . gansbeke reported a case of suprahepatic gallbladder which was associated with hepatomegaly due to macronodular cirrhosis complicating existing hepatitis . kabaroudis reported a case of floating gallbladder associated with hypoplasia of the right hepatic lobe , whereas maeda had reported a similar case associated with hypoplasia of left hepatic lobe . pet - ct is found to be useful in diagnosing this rare anatomical variant of ectopically located gall bladder and predicting its functional implication .

the purpose of this study was to appraise the imageologists of a possible mislocalization of tracer accumulation to anomalously placed gallbladder during positron emission tomography - computed tomography ( pet / ct ) examination . pet / ct is increasingly playing an important role in staging and restaging of the disease process in cancer patients . with the advent of fusion imaging , the tracer accumulation can be correctly localized to a structure or lesion on ct . we did a staging pet / ct scan of a patient with hepatocellular carcinoma for liver transplant evaluation . fluorine-18 fluorodeoxyglucose ( f-18 fdg ) was used as a tracer and the scan was performed on seimens biograph - mct pet / ct machine . we noted the tracer accumulation at the superior surface of liver , which was localized to the anomalously placed gallbladder in suprahepatic subdiaphragmatic location . the anomalously placed gallbladder can create localization confusion . keeping the possibility of ectopically placed gallbladder in mind , the imageologist can better localize the tracer uptake .

anterior cervical spine fusion and stabilization is a well established procedure for cervical myelopathy , radiculopathy , neoplasms , and cervical trauma2 ) . although injuries to the pharynx and esophagus are known complications of anterior cervical spine surgery , delayed pharyngeal or esophageal perforation is rare7,9,10 ) . here , we describe a rare but potentially life - threatening complication after anterior cervical spine fusion and plating . the authors highlight this issue by presenting this case , which had no associated morbidity , and include a review of the relevant literature . a 43-year - old man was admitted to our institute with a 3-month history of dysphagia and neck pain with swelling . he was paraplegic due to a c6 - 7 fracture and dislocation and has been operated on 8 years previously . initial surgical treatment included anterior corpectomy of c7 and anterior iliac crest graft placement using a plate and screws . hematological studies including erythrocyte sedimentation rate ( esr ) and c - reactive protein ( crp ) were normal . a simple lateral radiograph and a computed tomography scan showed partial anterior migration of the lower screw . a hydro - soluble contrast swallow image confirmed esophageal perforation ( fig . the loose screw was removed and esophageal perforation was found during surgery and repaired directly by a cardiovascular team(fig . the patient was fed using a nasogastric tube for 3 weeks and subsequently oral feeding was gradually resumed . further progress was favorable , and a contrast study performed at 3 weeks postoperatively showed no evidence of fistula . anterior cervical fusion and plate fixation is an effective procedure for the treatment of cervical myelopathy or radiculopathy and cervical spine trauma . plating has been reported to achieve a fusion rate of up 98% , and to result in early mobilization , reduced graft - related complications ( especially for multilevel fusion ) , and to avoid late deterioration of the cervical spine alignment obtained at surgery1,4 ) . the complication rate after anterior cervical plating is generally low and decreases with surgeon 's experience . according to zeidmann14 ) , the overall complication rate associated with anterior cervical spinal fusion is approximately 5% , and pharyngo - esophageal perforation is uncommon , but nevertheless of the utmost importance because of the possibility of graft infection leading to osteomyelitis , mediastinitis , sepsis , and death6 ) . acute injury can be caused iatrogenically during surgical approach due to inappropriate placement or dislodgement of sharp - toothed retractor blades in the esophagus . retraction is particularly dangerous when a nasogastric tube is positioned because the wall of the hypopharynx or esophagus may be " trapped " by a high - pressure claw between the retractor and the tube , causing ischemic injury and secondary perforation8 ) . delayed esophageal injuries are due to chronic compression or contact and subsequent necrosis , abscess formation , and perforation due to graft dislodgement or screw migration with or without plate failure4,7 ) . screw dislodgement often follows a benign course and is completely asymptomatic , due to the small diameters of the screws used and slow migration from the external to the internal mucosa , which permits spontaneous tissue repair of the defect caused repetitive friction between the retropharyngo - esophageal wall and the plating system(normally positioned with adhesion ) , traction - type pseudodiverticulum , and perforation are other causes of delayed injury11 ) . the complications of esophageal perforation range from asymptomatic with local infection to mediastinitis and death . the clinical course depends on the etiology , location , and timing of the perforation . asymptomatic perforation has as well been reported as incidental oral extrusion of screw even years after anterior cervical spine stabilization5 ) . patients generally present with swallowing difficulty , regional swelling , neck pain , dysphagia , weight loss , dysphonia , subcutaneous emphysema , and fever ; our patient presented with dysphagia and neck pain with regional swelling12,13 ) . conservative treatment may be preferred for small , contained defects of less than 1 cm , and consists of the elimination of oral feeding , tube feeding to restore fluid and nutritional balance , and intravenous antibiotics . some cases need surgical repair , such as , perforation closure with a primary suture or sternocleidomastoid or pectoralis major flap repair13 ) . we operated on our patient to remove the offending screw due to evident fistula confirmed by esophagography and esophagoscopy . direct repair was effective in achieving a successful perforation repair of the esophageal perforation with an early return to oral feeding . we report a rare case of delayed esophageal perforation caused by screw displacement after anterior cervical spine plating . careful periodic follow - up is necessary , and when encountered , early surgical closure following removal of the offending screw is mandatory .

although anterior approaches to the cervical spine are popular and safe , they cause some of complications . esophageal perforation after anterior spinal fusion is a rare but potentially life - threatening complication . we present a rare case of delayed esophageal perforation caused by a cervical screw placed via the anterior approach . a 43-year - old man , who had undergone surgery for complete cord injury at another orthopedic department 8 years previously , was admitted to our institute due to painful neck swelling and dysphagia . radiological studies revealed a protruding screw and esophageal perforation . the perforation was found during surgery and was successfully repaired . this case emphasizes the need for careful long - term follow - up to check for delayed esophageal perforation in patients that have undergone anterior cervical spine plating .

a dna sequence contains six potential open reading frames ( orfs ) , three on one strand and three on the reverse strand . however , typically only one of the six is actually expressed because it is associated with appropriate genetic signals that specify the dna strand and the reading frame to be transcribed and translate . exceptions occur in which more than one open reading frame is translated into a protein , as has long been observed in the case of viral genes , where it was suggested that this property permitted a high packing density of information ( 1 ) . however , analysis of the coding potential of 481 prokaryotic genomes revealed the surprisingly high frequency of alternate orfs of annotated genes especially in high g + c rich genomes , where almost every annotated orf exhibits an alternative orf that could potentially encode a protein of 100 amino acids or more ( 2 ) . the frequency of alternate open reading frames in high g + c genomes gives rise to the possibility that this property could be exploited to evolve novel genetic information and it is important to be able to detect this potential . however , this high frequency also provokes serious problems of gene annotation , where the incorrect orf may inadvertently be mis - annotated as the coding sequence . this potential for error is especially problematic when automatic gene prediction programs are used to annotate genomes , but errors can also slip by human annotators . the problem is exacerbated if an alternative orf is mis - annotated and the error is propagated in subsequent genome annotations . alterorf provides a searchable database of all possible alternative orfs in sequenced prokaryotic genomes that are potentially capable of encoding proteins of 100 amino acids or more . the objectives are 2-fold : to improve genome annotation by indicating possible errors in orf identification and , perhaps more important in the long term , to predict instances of genes that potentially could give rise to more than one protein . annotated protein coding genes were extracted from completely sequenced prokaryotic genomes in the genome database of ncbi . all alternative orfs , potentially encoding 100 amino acids or more , were extracted from each gene sequence using perl scripts and the bioperl application programming interface ( api ) ( 3 ) . using the standard genetic code , the in silico translated amino acid sequence of each alternative orf was searched for similarity in completely sequenced prokaryotic genomes ( 4 ) and for conserved domains and motifs using cdd ( 5 ) , pfam ( 6 ) , cog ( 7 ) , kog ( 8) , smart ( 9 ) and uniprot . ( 10 ) . hierarchical clustering using the software hcluster_sg developed as part of the treefam project ( 11 ) was used to build sequence families with the alternate orfs . blast e - values were normalized from 0 to 100 ( with 100 corresponding to e - value 0.0 ) . the resulting information was stored in a relational database built with microsoft sql server 2005 . release 1.0 ( september 2007 ) contains approximately 1.5 million annotated genes from 481 organisms and about 3 million alternate orfs . of these 942 856 ( 33% ) occur in frame 1 , 621 306 ( 21% ) in frame 2 , 322 284 ( 11% ) in frame 3 , 350 805 ( 12% ) in frame + 2 and 675 525 ( 23% ) in frame + 3 . the following are provided for each alternate orf sequence : ( i ) conserved domains and motifs including cdd ( 5 ) , pfam ( 6 ) , cog ( 7 ) , kog ( 8) , smart ( 9 ) and uniprot . ( 10 ) and ( ii ) blast results with annotated sequences in completely sequenced prokaryotic genomes and alternate orfs identified in alterorf . the cross genera conservation of some alternate orfs suggests that they might represent new protein families or domains and hierarchical clustering ( 11 ) was used to build sequence families from conserved alternate orfs . the alterorf database can be accessed through a simple and easy to use web interface at www.alterorf.cl . the database can be searched by protein i d ( derived from ncbi ) , by organism and by sequence using a sequence search service . in addition , an option is provided to analyze complete genome sequences not present in the database . searching by protein i d : a protein i d can be used to recover the original annotated gene that appeared in the database ( e.g. genbank ) , and also any alternate orf(s ) associated with that gene . if alternate orfs are detected , tables providing information regarding domains , motifs and protein family are displayed with links to further information . searching by organism : the user can select an organism from a pulldown menu or index for a pre - analyzed list of annotated protein coding genes with alternate orfs . searching by protein sequence : a search using a protein sequence can be carried out against all sequences stored in alterorf using wu - blast ( blast.wustl.edu/ ) . downloading data : all data in the alterorf database can be freely downloaded by ftp . additional information on the use of alterorf can be found in the faqs and tutorial sections .

alterorf is a searchable database that contains information regarding alternate open reading frames ( orfs ) for over 1.5 million genes in 481 prokaryotic genomes . the objective of the database is to provide a platform for improving genome annotation and to serve as an aid for the identification of prokaryotic genes that potentially encode proteins in more than one reading frame . the alterorf database can be accessed through a web interface at www.alterorf.cl

the epidermal growth factor receptor ( egfr ) is over expressed in various solid malignancies including non small cell lung cancer ( nsclc ) . however , they are associated with a dermatologic side effects , which can occasionally be responsible for discontinuation of the egfr inhibitors . hence , we report a case of metastatic adenocarcinoma of lung who developed skin ulceration with gefitinib and responded to interruption of the drug and early intervention . the present case report is about a 50-year - old female patient who had been diagnosed as having lung adenocarcinoma with multiple bone metastases was initiated on gefitinib therapy at an oral dose of 250 mg / d . after 2 weeks of initiating therapy , the patient presented with ulcer over the palm [ figure 1 ] . the ulcers improved with stopping gefitinib for 2 weeks and also with the addition of topical steroids and antibiotics . non - small - cell lung cancer ( nsclc ) with sensitive mutations of the egfr is highly responsive to gefitinib . gefitinib is a small molecule tyrosine kinase inhibitor ( tki ) of egfr . since 2004 , it was clear that a substantial proportion of nsclc obtaining objective response when treated with gefitinib harboring activating mutations in the egfr gene . the occurrence of skin disorders ( dry skin and acneiform rash ) is explained by the fact that egfr is also expressed in the basal layer of the skin ; inhibition of the receptor will disturb normal biology and result in skin rash . skin rash is notorious as an adverse event of egfr - tki and is noted in up to two - thirds of patients receiving any of these agents although severe in only 5 - 10% who can develop pyogenic granuloma like lesions . very rarely the cutaneous inflammation is so pronounced that skin necrosis with black eschar formation and ulceration is seen . the cutaneous side - effects are treated with topical steroids and antibiotics with interruption of treatment for 2 - 4 weeks as in our case .

we report a case of gefitinib - induced skin ulceration in a 50-year - old female with metastatic adenocarcinoma of lung who developed this adverse effect 2 weeks following initiation of gefitinib at a dose of 250 mg / day . the ulcer improved with stopping gefitinib for 2 weeks and also addition of topical steroids and antibiotics . we are reporting this case to create awareness among treating oncologists of this adverse effect and also prompt interruption of therapy and topical steroids / antibiotics is useful to treat this adverse event .

a 28-year - old man who was known to have fhi in the right eye was referred for secondary iol implantation . six years before referral , his right eye had undergone cataract surgery which was complicated by the capsular rupture and vitreous prolapse , for which the patient received complete anterior vitrectomy with removal of all capsular remnants . the patient was left aphakic and was prescribed with aphakic contact lens ; however , he developed contact lens intolerance over time . on presentation , his uncorrected visual acuity was 20/20 in the left eye and counting finger in the right eye which could be corrected to 20/20 with aphakic correction . slit - lamp examination of the right eye revealed diffuse fine keratic precipitates over the entire corneal endothelium and mild iris stromal atrophy with notable heterochromia . advantages and unknown risks of the surgery were thoroughly explained for the patient and he consented to have secondary iol implantation . under general anesthesia , an iris - claw iol ( artisan , ophtec , groningen , the netherlands ) was implanted in right eye through a limbal incision followed by a superior peripheral iridectomy . enclavation of the iol haptics was easily performed ; no intraoperative complication including hyphema was noted . the latter was prescribed as 0.1% betamethasone every 2 hours while awake for 1 week and then four times a day which was tapered within 6 weeks . postoperative follow - up examinations were performed at 1 , 2 , 3 , 5 , and 7 days , then weekly for 1 month , monthly for 3 months , and every 23 months thereafter until 1 year . postoperative course was uneventful with no significant anterior chamber inflammation ( more than 1 + cellular reaction ) or fibrin formation . on the first postoperative day , the examination showed 1 + cellular reaction and pigments in the anterior chamber which disappeared within 2 weeks . no subsequent exacerbation of the intraocular inflammation was observed during 12 months of postoperative follow - up ; therefore , no additional course of steroid was required . occasional cells in the anterior chamber were seen at some visits which were left untreated . one month after surgery , the patient achieved a best - corrected visual acuity of 20/20 in the right eye which was maintained for 12 months of follow - up . the iol remained stable with no subsequent iris atrophy at the enclavation sites , subluxation , or pupil ovalization . furthermore , the patient did not develop any anterior or posterior segment complication including glaucoma , vitreous inflammation , or clinical cystoid macular edema . secondary implantation of iris - claw artisan intraocular lens ( iol ) in an eye with fuchs heterochromic iridocyclitis . during 12 months of postoperative follow - up , no remarkable anterior chamber inflammation was observed in the right eye ( a ) and there were only few deposits on the iol surface ( b ) . the heterochromia in the involved eye is most obvious compared with the normal left eye ( c ) although secondary iol implantation in the ciliary sulcus has been reported to be safe in fhi , angle- and iris - supported iols have been feared because of the possible risk of postoperative uveitis , glaucoma , and hyphema . to the best of our knowledge , there has been no previous report of implantation of iris - claw artisan iols in eyes with fhi . even though our patient only received topical steroids , he did not show any significant postoperative inflammation or fibrinous reaction neither at the early postoperative period nor during 12 months of follow - up . therefore , it may suggest that in eyes with fhi the uveal irritation by iris - claw artisan iols is less than expected and the iol is more tolerable , even though recurrent or chronic anterior chamber inflammations has previously been reported in some eyes with these iols without preexisting uveitis . however , this lack of exacerbated postoperative inflammation in fhi may not be extrapolated to eyes with other more severe forms of uveitis . on the other hand , although fhi - associated iris atrophy in severe cases may theoretically make enclavation more difficult or compromise the long - term stability of an iris - claw iol , neither did develop in our case . therefore , it seems iris - claw iols , which have been shown to be safe in aphakic eyes without uveitis , may be an option in aphakic patients with fhi who do not have capsular support . however , studies on large number of patients with long - term follow up are required to determine the safety of these iols in eyes with uveitis including fhi .

implantation of iris - claw artisan intraocular lens ( iol ) is a surgical option for correction of aphakia ; however , these iols have not been used in eyes with uveitis including fuchs heterochromic iridocyclitis ( fhi ) due to possible risk of severe postoperative intraocular inflammation . in the case reported here , we secondarily implanted an artisan iol in a 28-year - old man with fhi who had aphakia with no capsular support due to a previous complicated cataract surgery . enclavation was easily performed and no intraoperative complication was noted . postoperative course was uneventful with no significant anterior chamber inflammation during 12 months of follow - up . although there were few deposits on the iol surface , the patient achieved a best - corrected visual acuity of 20/20 without developing glaucoma or other complications . therefore , artisan iol may be considered for correction of aphakia in patients with fhi . however , studies on large number of patients are required to evaluate safety of the procedure .

frontometaphyseal dysplasia ( fmd ) , also called gorlin cohen syndrome , is a hereditary x - linked dominant syndrome described in 1969 with less than 30 cases described in the literature . this case report of a child with fmd is presented owing to the rarity of the syndrome and the anticipated difficult airway , which was successfully managed by using a combination of dexmedetomidine and ketamine while preserving spontaneous ventilation . a 2-year - old female child , a known case of fmd , presented for open reduction of the left hip with osteotomy of femur . physical examination revealed a slender undernourished girl of 8 kg with prominent supraorbital ridges , ocular hypertelorism , low set ears and a wide bridge nose with prominent eyes . airway examination revealed a mallampatti score of iii with significant retrognathia , high arched palate with malocclusion of teeth . in addition , she had dorsolumbar scoliosis , pectus carinatum , bowing of long bones with distal phalangeal hypoplasia and multiple joint dislocations [ figure 1 ] . pre - operative blood investigations , echocardiography and chest x - ray were within physiological limits . on arrival to the operation theatre , monitors were connected and child pre - oxygenated for 5 minutes . injection dexmedetomidine 1 g / kg was administered for 10 min and then a continuous infusion at 1 g / kg / h was set for the duration of the remaining procedure . ketamine was administered in increments of 5 mg up to 12 mg until there was no response to jaw thrust while ensuring spontaneous respiration . just before direct laryngoscopy intravenous lignocaine rigid laryngoscopy with miller 1 straight blade offered a grade iv cormack and lehane view . after optimal external laryngeal manipulation , the visible glottic chink was sprayed with topical lignocaine and tracheal intubation was successfully performed using an uncuffed 4 sized endotracheal tube . anesthesia was continued with n2o in 40% o2 along with a continuous dexmedetomidine and atracurium infusion . adequate padding was provided at pressure points and extreme caution was exercised during positioning . at the end of fmd belongs to the otopalatodigital spectrum syndromes that includes four phenotypically related conditions , otopalatodigital syndrome types 1 and 2 , fmd and melnick - needles syndrome . the most common manifestations include supraorbital hyperostosis , hypertelorism , down - slanting palpebral fissures , broad nasal bridge and micrognathia with anomalies of teeth and generalized skeletal dysplasia . congenital heart disease , subglottic tracheal narrowing and genitourinary anomalies , muscular hypotonia . micrognathia , microstomia and malocclusion of teeth may make direct laryngoscopy impossible ; therefore , a well - planned airway strategy is mandatory . ketamine was preferred in our case of anticipated difficult airway due to it 's inherent sympathomimetic actions devoid of respiratory depression alongwith provision of excellent analgesia and amnesia . dexmedetomidine a specific and selective 2-adrenoceptor agonist known for its sedative , anxiolytic , analgesic properties was used to complement ketamine . at the same time dexmedetomidine offsets the sympathomimetic effects of ketamine , this unique pharmacological combination in the present case preserved the respiratory drive , allowed maintenance of a patent airway and provided sufficient sedation , analgesia and anesthesia to allow successful airway control . in addition , topical lignocaine was used as per recommendation of aroni et al . which states that ketamine does not depress coughing or swallowing reflexes . available literature describes the use of combination of both these drugs in children during procedural anesthesia and not as a complete anesthesia protocol in a challenging case . the present experience of using this combination successfully paves the way to emerging new solutions for management of a difficult pediatric airway . hence safety profile , rapid onset of action with adequate sedation and analgesia provided by the ketamine and dexmedetomidine make them a distinctive drug combination in the pediatric difficult airway situation in a child with fmd .

frontometaphyseal dysplasia ( fmd ) , also called gorlin - cohen syndrome , is a rare hereditary x - linked dominant craniotubular bone disorder . the presentation describes the airway management of a 2-year - old child suffering from fmd with significant retrognathia , posted for major long bone corrective osteotomy . induction with a combination of dexmedetomidine and ketamine preceded a successful endotracheal intubation under spontaneous ventilation .

multiple sclerosis ( ms ) is a chronic , autoimmune , demyelinating disease of the central nervous system ( cns ) . presenting symptoms can vary greatly , but most commonly involve weakness , paresthesia , gait difficulty , or visual deficits . virtually any area of the cns white matter can be involved , though this most classically involves the periventricular white matter . brain stem involvement is common , though isolated cranial nerve palsies are rare signs in ms . previous studies have suggested that isolated cranial nerve palsies in ms are more commonly found as presenting symptoms than as relapsing symptoms . among isolated cranial nerve palsies in ms , the fifth nerve is most commonly involved ( 4.8% ) , followed by the seventh nerve ( 3.7% ) , and the sixth nerve ( 1.0% ) . thus , abducens palsy is a rare isolated ms finding , either as a presenting sign or during disease exacerbation . patients with abducens palsy typically present with diplopia upon horizontal gaze , and examination can reveal a slow ipsilateral lateral rectus movement [ 4 , 5 ] . ms has been implicated as the cause of unilateral abducens palsy in 49% of cases , though mri may not detect brain stem lesions in all cases . one 2002 study investigating nontraumatic causes of sixth nerve palsies in patients 2050 years of age found ms to be the cause in 24% of cases . in addition to ms , the differential diagnosis for an abducens nerve palsy includes mass lesions , lyme disease , viral infection , syphilis , sarcoidosis , and vascular disease . here , we report a patient who presented with a unilateral isolated abducens palsy as the initial sign of ms . a 28-year - old man with a past medical history of hypertension and obesity presented to the emergency department with a 1-day history of double vision , most prominent upon left lateral gaze . the double vision resolved with covering either eye . in addition , he had a 12-week history of paresthesia of the distal right hand and forearm , and the fifth digit of the right foot . initial laboratory findings revealed only a mild leukocytosis ( 11.3 10/l ) and no other hematologic or electrolyte abnormalities . several focal areas of increased t2 signal intensity were noted within the periventricular white matter of the frontal and parietal lobes , subcortical white matter of the left temporal lobe , and the left pons . these findings likely represented multiple lesions distributed in both time and space , and , along with the patient 's clinical history and examination , were suggestive of a diagnosis of ms . the patient was admitted and started on intravenous methylprednisolone . further workup to rule out other etiological causes of illness revealed an elevated esr of 25 mm / h , negative viral and lyme serologies , nmo igg negative and a negative ana . he was treated with methylprednisolone 500 mg intravenously for 3 days and then discharged home . he was re - evaluated in the office 2 days after hospital discharge and had complete resolution of the cn vi palsy . isolated nerve palsies occur in only 10.4% of patients with ms , with abducens palsy as the third most common isolated nerve palsy , occurring in 1.0% of patients with ms , behind trigeminal ( 4.8% ) and facial ( 3.7% ) . these palsies occur most commonly at disease onset , though they can also occur during the course of the disease . the lesion in the medial pons was enhancing and thus consistent with an active lesion , and the location was consistent with his cn vi palsy . the sixth nerve nucleus is located in the pontine tegmentum , and a compact fiber tract bundle containing motor neurons from this nucleus runs medially towards the ventral region , where the cranial nerve exits the pons [ 3 , 8 ] . our patient 's pontine lesion appeared to be located along the fiber tract emerging from the sixth nerve nucleus , and correlates with his diplopia . while an mri lesion was detected clearly in this case , it should be noted that previous authors have found that mri does not always detect brain stem lesions accounting for these palsies in ms patients [ 4 , 6 ] . in any patient presenting with isolated cranial nerve palsies , ms must be considered within the differential diagnosis . in patients younger than 50 years of age ( as with our patient ) , infectious causes ( lyme disease , viral infections , syphilis ) , sarcoidosis , and autoimmune vasculitis should also be considered on the differential diagnosis , whereas for older patients small vessel vascular disease should be considered as well [ 7 , 8 ] . the presence of multiple presenting neurological deficits including cranial nerve palsies is suspicious for ms and should be investigated with mri . though mri may not always detect brain stem lesions responsible for cranial nerve palsies , it can reveal other white matter lesions of the cns that can aid in the diagnosis of ms , as was the case with our patient .

while brain stem involvement in multiple sclerosis ( ms ) is relatively common , isolated cranial nerve palsies are rare , especially when they represent the initial presenting sign of a new diagnosis of ms . this report describes a patient with no prior history of ms whose sole presenting sign was an isolated abducens palsy . an enhancing pontine lesion was found on mri which correlated with his abducens palsy , and additional nonactive lesions on mri led to a diagnosis of ms . this case demonstrates the importance of considering ms as part of the differential diagnosis of patients with isolated cranial nerve palsies .

non - hodgkin lymphomas ( nhls ) account for approximately 60% of all lymphomas in children and adolescents . childhood nhls are subdivided into burkitt 's lymphoma , diffuse large b - cell lymphoma ( dlbcl ) , lymphoblastic lymphoma , and anaplastic large - cell lymphoma . dlbcl is characterized by relatively more frequent extranodal presentation , seen in upto 40% of the cases . primary involvement of the lymphoma of the middle ear is rare , with only about 18 cases being reported in literature so far . here , we report a case of dlbcl , presented with features of facial palsy and otitis , who received initial symptomatic treatment and later chemotherapy after diagnosing dlbcl . a 2 years 8 months old boy visited our tertiary care hospital with complaints of ear ache ( left side ) and left facial palsy of 4 weeks duration . after initial 2 weeks of these symptoms , there was whitish serous discharge from the left ear . before referral to our hospital , he was treated for otitis media with antibiotics , details of which were not available . his complete blood picture and biochemistry investigations done in our hospital were within normal limits . as the symptoms persisted for 4 weeks , computed tomography of head and neck was done which was suggestive of solid mass lesion of 2 cm 2 cm size in the left mastoid with destruction of mastoid bone [ figure 1 ] . the disease was in stage 1 ( as per murphy 's staging ) and was completely resected . histopathological examination showed large cells of lymphoid cell proliferation immune histochemistry was positive for cd20 , bcl-2 and negative for cd3 , with low mib-1 , which confirmed dlbcl . his positron emission tomography for staging , bone marrow and cerebrospinal fluid revealed no abnormality . computed tomography head and neck suggestive of solid mass lesion of 2 cm 2 cm size in the left mastoid with destruction of mastoid bone computed tomography head and neck of right side showing no abnormality his initial clinical symptoms of earache and facial nerve palsy followed by ear discharge resolved after starting chemotherapy as per b - cell lymphoma protocol for 6 months . currently , he is 37 months off treatment , and no disease recurrence is seen clinically as well as radiologically . it is an aggressive form of lymphoma , usually curable with appropriate treatment and has high survival rate . rapid disease progression of dlbcl calls for an early , accurate diagnosis and appropriate treatment . however , unusual presentation can mislead the physician resulting in wrong diagnosis , which delays the treatment , thus promoting disease progression . extranodal presentations of childhood dlbcl are relatively uncommon in clinical practice , and much rarer are those primarily involving middle ear and mastoid . involvement of middle ear and mastoid can resemble the features of otitis media and unusual facial palsy mimicking mastoiditis . although these initial symptoms were suggestive of middle ear infection , the distinguishing factor was unresponsiveness to antibiotics . there have been very few reports of nhl with facial nerve involvement ; ogawa et al . mccabe et al . , reported a case of 2-year - old , an immunocompetent boy with spontaneous regression of an epstein - barr - virus - associated monoclonal lymphoid proliferation who presented with acute otitis media and facial palsy . have described a case of dlbcl with features of otitis media , mastoiditis , and facial palsy . as symptoms persisted even after 4 weeks of treatment , the patient was started on chemotherapy , to which he promptly responded . extranodal nhls of middle ear which is not a common clinical presentation may present as facial palsy , and misdiagnosed as otomastoiditis . there should be a high index of suspicion for primary neoplasms of the middle ear in patients with chronic otomastoiditis refractory to appropriate initial antibiotic therapy ; early diagnosis and appropriate treatment results in good therapeutic outcome and minimizes further complications .

extra nodal presentation of non hodgkins lymphoma ( nhl ) is a rare entity , and data available about the nhl that primarily involves of middle ear and mastoid is limited . we report a case of diffuse large b cell lymphoma ( dlbcl ) , in a 2 year 8 month old boy , who developed otalgia and facial palsy . computed tomography revealed a mass in the left mastoid . mastoid exploration and histopathological examination revealed dlbcl . this case highlights the importance of considering malignant lymphoma as one of the differential diagnosis in persistent otitis media and / facial palsy .

acute pancreatitis due to antipsychotic treatment is rare but sometimes causes a fatal adverse effect . some atypical antipsychotic agents , including clozapine , olanzapine , quetiapine , and risperidone , are associated with acute pancreatitis.1,2 ) among them , acute pancreatitis caused by risperidone is the rarest.3,4 ) although most cases of acute pancreatitis due to atypical antipsychotic agents occur within 6 months of starting antipsychotic administration,1 ) we experienced a schizophrenic patient suffering from pancreatitis after more than 6 months of risperidone therapy . a 69-year - old japanese woman was diagnosed with schizophrenia at the age of 30 years and received outpatient care at another mental hospital . her positive symptoms were not prominent , but her cognitive level was so impaired that she could not regulate her appetite and consumed about 2,000 kcal / day in addition to three ordinary meals . she had never smoked , did not drink alcohol , and did not take any illegal drugs . blood tests ( table 1 ) , abdominal ultrasonography , and a computed tomography ( ct ) scan were performed . clinical features were accompanied by laboratory findings of hyperamylasemia ( amylase , 1,191 u / l ) , hyperlipasemia ( lipase , 1,514 u / l ) , and mild liver enzyme elevations . results of the abdominal ultrasonography were positive for gallstones in the gallbladder and distention of the common bile duct . subsequently , the amylase and lipase titers remained high ( 461 u / l and 804 u / l , respectively ) , although alanine and aspartate aminotransferases decreased gradually to normal levels . at this point , we felt that it was safe for her to start taking the risperidone again . two days after starting the risperidone , serum lipase and amylase increased again to 1,275 u / l and 745 u / l , respectively , and ck also increased ( 766 u / l ) . we decided to suspend the risperidone and introduced 10 mg intravenous haloperidol injections once per day . two days after discontinuing the risperidone , the serum amylase decreased ( 605 u / l ) , but the serum lipase level remained elevated ( 1,654 u / l ) . one week after discontinuing the risperidone , the levels of amylase and lipase decreased gradually ( 309 u / l and 542 u / l , respectively ) , and ck dropped to the normal range . as her general clinical condition and biochemical markers were stable , we changed the haloperidol injection to an oral solution of 6 mg / day aripiprazole because her mental condition worsened after stopping the risperidone treatment . her mental status improved with the aripiprazole treatment , and she was discharged without positive laboratory findings . the patient 's monthly blood tests continue to be normal , including amylase , lipase , and blood cell counts . although atypical antipsychotic - induced pancreatitis has been reported in conjunction with hyperglycemia,5 ) the pathophysiological mechanism of these adverse events remains unclear . most antipsychotic - induced pancreatitis occurs within 6 months after administration1 ) ; however , our case developed pancreatitis more than 6 months after the start of risperidone treatment . risperidone is a 5-ht2a antagonist and ameliorates diet - induced necrotic pancreatitis in mice,6 ) and reduced serum pancreatic amylase levels is observed after endoscopic retrograde cholangiopancreatography.7 ) however , there is no evidence of an association between risperidone treatment and acute pancreatitis . a thorough evaluation for pancreatitis , such as alcohol , tumor , and autoimmune causes , gallstones were present , which were due to an adverse effect of risperidone because the two separate risperidone administrations elevated serum amylase and lipase independently . aripiprazole is currently used in such cases , as aripiprazole is thought to have fewer effects on metabolism , including saccharometabolism , than other atypical antipsychotic agents . lifestyle was also a risk factor in this case . thus , it is necessary to monitor pancreatic function in addition to hyperglycemia in such cases .

acute pancreatitis with antipsychotic treatment is rare but sometimes causes a fatal adverse effect . most cases of acute pancreatitis due to atypical antipsychotic agents are reported to occur within six months of starting antipsychotic administration . acute pancreatitis caused by risperidone is rare . the patient had a high fever , stomachache and vomiting . the results of the abdominal computed tomograhpy scan were negative . the results of the abdominal ultrasonography were positive for gallstones in gallbladder and distention of the common bile duct . she had been fasting and received antibiotic intravenous injections . amylase and lipase titers were high . after risperidone discontinuation , both the levels of the amylase and the lipase were gradually decreased . three months later , the patient still maintains a good clinical balance . although atypical antipsychotic - induced pancreatitis has been reported in conjunction with hyperglycemia , the pathophysiologic mechanism of these adverse events remains unclear . this case got pancreatitis 6 month after risperidone treatment . using the antipsychotic agents , it is necessary to monitor pancreas function .

an atlanto - axial synovial cyst is very rare . since the first report of this lesion by onofrio and mih1 ) in 1988 , to our knowledge . however , the current report described a patient with a large hemorrhagic cystic mass which was seen around prevertebral space of the atlantoaxial joint on the left side and the obstruction of the nasopharyngeal cavity on cervical magnetic resonance image ( mri ) . we report a symptomatic case associated with rheumatoid atlanto - axial subluxation , which regressed after the surgical management . a 72-year - old woman presented with sudden severe headache in her left occipital area with dyspnea . a laboratory examination of the patient 's blood revealed no remarkable abnormality indicative of inflammation , but high - titer of rheumatoid factor ( 95.9 iu / ml ) . seven months ago before visiting to our department , she checked brain mri due to sudden attack of severe headache on left occipital area , which revealed non - specific lesion except rheumatoid pannus with small prevertebral cyst of c1 - 2 junction ( fig . , there was a large hemorrhagic cystic mass around prevertebral space of the atlanto - axial joint on the left side , obstructing the nasopharyngeal cavity on cervical mri ( fig . the cystic mass was connected to atlanto - axial joint capsule on axial view of computed tomography ( ct ) . multiple bony erosion , rheumatoid atlanto - axial instability including left tilted c1 - 2 subluxation and cranial settling were demonstrated . and there were loss of lordosis and retrolisthesis in c 3 - 4 , 4 - 5 ( fig . 3 ) . in the first operation stage , considering patient 's dyspnea , aspiration of the cystic lesion was performed via transoral approach with otolaryngology surgeon ( fig . after 0.5 cm - sized mucosal incision on left side oropharyngeal wall , residual material of the cyst was squeezed by forceps and removed by suction tools . in the second operation stage , there were rheumatoid atlanto - axial instability and retrolisthesis in c 3 - 4 , 4 - 5 , so it was followed by posterior occipito - cervical fusion that connected from occiput to c5 , using vertex screw & rod system and iliac bone graft ( fig . 5 ) . the patient was tolerable on her postoperative course and showed good respiration and relieved headache . cervical synovial cysts are rare and located at the c1 - 2 junction or lower cervical spine . only 24 cases of synovial cysts of the c1 - 2 junction have been reported in the literature5 ) . moreover , the pathogenesis of spinal synovial cysts remains unclear but is thought to be attributable to degenerative changes of the facet joints or excessive joint motion2,3,5,7 ) . it revealed multiple bony erosions and a large pannus formation of c1 - 2 junction on this case . this patient also showed atlanto - axial instability caused by rheumatoid arthritis , such as left tilted antlanto - axial subluxation and basilar impression . the atlantoaxial articulation is a true synovial joint and is responsible for a large proportion of normal cervical mobility . the etiology of articular cysts is unclear , but they are assumed to be degenerative because minor chronic damage to articular surfaces produces a reactive proliferation of synovium or fibrocartilage that includes loculated collections of mucinous fluid . so , we hypothesized that hemorrhagic event was developed as a result of microtrauma caused by rheumatoid atlantoaxial instability . it is known that the higher titer of rheumatoid factor , the more destructive manifestations of joint occur1 ) . the patient was in the controlled state in serologic inflammatory marker , such as esr(erythrocyte sedimentation rate ) and crp ( c - reactive protein ) . however , the high titer of rheumatoid factor , in spite of long standing medication of rheumatology , was related factor of progressive destruction of joints . we report a rare case of large hemorrhagic cyst on prevertebral space of left side c1 - 2 area associated with rheumatoid arthritis causing airway obstruction and left occipital pain , successfully managed anterior and posterior approach . we suggest repeated microtrauma due to atlanto - axial subluxation associated with rheumatoid arthritis as a main cause of hemorrhagic event on the cyst .

synovial cyst on prevertebral space of c1 - 2 joint is rare but may be associated hemorrhagic event . we describe a case of a 72-year - old woman who presented with sudden severe headache in her left occipital area with dyspnea . she had rheumatoid arthritis for 14-years . large hemorrhagic cystic mass was seen around prevertebral space of the atlantoaxial joint on the left side on cervical mri ( magnetic resonance image ) and it obstructed the nasopharyngeal cavity . aspiration of the cystic lesion was performed via transoral approach , followed by posterior occipito - cervical fusion . the specimen was xanthochromic , suggesting old hemorrhage . the patient was tolerable on her postoperative course and showed good respiration and relieved headache . we suggest that repeated microtrauma due to atalantoaxial subluxation associated with rheumatoid arthritis as a main cause of hemorrhagic event on the cyst .

colchicine is a widely used drug for treatment of familial mediterranean fever ( fmf ) . clinical manifestations of colchicine intoxication include abdominal cramps , diarrhea , myotoxicity , hemolytic anemia and ( pan)cytopenia . a 9-years - old female patient , receiving colchicine for four months with a dose of 1 mg / day for fmf , was admitted to a hospital with gastrointestinal disturbance four days ago . she was referred to our hospital with liver and kidney dysfunction . at the initial physical examination her laboratory results revealed : hemoglobin 13.6 g / dl ; leukocyte , 9.610/l ; thrombocyte 5710/l ; fibrinogen 157 mg / dl ( 230 - 500 ) ; pt 26.1 sec ; inr 2.3 ; aptt 43.8 sec ; ldh 5329 iu / l ; ferritin 2320 g / l ( 10 - 55 ) ; triglyceride 7.1 mmol / l ( 0.32 - 1.46 ) . the patient was taken to intensive care unit ; vitamin k and fresh frozen plasma were administered . on the second day of her hospitalization hemoglobin was 9.6 g / dl ; leukocyte was 2.310/l ; neutrophil was 0.7210/l and thrombocyte was 2410/l . on peripheral blood smear , loss of lobulation in neutrophils was detected ( pelger - hut anomaly ) . laboratory tests revealed ferritin 54,632 g / l , triglyceride 7.4 mmol / l , and fibrinogen 63 mg / dl , serum creatinine 3.2 mg / dl ( 0.4 - 1.4 ) , serum blood urea nitrogen 43 mg / dl ( 6 - 21 ) , serum sodium 131 meq / l ( 134 - 148 ) , potassium 5.2 meq / l ( 3 - 4.8 ) , calcium 8.1 mg / dl ( 7.9 - 9.9 ) , and inorganic phosphate 2.1 mg / dl ( 2.4 - 4.7 ) . at the bone marrow aspiration , many pelger - hut cells were observed . soluble cd25 level was 2840 u / ml ( 220 - 710 ) , and creatine kinase level was 18,959 when the history of colchicine intoxication was detailed , during fmf attack - free period of five days prior to admission to the hospital , it is learned that the patient was upset over a quarrel between her parents , and that she had taken approximately 30 pills of her drug ( total of 15 mg ; 0.5 mg / kg body weight ) , at which vomiting and diarrhea complaints were started . the patient was administered hlh-2004 protocol and plasma exchange is applied twice . on the second day of therapy , severe hypotension , renal failure and av complete block occurred . the patient was resistant to all therapies and had died at the fourth day of her hospitalization . in the colchicine intoxication , the most affected organs are those that have a rapid cell turnover . liver damage , renal failure , arrhythmias , neuromuscular disturbances , and bone marrow depression can be detected in the later stage . the worst predicted doses were classified regarding the risk of toxicity as sub - toxic ( < 0.5 mg / kg ) , toxic ( 0.5 - 0.8 mg / kg ) , and lethal ( > 0.8 mg / kg ) doses . however , cases with cardiogenic shock and death were also reported with doses less than 0.5 mg / kg . although our patient had taken a dose of 0.5 mg / kg body weight colchicine , the patient died due to severe myelosupression , hlh and multi - organ failure . pelger - hut anomaly is a state of limitation in segmentation of lobes in neutrophils . a pelger - hut - like change in granulocyte morphology may occur as an acquired condition in several diseases . this same finding may be produced by certain drugs such as colchicine . on the peripheral blood smear of our patient , pelger - hut cells were detected in myeloid series , and as the history of colchicine use was detailed , it is learned that the patient had taken lots of colchicine pills . on the examination of concurrently taken bone marrow , pelger - hut cells were also detected in the myeloid series as well as hemophagocytosis . for this reason , we suggest that hlh was not due to her disease . to our knowledge , this is the first reported case of a patient with hlh associated with colchicine intoxication . in conclusion , if patients with colchicine intoxication present with pelger - hut anomaly in addition with unexplained fever , cytopenia , organomegaly , and biochemical changes , hlh should be investigated for prompt diagnosis and treatment .

colchicine is frequently used in the treatment of familial mediterranean fever ( fmf ) . first symptoms of colchicine intoxication are gastrointestinal disturbances , such as abdominal cramps , diarrhea , pancytopenia and so on . herein , we report a female fmf patient with pancytopenia and hemophagocytic lymphohitiocytosis ( hlh ) , following colchicine intoxication for committing suicide . to our knowledge , this is the first reported case of a patient with hlh associated with colchicine intoxication .

he had suffered from intermittent headache for 2 months and had taken benzodiazepines and analgesics under the diagnosis of somatoform disorder at a local clinic . he had a 5-day history of diplopia and a 3-day history of blurred vision that progressed to blindness during the preceding 24 hours . on admission his blood pressure was 130/70 mmhg , pulse rate was 82/min , respiratory rate was 20/min , and body temperature was 36.3. on neurologic examination the patient was alert and exhibited no meningeal signs . only light perception was possible in both eyes , but no other neurological abnormality was noted . lumbar puncture showed the opening pressure of 160 mm h2o with clear cerebrospinal ( csf ) fluid . csf evaluation showed 30 red blood cells / mm , 80 white blood cells / mm , 80% lymphocytes , 41 mg / dl glucose , and 114 mg / dl protein . his body temperature increased to 38.8 1 day after admission , but cbc revealed no leukocytosis . brain mri showed no meningeal enhancement , parenchymal lesion , or intracranial vascular abnormality supplying the optic nerve , optic chiasm , or optic tract . the results of fundoscopic examinations were unremarkable , and visual evoked potential showed no wave formation on bilateral pathways ( fig . an india ink smear of the csf demonstrated encapsulated yeast , and cryptococcus neoformans was cultured ( fig . he was found to be seropositive for hiv with a high antibody titer ( 53.87 s / co ) . he was treated with both antiretroviraland antifungal agents , and his visual acuity had improved upon discharge . neuro - ophthalmic lesions are present in 6% of patients with hiv infection during the course of the disease , with most of them being are attributable to cryptococcal meningitis.3 cryptococcus neoformans , the cause of cryptococcal meningitis , is the fourth most common source of life - threatening infection in aids patients after infections of cytomegalovirus , pneumocystis carinii , and mycobacterium avium intracellulare.1 it is present in pigeon droppings and infects by inhalation of contaminated soil . cryptococcal meningitis is fatal in hiv - infected patients if not treated , and hence early diagnosis is very important . the signs and symptoms of cryptococcal meningitis include headache ( 80~92% of cases ) , meningeal signs ( 50~80% ) , nausea / vomiting ( 40~80% ) , fever ( 36~67% ) , and visual disturbances ( 33~47%).1 our patient presented with acute blindness without other definite clinical symptoms at the time of admission . possible mechanisms for binocular blindness due to cryptococcal meningitis include direct fungal infiltration of the optic nerve , optic chiasm , or optic tracts , adhesive arachnoiditis , cerebral vasculitis , and intracranial hypertension.4 it has been suggested that rapid - onset visual loss is caused by infiltration of the optic nerve or optic chiasm , while slow - onset visual loss is due to increased csf pressure.4 a csf opening pressure exceeding 200 mmh2o and papilledema reflect intracranial hypertension , but our patient showed a normal csf opening pressure and unremarkable fundoscopic examination findings . moreover , his visual symptoms developed very early in the course of the disease . thus , the sudden visual loss might have been due to retrobulbar fungal infiltration . whereas the prevalence of cryptococcosis is decreasing because of the widespread availability of antiretroviral therapy , cryptococcal meningitis is still a fatal complication of hiv infection . thus , both early diagnosis of cryptococcal meningitis and detection of the underlying causes are important . in our opinion , unexpected sudden binocular blindness should be considered as a possible initial manifestation of cryptococcal meningitis related to hiv infection .

ocular complications of hiv - related cryptococcal meningitis are reasonably common , but complete binocular blindness as the first manifestation of hiv is extremely rare . a 58-year - old man presented with binocular blindness . he experienced blurred vision for 3 days before the blindness . mild pleocytosis was present in the cerebrospinal fluid , from which cryptococcus neoformans was cultured . serology revealed positivity for hiv antibody . he was treated with antifungal and antiretroviral therapy . this case indicates that hiv - related cryptococcal meningitis should be taken into consideration when determining the cause of unexpected sudden binocular blindness .

most common cause of lower gastrointestinal hemorrhage ( lgib ) in elderly patient is diverticular disease and mortality rate is very low 24% . a massive lgib from primary ilio - rectal fistula is rare and difficult to diagnosis but more common from secondary after previous vascular surgery a variety of treatment options are available , such as in situ graft , closure of defect alone , endovascular stent graft , extra - anatomical bypass and embolic coiling . exploration using laparotomy for ligation internal iliac aneurysm and rectal resection is a simple operative procedure which can be applied when emergency option is needed to save a life . we describe successful emergency surgery in primary ilio - rectal fistula when patient presents a massive lgib and hypovolemic shock . an 88-year - old man , his underlying diseases are hypertension , dyslipidemia , moderate aortic stenosis and mitral valve stenosis , chronic kidney disease and prostate cancer . at emergency department , physical exam showed hypotension blood pressure 70/50 mmhg and per rectal exam showed blood clot with enlarged prostate . after resuscitation until stable vital sign , he was sent for colonoscopy but can not be evaluated due to a lot of blood clots in the rectum . he was admitted for observation and we planned to repeat colonoscopy again following day because he was stable and bleeding was stopped . following day after admitting , he had massive lower gastrointestinal bleeding again fresh blood ~1000 ml from his anus . but the patient had a problem vascular access site and then send to computed tomography angiography ( cta ) for evaluate access site . we found 3 cm aneurysm of right internal iliac artery with partial thrombus and attached to rectosigmoid colon with leakage of contrast into sigmoid lumen ( figs 12 ) . he was sent to operating room during transferring we gave blood transfusion and then emergency explore laparotomy was performed , the operation performed by partial aneurysmectomy , ligated right internal iliac , wedge resection rectum wall and temporary abdominal closure with swab packing due to bowel distension and abdominal pressure was high . he was sent to operating room for change swab packing on day 3 and permanent abdominal closure on day 5 . during postoperative period primary aorto / ilio - enteric fistula ( paef ) is very rare , but secondary fistula is more common . sir astley cooper was the first to describe a paef as a condition caused by spontaneous erosion of the aorta into the gastrointestinal tract . etiology of paef are several causes , most causes are due to aneurysm , infection , tumor , radiotherapy and foreign body ingestion [ 59 ] . the most common site of fistula located in duodenum 54% , esophagus 28% , small bowel and large bowel 15% . the classical triad of symptoms associated with a fistula is gastrointestinal hemorrhage , abdominal pain and a pulsating abdominal mass . most common sign and symptoms of fistula is gastrointestinal bleeding , but only 11% presented with classical triad . the diagnosis of paef is difficult to make . because most of patients were send to endoscope due to gastrointestinal bleeding symptoms . several diagnosis investigations were used when patients are clinically stable such as cta , angiography , colonoscopy , and red blood cell scan . all of these do not constitute specific investigation . however , ct scan can diagnose specifically aorto / ilio - enteric fistula ( for example , air within aortic wall or contrast fill in bowel lumen ) that detection rate 61% when failure diagnosis from endoscopy . such as , in situ graft , closure of defect alone , endovascular stent graft , extra - anatomical bypass and embolic coiling . optional treatment depends on surgeon s experience , hospital facilities and the type of paef . this case was send to the operating room after diagnosis right internal ilio - rectal fistula for emergency exploration with laparotomy because the patient s active bleeding and vital signs were not stable preventing adequate preparation time for intervention or stent graft in hospital . we decided to ligate right internal iliac artery , wedge resection rectum with suture repair because this is a simple operation and can save patient s life . other options could be done by endovascular therapy or embolic coiling if we had time to prepare and the patient was already stabilized in this hospital . in conclusion , paef is very rare . the patient who has massive lower gastrointestinal bleeding with failure of endoscope may need to consider imaging to rule out paef . there are several treatment options for paef but no conclusive specific treatment it depends on patient s situation and physician s experience . although endovascular or embolization is minimally invasive surgery and good for the patient who is a high operative risk but an emergency simple operation is an effective procedure not only saves patient s life but also can be done by a general surgeon ( fig . figure 1:axial view iliac aneurysm with partially thrombose contact rectosigmoid colon and contrast leak.figure 2:coronal view iliac aneurysm.figure 3:cta after 1 year .

abstractmassive lower gastrointestinal from primary isolated ilio - rectal fistula is a rare condition and difficult to diagnosis and emergency surgery for this situation has a high mortality rate . this report describes a successful operation in an 88-year - old man at present with massive lower gastrointestinal hemorrhage from ilio - rectal fistula and hypovolemic shock . underlying diseases are prostate cancer , hypertension , dyslipidemia , aortic stenosis , mitral valve stenosis and chronic renal disease . operative treatment is to explore laparotomy with internal iliac artery ligation and rectal resection . during postoperative period patient developed acute cholecystitis and treated by cholecystectomy 1 month after operation the patient went home without morbidity and 1-year follow - up he had not any complications .

the majority of swallowed indigestible foreign bodies pass through the gastrointestinal tract without complications [ 1 , 2 , 3 , 4 ] . however , there are three physiological narrowings involving the pylorus , duodenal c - loop and ileocecal valve . foreign bodies longer than 10 cm , such as a toothbrush , can not negotiate the duodenal c - loop due to its fixed retroperitoneal position . these objects should be endoscopically removed as soon as possible to avoid pressure necrosis and gastrointestinal perforation [ 5 , 6 , 7 ] . if endoscopic removal fails or there is evidence of obstruction or perforation , laparoscopic gastrotomy should be performed . an 18-year - old caucasian woman with no previous history of related medical problems was admitted to the department of internal medicine , division of gastroenterology , clinical hospital split because she had accidentally swallowed a toothbrush . the patient admitted she had been using the toothbrush to induce emesis . on presentation , 2 h after ingestion , she was asymptomatic and her vital signs were within normal limits . a plain abdominal x - ray study confirmed the presence of the foreign body in the left upper abdominal quadrant ( fig . informed written consent for upper gastrointestinal endoscopy was obtained from the patient and her parents . esophagogastroduodenoscopy revealed the toothbrush in the stomach with its head positioned against the gastric fundus . the extracted toothbrush was 20 cm long . repeated upper gastrointestinal endoscopy was performed 4 h later and showed no evidence of mucosal lesion to the stomach or the esophagus . the patient was discharged home in excellent clinical condition after being observed for 6 hours . foreign bodies in the stomach will pass uneventfully through the gastrointestinal tract in 8090% of cases [ 1 , 2 , 3 ] . however , foreign objects longer than 10 cm , such as a toothbrush , can not negotiate the duodenal c - loop due to its fixed retroperitoneal position . in such cases , these objects should be removed as soon as possible to avoid pressure necrosis and gastric perforation [ 2 , 3 , 4 , 5 ] . removal of long foreign bodies from the stomach is influenced by the patient 's clinical condition and technical abilities of the endoscopist [ 2 , 3 , 4 , 5 ] . if endoscopic removal fails or there is evidence of obstruction or perforation , surgical gastrotomy should be performed . we had no need for conscious sedation since the patient was actively participating during the procedure . special attention has to be paid during the extraction of the toothbrush to its alongside alignment with the esophagus . otherwise , this most critical and demanding part of the extraction procedure may easily result in mucosal damage or foreign body impaction . the second important phase of the extraction procedure is when the foreign body reaches the oropharynx . the patient has to extend his head backwards and the endoscopist has to reach for the toothbrush with his hand and pull it out . this case report describes a rare case in whom a toothbrush was safely extracted from the stomach endoscopically by snare extraction . the procedure is brief , does not require conscious sedation , and the patient can be discharged from hospital after a few hours . early endoscopic retrieval of the toothbrush is critical for reducing morbidity and mortality . in cases when endoscopic removal fails

most ingested foreign bodies will pass uneventfully through the gastrointestinal tract . nevertheless , long and rigid foreign bodies are associated with an increased risk of gastrointestinal impaction , perforation and bleeding . moreover , there has been no case of spontaneous passage of a toothbrush reported . therefore , the prompt removal of such ingested foreign objects is recommended before complications develop . this case report describes a case of an 18-year - old woman who accidentally swallowed her toothbrush . the toothbrush was successfully removed via flexible endoscopy using a polypectomy snare . a swallowed toothbrush is a special clinical challenge . early endoscopic retrieval of the toothbrush is critical for reducing morbidity and mortality . in cases when endoscopic removal fails , a laparoscopic surgical approach may be an alternative .

a 55-year - old man presented at our emergency department with sudden - onset sharp chest pain that had started two hours previously . he also complained of progressive swelling and bruising on his neck , and the development of dysphagia and dyspnea over the previous two hours . he had a history of admission with spontaneous hemothorax seven years previously , and at that time , despite several work - ups for hemothorax , its origin was not found . other than this incident , he had hypertension but no history of gastrointestinal or bleeding disorders . upon arrival at the emergency department extensive neck swelling was observed , as well as bruising on the neck and upper chest . during the examination , he suddenly vomited bright red blood with food material three times , and approximately a quarter - cup of blood was generated on each occasion . other laboratory tests , including cardiac markers and his coagulation profile , were within their normal ranges . 1b ) revealed extensive non - enhancing soft tissue lesions in the posterior mediastinum and neck , which were suspected to be hematomas . emergency gastroscopy showed many blood clots but no definite focus of gastrointestinal bleeding , such as an ulcer , mass , or perforation . instead , gastroscopy showed extrinsic esophageal compression . since the patient was hemodynamically stable , conservative management was adopted in the intensive care unit . followup ct on the third day post - admission showed a focal aneurysm in the right bronchointercostal trunk ( fig . subsequent selective bronchial arteriography revealed a 1-cm aneurysm in the right bronchial artery ( fig . since the aneurysm was considered to be the cause of the hematemesis and mediastinal hemorrhage , we decided to perform embolization to prevent recurrence . the right bronchial artery was subsequently embolized with four microcoils ( vortx-18 ; boston scientific co. , marlborough , ma , usa ) and 33% glue ( fig . 2c ) , and repeat ct showed that the mediastinal hematoma had nearly disappeared ( fig . the patient was discharged without complications . over the course of one year of follow - up spontaneous mediastinal hemorrhage can develop as a result of trauma , aortic dissection , the valsalva maneuver , or iatrogenic procedures . the rupture of a bronchial artery aneurysm ( baa ) is also known to result in mediastinal hemorrhage . when a baa ruptures into the mediastinum , most patients present with chest pain , hemothorax , or hemomediastinum . furthermore , if hematemesis is a prominent symptom of baa rupture , it can be confused with boerhaave s syndrome , variceal disease , or a perforated ulcer . to the best of our knowledge , only three cases of baa presenting with hematemesis have been reported in the literature [ 46 ] . in one case , a pinhole connection between the aneurysm and esophagus was found during an endoscopic examination , but in the present case , no evidence of communication was found between the aneurysm and the esophagus . we first suspected that the mediastinal hemorrhage and hematemesis were caused by the perforation of an esophageal ulcer , but repeated gastroscopy showed a normal esophagus . the only abnormal finding was the finding of a baa without evidence of extravasation three days after the onset of symptoms . after ruling out the possibility of mediastinal hematoma , the baa was the only remaining possible source of the mediastinal hemorrhage . since the baa was regarded as the source of the mediastinal hemorrhage and hematemesis , it was embolized to avoid recurrence . the treatment of a ruptured baa depends on the patient s hemodynamic status and the presence of cardiorespiratory compromise . if the patient is hemodynamically stable , endovascular embolization is considered to be the first - line management strategy , and surgery should only be considered when embolization is contraindicated , as in patients allergic to contrast medium or when a medullary artery is involved . in patients presenting at an emergency department with hematemesis and mediastinal hemorrhage ,

hematemesis is a rare manifestation of a ruptured bronchial artery aneurysm ( baa ) in the mediastinum . it is difficult to diagnose a ruptured baa presenting as hematemesis , because it can be confused with other diseases , such as boerhaave s syndrome , variceal disease , or a perforated ulcer . in this report , we describe a case of baa resulting in hematemesis and mediastinal hemorrhage .

in the previous issue of critical care , kmpers and colleagues demonstrated a direct correlation between increased peripheral blood levels of the vascular growth factor , angiopoietin ( angpt)-2 , and mortality in 43 critically ill adults with sepsis . endothelial injury is one of the main hallmarks of sepsis , leading to capillary leak , microcirculatory dysfunction , organ failure , and eventual death in many critically ill patients . angpt-1 and angpt-2 are two of the best - characterized members of a family of endothelial - derived vascular growth factors necessary for both normal and pathologic angiogenesis and vasculogenesis . both angpt-1 and angpt-2 appear to bind to the tyrosine kinase receptor , tie-2 , found primarily on the luminal surface of endothelial cells . recent studies have also shown that the tie-2 receptor may be found on certain populations of peripheral blood monocytes , although the function and role of the tie-2 receptor in the host innate immune response remain relatively unexplored . angpt-1 is a tie-2 agonist and promotes endothelial stabilization and quiescence , whereas angpt-2 is a tie-2 antagonist and promotes endothelial activation , destabilization , and inflammation . as such , the relative balance between angpt-2 and angpt-1 at the tie-2 receptor may be more relevant to the pathobiology of sepsis than the absolute levels of the individual growth factors . several studies have demonstrated increased peripheral blood levels of angpt-2 in critically ill patients with sepsis [ 5,7 - 9 ] , multiple trauma , acute lung injury ( ali ) , and cardiopulmonary bypass when compared with healthy controls . more importantly , increased angpt-2 levels appear to be associated with adverse outcomes [ 5,6,9 - 12 ] . for example , the study of kmpers and colleagues showed that increased peripheral blood angpt-2 levels correlated with surrogate markers of tissue hypoxia , disease severity , and mortality in 43 critically ill adults with sepsis . also of note , consistent with the opposing roles of angpt-2 and angpt-1 on the tie-2 receptor , peripheral blood levels of angpt-1 were significantly lower in the patients with sepsis compared with healthy controls . unfortunately , in the study of kmpers and colleagues , similar to the aforementioned studies , the temporal kinetics of angpt-1 and angpt-2 were not assessed as blood samples were collected upon the first day of admission to the intensive care unit only . angpt-2 is stored in the weibel - palade bodies within endothelial cells in a more or less prepackaged form . it is therefore not surprising that angpt-2 levels are increased early in response to endothelial activation or injury . whether angpt-2 levels remain increased in critically ill patients with sepsis has not been directly addressed and is a question for future investigation . it is certainly tempting to speculate that peripheral blood angpt-2 levels would be an ideal biomarker of early endothelial activation and injury . similarly , whether angpt-1 levels remain decreased in critically ill patients who eventually succumb to their illness is an interesting question . angpt-1 may be a biomarker of endothelial recovery ; however , given its purported anti - inflammatory role , angpt-1 would appear to be an attractive therapeutic target as well . to this end , several studies have suggested that manipulating the ratio of angpt-2 to angpt-1 by augmenting angpt-1 levels may represent an ideal therapeutic strategy for patients with sepsis and ali . important translational laboratory studies are necessary to show that increased angpt-2 levels in critically ill patients are more than just an epiphenomenon . the role of angpt-2 in the pathobiology of sepsis and ali needs to be further elucidated by using in vitro cell - based studies and animal models of critical illness . similarly , the presence of the tie-2 receptor on certain subpopulations of peripheral blood monocytes suggests a larger role for angpt-2 in the host innate immune response . finally , manipulation of the angpt / tie-2 system may be a rational therapeutic strategy for the management of critically ill patients with sepsis and ali . all of these questions remain an active focus in several laboratories , including our own . the authors ' research is funded by the national institutes of health ( bethesda , md , usa ) ( grant numbers 5ko8gm077432 and 1r03hd058246 ) .

the early recognition and management of sepsis remain the greatest challenges in the field of critical care medicine . endothelial injury is one of the hallmarks of sepsis , leading to capillary leak , microcirculatory dysfunction , organ failure , and eventual death in many critically ill patients . the angiogenic growth factors , angiopoietin ( angpt)-1 and angpt-2 , act upon the tie-2 receptor in opposing roles . angpt-2 has been found in abundance in septic patients when compared with healthy controls . in the study by kmpers and colleagues in the previous issue of critical care , angpt-2 levels correlated with markers of tissue hypoxia , disease severity , and mortality in septic adults . however , the temporal kinetics of the angiopoietins were not assessed . it remains to be seen whether angpt-2 levels will function solely as an early marker of sepsis or whether the manipulation of the angpt / tie-2 system will become a rational therapeutic target for the management of sepsis .

pentalogy of cantrell is a rare multiple congenital malformation which occurs worldwide with a reported incidence of 5.5 per million live births.1 the exact cause is not known but is mainly thought to be sporadic , though its being associated with some chromosomal disorders like trisomy 1823 and deletion on locus at xq25 - 26 has been described in some cases.4 it was first described by cantrell et al . , in 19585 with the pentad consisting of a giant omphalocoele and a supra - umbilical anterior abdominal wall midline defect , sternal cleft , ectopia cordis , intracardiac congenital malformations like ventricular septal defect , atrial septal defect and tetralogy of fallot , ventral midline diaphragmatic defect with defect of the diaphragmatic pericardim.5 other associated defects include cranial and facial anomalies , clubfeet , malrotation of the colon , hydrocephalus and anencephaly.67 pentalogy of cantrell often have a poor outcome which is dependent on the severity of the malformations.8 though some cases of pentalogy of cantrell had been reported in nigeria , its true prevalence is not known and none of those reported had been proven to completely fulfill the five main components of the pentad.91011 we , therefore , report a case of pentalogy of cantrell in a 9-month - old boy who completely fulfilled the diagnostic criteria . a 9-month - old boy was first seen at the age of 5 months being delivered with multiple congenital malformations involving the anterior abdominal and chest walls . the child was delivered at term gestation and at home ; the pregnancy was not adversely eventful and she had no antenatal care . however , the child has defect on the anterior abdominal wall with a huge swelling extending from the lower anterior abdomen to the lower anterior chest wall , which was pulsatile and covered by a thin membrane which was initially reddish at birth but later became thickened and darker following daily cleaning and dressing . there was no history of vomiting or constipation , child sucked directly from the breast , though interrupted occasionally to catch his breath , there was no history of difficulty with breathing and no darkening of the lips or mucous membrane . the mother was a 25-year - old stay at home mother with four other children in a non - consanguineous marriage ; she neither smoked cigarette nor drank alcohol and had no adverse medical record . , there was a big pendulous and pulsatile mass extending from slightly above the symphysis pubis to the epigastrum measuring 12 10 cm [ figure 1 ] with an epithelised membranous covering ; it had visible peristaltic waves , it was pundunculated , with cardiac pulsation felt in the epigastric region [ figure 2 ] . bowel and heart sounds were heard over the mass below the level of the diaphragm . he was not tachypneic or tachycardic and had first and second heart sounds with a systolic murmur . his chest x - ray showed a midline heart with inferior displacement [ figure 3 ] , abdominal ultrasound showed the swelling to contain loops of bowl and echocardiography revealed a 6 mm secundum atrial septal defect . the child is currently being followed up awaiting staged repairs of the defects . a bulge in the region of the epigastrium and lower sternum x - ray showing loops of bowl in the swelling with displacement of cardiac shadow pentalogy of cantrell is commoner in boys and less than 60 cases have been documented so far worldwide as at 2007.8 the exact mechanism is not completely understood , however , the proposed pathogenesis involves a defect in embryogenesis between 14 and 18 days after conception due to failure of the in folding of the lateral mesoderm . while most affected children die shortly after birth due to the severity of their defect ( especially the associated intra - cardiac defect and risk of infection in open defects ) , it has been reported in a 32-year - old - man.12 our patient was 9-month - old and remained active despite the associated atrial septal defect and has better prospect with adequately staged surgical intervention . our case had all the major features of the pentad , though with a relatively favourable lesion because the membrane of the giant omphalocoele was completely epithelised [ figure 4 ] and the peduncle covered with skin , which helped in preventing infection ; furthermore , the atrial septal defect was of moderate size and the child had remained stable , though he stands the risk of trauma to the barely covered heart , but with proper counselling the child has survived up till this age . the mass covered by thickened , hyperpigmented keratinised membrane pentalogy of cantrell can be diagnosed prenatally but that has not been the case in those reported from nigeria so far because lack of accessibility to a proper antenatal healthcare and for the fact that most of those diagnostic tools are not readily accessible to these low income parents . patients with complete expression of pentalogy of cantrell are rare and few may survive to older age depending on the severity of the associated lesions , more especially the intracardiac defect . furthermore , we advised that patients with giant omphalocoele should be thoroughly evaluated , because they may have an incomplete expression of the syndrome .

pentalogy of cantrell is a rare congenital malformation whose exact cause is not completely understood ; it is characterized by defects in the anterior abdominal and thoracic walls consisting of omphalocoele , diaphragmatic defect , ectopia cordis , intracardiac defects and sternal clefts . the complex has variable clinical expression with complete and incomplete expressions reported . we , therefore , report a case of complete manifestation of the pentad in a 9-month - old boy .

we report involvement of unusual site in ilio - acetabular region with breach in articular cartilage . intra - operatively breach in acetabular roof was seen which was missed in the scan . this case report emphasizes about the rarity of the lesion in this location and the rare chances of breach in articular cartilage of the joint . bone desmoid tumor was an unknown entity until when jaffe hl reported a case in 1958 . it is a locally aggressive benign tumor reported commonly in mandible and meta - diaphyseal region of long bones . we report a case of desmoid tumor of ilio - acetabular region in a 40 year old female . a 40 year old female came with complaint of pain in the left hip region which aggravated on squatting and climbing stairs . radiological evaluation showed a lytic lesion in the left ilio - acetabular region , surrounded by a sclerotic margin superiorly . mri scan was done which showed a well defined homogenous lytic lesion with no break in the cortex and no soft tissue involvement ( fig . plain radiograph of pelvis with both the hips which shows a well defined lytic lesion over the left ilio - acetabular region . there appears no obvious breach in the cortex or the articular margin a ct scan of the pelvis was taken to rule out any breach in the cortex . there appears no obvious discontinuity through an ilio - inguinal incision the lesion was approached through inner table of ilium . a defect on the roof of the acetabulum was found which was missed by the scan ( fig . thorough curettage was done and the roof defect was reconstructed with a cortical graft harvested from the inner table of the ilium . there appears a hollow curetted lesion within which a breach in the roof of the acetabulum is seen histopathological finding showed multiple spindle shaped fibroblast cells with small and elongated nuclei in the background of dense collagen fibres . histopathology specimen picture showing spindle shaped fibroblast cells with small and elongated nuclei over a background of collagen fibers . there appears no nuclear atypia or mitotic activity patient was kept non weight bearing for 3 months with gradual return to full weight bearing walking . at follow up of 20 months patient is symptom free and xray showing no evidence of lytic lesion ( fig 5 ) . however , on ct scan there appears a persistent lytic area which we suspect to be a recurrence ( fig 6 ) . hence patient is kept on regular follow - up . a 20 month post operative x ray picture showing well maintained articular margin and the joint space . the lytic lesion seems filled up ct scan of the hip taken at 20 month post op , however shows lytic lesion anteriorly which seems to be a recurrence few cases have been reported since then and common occurrence being in mandible and meta - diaphyseal region of the long bone . recognition of desmoplastic fibroma is important because on radiology and histology , the lesion may be mistaken for an indolent , benign fibrous lesion or more aggressive spindle - cell sarcomas . it commonly occurs in the age group between the adolescent to 40 years with no specific sex predominance . patients commonly come with complaint of pain ; however there are few reported cases of pathological fracture especially those involving tibia and femur . the lesions are well defined with no sclerosis or periosteal reaction except if there is associated pathological fracture . if a soft tissue lesion is invading onto the bone , they are eccentric in position with sclerosis due to endosteal bone formation . significant t2 shortening of a non - sclerotic fibro - osseous lesion should place desmoplastic fibroma high among the diagnostic considerations . radiologically they have to be differentiated from giant cell tumor , fibrous dysplasia ( long bone lesions ) , fibrosarcoma , brown tumors , and chondromyxoid fibroma and hence a tissue diagnoses is must . the differentiation from a low grade fibrosarcoma is difficult though . as these are rare tumors , there is no standard protocol for treatment of these lesions . all kinds of procedures like intralesional , marginal or wide resection are reported as a treatment . but if wide resection would result a major functional deficit , an attempt of intralesional curettage with bone grafting seems warranted . desmoid fibroma of ilio - acetabular region is very rare hence a great sense of suspicion is required for the appropriate management . this case report emphasizes about the rarity of the lesion in this location and the chances of breach in articular cartilage of the joint . desmoid tumor , though rare , should be kept as one of the important differentials for the lytic lesion around pelvis . one should also define whether there is any associated cortical or articular margin breach ( as seen in our case report ) and then decide further management regarding reconstruction .

introduction : desmoid tumor of bone is a rare benign tumor . it is reported commonly in mandibular and meta - diaphyseal region of long bones . we report involvement of unusual site in ilio - acetabular region with breach in articular cartilage.case report : a 40 year old female presented with pain in the left hip . radiologically , a lytic lesion at ilio - acetabular region was seen . intra - operatively breach in acetabular roof was seen which was missed in the scan . curettage and defect reconstruction was done . histopathology reported as desmoid tumor . 20 months post - operatively patient was symptom free.conclusion:desmoid tumor is a rare bone tumor . this case report emphasizes about the rarity of the lesion in this location and the rare chances of breach in articular cartilage of the joint . the chances of recurrences are high with intralesional curettage .

few similar cases are reported in literature but none of them is associated with mirizzi syndrome . radiological images could help the surgeon to choose the surgical strategy and to evaluate the presence of associated diseases . in our case laparoscopic surgery showed to be an excellent approach for both the cholecystectomy and the repair of the defect of the abdominal wall . the patient was an 85 year - old man with history of hypertension , previous surgery for perforated diverticular disease ( hartmann procedure followed by reversal of colostomy ) . the physical examination showed a 5 cm mass in the right upper quadrant tender to palpation . ultrasound and ct confirmed the presence of a lithiasic gallbladder herniated through the abdominal wall ( fig.1 ) , with a dilatation of the common bile duct that measured 11 mm , due to a 17 mm obstructive infundibular stone as it happens in mirizzi syndrome type i ( fig.2 ) . lithiasic gallbladder herniated through the abdominal wall the routine complete blood test , including bilirubin level , was unremarkable . therefore the patient underwent a laparoscopic cholecystectomy and a repair of the hernia . during surgery , multiple adhesions were found and released carefully to identify the gallbladder that was fully included in the right upper quadrant abdominal wall covered by peritoneum . the gallbladder was completely released and the dissection of the pedicle showed a short cystic duct and a normal common bile duct . most of the cases reported in literature are internal hernias through the winslow foramen ( 1 ) . the herniation of the gallbladder through acquired defects of the abdominal wall ( incisional hernia ) has been much less reported . ( 2 ) presented the case of a gallbladder herniated through a fascial defect of a subcostal incision . garcia reported a patient who presented a gallbladder hernia through a parastomal defect ( 3 ) . more recently , the case of a gallbladder strangulation through an abdominal wall defect on the site of a previous colostomy was described ( 4 ) . in this case , the most remarkable thing is that herniation does not occur through a natural orifice or an acquired defect , such as respectively for the winslow foramen or for an incisional hernia , but directly into the abdominal wall . to our knowledge , there are only 3 published cases of spontaneous herniation of the gallbladder through the abdominal wall ( 5,6,7 ) . another interesting aspect of this case is the presence of a chronically distended gallbladder ( gallbladder hydrops ) , associated with extrinsic compression of the common hepatic duct by an impacted stone in the infundibulum ( mirizzi syndrome type i ) ( 8) . it is probably the gallbladder dilatation that plays an important role in the development of the hernia pressing constantly the gallbladder against the abdominal wall . usually the clinical picture is represented by a right upper quadrant pain , associated with variable degrees of a compromised general condition . in our experience the preoperative study based on computed tomography is essential for the diagnosis of the gallbladder hernia , and it provides also additional information on the abdominal wall defect . the management of this type of hernia consists in reducing the content and repairing the abdominal wall defect . in this case we suggest the laparoscopy as surgical approach of first choice because it allows to solve three problems at the same time : first , the reduction of the gallbladder s incarcerated hernia ; second , it enables to perform a cholecystectomy that was indicated for the presence of gallstones and hydrops ; third , it allows to repair the hernia defect preferably with a mesh , if the local conditions are favorable . in our experience , preoperative imaging has been proved to detect the gallbladder disease and the morphology of the fascial defect . mesh repair is the gold standard for hernias ; however , acute cholecystitis still remains a contraindication for mesh repair due to the high risk of infection .

a gallbladder incarcerated hernia associated with mirizzi syndrome is a very rare entity and to our knowledge this is the first case ever described in literature . an 85-year - old man presented at the emergency department with a tender right upper quadrant mass . computed tomography ( ct ) revealed the presence of a gallbladder lithiasis with signs of acute cholecystitis , herniated through the abdominal wall with an associated mirizzi syndrome . laparoscopic cholecystectomy and repair of the abdominal wall defect were performed . the patient recovered very well and the postoperative period was uneventful .

the long - term survival of patients with hematological malignancies has improved dramatically over the past decades . nowadays , about 40% of patients with acute leukemia or high - grade non - hodgkin lymphoma survive for more than 5 years and about 30% of these patients can be cured . unfortunately , owing to their underlying disease or treatment or both , these patients are at high risk of severe complications , often requiring transfer to the icu . historically , intensivists have been reluctant to admit these patients to the icu because of the almost uniformly fatal prognosis reported in the literature in patients with evolving organ dysfunction requiring mechanical ventilation , vasopressors , or renal replacement therapy alone or in combination . over the past decade , several centers around the world that specialize in the management of these patients have clearly shown that these grim prognostic estimates no longer hold and that the reluctance to admit these patients to the icu , simply because of their underlying malignancy , is no longer justified . an important remaining question , however , is how these patients perform in the long term with regard to survival and quality of life . in a study in the previous issue of critical care , bernal and colleagues focused on the determinants of survival beyond 1 year in a multicenter setting . as could be expected from what we observed at the bedside , functional status ( eastern cooperative oncology group performance status of more than 2 ) , relapsing hematological malignancy , and absence of compliance with the scheduled therapy for the underlying disease after icu discharge were associated with a worse survival . however , what was less expected is that the survival reached nearly 0% after 1.5 years if only one of these factors was present . of note , only 62 patients were included in this study , and depending on whether we focus on a half - empty or half - full glass , the other half of the patients achieved a 5-year post - icu survival of 40% to 50% . in the largest study ever published , including more than 1,000 patients with hematological malignancies admitted over a 16-month period in 17 specialized centers in france and belgium , hospital survival was 60.7% ; up to 80% of these patients had no change in treatment intensity , and 80% were in complete or partial remission 6 months after icu discharge . moreover , recent studies have shown that icu admission does not influence long - term outcome in patients with acute myeloid leukemia who survive the first 30 days after icu discharge : they had similar survival and complete remission rates up to 3 years and 6 years , respectively , after discharge in comparison with acute myeloid leukemia patients for whom icu admission was not necessary . therefore , what the study by bernal and colleagues shows above all is that being technically skilled in advanced life - support therapies is not enough to improve long - term outcome ; as intensivists , we also have to acknowledge better when to use these therapies and when we have to withdraw them during icu stay . more than ever , long - term estimations with regard to survival and quality of life should be taken into account upon referral to the icu . only close collaboration and in - depth communication between hematologists and intensivists upon referral and during icu stay can bridge the two extremes of the overoptimistic oncologists who often overestimate the long - term survival of their patients in daily practice and the overpessimistic intensivists who are reluctant to admit them . such an open and constructive atmosphere , in which physicians assume a leading role , disseminate a clear vision , and let other team members , the patients , and relatives actively and safely participate in the decision - making processes , will not only improve the average long - term outcome of published series focusing on any severe underlying comorbidity but also reduce the burden for individual patients and their relatives at the bedside . health - care workers will also benefit , since real or perceived disproportional care in the icu leads to acute or , much worse , more subtle chronic conflicts within the team , resulting in poor quality of care . the latter is particularly deleterious since it will affect the patient s short- and long - term outcome in general , regardless of whether the admission is justified or not . a good admission policy is necessary in order to safeguard the quality of icu care provided to patients with good long - term expectations on the one hand and to reduce the burden for patients and relatives with poor long - term expectations on the other . this can be achieved only by creating working environments enhancing close collaboration and communication between intensivists and hematologists and where the patient and relatives are closely involved in the decision - making process upon icu referral and during icu stay . it is important to note that this holds not only for patients with hematological malignancies such as in the study by bernal and colleagues but also for patients with any other severe underlying comorbidity that are increasingly referred to the icu . a good admission policy is necessary in order to safeguard the quality of icu care provided to patients with good long - term expectations on the one hand and to reduce the burden for patients and relatives with poor long - term expectations on the other . this can be achieved only by creating working environments enhancing close collaboration and communication between intensivists and hematologists and where the patient and relatives are closely involved in the decision - making process upon icu referral and during icu stay . it is important to note that this holds not only for patients with hematological malignancies such as in the study by bernal and colleagues but also for patients with any other severe underlying comorbidity that are increasingly referred to the icu .

the spectacular improvement in long - term prognosis of patients with hematological malignancies since the 1980s , coupled with the subsequent improvement over the past decade in short- and mid - term survival in cases of critical illness , resulted in an increasing referral of such patients to the icu . a remaining question , however , is how these patients perform in the long term with regard to survival and quality of life . here we discuss the present multicenter study on survival beyond 1 year in critically ill patients with hematological malignancies . we conclude with suggestions on how we can further improve the long - term outcome of these patients .

congenital coarctation of the aorta is a narrowing of the descending aorta which typically is located at the ligamentum arteriosum just distal to the left subclavian artery . this condition may be undiagnosed until adult life , when the clinical presentation most often is high blood pressure ( bp ) in both or more seldom in only one of the upper extremities . other typical clinical manifestations may include headache , fatigue on exertion , and bilateral lower limb claudication . coarctation of the aorta occurs in 5 - 8% of cases of congenital heart defects . this condition may occur along with ventricular septal defect and other related heart defects , or may occur isolated . in rare cases , severe trauma and injury may lead to coarctation of the aorta . in extremely rare cases , severe atherosclerosis or inflammatory diseases of the aorta may cause narrowing of the artery leading to aortic coarctation . a 57-year - old patient was referred to our outpatient clinic by his primary care physician because the 12-lead ecg demonstrated left ventricular ( lv ) hypertrophy . twenty - two years earlier , the patient had been referred for cardiological examination due to a cardiac systolic murmur . at that time , his bp was 98/50 mmhg , and simultaneous and equal radial and femoral pulses were described . no medical or cardiovascular history or cardiovascular risk factors were present , and the patient had no signs of genetic disorders . at the present consultation , the patient confirmed the absence of any cardiovascular symptoms . transthoracic echocardiography showed a non - dilated , hypertrophic left ventricle [ figure 1a and b ] with end - diastolic interventricular septal thickness of 21 mm , end - diastolic lv posterior wall thickness of 12 mm , and an estimated lv mass of 449 g ( lv mass index 214 g / m ) . the lv ejection fraction was 50% . except for a mild aortic regurgitation ( in a normally shaped tricuspid aortic valve ) and a dilatation of the ascending aorta of 40 mm a continuous wave doppler examination from the suprasternal notch showed a peak systolic pressure gradient in the thoracic descending aorta of 80 mmhg without diastolic run - off [ figure 1c and d ] , indicating a severe obstruction at the classical site of a coarctation . multislice computed tomographic ( ct ) angiography confirmed the finding of severe coarctation of the aorta . the ct scan demonstrated that both subclavian arteries originated distal to the severe coarctation , explaining the normal bp in both arms [ figure 2 ] . moreover , a ct scan of the cerebrum revealed the vessels in the circle of willis giving rise to numerous collaterals in the brain circulation . 57-year - old male was referred to our outpatient clinic because the 12-lead ecg demonstrated left ventricular ( lv ) hypertrophy that was later diagnosed as due to congenital coarctation of the aorta . transthoracic echocardiography ( a ) apical four - chamber view and ( b ) m - mode show left ventricle hypertrophy ( arrows ) ; ( c and d ) suprasternal views show the narrowing in the thoracic descending aorta ( arrow ) and the continuous wave doppler curve without diastolic run - off ( arrow ) . 57-year - old male was referred to our outpatient clinic because the 12-lead ecg demonstrated left ventricular ( lv ) hypertrophy that was later diagnosed as due to congenital coarctation of the aorta . we report an uncommon case of congenital coarctation in a 57-year - old man without the clinical signs of coarctation . because of the uncommon location of the aortic narrowing with both the right and left subclavian arteries originating distal to the area of coarctation , the bp was equally low in both upper extremities . the present case shows that a normal brachial bp does not rule out severe coarctation and should be considered in apparently normotensive patients presenting with a systolic murmur or target organ damage , in this case severe lv hypertrophy . uncorrected coarctation of the aorta in adults predisposes to congestive heart failure , aortic dissection and rupture , stroke , cerebral hemorrhage , and infective endocarditis . therefore , an early diagnosis is important , and the present case emphasizes the use of suprasternal view as a part of a standard diagnostic echocardiography . treatment options include surgical repair or balloon angioplasty with or without stent implantation . taking the atypical location , extent , and complexity of the lesion into account ,

the present case shows that a normal brachial blood pressure ( bp ) does not exclude severe coarctation and should be considered in normotensive patients presenting with a systolic murmur and/or unexplained severe left ventricular hypertrophy . congenital coarctation of the aorta is a narrowing of the descending aorta , usually located distal to the origin of the subclavian artery , causing hypertension in the upper part of the body . this condition may be undiagnosed until adult life where the clinical presentation most often is high bp in the upper extremities . a 57-year - old patient with severe aortic coarctation and left ventricular hypertrophy presented with normal brachial bp . however , standard suprasternal view by echocardiography indicated coarctation . multislice computed tomographic ( ct ) angiography revealed an uncommon location of the aortic narrowing with the right and left subclavian arteries originating below the area of coarctation , explaining the equally low bp in both upper extremities .

in rare conditions , bacteria from carbuncles can spread into the bloodstream and migrate to other areas of the body , causing serious complications such as septicemia and infections in the liver , bones , joints , heart , and central nervous system . we describe an original case of forehead carbuncle with intractable headache , later confirmed as a subgaleal abscess . a 74-year - old female visited our hospital due to a 2 cm , painful , erythematous nodule with a small necrotic plug on her forehead , which had been resident for 2 days . she had suffered for 5 years from diabetes mellitus , which was not aggressively controlled . one day later , the patient visited our emergency room again due to progressive erythema and worsening headache . she had mild fever ( 37.7c ) and bilateral periorbital soft tissue swelling with local heat . laboratory data showed elevated white blood cell count ( 10.521,000 cells/l ) and c - reactive protein levels ( 78.90 preliminary diagnosis suspected cellulitis ; she was admitted to kaohsiung municipal ta - tung hospital , kaohsiung , for further management . however , her headache kept worsening and interfered with her sleep over the next 2 days . she described the headache as severe , persistent aching all over her head , which was not associated with postural change . nonsteroidal anti - inflammatory drugs and tramadol hydrochloride were administered but completely in vain . in the fear of central nervous system involvement however , brain computed tomography ( ct ) was still arranged due to intractable headache . brain ct showed no intracranial lesion , but subgaleal emphysema and abscess were suspected ( figure 1 ) . a neurosurgeon was then consulted , and operative debridement was promptly arranged . during the operation , widespread subgaleal abscess was noted and drained . as previously described in the case history section , this 74-year - old female had intractable headache , which developed in close relationship with subgaleal abscess . in addition , her headache resolved within 3 months after successful treatment of subgaleal abscess with operative debridement and antibiotics . according to the international classification of headache disorders ( ichd-2 ) criteria , headache disorders attributed to extracranial infection of the head ( such as ear , eye , and sinus infection ) are coded as subtypes 11 . headache or facial pain can be attributed to a disorder of the cranium , neck , eyes , ears , nose , sinuses , teeth , mouth , or other facial or cranial structures.1 carbuncle is a common dermatologic disease , and staphylococcus aureus is the pathogen responsible in most cases . though some authors advocate that systemic antimicrobial treatment is not needed for simple furuncles and carbuncles,2 we agree that incision and drainage with ancillary antimicrobial therapy is recommended for patients with immunosuppression or comorbidities , extremes of age ; rapid progression to cellulitis and the lack of an adequate response to incision and drainage are also indications for such treatment.3 however , empiric antibiotics for carbuncle , even vancomycin , did not work for the unusual bacterial culture of klebsiella in this patient . although klebsiella is strongly associated with infections in patients with diabetes , skin and soft tissue infections from klebsiella are still uncommon.4 this case reminds us that empiric , systemic antibiotics for carbuncles and cellulitis may respond poorly in situations as described in the case history section . the most common cause of subgaleal abscess is direct inoculation of microbes into the subgaleal space following scalp trauma . however , subgaleal abscess may result from hematogenous infection or contiguous spread , and the diagnosis may not be initially obvious.5 carbuncles may progress to cellulitis and cause redness of the skin , swelling , and pain . however , carbuncles located on the middle of the face may raise concern , especially when the patient is elderly and immune - compromised . intractable headache that is unresponsive to the standard medications and therapies utilized in the treatment of headaches also indicates the need for further survey . head ct is often needed in the diagnosis of subgaleal abscess , and if operative debridement is not promptly performed , subgaleal abscess may further progress to life - threatening septicemia , osteomyelitis , and even subdural or brain abscess or meningitis.6 there are no focal neurological signs or specific symptoms in the early stages of subgaleal abscess . thus , when encountering patients with intractable headaches , unusual causes should be kept in mind , which may include moyamoya syndrome,7 headache after botulinum a exotoxin injections,8 acquired immunodeficiency syndrome - related lymphoma confined to bone,9 migraine in obese individuals,10,11 and children with both migraine and periodic limb movement disorders in sleep.12 in conclusion , this case highlights that special attention should be paid to elderly and immune - compromised patients with carbuncles located on the middle of the face , especially when accompanied by intractable headache .

although carbuncles are commonly seen and may heal on their own or respond well to treatment , in rare conditions , bacteria from carbuncles can spread into the bloodstream and migrate to other areas of the body . herein , we report on an elderly female who suffered from forehead carbuncle with intractable headache , later confirmed as having subgaleal abscess . physicians should pay special attention to elderly and immune - compromised patients with carbuncles located on the middle of the face , especially when accompanied by intractable headache , to avoid poor outcome .

placental polyp is a somewhat pedunculated remnant of chorionic tissue retained in the uterine cavity for an indefinite time . it may result in abnormal uterine bleeding and slightly elevated detectable titers of serum -human chorionic gonadotropin ( hcg ) . these pedunculated masses of villi are often found within days to weeks following abortion or delivery of a term placenta . since trophoblastic neoplasms especially placental site trophoblastic tumor may have similar symptoms and signs , it is important to consider placental polyp in differential diagnosis in such situations . a 34-year - old g4l3ab1 woman came with abnormal uterine bleeding since her last normal vaginal delivery 3 months ago . serum -hcg level was slightly elevated ranging from 86 to 103 iu / ml during diagnostic investigations . ultrasonography revealed enlarged uterus with an echolucent intracavitary uterine mass measuring 73 mm 55 mm 24 mm . computerized topography confirmed the presence of the mass and showed no abnormality in thorax . clinical , laboratory , and imaging findings raised the suspicion of gestational trophoblastic tumors especially those arising from intermediate trophoblastic cells . macroscopically , the uterus showed slight global enlargement resulting from the presence of a polypoid mass within the endometrial cavity . the cut surface was diffusely red with some fine streaks of a gray colored tissue . it was attached to the uterine wall in the fundal region without any macroscopic permeation into the myometrium [ figure 1 ] . microscopic study showed largely necrotic villi in a network of fibrin deposition [ figures 2 and 3 ] . a large polypoid mass with smooth outer surface has completely filled the endometrial cavity necrotic chorionic villi are seen in the background of fibrin deposition ( 40 ) nuclear debris are seen in the stroma of necrotic chorionic villi ( 400 ) placental polyp is a fragment of retained placental tissue in the uterus that has undergone neovascularization after resolution of gestation . chronic uterine inversion due to placental polyp has also been reported . a case of placental these pedunculated masses of villi are often found within days to weeks following abortion or delivery of a term placenta . rarely , they persist for months or even years after pregnancy . abnormal uterine bleeding due to placental polyp has been attributed to preserved villi , clusters of destructive villi , and isolated viable cotyledons . preservation of the brush border of syncytiotrophoblastic cells and the presence of placental phosphatase maintain the anticoagulative properties of villi . thromboplastic properties of the preserved villi play an important role in the pathogenesis of uterine bleeding when necrotic villi with epithelial remnants are prevalent . computed tomographic angiography is also useful in diagnosis and management of placental polyp with neovascularization . magnetic resonance imaging may also be used in diagnosis and follow - up of placental polyps . . a hypervascular placental polyp may lead to severe hemorrhage that requires blood transfusions , interventional radiology procedures , hysteroscopic resection , and even hysterectomy to control bleeding . evaluation of neovascularization by multimodal imaging is potentially useful in management of placental polyp in women who wish to preserve fertility . successful treatment with the use of iliac artery occlusion catheters and concomitant hysteroscopic resection has been reported . intraoperative injection of prostaglandin f2 followed by hysteroscopic resection has been successful in management of these cases . serum hcg fell to undetectable level following surgery . although the patient had completed her family and did not have any desire to preserve her fertility , a proper preoperative diagnosis with accurate interpretation of imaging findings and satisfactory curettage would have prevented hysterectomy in this patient . placental polyp should be considered in any case of parous woman with unexplained abnormal uterine bleeding and slightly elevated serum hcg level . this does not exclude the possibility of the presence of a placental polyp as the source of abnormal bleeding . all authors have contributed in designing and preparation of the first draft of the manuscript . they have read and approved the content of the manuscript and confirmed the accuracy or integrity of any part of the work .

placental polyp is retained placental tissue within the endometrial cavity , which forms a nidus for inflammation and bleeding . there are very few reported cases of the clinical placental polyp . here , we report a case of 34-year - old g4l3ab1 woman with the chief complaint of intermittent vaginal bleeding since her last normal vaginal delivery 3 months ago . serum human chorionic gonadotropin ( hcg ) titer was slightly elevated . a polypoid mass was detected within the endometrial cavity by imaging studies . history of the patient , mass lesion within the endometrial cavity and slightly elevated serum hcg titer raised the suspicion of trophoblastic neoplasms . endometrial curettage yielded unsatisfactory specimen containing only fibrin deposition and was followed by total hysterectomy . the uterus showed slight global enlargement resulting from the presence of a polypoid mass within the endometrial cavity . the red - colored mass had a smooth outer surface and fragile consistency without any permeation into the myometrium . pathology reported it as the placental polyp . although very rare , placental polyp should be kept in mind as one of the reasons of abnormal uterine bleeding in parous women . definite diagnosis is made by pathology examination .

many organs can be herniated into the scrotum such as small intestine , appendix , colon , and ovaries . ureteral herniation is extremely rare , usually asymptomatic and is reported as isolated case report or small series . we report the case of an 88-year - old man treated for inguinoscrotal hernia where the left ureter was incidentally found in the herniated retroperitoneal fat . presenting symptoms , diagnostic evaluation , and surgical management an 88-year - old man was admitted for a left moderately sized inguinoscrotal hernia . his medical history included hypertension and benign prostatic hyperplasia . the herniated parts were dislocated from the scrotum , as well as the testicle , and cord strictures . the cord was separated from the herniated parts and was partially covered from preperitoneal fat . a large amount of retroperitoneal fat surrounded from a sac - like formation was found adjacent to the cordis [ figure 1a and b ] . these adhesions , as well as a part of this fat , were excised because of the irreducibility of the mass . during the excision , 24 h later , an abdominal ultrasound was performed to rule out any structural abnormality , which may have been missed preoperatively . ( a and b ) the left extraperitoneal inguinoscrotal hernia the ureter identified into the herniated retroperitoneal fat ureteral herniation is rare , and approximately 140 cases have been reported in the literature , mainly as isolated case reports or small series . ureteric hernia is also reported as spontaneous , postoperative or as a complication of renal transplantation . ureteral herniation presents as a groin mass usually asymptomatic although many cases describe association with dysuria , hematuria , and hydronephrosis . the hernia has the classical aspect of an indirect hernia ; it is formed by the sac anteromedially that contain viscera that make up the wall of the sac , and the ureter lying posterolaterally . the ureter slides into the canal drawn by the posterior peritoneum that follows the herniated viscera . paraperitoneal hernias are more common in men , usually located on the right side , are often large in size , usually reducible and rarely symptomatic . there is not a clear association with kidney or ureteric abnormalities . on the other hand , the hernia is often accompanied by the large amount of retroperitoneal fat , is often nonreducible , usually small and commonly associated with urinary symptoms . authors consider this type of hernia congenital and related to developmental abnormalities of differentiation of the ureter from the wolffian duct . the ureter slides along with the testis into the scrotum ; a process also favored by adhesions between the ureter and genitoinguinal ligaments . many extraperitoneal hernias have a congenital association to renal or ureteral malformation such as crossed renal ectopia or nephroptosis . however , in our case the hernia was sizable , partially reducible and was no associated with urinary symptoms . the diagnosis of ureteral hernia is often missed due to lack of urinary symptoms or signs or symptoms that could lead doctors to apply an extended preoperative work up . although computed tomography may determine the type and the contents of hernias and the intravenous urography may determine abnormalities before surgery , they are not justifiable on every inguinal hernia repair . considering the fact that ureteric injuries are serious complications and require additional surgical approaches , we emphasize the high index of suspicion needed by surgeons when repairing hernias identifying gross amount of sliding fat and resecting fat trying to reduce hernia into the abdomen .

an inguinoscrotal hernia is a common disorder that usually contains intraperitoneal organs ( small intestine , colon , appendix , ovaries ) . extraperitoneal ureteral herniation into an inguinoscrotal hernia is a rare condition and often associated with congenital abnormalities or postoperative anatomic changes . a high index of suspicion is needed in order to avoid intraoperative ureteric injuries . we herein report the case of a ureteric herniation into an inguinoscrotal hernia incidentally found during a scheduled hernia repair .

pancreatic heterotopia is defined as the presence , outside its usual location , of pancreatic tissue which lacks anatomical and vascular continuity with the pancreas proper ( 1 ) . the heterotopic pancreas ( hp ) is a relatively uncommon congenital anomaly , with an incidence between 0.55% and 13.7% in autopsy series and mean frequency between 1 and 2% . hp has been found in all age groups , predominantly in the sixth decade of life ( 2 ) . the usual locations of hp are in the stomach in 25 - 38% cases , the duodenum in 17 - 36% and the jejunum in 15 - 22% of cases . it is usually silent but it may become clinically evident when complicated by inflammation , bleeding , obstruction or malignant transformation ( 3 ) . symptomatic patients require surgical exploration in order to obtain a definitive diagnosis and to exclude malignancy . a 12 years old male child presented with severe abdominal pain and intermittent vomiting , not relieved with medications . usg showed telescopy of gut loop along with its mesentry into other infraumblical region at the level of anterior superior iliac spine suggestive of ileoileal intesusception . an ileal polyp was found to be the cause of intussusceptions which was removed along with small segment of adjacent bowel and sent for histopathological examination . surgical specimen of resected ileal polyp with adjacent bowel loop ( 1a ) cut surface of which was pale yellow ( 1b ) . histological examination revealed presence of pancreatic tissue in muscularis propria of ileum ( 1c ) ( h&e , x40 ) with overlying mucosa showing congestion and metaplasia ( 1d ) ( h&e , x40 ) on gross examination , the polyp was brown , oval sessile mass with a broad base measuring 63.52 cm ( fig . the histological examination revealed the presence of pancreatic tissue in the muscularis propria of ileum ( fig . 1c ) made up of pancreatic acini and dialated ducts interspersed by smooth muscle bundles ( fig . photomicrograph showing pancreatic acini and ducts ( h&e , x100 ) the patient had an uneventful recovery and remains asymptomatic postoperatively . as stated by hunt and bonesteel ( 5 ) the first case of heterotopic pancreas was reported by schultz in 1729 , and klob provided its histological confirmation in 1859 ( 6 ) . the reported incidence in autopsy studies is 0.5 - 13% ( 3 ) . in adults it is found mainly in the stomach , duodenum and jejunum , in much smaller proportions in the ileum and meckel s diverticulum , and it is rarely found in the esophagus , liver , gallbladder , omentum , lungs , mediastinum , fallopian tubes and umbilicus ( 2 ) . in adults the incidence is higher in males , while in pediatric patients the female gender prevails . the proposed theory is that during rotation of foregut in a fetus and fusion of dorsal and ventral parts of pancreas , small islands of pancreas are carried away and continue to develop at its aberrant location ( 2 ) . most patients with ectopic pancreas are asymptomatic and diagnosis is usually performed during radiological examination or endoscopy of the digestive tract or during surgical explorations motivated by other diseases ( 2 ) . when symptomatic , about 30% of total mimic clinical symptoms similar to diseases that affect the organ in which the heterotopia is located ( 3 ) . usually they present in the form of small yellowish nodules , ranging from 1 mm to 5 cm , typically covered by intact mucosa , and often exhibit a central hole representing exteriorization of the rudimentary pancreatic duct . however , lesions smaller than 1.5 cm do not usually show such an orifice ( 8) . the ectopic pancreatic tissue is detected more frequently in the submucosa and muscularis propria layers of the gastrointestinal tract and may be observed in the sub - serosa or even in the serosa of the affected segment ( 2 ) . the heinrich classification system is frequently used to classify heterotopic pancreas : type 1 ( containing acini , islets and ducts ) , type 2 ( acini and ducts , no islets ) and type 3 ( ducts alone ) ( 9 ) . the preoperative imaging studies ( ultrasonography , endoscopic ultrasonography and computerized tomography ) are not very specific ( 3 ) . hence , in the majority of cases , the diagnosis is made by histological evaluation following resection of a symptomatic or suspicious lesion ( 10 ) . the management of asymptomatic , histologically verified heterotopic pancreas or those found incidentally during other surgery is under debate . although , in the majority of the cases of heterotopic pancreas reported surgical resections were done ; endoscopic mucosal removal can be an attractive , less invasive option for the resection of accessible lesions ( 3 ) . although there have been studies describing clinicopathological analysis of patients presenting with heterotopic pancreas(2,10 ) , ileal heterotopic pancreas has been rarely reported in children . heterotopic pancreas is a rare congenital lesion , often diagnosed incidentally on histopathological examination and should be considered in the differential diagnosis of intestinal mass lesions .

heterotopic , aberrant or ectopic pancreas is defined as the presence of pancreatic tissue in topographic anomaly , with no anatomical , neural or vascular connection to the normal pancreas . it is a rare condition found mainly in stomach , duodenum and jejunum . ileal heterotopic pancreas is an uncommon condition and has been rarely reported in children so far . hereby we report a case of heterotopic pancreas presenting as ileal poyp leading to ileoileal intussusception in a 12 year child .

primary neuroendocrine carcinoma ( nec ) of the breast is a rare distinct clinicopathological entity , comprising 0.5 - 2% of breast carcinomas world - wide . in 2003 , primary nec of the breast was identified as a distinct entity by the world health organization ( who ) classification of tumors . the who classification defines primary nec of the breast as tumors that express 50% or more of ne markers there are no previous reports of f-18 fluorodeoxyglucose ( fdg ) positron emission tomography / computed tomography ( pet / ct ) in patients with primary nec of breast with liver and bone metastasis . here we describe a case of a 45-year - old female patient who presented with jaundice and was evaluated to have multiple liver lesions and biopsy from liver showed metastatic neuroendocrine tumor . her chromogranin level was 886 ng / ml ( normal < 78 ng / ml ) . she was referred for the whole body pet / ct for detection of the primary site . pet / ct showed an intense uptake in the soft- tissue necrotic lesion in the inner quadrant of the left breast [ figure 1a and b ] with the same charecteristic feature of multiple hypodense liver lesions [ figure 1c ] . furthermore uptake noted in a lytic lesion in the d4 vertebra [ figure 1d and e ] . patient underwent fine - needle aspiration of the breast lesion , which confirmed neuroendocrine origin [ figure 2a and b ] . a diagnosis of primary nec of the left breast with metastasis was made and she was treated with peptide receptor radionuclide therapy and is on follow - up now . whole body fluorodeoxyglucose - positron emission tomography / computed tomography ( pet / ct ) maximum intensity projection image ( a ) , axial fused pet / ct showed a intense uptake in the soft - tissue lesion in the left breast ( b ) , liver lesions ( c ) and bone lesion ( d ) , axial ct showing lytic bone lesion in d4 vertebra ( e ) immunohistochemistry staining showing positive for chromogranin ( a ) and synaptophysin ( b ) primary nec of the breast is extremely rare with the first reported case in 1983 . the most frequent reported age varies from 40 to 70 years , with a higher incidence in women greater than 60 years . as metastatic neuroendocrine tumors of the breast are more common than that of primary neuroendocrine tumors of the breast , it is , therefore , important to differentiate primary breast neuroendocrine tumor from metastatic disease to the breast because of the differences in treatment focus . primary nec of the breast can be diagnosed if the presence of a non - mammary primary site can be clinically ruled out or if an in situ component is histologically detected or both . however , findings of certain studies have revealed that ne - differentiated tumors of the breast present as dense round or irregular masses with spiculated or lobular margins on the mammogram . definitive diagnosis is made with core needle biopsy , allowing for the immunohistochemical evaluation of the specimen for the ne markers . although the use of pet for the evaluation of ne tumors has been limited , tumors with moderate or high proliferative activity can be identified by fdg pet . there are reports of fdg pet / ct in a case of neuroendocrine differentiated breast carcinoma with pleural metastases using indium-111 octreotide . there are case reports of synchronous metastases to the liver and pancreas from a primary nec of the breast . our case is the first demonstrates that 18f - fdg pet / ct provides the most significant additional information related to the accurate detection of primary nec of breast and bone metastasis and guiding treatment .

cases of primary neuroendocrine carcinoma ( nec ) of the breast have been reported , though rare . we report the case of a 45-year - old woman presented with jaundice and evaluated to have liver metastasis from neuroendocrine origin . she underwent whole body positron emission tomography / computed tomography , which showed left breast lesion and bone metastasis . fine - needle aspiration ( fna ) of breast revealed a nec . a diagnosis of a primary nec of the breast was rendered with hepatic and bone metastasis . she was treated with peptide receptor radionuclide therapy and is on follow - up .

hemifacial spasm is a disorder of the seventh cranial nerve , and is characterized by irregular , involuntary and recurrent tonic and clonic contractions of the ipsilateral facial expression muscles . each spontaneous motor paroxysm starts with eye twitching and progresses to involve the other muscles innervated by the facial nerve . the episode characteristically begins with a series of twitches that increase in frequency and intensity , followed by a sustained spasm . the disorder is typical during adulthood and is commonly attributed to vascular compression of the facial nerve emergence at the brain stem . altogether , posterior fossa or cerebellopontine angle tumors are rare causes of hemifacial spasm , reported in less than 1% of a large series of adult patients . in children , the association of hemifacial spasm with tumors is also rare , with very few cases reported . a 6-year - old girl without any significant past medical history was admitted with intermittent involuntary twitching of the right orbicular region ; the twitching had occurred for 18 months . over time , the spasms became more tonic , and after 4 months , the spasms also involved the right orbicularis oris area . she was noted to be in good overall condition , showing a normal physical examination without fever or any other signs of infection . her height was 133 cm , and she weighed 39 kg , with a body mass index of 22.4 . the neurological examination was noteworthy for dysarthria and right hemifacial spasm [ figure 1 ] . sustained right hemifacial spasm laboratory evaluations , including a complete blood cell count , electrolytes , blood urea nitrogen and liver enzymes were within the normal range . cranial magnetic resonance imaging ( mri ) revealed a right - sided heterogeneous lesion from the midbrain to the pons , extending to the cerebellopontine angle , with a slight mass effect on the fourth ventricle [ figure 2 ] . after the neuroimaging procedures , a cerebral biopsy was performed , which revealed a pilocytic astrocytoma . the hospital ethic commission approved this case report , and the patient 's parents gave informed consent for publication . ( a ) t2-weighted coronal and ( b ) flair axial mri images showing a right - sided heterogeneous high signal lesion from the midbrain to the pons , extending to the cerebellopontine angle , with a slight mass effect on the fourth ventricle . ( c ) t1-weighted aspect of the lesion , with heterogeneous low signal and ( d ) t1-weighted post - gadolinium sagittal image showing its enhanced pattern these causes include venous sinus thrombosis , masses of the fourth ventricle , pilocytic astrocytoma , congenital or acquired cholesteatoma , tuberculous meningitis , thickening of the arachnoid membrane , neurosurgical facial nerve injury , accommodative esotropia and mandibular prognathism . masses may directly impinge on the facial nerve depending on the size and location of the tumor . some studies described cases in which the facial nerve was compressed against bony structures or tethered to arachnoid adhesions . this case shows the importance of a thorough neurological evaluation because our patient presented with subtle clinical signs of hemifacial spasm as the initial manifestation of a pilocytic astrocytoma . children who present with hemifacial spasm , even if very mild , should undergo further investigation .

hemifacial spasm is a disorder of the seventh cranial nerve , which is characterized by irregular , involuntary and recurrent tonic and clonic contractions of the ipsilateral facial expression muscles . this disorder affects mainly adults , and there are few cases reported in childhood . the main etiologies are vascular problems , although tumors are an important cause of hemifacial spasm via a direct or an indirect mass effect . we report a 6-year - old girl who presented with right hemifacial spasm . magnetic resonance imaging showed a lesion in the cerebellopontine angle , extending from the midbrain to the pons with a slight mass effect on the fourth ventricle . the histological examination revealed a pilocytic astrocytoma .

the common occurrence of these tumors is prevalent among males in their second or third decades of life with site predilection toward trunk and extremities , especially in the forearm . however , the incidence of al is extremely rare in the intraoral region , with only 21 reported cases in english literature . a 90-year - old woman with no significant medical history was referred to our department for evaluation of painless mass arising from oral cavity . the tumor was noticed by the patient 20 years ago as a small nodule on the right buccal mucosa and since then it gradually increased in its size . the growth reached a size , which could not accommodate in mouth , and due to constant irritation from the tumor , the patient coughed the growth for 5 years . since then on extraoral examination , a solitary , smooth , nontender and nonpulsatile pedunculated growth of size 14 cm 10 cm with variable consistency was evident with intraoral origin [ figure 1 ] . clinical image shows preoperative tumor on intraoral examination , single , smooth , firm and nontender stalk - like pedicle of diameter 2 cm was seen originating from the right buccal mucosa . based on the history and clinical examination , we provisionally diagnosed it as a benign growth . surgical excision of the tumor was done under general anesthesia [ figures 2 and 3 ] . clinical image shows excised tumor mass clinical image shows postoperative frontal view histopathology confirmed it as noninfiltrating al [ figures 46 ] . one - year follow - up of the patient revealed no evidence of recurrence . ethical approval from the institutional review board was obtained for the publication , and patient release form was signed by the patient . clinical image shows histopathology section ( 4 magnifications ) clinical image shows histopathology section ( 10 magnifications ) clinical image shows histopathology section ( 40 magnifications ) lipomas are the most frequently found soft - tissue benign tumors , but their occurrence in head and neck region is rare . al , in the oral cavity , was first documented by davis et al . as a growth on the hard palate . history of trauma , lipomatous differentiation by hormones during puberty , vascular proliferation of a congenital lipoma and fatty degeneration of a central hemangioma have been implicated as possible etiological factors . the mean diameter at the largest portions of all the 21 documented als occurring in oral region was 3 cm , and the mean onset age of the patients was about 29 years old . although diagnostic modalities such as magnetic resonance imaging , computed tomography , ultrasonography and aspiration biopsy have been used to differentiate between hemangioma , lipomas and al , the diagnosis of these tumors is confirmed only by histopathology . the standard treatment of choice is surgical excision for the noninfiltrating als and complete surgical excision with a clear surgical margin for poorly encapsulated infiltrating als to avoid recurrence . the case we have presented showed the typical clinical and histological findings of a noninfiltrating al . its most striking and unique features were its occurrence in a 90-year - old female with a 20-year long history and pedunculated mass of 14 cm 10 cm . with regard to the size and its typical pedunculated appearance , our present case can be considered to be the first of its kind in literature .

we present an extremely rare case of noninfiltrating angiolipoma ( al ) of the buccal mucosa in a 90-year - old patient reaching a size of 14 cm 10 cm . al is rare in the soft tissues of oral cavity , and till date , only 22 cases have been reported , including our case . if size be taken into consideration , our case can be considered to be the first in literature to reach this massive size . surgical excision of the tumor mass was performed . the histopathological findings confirmed the diagnosis of noninfiltrating al . follow - up for 1 year revealed no signs of recurrence .

oral angiokeratomas are most commonly found as a component of the generalized systemic disorder in fabry 's disease or fucosidosis , where multiple angiokeratomas can be found on the skin and the oral mucosa . we report a rare case of a patient with multiple oral and scrotal angiokeratomas in the absence of a systemic disorder . a 60-year - old man presented with a 2-year history of painless red raised lesions involving the tongue . he complained of burning sensation in the mouth in the region of the papules . clinical examination revealed multiple erythematous to slightly bluish , shiny , vascular papules ranging from 1to3 mm size , discrete to grouped on the undersurface and lateral aspects of the tongue [ figure 1 a and b ] . biopsy from a vascular papule on the tongue showed acanthosis , and papillomatosis , with large , dilated spaces lined by normal - appearing endothelium which were filled with erythrocytes and organizing thrombi [ figure 1d ] . the patient was counseled about the benign nature of the disease after which he chose not to take any treatment . ( a - b ) multiple erythematous to bluish , shiny , vascular papules on the undersurface and lateral aspects of the tongue ; ( c ) similar vascular papules on the scrotum ; ( d ) acanthosis , and papillomatosis , with large , dilated spaces lined by normal - appearing endothelium which are filled with erythrocytes and organizing thrombi ( h and e , 200 ) angiokeratoma is an asymptomatic cutaneous vascular disorder of the papillary dermis characterized by dermal vasculsar ectasia with overlying hyperkeratosis of the epidermis . it is thought to be a telangiectatic lesion arising from local injury to papillary dermal capillaries , either from trauma or venous hypertension . they are ( 1 ) the generalized systemic type : angiokeratoma corporis diffusum of fabry characterized by multiple tiny red papules in a symmetrical distribution in the bathing area ; ( 2 ) angiokeratoma of mibelli , the bilateral form occurring on the dorsal areas of the fingers and toes ; ( 3 ) angiokeratoma of fordyce , the most common angiokeratoma which occurs on the scrotum ; ( 4 ) the solitary papular angiokeratoma which has a predilection for the legs ; and ( 5 ) angiokeratoma circumscriptum , the multiple papular and plaque- like form . oral mucosal angiokeratomas have also been associated , uncommonly , with angiokeratomas of the scrotum , gastrointestinal mucosa ( jejunum ) , or both . recently ranjan & mahajan have proposed a clinical classification for oral angiokeratomas , depending on the number of lesions , associated other muco - cutaneous involvement and systemic disease . oral angiokeratomas present as single / multiple , erythematous , shiny papules , which may be studded with keratotic tops . they are firm on palpation , nontender , show telangiectatic vessels on diascopy , and bleed occasionally . the tongue , with a predilection for the dorsal aspect , appears to be the most common site for isolated oral angiokeratoma . they may be mistaken for hemangiomas , lymph - hemangiomas , focal epithelial hyperplasia , or nevi . the histologic features are similar to their cutaneous counterparts ; hyperkeratosis , acanthosis and dilated capillaries in the papillary dermis , partly or completely enclosed by the papillomatous epidermis . organized or organizing thrombi are occasionally observed within the dilated capillaries . the only difference being the presence of parakeratosis in oral angiokeratomas . however , in fabry 's disease and fucosidosis , swollen and vacuolated ( lipid containing ) endothelial cells are characteristic differentiating features .

we report a 60-year - old man who presented with a 2-year history of painless red raised lesions involving the tongue and scrotum . histopathology was suggestive of angiokeratoma . oral angiokeratomas are most commonly found as a component of the generalized systemic disorder in fabry 's disease or fucosidosis . our patient had isolated mucosal angiokeratomas which is very rare .

subdural spinal hematoma is an extremely rare complication of spinal and epidural anesthesia and may lead to cauda equina syndrome , bowel bladder dysfunction or even complete permanent paraplegia . a 60-year - old female patient was diagnosed to have osteoarthritis of right knee joint and was advised knee arthroplasty . enoxaparin sodium 40 mg ( lmwh ) was started 9 h after surgery and was followed by once daily dose . foot pump and compression stockings were applied for deep vein thrombosis ( dvt ) prophylaxis . on day 2 , the epidural catheter was removed 13 h after last dose , and she was discharged on 3 postoperative day in stable condition . at the time of discharge , on 4 postoperative day , she developed sudden onset pain in the lower back which was radiating to left lower limb . the pain was followed by loss of sensation and weakness in the left lower limb . it showed a large subdural hematoma , which was compressing the thecal sac at l2-l3 level . laminectomy with decompression of spinal cord and evacuation of hematoma was done on the emergent basis . postoperatively patient recovered well with complete control over bowel and bladder functions , but foot drop on the left side persisted after 6 months of follow - up . combined spinal epidural anesthesia though safe has been associated with uncommon neurologic complications like subdural hematoma . venous stasis , endothelial injury and hypercoagulable conditions contribute to the postoperative development of dvt which can be a life - threatening complication . in surgeries as total knee and hip replacement , direct injury to the large vessels of lower limb predispose patients for increased chances of dvt especially in absence of postoperative anticoagulation prophylaxis . however , prophylaxis must be balanced against the risks for postoperative bleeding and epidural hematoma . spinal and epidural anesthetic procedures in combination with anti - coagulant therapy represent the fifth most common cause of spinal hematoma . three cases developed paraplegia due to subdural hematoma which was due to underlying coagulation disorder . and horlocker and wedel highlighted the risk of spinal hematoma which gets aggravated by concomitant administration of anticoagulants and anti - platelet drugs . fryburg et al . , reported two patients who suffered from spontaneous acute spontaneous subdural hematoma while taking fondaparinux for venous thromboembolism prophylaxis . it is recommended that lmwh should be used once daily and to be started 12 - 24 h postoperatively , especially when indwelling spinal catheter are present or when concomitant antiplatelet or oral anticoagulant medication is being given . patients who develop extra or subdural hematoma usually present with acute back or radicular pain radiating to limbs , followed by progressive sensory and motor involvement in either one or both the lower limbs along with saddle anesthesia and bowel and bladder dysfunction . in most of the cases , these symptoms usually develop shortly after the procedure with mean age of onset being 30 h after operation , but in our case , the patient developed sudden onset neurological symptoms suggestive of cauda equina syndrome on 4 postoperative day . urgent mri was done to confirm the diagnosis and patient was immediately taken to the operation theatre where laminectomy with decompression of spinal canal and evacuation of hematoma was done . , neurosurgical intervention must be sought immediately , because recovery is unlikely if surgery is postponed for more than 8 h. this case highlights that even in the absence of an existing spinal pathology and carefully administrated spinal - epidural anesthesia , cse may cause dreaded neurologic complication like subdural hematoma especially in the presence of anti - coagulant therapy . hence frequent 4 hourly neurological examination is essential for early detection of hematoma , which should be continued 24 hours postoperatively following a neuraxial block or upto 24 hours following catheter removal if patient is anticoagulated . in a case of suspected cauda equina syndrome , the patient should be investigated and urgent decompression should be done on emergent basis to prevent permanent neurological sequelae .

combined spinal - epidural anesthesia ( cse ) is considered safe in lower limb surgeries . we report a case of sudden neurological deterioration in a stable postoperative patient who was given cse for total knee replacement and low molecular weight heparin in postoperative period . on the 4th postoperative day , she developed sudden onset weakness in left lower limb along with bladder incontinence . magnetic resonance imaging spine revealed a subdural hematoma at l2-l3 level . immediate laminectomy along with cord decompression was done and patient recovered well except for a persistent foot drop on left side .

successful laparoscopic treatment has been described previously in only a few cases . rarely the diagnosis is suspected preoperatively when using only ultrasound . other diagnostic tests like magnetic resonance cholangiopancreatography ( mrcp ) , endoscopic retrograde cholangiopancreatography ( ercp ) and intraoperative cholangiogram can be more accurate in the diagnosis of this condition . intraoperative cholangiogram represents a powerful tool for the surgeon when dealing with double gallbladder , it help to delineate the anatomy and confirms the diagnosis . ( 1,2 ) we present a case report of a patient with symptomatic cholelithiasis with double gallbladder treated laparoscopically using intraoperative cholangiogram . a 21 year old male otherwise healthy with no previous surgical history , presented to the emergency room with the chief complaint of several hours of right upper quadrant pain that started after a large meal . the patient described a history of several weeks of right upper quadrant pain after meals but normally it would subside without any intervention . on admission , the patient had normal and stable vital signs and on physical exam there was tenderness to palpation on the right upper quadrant but no peritoneal signs . his laboratory exams were unremarkable with a normal white blood cell count and normal liver function test . the patient was admitted to the hospital and he was taken to the operating room where he underwent a laparoscopic cholecystectomy using the standard 4 port technique with intraoperative cholangiogram ( fig 1 ) . also appreciated in the image : the common bile duct , the common hepatic duct and the left and right hepatic ducts . during the operation ( fig 23 ) the intraoperative cholangiogram helped to identify each cystic duct and the operation was otherwise uneventful . he was started on clear liquid diet postoperatively and he was discharged home on postoperative day one . gallbladder duplication is a very rare diagnosis . even though the true incidence reported during autopsy is about 1:40005000 the gallbladder primordium can split and form a gallbladder duplication but this only represents a congenital anomaly of the gallbladder . true gallbladder duplication has two cystic ducts and two cystic arteries . the true double gallbladder forms from an extra primordium during the embryonic development . the symptomatic patient with two gallbladder represents a diagnostic and treatment challenge to the general surgeon.(13 ) to aid in the diagnosis the surgeon can use ultrasound , mrcp , ercp and ultrasound . none of these tools are 100% sensitive and only in little more than 50% of the cases the diagnosis is made preoperatively.(2,3 ) in our case the ultrasound was questionable but certainly prompted the use of intraoperative cholangiogram to help define the anatomy . in figure 2 two cystic ducts can clearly be seen which makes our case a true gallbladder duplication treated successfully with standard laparoscopic technique . the differential diagnosis of a gb duplication seen in us is large , but the most common diagnosis are a phrygian cap , gallbladder diverticulum or a choledochal cyst.(3 ) once the diagnosis has been made by seen two cystic ducts in the symptomatic patient , the surgical removal of both gallbladders is indicated . there are only a few case reports of double gb successfully managed laparoscopically in the literature.(3 - 7 ) our case shows that the use of intraoperative cholangiogram confirms the diagnosis and helps to identify both cystic ducts . previous literature have shown conflicting and controversial results when trying to use intraoperative cholangiogram to prevent bile duct injuries , but there no large series or randomized studies evaluating the use of intraoperative cholangiogram in patients with double gallbladder . ( 8 - 10 ) we recommend routine use of ioc when dealing with abnormal anatomy or congenital anomalies of the gallbladder . the evidence is anecdotal but as shown on this case report clearly seen two cystic ducts accurately diagnosed a gallbladder duplication and prevented the surgeon from leaving an unidentified gallbladder which later can become a diagnostic enigma .

double gallbladder is a rare finding in patients with symptomatic cholelithiasis or acute cholecystitis . the incidence has been described as 1 in every 4000 - 5000 patients during autopsy . to identify the gallbladder ( gb ) duplication prior to surgical removal of the gb is of upmost importance . it is not unusual to identify this diagnosis intraoperatively , but by using us , ercp or mrcp more than 50% of the cases are diagnosed preoperatively . the use of intraoperative cholangiogram helps to identify the anatomy and confirm the diagnosis during laparoscopic cholecystectomy in patients with gallbladder duplication .

in the present issue of critical care , linder and colleagues present a new study in which they assess the clinical importance of serial measurements of heparin - binding protein ( hbp ) plasma levels in critically ill septic and nonseptic patients . they found that hbp plasma levels are significantly higher in patients with severe sepsis and septic shock in comparison with patients with a nonseptic critical condition . the authors also demonstrated that hbp plasma levels obtained at admission to the icu and during the last individual sampling are higher in nonsurvivors as compared with survivors in both the septic group and the whole study group . moreover , the high baseline hbp plasma levels in septic patients were associated with an increased 28-day mortality rate . altogether , these results indicate that serial hbp measurements might be very helpful in stratification of icu patients . however , there are some issues that should be raised before the study results can be translated into the daily routine . the study was designed to compare hbp plasma levels in patients with severe sepsis and septic shock with levels in patients with noninfectious critical illness . however , these two groups of patients were not equal in size . also , a significant proportion of patients from the nonseptic group developed infection and was treated with antibiotics . this raises the question of whether the comparison between septic and nonseptic icu patients is hindered by this treatment . nevertheless , the study design is logical because finding a biomarker that would predict development of any shock state is highly desirable . previous studies have demonstrated significant predictive values of elevated levels of lactate , cortisol and il-6 in the blood of patients with different etiologies of shock [ 2 - 4 ] . however , these biomarkers have some limitations : lactate levels are less influenced by arterial sampling , endogenous cortisol levels are downregulated by corticosteroids used in the treatment of septic shock or by relative adrenal insufficiency , and il-6 analysis is not generally available in regular hospital laboratories . other routinely measured biomarkers - such as procalcitonin , c - reactive protein , neutrophil and lymphocyte counts - have only a limited value in prognostic scoring of the critically ill patients and are mostly used in the early diagnostics of bacterial etiology of critical illness [ 6 - 8 ] . notably , hbp has antibacterial activity , which includes a direct microbicidal effect , and also helps neutrophils to migrate into the focus of infection . similarly to hbp , c - reactive protein and il-6 play an active role during the immune responses against infections : c - reactive protein is an inflammation opsonin , and the major function of il-6 is amplification as well as downregulation of inflammatory reactions , depending on the concentrations . regarding procalcitonin , there are only limited data from animal studies - which demonstrate that immunoneutralization of procalcitonin improved survival in experimental porcine sepsis . additionally , elevated cortisol levels in peripheral blood during sepsis are considered an integral part of compensatory anti - inflammatory response syndrome , leading to downregulation of exaggerated systemic immune responses . from the functional point of view , in comparison with the abovementioned biomarkers , hbp therefore plays the most complex role in severe sepsis and septic shock - highlighting its potential for clinical use . in conclusion , the serial measurements of hbp plasma levels can be a useful tool for close monitoring of critically ill septic patients . however , availability of a routine diagnostic method for hbp analysis is essential to confirm these interesting data . the authors thank dr e david mcintosh ( imperial college , london , uk ) for help with the manuscript .

heparin - binding protein ( hbp ) , also known as azurocidin , has multiple functions in the inflammatory process , especially during severe infections . beside its antimicrobial properties , hbp may induce vascular leakage leading to extravascular efflux , which is an important pathophysiologic event in the development of septic shock . not surprisingly , high hbp plasma levels are found in severe sepsis patients and in septic shock patients as well as in serious infections associated with endothelial damage . in the present issue of critical care , linder and colleagues demonstrate new aspects of hbp daily monitoring in icu patients . the authors observed that high hbp plasma levels are associated with an increased mortality rate in both septic and nonseptic critically ill patients , indicating that hbp may be a reliable prognostic biomarker . however , there are some limitations hindering rapid translation of these interesting findings into the daily routine . first , the group of nonseptic critically ill patients ( n = 28 ) enrolled in the study was rather small as compared with the septic group ( n = 151 ) . moreover , 50% of nonseptic patients developed infection while hospitalized in the icu , and to classify them as truly nonseptic patients is problematic . second , there is a lack of a routine diagnostic method for hbp analysis . nevertheless , if the results of the present study are validated in large clinical trials in different icu populations and cost - effectiveness data become available , the serial hbp measurements will have a promising future .

adrenal myelolipoma is a tumor - like lesion composed of variable amounts of mature adipose tissue and bone marrow elements . in spite of wbc and rbc precursors such as megakaryocytes giercke in 1905 first described and 24 years later , oberling coined the term myelolipoma. only two cases under the age of 16 are reported and to the best of our knowledge , this patient is the youngest pediatric case of adrenal myelolipoma reported in the english literature . an 11-year - old girl presented with recurrent pain abdomen for 1 year , which was gradually increasing in frequency and severity for last 5 months . ultrasonography ( usg ) of abdomen showed a well - encapsulated and hypo echoic lesion in right suprarenal region measuring 27.1 24.3 mm . contrast enhanced computed tomography ( cect ) scan of abdomen confirmed the lesion to be arising from right adrenal gland with fat density measuring 1.8 2.3 cm [ figure 1 ] . gross examination of the specimen showed reddish yellow colored friable mass , soft in consistency ; and on microscopy , islands of hematopoietic tissue were found scattered among the fat cells [ figure 2 ] . cect reveal small fat containing lesion in right adrenal suggestive of myelolipoma histopathology showing fat lobules ( f ) and megakaryocyte ( m ) adrenal myelolipoma is a tumor - like lesion composed of variable amounts of mature adipose tissue and bone marrow elements . in spite of wbc and rbc precursors such as megakaryocytes myelolipoma may occur in retroperitoneum around kidney and pre - sacral space or in liver ; however , adrenal gland is the most common site . most of the cases of myelolipomas are asymptomatic . usually diagnosed incidentally at imaging for other purposes and the reported incidence are reaching up to 7% of the adrenal masses . majority of incidentally discovered myelolipomas are small and asymptomatic though large symptomatic lesions are also reported but in adult population . symptoms may be due to large tumor causing the pressure effect , tumor necrosis and intralesional hemorrhage . malignant potential of adrenal myelolipoma has not been reported . in our study , the child presented with pain abdomen and , on investigation diagnosis was confirmed . the lesion is itself hormonally inactive but may be associated with metabolically active adrenal lesion like cushing syndrome , conn 's syndrome , congenital adrenal hyperplasia etc . myelolipoma can be regarded as an exception to the mandatory metabolic work - up of a newly discovered adrenal mass . large myelolipoma usually associated with hematological disorders like hereditary spherocytosis , thalassemia intermedia , thalassemia major , sickle cell anemia and usually bilateral if we get a case of large or bilateral adrenal myelolipoma we have to investigate for chronic hematological disorders . before removal the of tumor , it may be necessary for bone marrow transplantation to avoid aggravation of hemolytic anemia . most accepted theory regarding etiologies are that it arises in response to infection , stress or necrosis causing metaplasia of reticuloendothelial cells of the capillaries of adrenal gland . focal fat density , peripheral calcification and hemorrhage within the tumor can be better identified with cect scan . myelolipoma contains adipocytes with hematopoietic elements , consisting of myeloid and erthyroid precursors , as well as , megakaryocytes . these hematopoietic elements are scattered in the adrenal tissue and separated by sheets and large clusters of mature adipocytes admixed with hemorrhagic foci . though open surgery is the classical method , laparoscopic adrenalectomy has now become the standard of care for the treatment of functioning and non - functioning adrenal tumors , introduced by gagner in 1992 . small asymptomatic myelolipomas can be treated conservatively but the symptomatic one should be treated with surgical excision and/or adrenalectomy .

myelolipoma is a rare benign tumor of adrenal gland and rarer in children . myelolipoma contains adipose tissue and myeloid precursor producing white blood cells ( wbc ) , red blood cells ( rbc ) and megakaryocytes . asymptomatic tumor does not require treatment whereas symptomatic tumor needs operation . we are reporting a rare adrenal myelolipoma in a child with review of literature .

obsessive compulsive disorder ( ocd ) is a common psychiatric disorder ( 2% - 3% of the general population ) which is diagnosed easily most of the time by the psychiatrist or even the physician . it is sometimes very difficult to properly diagnose a person for ocd based only on an interview . the presentation of ocd may be so atypical or unusual that the patients may be referred to different specialties before the actual diagnosis can be made . neuropsychological studies have consistently found cognitive impairment in the domains of memory and attention in patients of ocd . anxiety , lack of confidence , indecisiveness , associated clinical symptoms of ocd , along with impaired memory and attention , may further complicate or interfere in the delivery of information . a 36-year - old man used to request multiple repetitions of spoken words in order to understand what was said . he was then referred to a neurologist and a general physician for evaluation of neurological cause of his symptoms . even after multiple consultations with the ent , neurology and medicine specialists , no organic pathology to explain his symptoms could be detected . the patient lost considerable time and money because of delay in diagnosis caused by the atypical presentation to specialties other than psychiatry . at last , the patient was referred to the department of psychiatry for further evaluation . the patient 's chief complaints were difficulty in hearing , grasping or comprehending the components of conversations , interactions or clinical interviews at once . he had this problem for the last 6 months . during the interview , almost every question or the instruction had to be repeated slowly 2 to 3 times or more to make him understand . he was anxious and expressed regret repeatedly for the inconvenience caused to the doctor because of his disability . initially the patient was put on mirtazapine 15 mg / day and clonazepam 0.75 mg / day , keeping in mind the possibility of anxiety disorder nos ( not otherwise specified ) . mental state examination of the patient revealed impaired attention and concentration with depressive and anxiety symptoms . the possibility of ocd , predominantly obsessive type , was kept on the basis of answers of leading questions , and he was put on fluoxetine 60 mg / day ( titrated from 40 to 60 mg ) and clonazepam 0.5 mg / day . there was drastic improvement in all the presenting symptoms , including his ability to grasp and comprehend conversation , along with improvement in anxiety symptoms and clarity in thinking over a period of 6 weeks . the patient was then able to report his pre - treatment problem and the level of improvement comprehensively . he accepted that he was unable to understand or express his own problem before treatment . according to him , there were thoughts keeping his mind busy all the time , to the extent that he was unable to think or communicate his problem effectively . according to him , initially he used to make frequent unsuccessful attempts to get rid of these excessive and unnecessary thoughts . according to the wife of the patient , after treatment the patient was able to hear clearly . the diagnosis could be confirmed as ocd on the basis of patient 's spontaneous elaboration of symptoms and the level of improvement . in this case , the presentation of ocd is atypical , as the chief complaint was problem in hearing . he was able to hear on normal volume of sound , but the sentences needed to be repeated multiple times . moreover , no ent - related or neurological cause of hearing impairment was found in the patient . though hearing difficulty was not his chief subjective problem , he consulted the ent doctor only after repeated and forced advice by his wife and relatives . the hearing problem as perceived by the patient 's friends and relatives was basically a misinterpretation of the patient 's problem secondary to his psychiatric illness . also the patient was unable to express his actual problem at the time of presentation . the patient used to ask for repetition of the spoken sentences multiple times in order to grasp the components of interaction because of his significantly impaired attention . however , there could be the other possibility that this behavior could be a compulsive act of the patient to confirm his doubts . the patient could not express his problem elaborately , which was one of the reasons for not being able to make an early diagnosis . there were multiple factors that had complicated and hindered the narration of history by the patient . lack of clarity of thoughts and associated clinical symptoms of ocd ( especially predominantly obsessive type ) , indecisiveness , anxiety , lack of confidence , along with impaired memory and attention , were the possible factors in this case , as also reported in different studies . the patient could express details of his illness comprehensively once his above - mentioned signs and symptoms improved significantly . his wife and relatives also reported improvement in his hearing , which was actually the improvement in his attention and ocd symptoms . such an atypical presentation may lead to misdiagnosis , delay in diagnosis , loss of time and money as the patient may present to other specialties instead of psychiatry . high suspicion for diagnosis of ocd and response to treatment may help in managing such cases . obsessive compulsive disorder is usually easily recognized , but sometimes its presentation is so atypical or bizarre that the problem comes to notice as being a psychiatric disorder after multiple consultations in different specialties . but if proper evaluation is done , such cases can easily be recognized and treated effectively .

obsessive compulsive disorder ( ocd ) is a common psychiatric disorder which is easily recognized . however , sometimes patients of ocd present in such an atypical or bizarre way that their problem comes to notice as being a psychiatric disorder after multiple consultations in different specialties . we are reporting a case of a man who had first sought opinion in the department of ear , nose and throat ( ent ) for hearing impairment . he was then referred to a neurologist and a general physician for evaluation of neurological cause of his symptom . as no pathology related to ent or neurology could be detected , he was referred to the department of psychiatry . the patient 's chief complaints were difficulty in hearing and inability to understand at once . he could be diagnosed as a case of ocd after meticulous evaluation and studying his response to treatment . there was significant improvement in all the presenting symptoms over a period of 6 weeks on 60 mg of fluoxetine .

we did a single - center retrospective analysis of seven patients with pelvic abscess treated by eus transrectal drainage between january 2010 and august 2014 . there were four men and three women , with a median age of 50 years ( range 22 - 68 ) . a concomitant intravenous antibiotic treatment was always administered be for eus and for a minimum of 7 days after drainage . the method of drainage was done with a linear interventional echoendoscope ( pentax ) ( eg 3870utk pentax - hitachi , hambourg , germany ) . eus - doppler evaluation was first performed to exclude the presence of intercalated blood vessels before puncture with a 19-gauge access needle ( cook ) ( 19 g , echotip access needle , cook ireland ltd . , limerick , ireland ) . the puncture tract was then enlarged with a 10 french diathermic cystostomy over a tetrafluoroethylene ( tfe)-coated 0.035-inch guidewire ( cook endoscopy , winston - salem , nc , usa ) . a second guidewire was then put into the cavity , and two 7 french double pigtail plastic stents were positioned ( 4 or 7 cm length ) . eus drainages were done for a majority of abscesses post surgery ( n = 5/7 ) . the treatment was feasible and effective in 100% of cases [ figures 17 ] , without supplementary radiological or surgical intervention [ table 1 ] . the median time of hospitalization was 10 days ( range 4 - 25 days ) . the main difficulty related to this technique is the positioning of the double pigtail plastic stents , induced by pus outflow that can reduce the endoscopic visibility . two of our patients were embarrassed by the length of the double pigtail plastic stents which protruded in the anal canal . pelvic abscess before drainages pelvic abscess after drainage sagittal view of pigtail stent in pelvic abscess fluoroscopic view of first pigtail insertion endoscopic ultrasound ( eus ) view of douglas abscess eus view of abscess puncture endoscopic view with first guidewire insertion etiology and outcomes since 2003 , eus pelvic abscesses drainage is performed ; given the proximity between the rectal lumen and the abscess , with a mini - invasive technique compare to radiological or surgical drainage . moreover , percutaneous drainage may be difficult to realize and uncomfortable , especially if the collection is in deep location which needs a posterior drainage . our technique is safe , without adverse events observed ; and is actually well standardized , in analogy with 10 years of practice for eus drainage of pancreatic pseudocysts . the use of the fluoroscopy and cystostomy facilitates the procedure and can be easily used by experienced operators . the length of double pigtail plastic stents should be as short as possible , especially if drainage is done in the lower rectum , because it may cause discomfort if it touches the anal canal . we can also conceive that the length of hospital stay could be further reduced if the antibiotic treatment is continued orally in selected patients . eus transrectal drainage is a safe and an efficient method for therapeutical treatment of pelvic abscess . in our experience , we recommend eus transrectal drainage for pelvic abscess as the first - line technique for experienced hands .

background and objective : pelvic abscesses are a well - known complication of intestinal diseases or abdominal surgery . we report our case series concerning transrectal drainage by endoscopic ultrasound ( eus).methods : between january 2010 and august 2014 , seven patients received transrectal drainage by endoscopic ultrasound ( eus ) were selected and analyzed.results:two pigtails was positioned under fluoroscopic and eus control . the success rate was 100% and complication rate was 0% . the median time of hospitalization was 10 days [ range 4 - 25].conclusions : the technique appears to be safe and feasible in all etiologies . in our experience , we can considerate transrectal drainage by eus like a first - line technique in experienced hands .

lymphangioma circumscriptum ( lc ) or microcystic lymphatic malformation is a hamartomatous malformation of the lymphatic channels of the skin . treatment of lc is difficult because of the persistent nature of the disease due to deeper subcutaneous cisternal connections . we report here a case of lc treated effectively with radiofrequency ablation without any recurrence . a 16-year - old male with fitzpatrick skin type v presented to our clinic with partially fluid - filled lesions on left upper arm with slight local swelling . the patient had these lesions since the age of 2 years and had been repeatedly treated with antibiotics for local infection . examination showed a well - defined plaque on left upper arm with grouped vesicular lesions , giving the typical appearance of a a biopsy was taken from the edge of the lesion and histopathology showed multiple thin - walled , dilated lymphatic spaces in the papillary dermis and these spaces contained lymph and few erythrocytes . the overlying epidermis was thin , and there were elongated rete ridges that appeared to surround the lymphatic channels . the patient was given a systemic antiobiotic , cefadroxil 500 mg twice daily for 5 days , to treat the infection including oozing from the lesions and to decrease the inflammation . radiofrequency ablation was done a week later ( basco radiofrequency device , model rf - b2 , high frequency 2 mhz , power < 150 w ) , in cut and coagulate mode with wire loop electrode , under local anesthesia . the patient was advised to clean the area with betadine lotion and apply topical antibiotic mupirocin on the lesions . three sessions were required at weekly intervals for the lesions to clear as some deeper components were left untreated at the first two sessions . one week after last treatment , the area had partially healed with slight depigmentation . at 1 month , the lesions had completely healed and swelling had subsided [ figure 1 ] . no recurrence has occurred in the past 1 year and the patient is still under surveillance . ( a ) lc lesion on the left upper arm ; ( b ) lesions being treated with radiofrequency ablation ; ( c ) immediate post treatment red erythematous area ; ( d ) complete healing of the lesions at 1 month lc is benign ectasia with two components : the clinically obvious , dermal vesicular component , visible on the skin , and the deeper subcutaneous cisternal element . whimster described the pathogenesis and said that lc arises from the subcutaneous muscle - coated lymphatic cisterns which receive lymphatic flow from the surrounding tissue , but this is not drained to the normal lymphatic system . these dilated cisterns conduct the lymph through communicating channels into the dermal thin lymphatics , which balloon out into the epidermis . treatment modalities include surgical excision , lasers and sclerotherapy with varying success.[35 ] we tried the radiofrequency ablation to treat lc , which produced near - complete clinical ablation with coagulation of lesional and perilesional skin leading to fibrosis of the perivesicular lymphatics . the follow up was longer in our case , i.e. , 1 year and we are encouraged to do a case series to determine the efficacy of radiofrequency in this notorious condition .

lymphangioma circumscriptum ( lc ) , a hamartomatous lymphatic malformation , is a therapeutic challenge for the dermatologist . various modalities like surgical excision , lasers , and sclerotherapy have been used in the past to treat this notorious skin condition . we report the efficacy of a radiofrequency ablation in a patient with lc . the treatment efficacy of radiofrequency was satisfactory in our patient with no recurrence during 1 year follow - up period . the radiofrequency technique is a safe and economic treatment for management of lc .

a patient was immediately referred to our department after epidural endoscopy with severe bilateral visual impairment and underwent complete ophthalmologic examination . a 45-year old man suffered from low back pain unresponsive to pharmacologic treatment , radiating to the left hip and left lower extremity , due to a back injury 4 years ago . other medical history was noncontributory and he was otherwise healthy without hypertension , diabetes mellitus , cardiovascular disease , or blood clotting abnormalities . the patient underwent an epidural endoscopy and endoscopic adhesiolysis in the level of l4l5 and o5s1 by infusion of 120 cc of normal saline . at the end of the procedure the patient received an epidural injection of 80 mg methylprednisolone . after the operation the general condition of the patient was good without clinical signs of elevated cerebrospinal pressure and blood pressure and heart rate remained stable . however , a few hours later , he became aware of a major decrease of vision in both eyes and was immediately admitted to the department of ophthalmology . at presentation , best corrected visual acuity ( bcva ) was 20/400 re and counting fingers le . the ophthalmic examination revealed the presence of extensive scattered preretinal , subhyaloid , and subretinal hemorrhages in both eyes and especially in the le ( figure 1 ) . ocular history before the operation did not reveal any ocular disease and bcva was 20/20 in both eyes . examination of the fundus showed mild vitreous hemorrhage with extensive intraretinal and subretinal hemorrhages involving the macula especially of the le . four months after the operation , bcva was 20/30 in both eyes . despite the improved vision fundus examination revealed a remarkable resolution of the retinal and subretinal hemorrhages bilaterally with mild pigmentary changes of the macula especially of the le ( figure 2 ) . intraocular hemorrhages often occur in association with acute subarachnoid hemorrhage and secondary aneurysms of the anterior communicating and internal carotid arteries ( terson 1900 ) . the present case represents an extremely rare incidence of intraocular hemorrhage following epiduroscopy and endoscopic adhesiolysis ( amirikia et al 2000 ; brian et al 2005 ) . several mechanisms have been proposed to explain the occurrence of intraocular hemorrhage ( purdy et al 1998 ) . it seems that a sudden increase of the epidural pressure after the epiduroscopy causes cerebrospinal fluid to effuse through the communication of the subarachnoid space within the optic nerve sheath and subsequently compresses the optic nerve and its vasculature . specifically , the retinochoroidal anastomosis and the central retinal vein are occluded resulting in venous stasis allowing extravasation of blood through the vessels causing subhyaloid , retinal , and subretinal hemorrhages . the different types of hemorrhages suggest an acute generalized extravasation of blood within the various layers of the posterior segment opposed to the direct tracking of blood from within the optic nerve sheath . more particularly , intracranial pressure can be directly affected if the dura is punctured and fluid is added to the subarachnoid space . the visual prognosis is considered to be good , with recovery occurring within 6 months ( tabandeh 2000 ) . the present case is rare and it represents a rare complication of a rather common operation . however , as endoscopic spinal procedures become widely established , it is anticipated that similar cases will be recognized more frequently in the future . therefore , surgeons should be aware of the possibility of possible vision loss after this procedure .

purposeto report a case of acute visual loss after endoscopic spinal surgery.methodsa patient was immediately referred to our department after epidural endoscopy with severe bilateral visual impairment and underwent complete ophthalmologic examination.resultsvisual acuity was decreased in both eyes . fundus examination revealed the presence of retinal and vitreous hemorrhages bilaterally . four months later , visual acuity increased and the hemorrhages were remarkably resolved.conclusionthe present case represents an extremely rare incidence of intraocular hemorrhage following epiduroscopy .

spinal epidural hemangiomas have been reported in the literature , but most of them were cavernous type hemangiomas that enable a preoperative differential diagnosis with relative ease . the limited number of spinal epidural hemangiomas and few radiological findings make an exact diagnosis difficult prior to surgery . a high vascularization of spinal epidural hemangiomas may result in an unexpected surgical situation in the case of preoperative misinterpretation . in the current case , a 51-year - old woman presented with a 3-week history of lower back pain with right anterior thigh numbness . the patient had a magnetic resonance imaging ( mri ) at a local hospital which revealed a lesion at the l3 level , located in the ventral epidural space and connected with l3/4 protruded disc material that demonstrated a heterogeneous signal at t2 weighted images and an iso- to low signal at t1 weighted image ( t1-wi ) . 1 ) . based on a presumed diagnosis of a ruptured disc with possible sequestration or granulation tissue formation , the patient underwent surgery . a right hemilamincetomy of l3 was performed , and a retracting thecal sac revealed a highly engorged vascular structure . near - infrared indocyanine green videoangiography ( icg - va ) showed a delayed mass filling . histological examination revealed a vascular lesion composed of small to medium sized veins with irregular calibers , which is consistent with an arteriovenous hemangioma ( fig . the typical symptoms of epidural lesions other than disc herniation of the lumbar region are low back pain or radiculopathy which are indistinguishable from the clinical symptoms of disc herniation diseases . moreover , spinal epidural hemangiomas are very rare . also , spinal epidural hemangiomas constitute approximately 4% of all epidural tumors and 12% of all intraspinal hemangiomas4 ) . the differential diagnosis for spinal epidural hemangiomas before surgery included schwannoma , lymphoma , meningioma , angiolipoma , disk herniation , synovial cysts , granulomatous infection , pure epidural hematoma , and extramedullary hematopoiesis9,12 ) . the cavernous type displays histologically with large number of sinusoidal channels in collagenous tissue7 ) , whereas the arteriovenous type shows with a cluster of abnormal arteries and veins and vessel walls containing elastin , and smooth muscle5 ) . a complete surgical en bloc removal is the treatment of choice for spinal epidural hemangiomas with mass effect because of the excessive vascularity of hemangioma , piece to piece resection should be avoided6 ) . an indocyanine green videoangiography can help surgeons understand the vasculature surrounding the mass and facilitate the en bloc removal of the hemangioma . fluorescence angiography with indocyanine green provides real - time information regarding the patency of vessels . an icg - va enhances the flow direction delineation capability , flow velocity and sequence of dye filling in different components of complex spinal vascular lesions3 ) . due to the high vascularization of hemangiomas , the incomplete surgical removal of a spinal hemagioma because of diffuse bleeding or minimal exposure during disk surgery might result in the persistence of clinical symptoms or recurrence . reoperation for remnant or recurrent spinal hemangioma is very difficult due to peridural or periradicular adhesion and unclear margins ; as a result , complete resection can not be guaranteed . therefore , proper preoperative planning and complete resection during the operation is essential . for this , but , like this case , an angiography may not always confirm the diagnosis of an artriovenous hemangioma . clinicians should be aware that an angiography can not provide conclusive evidence of the presence of an antriovenous hemangioma . if spinal epidural hemangiomas are unexpected encountered during surgery , an icg - va can be helpful to diagnose and surgery . this technique provides accurate information about the flow dynamics through the anatomy of vascular lesions in real time10,11,13,14 ) . further study is required to recognize and to provide a differential diagnosis of spinal epidural hemangiomas . if the lesion is like a ruptured disc in mri , we should consider spinal epidural hemangioma as one of differential diagnosis .

a spinal epidural hemangioma is rare . in this case , a 51 year - old female patient had low back pain and right thigh numbness . she was initially misdiagnosed as having a ruptured disc with possible sequestration of granulation tissue formation due to the limited number of spinal epidural hemangiomas and little - known radiological findings . because there are no effective diagnostic tools to verify the hemangioma , more effort should be put into preoperative imaging tests to avoid misdiagnosis and poor decisions ) .

schwannoma may arise from any peripheral nerve and is often found in the chest wall and posterior mediastinum . however , case reports of intrapulmonary schwannoma are extremely rare . a 38-year - old man was referred to our institution because of an abnormal shadow found incidentally on the chest x - ray . the plain chest x - ray showed a mass lesion in the left middle zone . chest computed tomography ( ct ) showed a round and homogeneous mass 25 18 mm in size with a well - defined margin in the lingular segment of the left upper lobe ( fig . 18-fluorodeoxy - glucose ( fdg ) positron - emission tomography ( pet ) showed no accumulation in the tumor ( fig . the ct and fdg - pet findings suggested the possibility of a benign tumor or a low - grade malignancy . as a malignant tumor could not be definitively ruled out , we performed lingular segmentectomy.fig . 1 a computed tomography shows a mass with well - defined margins in the lingular segment of the left upper lobe . b 18-fluorodeoxy - glucose ( fdg ) positron - emission tomography ( pet ) showed no accumulation in the tumor a computed tomography shows a mass with well - defined margins in the lingular segment of the left upper lobe . b 18-fluorodeoxy - glucose ( fdg ) positron - emission tomography ( pet ) showed no accumulation in the tumor macroscopic examination of the resected specimen showed a well - demarcated round tumor in the lung , without any evidence of invasion of the surrounding tissues . microscopic examination revealed proliferation of elongated tumor cells having spindle - shaped nuclei , with cellular palisading ( fig . immunohistochemical staining demonstrated positive staining of the tumor cells for s-100 protein and bcl2 , but negative staining for cd34 and desmin . the histopathological diagnosis was intrapulmonary schwannoma.fig . 2 a macroscopic examination of the specimen showed a round , well - demarcated tumor in the lung , without invasion of the surrounding tissues . b microscopic examination revealed elongated tumor cells with spindle - shaped nuclei a macroscopic examination of the specimen showed a round , well - demarcated tumor in the lung , without invasion of the surrounding tissues . schwannoma is one of the few truly encapsulated neoplasms of the human body , and is almost always solitary . it most commonly occurs on the flexor surfaces of the extremities , neck , mediastinum , retroperitoneum , posterior spinal roots , and cerebellopontine angle . however , schwannomas are extremely rare in the lung , regardless of the patient age . ohtsuka and colleagues reported 62 patients ( 28 men , 34 women ) aged 583 years , with intrapulmonary or bronchial schwannomas , and stated that this neoplasm accounted for about 0.2 % of all pulmonary neoplasms . in 55 % of these patients , the tumor originated within the tissues in proximity to the terminal segmental bronchus . on radiographic images , peripheral intrapulmonary schwannoma appears as a round mass with well - defined margins . in patients with the tumor located proximal to a lobar bronchus , atelectasis or pneumonia about half of the patients have some symptoms ; however , most patients with peripheral intrapulmonary schwannomas , as in the present case , have no symptoms . today , fdg - pet is a useful approach to differentiate malignant solitary pulmonary nodules from benign nodules . beaulieu et al . reported the maximum standard uptake values ( suvmax ) of the 10 schwannomas ranged from 1.9 to 7.2 , and the variation in the suvmax could be explained by the variation in cellularity . however , the reason why high fdg accumulation is found in benign tumors such as schwannoma remains unclear , and a diagnostic value of fdg - pet with intrapulmonary schwannoma is not established . it is reported that in rare instances , schwannomas may undergo malignant transformation . the expression level of ki67 , a tumor cell proliferation marker , has been reported to be useful for determining the malignant potential of these tumors . kindblom and colleagues compared the ki67 expression levels in 26 malignant peripheral nerve sheath tumors and 24 benign nerve sheath tumors ( schwannomas ) , and reported that significantly high density of nuclear staining was found in malignant peripheral nerve sheath tumors . for the treatment of primary intrapulmonary schwannoma , surgical resection , intrabronchial resection with endoscopy , and yttrium aluminium garnet ( yag ) laser resection have been employed [ 57 ] . because of the low malignant potential of these tumors , tumor enucleation or partial lung resection is thought to be adequate , with lobectomy not being necessary . in the present case , we performed segmentectomy to accomplish complete resection , because we did not obtain the pathological diagnosis before the operation and the tumor was located in the central part of the superior lingular segment . in conclusion ,

a 38-year - old man without any symptoms was admitted to our institution because of an abnormal shadow found incidentally on a chest x - ray . chest computed tomography showed a round mass in the lingular segment of the left upper lobe . lingular segmentectomy was performed , and the histopathological diagnosis was intrapulmonary schwannoma . immunohistochemical staining revealed a positive result for s-100 protein and negative results for cd34 and desmin . we report this case of intrapulmonary schwannoma , which is extremely rare .

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 . lumbar hernias are rare and good history and general physical examination can rule out most of the differential diagnosis.ct scan should be done as routine prior to planning surgical approach unless patient is in life threatening emergency situation.even though the data available for us regarding the management of lumber hernias are limited current literature suggests laparoscopic approach is the best method of treatment.open surgery should be reserved for patients who have very large defects or failed laparoscopic approach.the operative technique should be decided on the size of the hernia , location , contents , etiology , recurrence and availability of facilities and expertise of the hospital . lumbar hernias are rare and good history and general physical examination can rule out most of the differential diagnosis . ct scan should be done as routine prior to planning surgical approach unless patient is in life threatening emergency situation . even though the data available for us regarding the management of lumber hernias are limited current literature open surgery should be reserved for patients who have very large defects or failed laparoscopic approach . the operative technique should be decided on the size of the hernia , location , contents , etiology , recurrence and availability of facilities and expertise of the hospital .

lumbar hernias are uncommon and about 300 cases have been reported till date . they commonly occur due to trauma , surgery and infection . they are increasingly being reported after motor vehicle collision injuries . however , spontaneous lumbar hernias are rare and are reported infrequently . it is treated with different surgical approaches and methods . we report a case of primary spontaneous lumbar hernia which was repaired by transperitonial laparoscopic approach using vypro ( polypropylene / polyglactin ) mesh and covered with a peritoneal flap .

duodeno - duodenal intussusception , which involves the distal invagination of a segment of the duodenum , is a rare condition owing to the retroperitoneal fixation of the duodenum , which is sometime absent in cases of intestinal malrotation . the vast majority ( 8090% ) of cases of intestinal intussusception are secondary to pathological masses in the intestine , such as brunner s gland hamartomas , lipomas and adenomas . the presence of a duodenal membrane may cause retention of food resembling a pathologic mass , which may in turn facilitate intussusception . we describe the interesting case of a patient with intestinal malrotation who developed acute pancreatitis as a result of a duodenal intussusception involving the head of pancreas which was caused by a duodenal membrane . other symptoms include gastro - oesophageal reflux , weight loss , fatigue , anaemia due to iron deficiency ; pancreatitis due to obstruction of the outlet duct has also been described [ 36 ] . owing to the intermittent nature of the symptoms delay in diagnosis symptoms had started three days previously and consisted of intermittent peri - umbilical pain , nausea and vomiting . the initial physical examination indicated a healthy young man with mild epigastric tenderness . in infancy he had undergone surgery for a congenital heart malformation involving closure of atrial and ventricular septal defects . during childhood he had been treated with proton - pump inhibitors for symptoms of gastro - oesophageal reflux , and he had a history of intermittent post - prandial abdominal pain , but had never undergone endoscopic examination , or any abdominal surgery . presented with a normal height and weight for his age with a body mass index of 25 . routine blood analyses revealed elevated levels of s - amylase ( 408 u / l ; ref . subsequently the patient developed fever , ( core body temperature 38.6 c ) ; acute cholecystitis was suspected so he was treated with intravenous antibiotics . subsequent abdominal ultrasonography was inconclusive , although there were signs consistent with a tumour in the head of the pancreas . a ct - scan revealed a duodeno - duodenal intussusception involving the head of the pancreas and the common bile duct ( figs . 1 and 2 ) . these finding were confirmed at laparotomy and non - rotation of the duodenum was also noted ( fig . the intussusception was released , and a duodenotomy revealed a duodenal membrane with a narrow central opening ( fig . s - bilirubin and s - amylase levels were within the normal range at discharge . to our knowledge this is the first case report of pancreatitis resulting from duodenal invagination caused by a duodenal membrane . high peristaltic pressure proximal to the stenosis may have contributed to the development of the invagination , which may also have been facilitated by the mobile , non - rotated duodenum , which had a vertical straight course without retroperitoneal fixation . cases in which an intraluminal polypoid mass or tumour in the duodenum resulted in duodeno - jejunal intussusception have been reported . in a few cases the intussusception involved the head of the pancreas , resulting in acute pancreatitis . these patients were treated by surgical reduction of the intussusception and duodenal resection or polypectomy . membranous duodenal stenosis is often treated by duodenotomy and excision of the membrane followed by a duodenoplasty , or by duodeno - jejunal anastomosis , with good results . in our case the patient had persistent symptoms of gastro - oesophageal reflux , which should have triggered an upper gi endoscopy ; had this revealed the intestinal malformation the patient could have been treated in a timely fashion and which would have avoided this serious complication . the intussusception was not detected by ultrasonography but was revealed by a ct - scan . a previous study found that 27.1% of patients with intestinal malrotation had a history of congenital cardiovascular defects . this suggests that all children with intermittent upper gastrointestinal symptoms such as vomiting , abdominal pain and gastro - oesophageal reflux , particularly those with a history of congenital heart malformation , should undergo upper gi endoscopy and imaging of the gi - tract to exclude gi anomalies . 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 .

highlightsintussusception is not always seen on ultrasonography but can revealed by a ct-scan.any child , and especially those with previous congenital disorders , must undergo upper gi- endoscopy at the presence of intermittent upper gastrointestinal symptoms as vomiting , abdominal pain and gastro - oesophageal reflux , to exclude upper gi anomaly .

we report the case of a 13yearold boy with neuromuscular proximal thoracic scoliosis who was found to have significant torsion of the left main bronchus during general anesthesia for posterior instrumented spinal fusion of t2 to l4 . this patient had a background history of multicore myopathy , which resulted in progressive scoliosis . endotracheal intubation was noted to be difficult on review of a previous anesthetic chart ( grade iii on the cormack and lehane scale ) . this patient reported increasing shortness of breath over the preceding few months , particularly on exertion . as part of his preoperative investigations , spirometry was performed , which showed that the forced vital capacity ( fvc ) was 36% of predicted ( 1.09 l ) and the forced expiratory volume in 1 sec ( fev1 ) to fvc ratio was 101% , which was in keeping with a restrictive lung defect . he underwent a level1 sleep study preoperatively which showed normal gas exchange with no significant desaturations or hypercapnoeic episodes . anesthesia was induced using a targetcontrolled infusion ( tci ) technique with propofol and remifentanil . the patient 's trachea was intubated using the airtraq videolaryngoscope ( prodol meditec s.a . , vizcaya , spain ) with the aid of a bougie . this resulted in rapid desaturation , a significant decrease in the end tidal carbon dioxide values and hypotension . there was a precipitous decrease in the expired tidal volume ( vte ) from 400 to 100 ml . a total of 100% oxygen , small aliquots of phenylephrine , and intravenous fluids was administered . the attending respiratory physician was called in for advice and flexible bronchoscopy was performed , which revealed a slitlike left main bronchus . following a multidisciplinary discussion involving the spinal surgeon , the anesthetic team and the respiratory physician , the decision was made to apply halo traction through the spine in order to reduce the magnitude of the scoliosis and , therefore , the extrinsic compression on the bronchus . this was achieved using gardner wells tongs to the skull and bilateral lower limb skin traction with 4 kg weight to the tongs and each lower limb . improved lung compliance and tidal volumes were achieved following application of traction , and the patient was able to tolerate the prone position without further ventilatory complication . neuromuscular scoliosis is caused by a heterogeneous group of conditions , in which the underlying pathology will have significant impact on the patient 's perioperative course 1 . he was noted to have restrictive lung disease on spirometry , which is well known to be the most common lung defect in young patients with progressive scoliosis 2 . extensive pulmonary testing including measurement of flowvolume loops and lung volumes were not carried out preoperatively . boyer et al . 3 in their review of lung function tests of 44 children with idiopathic scoliosis found that while only 7% met the criteria for airflow obstruction using standard spirometric techniques , 46% were found to have moderatetosevere gas trapping using by plethysmography and helium dilution methods . 2 demonstrated in a small case series of 18 pediatric patients with syndromic and congenital scoliosis that 33% of these patients had obstructive lung disease ( old ) as evidenced by pulmonary function tests . all patients with old demonstrated compression of the bronchial main stems as confirmed by preoperative flexible bronchoscopy and computed tomography ( ct ) . our patient had compression of his left main bronchus , which was associated with his primary leftsided thoracic curvature ( fig . it is also worth noting that this patient 's main curve was relatively proximal compared to the majority of patients with a main thoracic curve ; the apex was located at t6 compared to the usual t89 . furthermore , as the spirometric evidence of old in the above case series was supported by radiological imaging which showed airway compression , it is likely that we will consider performing preoperative thoracic ct imaging with threedimensional reconstruction on all our highrisk patients undergoing this type of surgery , particularly patients with significant or worsening respiratory symptoms . spinal radiograph taken preoperatively demonstrating a 79 left convex proximal thoracic scoliosis from t2t10 , apex at t6 , with compensatory thoracolumbar curve . we postulate that the degree of bronchial compression worsened significantly in prone position , resulting in gas trapping , high peak airway pressures , and the consequent circulatory disturbances . describe a similar case of a patient with thoracolumbar scoliosis whose ventilation deteriorated rapidly when moved into prone position . urgent flexible bronchoscopy performed in prone position revealed complete collapse of the trachea proximal to the carina . the principle anesthetist addressed the problem by inserting the endotracheal tube further , beyond the collapsed trachea , thus stenting the trachea open . this would not have possible in the case of our patient as the obstruction was at the level of the left main bronchus 4 . the application of modified halofemoral traction to this patient resulted in an immediate improvement in the ventilatory parameters , and the patient was moved to the prone position successfully . although studies have shown an improvement in pulmonary function with perioperative application of halogravity traction 5 , to the best of our knowledge , this is the first reported case of using halofemoral traction to negate the pressure effects of prone position in the context of bronchial torsion .

key clinical messagepulmonary function tests such as flowvolume loops and reconstructive radiological imaging may aid the detection of large airway obstruction prior to corrective surgery for severe scoliosis . intraoperative use of halogravity traction may help to reduce the severity of the scoliosis , and thus the extrinsic compression or torsion of the airways .

the vertebral fractures is the most common complications of osteoporosis.13 ) these fractures result in significant mortality and morbidity including prolonged and intractable pain.4,13 ) percutaneous vertebroplasty , a therapeutic procedure for filling the collapsed vertebral body with polymethylmethacrylate , provides pain relief.2,4 ) in general , percutaneous vertebroplasty is simple and safe if performed under continuing fluoroscopic control and technical precautions . vertebroplasty has the potential risk of serious complications such as leakages of bone cement , cardiopulmonary complications , infection and the new fractures of the adjacent vertebrae.6,7 ) we present a case of extraspinal leakage after vertebroplasty at our hospital . a 73-year - old male was admitted to our hospital for low back pain after slip down at one day earlier . the patient had experienced l1 vertebroplasty and t12-l2 screw fixation for l1 compression fracture at another hospital before 2 years ago . after incision of the skin , an 11-guage vertebroplasty needle was placed percutaneously on the posterior part of the vertebral body via bilateral transpedicular approach . the needle was pushed through the cortex , situated the center of the pedicle as possible , and then directed into the vertebral body . the contrast medium ( iohexol ) was injected to estimate bone cement distribution and minimize bone cement leakage and intraoperative complication such as pulmonary thromboembolism . when a thin toothpaste consistency was achieved , the bone cement was injected into the vertebral body under continuous fluoroscopic control . the filling process was stopped immediately when leakage of bone cement was observed into lateral space of body . lumbar simple x - rays after procedure showed leakage of bone cement to right lateral side of the l4 vertebral body ( figure 1 ) . lumbar computed tomography ( ct ) scanning revealed extraforaminal leakage of bone cement to outside of right l4 pedicle and it caused significant compression of l4 nerve root ( figure 2 ) . the leaked bone cement along the l4 nerve root was removed carefully via paraspinal muscle - splitting approach . during surgery , two pieces of bone cements were removed carefully . two whitish bone cements were located in the right lateral space of l4 - 5 body and the intervertebral foramen ( figure 3 ) . postoperative lumbar spine plain images show that the leaked bone cement along right l4 nerve root was disappeared ( figure 4 ) . complications related with vertebroplasty are not uncommon such as cement extravasation , pulmonary embolism , infection , epidural hematoma , systemic toxicity , and vertebral body fractures.1,7,8 ) among the commonest complications , cement extravasation has been estimated in 70% cases for vertebroplasty procedures.3,5 ) most of the cement extravasation is asymptomatic but , disastrous complications causing paraparesis have been also reported in the literature.5,7,12 ) the biplanar fluoroscopy is the best way to monitor the leakage of cement in procedure of vertebroplasty , but sometimes it is difficult to judge the leakage of cement after injection of the contrast medium . yeom et al.14 ) described three different types of leakages of cement after vertebroplasty such as type b ( via basivertebral vein ) , type s ( via segmental vein ) , and type c ( via cortical defect ) . nieuwenhuijse et al.9 ) recommended that the high viscosity of bone cement should decrease the rate of cement leakage during vertebroplasty . due to high risk of pedicle fracture during vertebroplasty , cement leakage via pedicle violation can cause significant morbidity.11 ) park and kim10 ) mentioned technical tips while taking entry into the pedicle and the vertebral body . the bone access needle can be advanced through the center of pedicle with use of a tunnel vision technique ( turn the c - arm obliquely until pedicle can be visualized at its widest and roundest ) and verification of needle trajectory at midpedicular level and posterior surface of vertebral body on lateral view . on anterior - posterior view , if the tip is located too medially , the medial cortical wall of pedicle may be damage and leading to spinal canal violation . if the tip is located too far laterally , lateral cortical bone damage and lateral violation could occurred . in our case , the reason of cement leakage might be presumed . the tip of needle located more laterally when needle tip is located in the pedicle and vertebral body . we experienced a case of lumbar nerve root compression by leaked bone cement after vertebroplasty . proper entry point of trocar , keeping trocar within pedicle and proper position of trocar between the pedicle and spinous process under biplanar fluoroscopy view would be help to prevent leakage of bone cement after vertebroplasty .

we experienced a 73-year - old male with lumbar nerve root compression due to leakage of bone cement after vertebroplasty . he was underwent vertebroplasty for acute osteoporotic l4 compression fracture at our hospital . after vertebroplasty , his back pain was improved but right leg pain was newly developed . lumbar computed tomography scanning showed that bone cements were leaked along the l4 nerve root . the leaked cements around l4 nerve root were removed carefully via paraspinal muscle - splitting approach . after operation , severe right leg radiating pain was improved . we recommend proper entry point , high viscosity of polymethylmethacrylate and constant monitoring can reduce complication .

in order to select dna fragments of interest to be purified , these should be resolved in agarose or acrylamide gels gel stained with ethidium bromide by electrophoresis using 0.5x tbe buffer ( tris borate , edta ) at 120 volts for 1 hour . for this , ~ 700 ng of plasmid pproex - gdmre11s ( 6000-bp ) previously digested with ndei and hindiii was used to release a 900-bp fragment ( 560 ng of plasmid and 84 ng of fragment ) . the electroeluter tank ( figure 1 ) should be filled with 0.5x tbe equally distributed in each side of the mid plateau taking care of not spill it onto the mid plateau . the selected band ( or bands ) is cut out of the gel , and placed in sample chamber as close as possible to the v channel ( one slice per well ) . running buffer should be added to each chamber ; just enough to cover the gel slice . each v channel used must be flushed with a pasteur pipette to eliminate any air bubble trapped . then 100 ul of 10 m nh4 acetate ( to facilitate visualization a small amount of bromophenol blue is added , just enough to color it ) are gently added inside the v channel . the lid should be closed gently to prevent any resuspension of the high salt cushion . when electrolution is completed , 400 ul are removed from v - channel , and placed in a microfuge tube to be precipitated with 2 volumes of cold ethanol and glycogen ( recommended to improve dna recovery ) at 4 c for 1 hour or overnight . the recovery obtained was 75% ( 63 ng recovered when 84 ng were placed on the v - channel ) . anod an cathode are indicated on each side of tank , dna contained in gel sliced ( illustrated as a black square ) will migrate towards cathode due to its negative charge . then it will be trapped in the salt cushion ( represented as an inverted black triangle ) located in the v - channel . the duration of the run will depend highly on the size of the fragments , normally for fragments up to 20 kb 50 minutes to 1 hour is enough , while for small fragments uv light monitoring every 10 minutes is required to prevent the fragment to go through the salt cushion and consequently to the anodal buffer chamber decreasing recovery . it is important to make sure that when you set your power supply at 100 volts , there is a current at least of 10 mamp . the dna band can be monitored by using a uv - hand lamp and detect when this abandons the gel slice . this procedure allows the purification of dna or rna fragments of different sizes with good recovery ( ~80% ) to be radiolabeled , digested by restriction enzymes , processed by modifying enzymes , etc .

purified dna fragments are used for different purposes in molecular biology and they can be prepared by several procedures . most of them require a previous electrophoresis of the dna fragments in order to separate the band of interest . then , this band is excised out from an agarose or acrylamide gel and purified by using either : binding and elution from glass or silica particles , deae - cellulose membranes , " crush and soak method " , electroelution or very often expensive commercial purification kits . thus , selecting a method will depend mostly of what is available in the laboratory . the electroelution procedure allows one to purify very clean dna to be used in a large number of applications ( sequencing , radiolabeling , enzymatic restriction , enzymatic modification , cloning etc ) . this procedure consists in placing dna band - containing agarose or acrylamide slices into sample wells of the electroeluter , then applying current will make the dna fragment to leave the agarose and thus be trapped in a cushion salt to be recovered later by ethanol precipitation .

germ cell tumors often complicate uncorrected cryptorchidism with an incidence of 9.8% reported by martin . occurrence of pure yolk sac tumor however is uncommon in the undescended testis with only a few cases reported in literature . we present a case of yolk sac tumor in a 2-year - old boy in the undescended testis which was primarily diagnosed by fine needle aspiration cytology ( fnac ) . a 2-year - old boy presented to the pediatric surgical out patient department ( opd ) with 5 days history of a right sided abdominal mass . on examination the lump was 5 cm 5 cm in size , firm in consistency with restricted mobility . a tumor was noticed at the right renal hilum , causing ureteric narrowing with resultant hydronephrosis along with presence of multiple , large oval , heteroechoic lesions in the right iliac region and reteroperitoneum . possibility of lymphoma was suggested . due to the absent testis in the right scrotum , testicular neoplasm smears were highly cellular showing tumor cells in variably sized loose clusters with occasional cells forming glomeruloid structures [ figure 1 ] . the nuclei were round to oval with irregular nuclear membranes , coarsely clumped chromatin and 0 - 1 nucleoli . there was abundant mucoid material in the background with presence of intracytoplasmic as well as extracellular periodic acid - schiff ( pas ) positive hyaline globules . this was corraborated by the raised alpha feto - protein ( afp ) levels ( > 2000 beta human chorionic gonadotropin ( hcg ) levels were within normal limits ( 1.61 miu / ml ) . contrast - enhanced computed tomography ( cect ) of the chest and abdomen were performed and revealed an elongated nearly oval shaped heterogeneously enhancing lesion in the right lower abdomen . multiple heterogeneously enhancing retroperitoneal lymph nodes , right sided hydroureteronephrosis with left sided pleural deposits was also seen . in view of undescended testis , possibility of germ cell malignancy was suggested . it was gray to yellow in colour with some myxoid areas . also present in the specimen sections were taken extensively and showed features consistent with yolk sac tumor with cells arranged in microcystic - reticular , myxomatous and focal macrocystic , alveolar - glandular and papillary patterns [ figure 2 ] . the rete testis , epididymis and surgically resected end of the spermatic cord were free of tumor . intracytoplasmic and extracellular hyaline globules present in the tumor were pas positive and diastase resistant . cd30 , epithelial membrane antigen ( ema ) and carcinoembryonic antigen ( cea ) were negative ruling out embryonal carcinoma and choriocarcinoma . smear showing clusters of pleomorphic cells with abundant mucoid material in the background ( giemsa stain , 400 ) . inset shows pleomorphic cells with intracellular periodic acid - schiff positive hyaline globules section showing glandular , microcystic pattern and myxomatous stroma ( h and e , 100 ) . inset on the left shows glands and inset on the right shows papillae ( h and e , 400 ) fine needle aspiration cytology is a useful first line of investigation to diagnose testicular masses . it provides a triage of cases of testicular tumors into those who require surgery and those who do not . smears are cellular with presence of cohesive clusters of very immature cells having basophilic cytoplasm and a prominent nucleolus . presence of intra and extracellular pas positive hyaline globules and a myxoid background are characteristic features . reported yolk sac tumor of the undescended testis which initially presented with a mass in the left lobe of the liver . in the present case , fnac provided a precise diagnosis of yolk sac tumor of the undescended testis which was clinically suspected to be either a renal or lymph node mass . fnac in conjuction with raised afp levels is useful to diagnose yolk sac tumors and for planning further therapy . sinha et al . and cox et al . reported similar cases of yolk sac tumor in an undescended testis in small children . testicular malignancy should always be ruled out when a cyrptorchid child presents with an abdominal mass . mixed germ cell tumors occur frequently in the testis and only one component may be sampled on fnac . the type of components present in the mixed germ cell tumor has major implications on the prognosis of the patient . tumor markers like afp , hcg , lactate dehydrogenase and placental like alkaline phosphatase are useful in making the diagnosis . treatment and outcome of germ cell tumors in undescended testis is similar to those of germ cell tumors in general . reported that survival among patients with testicular malignancy in descended and undescended testis was similar . the present case highlights the use of fnac in diagnosing testicular masses , especially in our case where the lesion presented with multiple lymph node masses and renal hydronephrosis and was clinically and radiologically suspected to be a wilm 's tumor with metastasis or a lymphoma . fnac is a useful , rapid and inexpensive tool , making it a first line of investigation in many hospitals . however , mixed germ cell tumors may be missed on cytology and should be correlated with clinical and radiological findings and serum tumor markers prior to surgery .

yolk sac tumor is the most common germ cell tumor in infants and children . majority of them arise in the gonads . yolk sac tumor of undescended testis has been rarely diagnosed . we present a case of yolk sac tumor in right undescended testis in a 2-year - old child primarily diagnosed by fine needle aspiration cytology .

a 70 year old woman first visited our clinic for right hand bradykinesia and gait disturbance unresponsive to levodopa treatment . at age 67 , she started to feel clumsiness in her right hand and to walk with very short stride and festination . her gait disturbance rapidly worsened until she was unable to walk without assistance after two years . at age 69 , she was diagnosed with pd and started to take levodopa . at age 70 , she took 450 mg of levodopa by regular levodopa / carbidopa , 150 mg by controlled release form of levodopa / carbidopa , 6 mg of ropinirole , and 200 mg of amantadine per day , but felt no clinical improvement . her verbal output was markedly reduced , and she could speak only simple words . on neurological examination , she showed masked face and no rest tremor . muscle tone was moderately elevated in her right limbs and mildly in the left limbs . she could not perform hand rolling , finger tapping , and foot tapping movements with her right limbs . deep tendon reflexes were normoactive . the stimulus sensitive jerks and ideomotor apraxia were observed in her right hand . a t2-weighted brain magnetic resonance imaging ( mri ) study showed diffuse cortical atrophy which was prominent in the left fronto - tempo - parietal cortex , and moderate degree of hypersignal intensities in diffuse subcortical white matter . an [ f]-deoxyglucose positron emission tomography study showed severe hypometabolism in left fronto - temporo - parietal cortex , striatum and thalamus ( figure 1 ) . because there was no response to levodopa treatment , we started to taper off anti - parkinsonian medications . three days after abrupt discontinuation of ropinirole , amantadine , and controlled release form of levodopa except regular levodopa / carbidopa , she developed severe dysphagia and dyspnea . serum ck level was 10,632 iu / l and urine myoglobin level was 2,881 ng / ml . the dosage of levodopa was increased to 750 mg per day and antibiotics treatment was started . during the course of following seven days , body temperature and serum ck level slowly returned to the normal level . the pd patients with longer disease duration , higher motor severity and motor fluctuation are likely to develop nms after abrupt reduction of anti - parkinsonian medications.3 abrupt deterioration of dopaminergic transmission is suggested to be a common pathophysiological mechanism of nms.2,4 however , the nms can occur in atypical parkinsonisms , including progressive supranuclear palsy , multiple system atrophy , and cbd , which accompany the pathology in postsynaptic striatal neurons and poor levodopa responsiveness.2,5 these suggest that peripheral mechanism or the alteration of neurotransmitters other than dopamine may also be involved in the pathogenesis of nms.2,4 in this patient , both reduction of levodopa dosage and concurrent infection might precipitate nms . therefore , prevention of infection , a common complication of parkinson - plus syndromes , is necessary to prevent nms . additionally , dose reduction or withdrawal of anti - parkinsonian medications should be carefully performed even in the patients with cbd who are expected to be unresponsive to levodopa treatment .

parkinson s disease is a principal underlying disease of neuroleptic malignant syndrome ( nms ) occurring in parkinsonian disorders , but nms may occur in patients with progressive supranuclear palsy and multiple system atrophy . we report first patient with corticobasal degeneration ( cbd ) who developed nms after abrupt reduction of antiparkinsonian medication and concurrent infection . it should be kept in mind that the prevention of infectious illness , which is common complication in parkinson - plus syndrome , is important , and dose reduction or withdrawal of anti - parkinsonian medications should be carefully performed even in the patients with cbd who are expected to be unresponsive to levodopa treatment .

kawasaki disease ( kd ) is an acute systemic vasculitis of unknown cause that occurs primarily in children and rarely in adults . in the absence of specific laboratory tests , we report an unusual case of an elderly man with several unique features of incomplete kd . a 75-year - old white man was admitted to our hospital for a 3-week history of fever and poor general condition . his past medical history included hypertension , hyperlipidemia , myocardial infarction , and a coronary artery bypass graft surgery 2 years ago . the patient was febrile ( 39c ) , and physical examination revealed bilateral nonpurulent conjunctivitis , red and cracked lips ( fig . 1 ) , and slightly edematous erythema with desquamation of the hands and feet ( fig . laboratory tests revealed anemia ( hemoglobin 8.5 g / dl ) , hypoalbuminemia ( 2.6 g / dl ) , elevated erythrocyte sedimentation rate ( esr ) and c - reactive protein ( crp ) ( 83 mm / h and 100.3 mg / l , respectively ) , elevated alanine aminotransferase ( 56 iu / l ; normal < 40 ) , and sterile leukocyturia ( 30 cells/l ) . serological assays for human immunodeficiency virus , hepatotropic viruses , epstein - barr virus , cytomegalovirus , and antinuclear antibodies were negative . the patient was subsequently treated with an intravenous immunoglobulin infusion ( 1 g / kg for 2 days ) and high - dose aspirin ( 3 g / day ) . the fever remitted within 3 days , and within 1 week , the laboratory abnormalities returned to normal and mucocutaneous lesions improved dramatically . low - dose aspirin , which the patient had taken since his bypass surgery , was then restarted . kd is defined as the presence of a fever for 5 days and 4 of the 5 major clinical features : conjunctivitis , oral mucosal changes , polymorphous rash , palmoplantar erythema with desquamation , and cervical lymphadenopathy . incomplete kd refers to patients who do not fulfill the classic criteria of 4 of the 5 findings and in whom alternative diagnoses have been ruled out . in adults , the main differential diagnoses the higher prevalence of coronary artery lesions in patients with incomplete kd reflects difficulties in diagnosis and delays in treatment . although adults are less frequently affected by coronary aneurysms compared with children ( 5 vs. 20% , respectively ) , establishing the diagnosis of incomplete kd and initiating treatment is essential . in 2004 , a multidisciplinary committee of experts proposed an algorithm to diagnose incomplete kd in children . for pediatric patients with a fever for 5 days and < 4 classical criteria of kd , laboratory tests , including crp and esr , should be obtained . in patients with elevated crp ( 30 mg / l ) and/or esr ( 40 mm / h ) levels who fulfill 3 supplemental laboratory criteria [ including albumin 3.0 g / dl , anemia , elevation of alanine aminotransferase , 450,000/mm platelets after 7 days , white blood count 15,000/mm , and sterile pyuria ( 10 cells / high - power field ) ] , intravenous immunoglobulin and aspirin should be instituted and echocardiography should be performed . our case emphasizes the importance of considering kd at any age , even among elderly individuals . this case also highlights the usefulness of the algorithm proposed for children to diagnose incomplete kd in adults .

kawasaki disease ( kd ) is a systemic vasculitis of unknown etiology , affecting predominantly young children . here , we describe an unusual case of a 75-year - old man with several unique features of incomplete kd . healthcare professionals should therefore be aware of the importance of considering kd at any age , even among elderly individuals . this case also highlights the usefulness of the algorithm proposed for children to diagnose incomplete kd in adults .

this 41-year - old housewife , educated up to sixth standard , hailing from middle socioeconomic status , with nil contributory family history , and suffering from hypertension and myopia in left eye ( + 0.75 ) and hypermetropia in right eye ( 0.75 ) , reported to outpatient clinic with history of 10-years duration characterized by unpleasant , frequent , and distressing doubts related to dirt and contamination . these resulted in performance of long , nonfunctional repetitive activities like cleaning and saying same words again and again . it was also reported both by husband and the patient herself that these symptoms have a seasonal pattern appearing in october and complete resolution in april - may . this seasonal pattern was so well - recognized that no treatment was taken for initial 3 - 4 years as they considered it an effect of change of season and that symptoms would disappear once the winter is over . no associated stress or precipitating factor was identified that might lead to reoccurrence of these symptoms every year in winter . gradually over the years she noted that the severity of her illness increased and was causing socio - occupational dysfunctions . therefore , this year she reported for psychiatric treatment at the beginning of october . on mental state examinations she had obsessions of contamination , compulsions for washing , and assurance seeking . the severity of symptoms was assessed by administrating yale brown obsessive compulsive scale ( y - bocs ) . the total y bocs score was 30 ( obsessions score 17 and compulsions score 13 ) , other routine investigations were within normal limit . other than ocd in subsequent follow - ups , patient was also diagnosed as having cervical spondylitis . she was on fluoxetine 20 mg once daily for 1month , but did not show much improvement . therefore , keeping in view the seasonal variation in the pattern of oc symptoms , she was also considered for phototherapy . she was also taken up for exposure and response prevention ( erp ) therapy twice a week for 1hour , where therapist assisted the patient in exposure . her y - bocs score came down to 8 ( 5 for obsession and 3 for compulsion ) and she was discharged on fluoxetine 20 mg once daily maintenance treatment . epidemiological studies have found the prevalence rates of sad to be generally higher in northern locations like north america and europe , and generally lower in warmer , tropical countries . however , the influence of latitude in prevalence of ocd is yet to be established by cross - sectional surveys from different countries . studies also suggest that seasonal ocd is rare in prevalence and difficult to diagnose . one reason might be the requirement of long history with respect to seasonality is required for establishing diagnosis . in a large - scale study of children in united states aged 9 - 17 years , significant seasonal variations were found in overanxious disorder , ocd , separation anxiety disorder , social phobia , and major depressive disorder , with worsening of symptoms in august - october . similarly , a retrospective study of 34 patients with ocd found that 53% patients with ocd reported a marked seasonal variation in their symptoms . while the reasons for the seasonal variation in ocd symptoms is not known , alterations in monoaminergic neurotransmission in the brain are believed to be the reason for seasonal variations in mood disorders . in a study of 101 healthy men , it was found that the turnover of serotonin by the brain was lowest in winter . moreover , the rate of production of serotonin by the brain was directly related to the duration of bright sunlight , and increase rapidly with greater duration of sunlight . these findings are supportive of the notion that changes in release of serotonin by the brain may underlie seasonal variations in ocd . the alteration of brain serotoninergic systems in ocd supports the use of light therapy for the treatment of ocd . in fact , just like in the present case , a reduction in oc symptoms by bright light therapy has been reported earlier in a patient having seasonal variation in ocd . can these variations in symptoms be solely attributed to climate ( light ) changes or there are factors that still remain unexplored . it is also questionable whether the response is because of anti - obsessional drugs or it was just a placebo effect of the drug therapy . a careful prospective study of seasonal pattern of ocd will help in understanding symptoms , course , and suitable treatment options in such cases . different clinical course and treatment response indicates different and/or overlapping neurobiological basis for the seasonal ocd . is seasonal variation of ocd different from ocd unrelated to seasons ? our case had contamination obsession and washing compulsion , but whether seasonal ocd manifest in other types like aggression , sexual , hoarding or symmetry , and whether it may be classified as reactive or further it can be speculated that , like sad , seasonal ocd may be of some diagnostic value or can be taken as part of spectrum or a course specifier in nosology .

a case of obsessive - compulsive disorder ( ocd ) with seasonal variation in symptoms of 10-years duration is reported because of its rarity . the phenomenology of the observed disorder was obsessions related to dirt and contamination resulting in washing compulsions with onset in october and complete resolution in april - may every year . the patient responded to phototherapy along with exposure and response prevention therapy and pharmacotherapy .

restrictive cardiomyopathies are defined as restrictive ventricular physiology in the presence of normal or reduced diastolic volumes ( of one or both ventricles ) , normal or reduced systolic volumes , and normal ventricular wall thickness . usually , patients develop severe symptoms of heart failure over a short period , and the majority die within a few years following diagnosis unless they receive a cardiac transplant . genetic investigations have shown that the condition may be caused by mutations in sarcomeric disease genes or genes for desmin and even may coexist with hypertrophic cardiomyopathy in the same family as seen in our case . a 25-year - old woman , gravida 4 , para 1 , living 1 , abortion 2 , presented to us at 34 weeks of gestation with antepartum hemorrhage . her past pregnancies were uneventful . on examination , pulse was 112/min and blood pressure was 120/80 mm hg . respiratory system showed bilaterally equal , normal vesicular breath sounds with no rhonchus or crepitations . obstetric scan showed a single live intrauterine gestation without any evidence of placenta previa / abruption . her electrocardiogram ( ecg ) showed biatrial enlargement and partial right bundle branch block pattern . echocardiography showed dilated left and right atria , concentric left ventricular hypertrophy with mild mitral and tricuspid regurgitation , normal left ventricle systolic function , ejection fraction 60% , pulmonary artery hypertension ( pulmonary artery systolic pressure-45 mmhg ) with small pericardial effusion [ figure 1 ] . doppler showed increased early diastolic filling ( e ) to atrial filling ( a ) ( e / a ) ratio ( 2.4 ) of the mitral inflow signal , mitral flow ( e-0.85 , a-0.35 ) , and pulmonary flow ( 0.90 m / s ) [ figure 2 ] . in light of these results , genetic counseling of the family was done and genetic testing was advised , but the patient declined testing . connective tissue disorders were ruled out ( antinuclear antibody and antiphospholipid antibody were negative ) . metabolic disorders were ruled out by serum creatine phosphokinase ( cpk ) ( 112.8 u / l ) and serum lactate ( 1.4 mmol / l ) which were found to be normal . she went into spontaneous labor 10 days later , and she had a preterm vaginal delivery of a live female baby weighing 2 kg . the patient is on diuretics and she continues to be on regular clinical follow - up . echocardiography reveals biatrial enlargement with normal systolic function doppler shows increased early diastolic filling to atrial filling ratio ( 1.6 ) common etiologies of rcm include infiltrative ( amyloidosis , sarcoidosis ) , storage ( hemochromatosis ) , noninfiltrative ( scleroderma , idiopathic ) , and endomyocardial processes ( endomyocardial fibrosis , hypereosinophilic syndrome , carcinoid , radiation , malignancy , anthracycline toxicity ) . feld and caspi reported a cardiomyopathy with variable hypertrophic and restrictive features that affected three generations of a family with a shared human leukocyte antigens haplotype . in our case , the sibling had hypertrophic cardiomyopathy . depending on the stage of the disease , the fourth heart sound or third heart sound may be present . in our patient , ecg may show progressive atrioventricular ( av ) conduction delay due to disease of the av node , or his - purkinje system is common in many genetic diseases that affect the myocardium , and in this case , ecg showed biatrial enlargement and partial right bundle branch block pattern . certain signs and symptoms that could raise the suspicion of specific diagnoses grouped according to the main echocardiographic phenotype such as learning difficulties and mental retardation ( noonan syndrome ) , paresthesia / sensory abnormalities / neuropathic pain with bilateral carpal tunnel syndrome ( amyloidosis ) and muscle weakness generally distal progressing to proximal ( desminopathies ) . in our patient the classical doppler finding is the restrictive pattern - mitral inflow pattern e / a > 1.5 as seen in our case . increased creatine kinase is seen in desminopathies , and increased proteinuria is seen in amyloidosis . in our case , rectal biopsy was done and it did not show any deposits of amyloidosis and cpk was normal . cardiac transplantation can be considered in patients with refractory symptoms in idiopathic or familial restrictive cardiomyopathies . the present case report shows the importance of careful evaluation of patients so that risk stratification can be done to avoid adverse disease complications and diminish the rate of sudden death .

restrictive cardiomyopathy ( rcm ) is a relatively rare form of cardiomyopathy with high mortality which is characterized by impaired filling of the ventricles in the presence of normal wall thickness and systolic function . rcm is generally seen in association with infiltrative , storage , or systemic diseases . we present a rare case of familial rcm with pregnancy which was successfully managed .

maintaining the microsurgical field , free from flooding with irrigation fluid , is important to get good vessel approximation in microsurgery . the commonly followed practice is to keep dry gauze at the periphery of the field so as to siphon off the excessive fluid . a certain amount of the irrigation fluid still remains in the field and causes adhesion of the suture material with the anastomotic clamp or the background material or to the vessel wall and thereby frustrating the surgeon while applying the microknots . we present our technique that avoids the aforementioned , and in addition provides a good platform to perform microvascular anastomosis . this is folded over a dry gauze and then fenestrations are made in the surface and on the two margins [ figure 1 ] of the glove component so as to provide for continuous drainage of the irrigation fluid to the gauze . the tip of the infant feeding tube ( size 4 ) is then passed in to the gauze [ figure 2 ] and the whole assembly is then placed in the microsurgical field deep to the vessels to be anastomosed and thus provides a platform for the microanastomosis . the vessels to be anastomosed are laid over a background on the platform and then the proximal part of the feeding tube is connected to a suction system so as to provide continuous suctioning of the irrigation fluid that keeps the microsurgical field clean and dry and also by keeping away the tip of the feeding tube from the surgical field [ figure 3 ] . the wrist part of the glove with open ends and fenestrations on the surface to facilitate siphoning off of the irrigation fluid the tip of a size 4 infant feeding tube is passed between the layers of gauze the entire assembly is shifted to the neck for anastomosis forming a good platform for anastomosis . the proximal end of the infant feeding tube is connected to the suction tube the wrist part of the glove component has been described in the past to transfer the pedicle of the flap from the oral cavity to the neck for microanastomosis and in this report we present a technique in which the component can be used to keep the operative field clean and dry and also to provide a stable platform to perform a perfect microanastomosis . this is folded over a dry gauze and then fenestrations are made in the surface and on the two margins [ figure 1 ] of the glove component so as to provide for continuous drainage of the irrigation fluid to the gauze . the tip of the infant feeding tube ( size 4 ) is then passed in to the gauze [ figure 2 ] and the whole assembly is then placed in the microsurgical field deep to the vessels to be anastomosed and thus provides a platform for the microanastomosis . the vessels to be anastomosed are laid over a background on the platform and then the proximal part of the feeding tube is connected to a suction system so as to provide continuous suctioning of the irrigation fluid that keeps the microsurgical field clean and dry and also by keeping away the tip of the feeding tube from the surgical field [ figure 3 ] . the wrist part of the glove with open ends and fenestrations on the surface to facilitate siphoning off of the irrigation fluid the tip of a size 4 infant feeding tube is passed between the layers of gauze the entire assembly is shifted to the neck for anastomosis forming a good platform for anastomosis . the proximal end of the infant feeding tube is connected to the suction tube the wrist part of the glove component has been described in the past to transfer the pedicle of the flap from the oral cavity to the neck for microanastomosis and in this report we present a technique in which the component can be used to keep the operative field clean and dry and also to provide a stable platform to perform a perfect microanastomosis .

during microvascular anastomosis , it is important to maintain the microsurgical field irrigated yet dry so as to achieve a good view of the vessels for approximation . in this method , an infant feeding tube ( size 4 ) , with its tip sandwiched between layers of dry gauze and a surgical glove component placed in the anastomotic field and the other end connected to a suction apparatus , is used to maintain the microsurgical field free from flooding . it also has the additional advantage of providing a stable platform for microvascular anastomosis .

kerosene is refined oil belonging to the hydrocarbon group of compounds , obtained from crude petroleum . poisoning is due to inhalation of fumes or ingestion of small amounts accidentally ( children ) or most of the cases reported in the literature were self - inflicted with the intention of committing suicide which constitutes significant emergency admissions . a 34-year - old male patient presented to our out - patient department with a history of injecting about 5 ml of kerosene to his left hand at two sites following an argument with his family members 2 days prior to presentation , with an intention to commit suicide . after 2 days , the pain became intolerable leading to disturbed sleep , with multiple blisters and swelling of the left hand . no other significant medical history was noted . on examination , he was an alert middle - aged man , moderately built and nourished , and well oriented to time , place , and person . multiple vesicles and blisters were present over the left forearm and few over the dorsal aspect of the left hand . black discoloration extending from the hand up to the lower third of the arm was present . local rise of temperature and tenderness was present from the hand up to lower third of arm . refilling could not be elicited [ figures 1 and 2 ] . multiple vesicles and blisters black discoloration extending from the hand up to the lower third of the arm was present . patient was unable to flex the hand few vesicles , blisters , and erosions were present over the dorsal aspect of the left hand there were no other lesions . irritant contact dermatitis the patient was admitted to the ward ; intravenous ( iv ) amoxycillin with clavulinic acid , iv steroid , and iv fluids were started . iv or subcutaneous self - injections of commercial gasoline or kerosene with suicidal intent constitute extraordinary events in psychotic patients . the lethal dose of kerosene for a 70 kg adult is 100 ml . in 1977 , green first described a patient who survived a 3 ml iv injection of energine , a derivate of kerosene . this patient developed lethargy , drowsiness , and a sterile abscess at the injection site without other systemic effects . our patient had injected 5 ml of kerosene and developed lesions over the forearm , as described . neeld and vaziri each reported a case of iv injection of petroleum distillate that caused severe chemical pneumonitis . in both cases , pulmonary edema and hypoxemia developed , and in one , the patient suffered abrupt respiratory arrest immediately after injection . kosa reported an accidental iv injection of 10 ml of gasoline that resulted in a fatal outcome . the case strongly suggested that hydrocarbons , as low - viscosity chemical compounds , have a direct toxic effect on lung tissue , interfering with gas exchange and leading to liquid interstitial pulmonary edema and severe hypoxemia caused by impaired diffusion . other effects of hydrocarbon intoxication include acute renal damage with oliguria , hepatocellular damage , intracellular hemolysis , gastric ulcers , and cardiac toxicity with negative inotropism . a case of self - inflicted acute necrotizing fasciitis with compromised venous return secondary to injection of kerosene was reported . a study on the clinical findings and outcome in suicide attempts by iv injection of kerosene among iv drug abusers was done in iran . although kerosene is a easily available refined oil as it is used for household purposes , poisoning occurs by inhaling fumes and ingestion accidentally in children and with the intention of committing suicide in adults . kerosene injection can produce severe tissue damage , especially if prompt surgical treatment is delayed . therefore , it is important to initiate active and immediate surgical intervention in the form of complete multiple fasciotomies , incision , and surgical excision of non - viable tissue . it should also be followed by active and repeated aggressive wound debridement until healthy granulation tissue is formed .

kerosene is refined oil belonging to the hydrocarbon group of compounds , available for domestic use in developing countries . poisoning is due to inhalation , ingestion . kerosene . we report a rare case of attempted suicide by means of intravenous injection of kerosene . it has a devastating effect and it is important to initiate active and immediate surgical intervention . psychotherapy should also be an integral part of the management .

a 16-year - old boy visited to our neurology clinic with a 12-month history of a clicking noise in the both ears and palatal discomfort . the clicking resembled the sound of snapping fingernails and was externally audible at a distance of 50 cm . he denied any voluntary control over this movement as well as any sensation of urge before the movement . he complained of throat fullness in daytime . on neurologic and otolaryngologic examination , rhythmic contraction of whole soft palate muscles the movement was able to be suppressed for a few seconds by touching the back of his neck , but it could soon return after the voluntary suppression . in addition , the entrainment at each slow and fast finger tapping with external pace was found ( video ) . needle electromyography ( emg ) of tvp muscle showed rhythmic contractions with a frequency of 2.6 hz with amplitude of 150 v ( figure 1 ) . there were no abnormal results in other laboratory , audiologic tests , and brain magnetic resonance imaging . after diagnosis of ept , despite of medications including benzodiazepines , muscle relaxants , and anticonvulsants for 1 month , his symptoms were not changed at all . therefore , we started to inject 15 units of bta ( botox , allergan , inc . , though the success of the first bta therapy was lasted about 10 weeks , the additional injections of bta were needed for 3 times due to recurrence . the dosage of bta was finally elevated to 20 units and there were 4 times injection of bta at interval of 3 months , but the presenting symptoms showed again . his involuntary movements were clinically closed to ept because of ear click perceived as objective tinnitus , bilateral involvement , no brain lesions and involvement of tvp muscle by emg . although no single clinical finding is pathognomonic for pmds , several features are quite helpful.10 in general , pmds are characterized by distractibility , entrainment , coactivation sign , variable frequency , amplitude and direction , increase with attention , and poor response to medications.8,11 this patient also showed entrainment of soft palate muscle contraction to external paced finger tapping . furthermore , pmds have particular histories including precipitating factor or trivial trauma preceding acute onset , emotional trigger , psychological stressors and psychiatric comorbidities such as anxiety disorders.8 in this patient , mild trauma ( e.g .. voice abuse ) before onset suggest to psychogenic type of ept rather than primary type . in our case , the only difference from usual psychogenic pt is that this abnormal movement was not well responded to treatment . psychogenic pt is usually reported to have good response to non - physiological treatment or placebo.8 in summary , bilateral objective tinnitus , bilateral tvp muscles involvement , mild trauma before onset , and entrainment of soft palate contraction suggest a psychogenic ept .

essential palatal tremor ( ept ) is a rare disorder which shows rhythmic involuntary movement of the muscles of soft palate , especially tensor veli palatini muscle . ept is classified by two subtypes , which is primary and secondary ept . secondary ept includes psychogenic type . we describe a case of intractable psychogenic ept .

a 54 year - old - man , presented with multiple , small , well- defined , gray - brown , papules and small papillomatous patches located on his penis , which had appeared over the last year ( figure 1 ) . genital warts , lichen planus , a verrucous nevus and bp were suspected among our clinical diagnosis . the dermoscopy revealed a pigmented papillomatous surface , brown - gray dots arranged in a linear distribution at the periphery of the lesion , and widespread dotted vessels ( figures 2 and 3 ) . a biopsy was done , and the histology showed mild hyperkeratosis , irregular acanthosis , dyskeratosis , cytological atypia and mitosis ( figures 4 and 5 ) , consistent with the diagnosis of bp . a 31-year - old male patient with no relevant medical history presented with gray - brown asymptomatic small papules on his penis that had appeared a few months before ( figure 6 ) . the dermoscopy revealed multiple areas with grey - brown dots aligned in a linear fashion and a keratotic surface . a 54 year - old - man , presented with multiple , small , well- defined , gray - brown , papules and small papillomatous patches located on his penis , which had appeared over the last year ( figure 1 ) . genital warts , lichen planus , a verrucous nevus and bp were suspected among our clinical diagnosis . the dermoscopy revealed a pigmented papillomatous surface , brown - gray dots arranged in a linear distribution at the periphery of the lesion , and widespread dotted vessels ( figures 2 and 3 ) . a biopsy was done , and the histology showed mild hyperkeratosis , irregular acanthosis , dyskeratosis , cytological atypia and mitosis ( figures 4 and 5 ) , consistent with the diagnosis of bp . a 31-year - old male patient with no relevant medical history presented with gray - brown asymptomatic small papules on his penis that had appeared a few months before ( figure 6 ) . the dermoscopy revealed multiple areas with grey - brown dots aligned in a linear fashion and a keratotic surface . the natural course of this disease is unpredictable : the lesions may increase , decrease , and even disappear spontaneously . although progression to an invasive scc is uncommon , it has been estimated in 2.6% of cases . the most important differential diagnoses are genital warts , both clinically and dermoscopically . to date and to our knowledge , no reports that specifically describe the dermoscopic findings of bp are available , and a few reports of dermoscopic examinations of this dermatosis have been published in the literature . dong et al . reported two cases of bp showing an unspecific pattern , and one of the lesions also showed dotted vessels and a keratotic surface as in our first case . in a study describing pigmented lesions of the vulva , ferrari et al . also presented 2 cases of bp : one lesion revealed brown to gray structureless areas and glomerular vessels in a clustered and linear arrangement ; the other lacked pigmentation and revealed multiple whitish - red exophytic papillary structures with central glomerular and hairpin vessels . the features of the two cases we presented were similar : brown - gray dots with a linear arrangement , located at the periphery of the lesion . these features remind us of pigmented bowen s disease , an in situ variant of cutaneous squamous cell carcinoma , which needs to be differentiated from bp at histopathological level . although more studies are needed to confirm these findings as criteria for bp , we think that in the presence of linear arrangement of brown - gray dots in a genital lesion , we should rule out bp among other diagnosis .

bowenoid papulosis ( bp ) corresponds to an in situ squamous cell carcinoma ( scc ) located in the anogenital region . it is related to hpv , and presents with gray - brown elevated papules or plaques . a biopsy is needed to confirm the diagnosis ; however , dermoscopy may be useful to differentiate this disease from other conditions , such as genital warts , seborrheic keratosis and lichen planus . in this paper we describe the dermoscopic findings in two patients with this disease .

however , the style of the application may induce both allergic and photoallergic contact dermatitis from the nsaids and their ingredients . we describe a case of allergic contact dermatitis with diffuse erythematous reaction caused by allergic sensitivity to a component , diisopropanolamine , of a compress used by the patient . an 87-year - old japanese man with dementia presented with a pruritic eruption following the use of compresses for lumbago . the patient had used the same compresses for three weeks . during the last ten days of use , pruritic eruptions appeared on the bilateral lower back and upper buttock where the compresses were being applied . then , diffuse erythema developed on the trunk and extremities . physical examination revealed rectangular - shaped , pruritic exudative erythematous macular lesions on the bilateral lower back and upper buttock and diffuse erythema on the chest , abdomen , back and extremities ( fig . a patch test ( international contact dermatitis research group criteria ; finn chambers on scanpor tape , epitest ltd . , tuusula , finland ) was performed with the compress ingredients and the japanese baseline series . the positive reactions at both 2 and 4 days after application were to diisopropanolamine 1% pet . , fragrance mix 8% pet . ( brial allergen gmbh , greven , germany ) , and mercuric chloride 0.05% aq . it is used in emulsifying agents for cosmetic lotions , neutralizers in cosmetics , and bath preparations . until now , eight cases of allergic contact dermatitis from diisopropanolamine , including the present case , have been described ( table 1 ) . we previously reported a case of diffuse erythematic reaction after using compresses . in the previous case , three concomitant sensitizations to diisopropanolamine , felbinac , and crotamiton supposedly caused a diffuse erythematic reaction . in the present case , a single sensitization to diisopropanolamine was associated with a diffuse erythema . thus , similar phenomena of allergic contact dermatitis with diffuse erythematous reaction may be caused by allergic sensitivity to a different component or different combinations of ingredients in the topical medicament . patch testing with full ingredients from the manufacturer is essential for detecting the sensitized allergens in each case .

compresses containing a nonsteroidal antiinflammatory drug ( nsaid ) are commonly used in japan . however , this treatment may induce both allergic and photoallergic contact dermatitis from the nsaids and their ingredients . here , we describe a case of allergic contact dermatitis with diffuse erythematous reaction due to diisopropanolamine in the applied compress . the absorption of diisopropanolamine might have been enhanced by the occlusive condition .

torsion of uterine adnexa is an important cause of acute abdominal pain reported in the literature.1 however , isolated torsion of fimbrial cysts has rarely been described as a cause for acute abdomen.23 we report a rare case of isolated torsion of fimbrial cysts leading to acute abdomen . a 22-yr - old female presented to the hospital with acute abdomen , amenorrhea for a half month and a half , and spotting on and off . the patient provided written consent to reproduce information or photographs . on physical examination , the patient s vital signs were found to be normal . laboratory investigations including hemoglobin , total leucocyte count , differential leucocyte count , and routine and microscopic examination of the urine were found to be normal . therefore , a serum beta human chorionic gonadotropin ( hcg ) test was done to confirm pregnancy . however , serum beta hcg levels were within normal range . the ultrasound report showed a tubo - ovarian mass in the right adnexa along with fluid in the pouch of douglas , suggestive of fimbrial cysts or ectopic pregnancy ( fig . on laprotomy , multiple cystic structures attached to the fimbriae were seen , which were twisted at their pedicle . many of them had ruptured leading to collection of about 200 ml of straw colored fluid . however , the fallopian tubes and ovaries were normal on both the sides , so a cystectomy was done . multiple cystic structures varying in size from 3 3 cm to 2 2 cm were seen . the cystic structures were filled with yellow colored fluid and were twisted at the pedicle ( fig . 2 ) . histopathology showed ciliated , columnar cells with underlying stroma and few chronic inflammatory cells , and a diagnosis of fimbrial cysts was made ( fig . paraovarian cysts represent approximately 10% of adnexal masses.4 they are more common in childbearing women.5 paratubal cysts arise from mllerian or wolffian structures and are common in adult females . these are hormone sensitive and are generally asymptomatic.6 malignant neoplasms arising from paratubal cysts are very rare.7 rarely , they can be associated with torsion of fallopian tubes.7 other complications include hemorrhage , rupture , and infection.3 paratubal cysts are difficult to diagnose preoperatively , and even transvaginal ultrasound in older women has detected only about 44% of paratubal cysts preoperatively.8 in only 1 of 15 patients is the diagnosis of fimbrial cyst suspected before surgery.4 thus , acute abodomen is a rare presentation of fimbrial cysts , which needs to be considered in a female of reproductive age group . timely diagnosis and excision of these cysts may prevent the rare complications of torsion and rupture that are associated with them .

we present a case of a 22-year - old female who presented with acute abdomen and amenorrhea . emergency laprotomy was done with a clinical diagnosis of ectopic pregnancy . on laprotomy , twisted fimbrial cysts were found . thus , although fimbrial cysts are rarely twisted , they should be considered as a cause of acute abdomen in a female of reproductive age group .

gender bias in different types of congenital defects is well know . a significant bias in sex ratio has been documented for congenital heart disease with several lesions occurring more frequently in males or in females.12 this difference may be related to differences in hormonal constitution . it has been proposed that foetal sex is partially determined by hormone levels of both parents around the time of conception has put forward35 but it is unclear whether such hormonal variations may also be responsible for sex - biasing of congenital anomalies . a literature search shows that transposition of the great arteries has been shown to have a gender bias ( table 1 ) but no explanation has been put forward in order to account for this observation . sex ratio of transposition of the great arteries in published reports in this study , we compare gender of patients with transposition with controls . in the general population , females tend to be smaller than male and in this study , we also attempt to relate gender ratios of patients with transposition with birth weight , maternal age and parental occupation . we evaluated 95 isolated livebirths with transposition of the great arteries cases referred to sicilian registry of congenital malformations from 1991 to 1998 , and compared these with a control group of 1000 consecutive newborns from the same geographic origin . all types of transposition of the great arteries were evaluated together and we excluded cases with other associated birth defects . we found a sex ratio ( male / female ) of 2.8 in transposition of the great arteries while the control group had a sex ratio of 1.04 . we did not find any statistical association between birth weights and gender bias in transposition of the great arteries and controls . stratification of our cases by gender and maternal age was not sigificant , with a mean maternal age of 29 years for both male and female cases of transposition of the great arteries ( p=1 ) . a statistically significant association both for maternal ( p=0.03 ) and paternal ( p=0.04 ) occupation related to agriculture was found for males with transposition , while none was found for affected females . moreover , in transposition of the great arteries , gender and birth weight are independent factors . hytten and leitch16 proposed that a high male sex ratio correlated with high maternal age , but james and rostron17 in a large sample of data found a decline in sex ratio of births at high maternal age . recently loffredo et al18 reported an association between transposition of the great arteries and maternal exposure to herbicides and rodenticides . . the aetiological agent / s may be chemicals used in agriculture that produce a hormonal disruptor effect . the results of the present study , despite the limitations attributable to the small number of sample and controls , suggest further studies on environmental agents and their possible teratogenic effect .

a significant bias in sex ratio has been documented for several congenital cardiac malformations . transposition of the great arteries has been associated with a such a bias but no explanation has been proposed for this bias . we evaluated 95 isolated livebirths with transposition of the great arteries cases referred to the sicilian registry of congenital malformations from 1991 to 1998 . we found a statistically significant male bias of 2.8 and this was significantly associated with both maternal and paternal occupational exposure to agricultural chemicals for male infants with transposition , but not for female infants . this study raises new questions about the possible role played by environmental chemicals in relationship to birth defects and to sex ratio imbalance .

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 .

high concentrations of factor viii and von willebrand factor ( vwf ) contribute to a hypercoagulable state in hyperthyroidism . lower vwf concentrations in hypothyroidism may protect against venous thrombosis .. studies have suggested hypercoagulable state in hypothyroidism . 45-year - old female presented in emergency with complaints of headache since 1 month , vomiting since 1 day , and weakness with numbness and tingling in right half of body since 12 h. her weakness progressed to quadriparesis overnight . on examination she was drowsy and disoriented . on neurological examination , reflexes were present and muscle tone was normal but power was 1/5 on right side and 3/5 in left half of body . thyroid function tests were suggestive of subclinical hypothroidism t3 - 0.94 ng / ml , t4 - 8.36 g / dl , tsh - 13.92 miu / ml . thrombophilia profile including prothrombin time index / international normalized ratio , serum homocysteine ( 5.6 mol / l ) , ana , lupus anticoagulant , igm and igg cardiolipin antibodies , and apla antibodies were negative . mri brain showed loss of flow void of superior sagittal and left transverse sinuses with altered signal appearing hyperintense on t1w and fluid - attenuated inversion recovery ( flair ) images suggesting thrombosis . she was put on heparin and warfarin . her headache improved after 4 days of treatment and patient was discharged after 7 days with no residual neurological deficit . hypothyroidism favors a procoagulant by decreasing fibrinolysis ( high levels of alfa2-antiplasmin and plasminogen activator inhibitor-1 ) , inducing hyperhomocysteinemia , and high c - reactive protein ( crp ) . decreased fibrinolytic capacity , high crp levels , and coagulation factors abnormalities can occur even in subclinical hypothyroidism . elevated plasma thrombin - activatable fibrinolysis inhibitor levels were observed in patients with mild and overt hypothyroidism , and levothyroxine treatment was effective in reducing these levels . chronic low - grade inflammation and impaired nitric oxide availability in the endothelium have been demonstrated in hypothyroidsm . this case emphasizes the need for thyroid evaluation in all patients with cvt and other venous thromboembolic event even in the absence of clinical signs of hypothyroidism .

cerebral venous thrombosis ( cvt ) is a multifactorial condition which is described as idiopathic in 12.5% of patients . hyperthyroidism has been associated with cvt in many case reports , and increased levels of factor viii and von willebrand factor ( vwf ) have been proposed as the possible link in this association , but only few rare case reports have described an association of hypothyroidism with cvt . we report here a case of autoimmune thyroiditis presenting with cvt .

the main therapeutic approach is adrenalectomy and extraction of the tumor from the inferior vena cava and the right atrium . this requires a precise evaluation of the extent of spread of the tumor , a meticulous pre - operative planning and a combined team including general and cardiac surgeons and a cardio - pulmonary bypass team . jugular venous pulse and heart sounds were normal . a soft murmur compatible with tricuspid regurgitation was heard . abdominal ultrasound revealed a cirrhotic liver with an enlarged portal vein , splenomegaly and ascites . a large uniform , echodense , immobile mass ( area- 3.3 cm ) , attached to the interatrial septum was seen in the right atrium ( figure 1 ) . the inferior vena cava was mildly enlarged and an elongated mass attached to its wall was seen . the patient was operated and combined cardiac and abdominal procedures were performed , monitored by transesophageal echocardiography , which did not add any additional information . inferior vena cava and right atrium were exposed and a large mass extending from the hepatic portion of the inferior vena cava to the right atrium was removed . postoperative course was complicated by massive bleeding and coagulopathy and the patient died few hours after the operation . we describe a rare case of adrenocortical carcinoma that extended to the inferior vena cava and the right atrium . tumors that affect the right atrium include primary neoplasms and secondary tumors such as hypernephroma , hepatoma , testicular sarcoma and melanoma . adrenal carcinoma may also extend to the renal veins and the inferior vena cava , usually accompanied by a thrombus . most of the described cases of adrenal carcinomas extending to the right atrium including the present case were right - sided [ 4,6,7,9 - 15 ] . this is explained by the direct course of the right adrenal vein to the inferior vena cava . other forms of cardiac involvement include infiltration of the inter - atrial septum , and a malignant pericardial effusion . the main clinical manifestations of vena caval and right atrial extension of the tumor include peripheral edema , ascites and hepatomegaly as in our case . a patient with bouts of dyspnea and cyanosis due to a patent foramen ovale and a right atrial tumor was described . due to the tendency of the tumor to disseminate , a precise pre - operative assessment is essential . evaluation should involve various additional modalities such as ct , [ 4,6 - 8 ] venography and mri . echocardiography is a very useful tool in the assessment of cardiac tumors [ 5,7,8,10,13,16,17,19 - 22 ] . in the present case transthoracic echo identified the cardiac involvement , leading to change in the operative approach by adding cardiac surgeons to the operation . transesophageal echo can provide high quality images of the inferior vena cava and right atrial involvement , and direct the surgeons in the removal of the neoplasm from both sites . in cases in which a good quality transthoracic study is positive for cardiac involvement , transesophageal study can be performed only intraoperativlely , to monitor and direct surgery in the operative arena . a patent foramen ovale should be looked for before putting the patient on by - pass . we suggest that adrenal carcinoma , although very rare , should be included in the differential diagnosis of right atrial tumors . once an adrenal tumor is detected , the work - up should include echocardiography , which is of a paramount importance in the evaluation of cardiac involvement , operative planning and follow - up . none declared . there are no financial or other relations that could lead to a conflict of interest .

backgroundadrenocortical carcinoma is a rare , highly malignant tumor . cardiac involvement of the tumor is very rare . echocardiography facilitates the evaluation of the cardiac involvement of the tumor.case presentationwe describe a patient with an adrenal tumor . transthoracic echo showed its extension into the right atrium . accordingly , a combined abdominal and cardiac operation was performed , monitored by transesophageal echocardiography.conclusionthis case highlights the importance of echocardiography in revealing the cardiac involvement by this tumor and in planning the operative procedure .

syndrome of inappropriate secretion of antidiuretic hormone ( siadh ) is a common cause of hyponatremia . although it has been associated with different pulmonary infections , there have been only few case reports describing the association of siadh with influenza . we report a case of siadh in a patient with influenza who was successfully treated with fluid restriction . it is essential for clinicians to be aware of the association between influenza and siadh . syndrome of inappropriate secretion of antidiuretic hormone ( siadh ) is one of the most common causes of hyponatremia in hospitalized patients , with a prevalence as high as 35% . it is characterized by the impairment of urinary dilution in the absence of any renal disease or any identifiable nonosmotic stimulus that induces antidiuretic hormone ( adh ) release . although siadh has been known to be associated with different pulmonary infections , only rarely has it been reported with influenza . we present a case of hyponatremia associated with influenza , which was subsequently diagnosed as siadh . a 65-year - oldmale presented to the emergency department with low - grade fever and productive cough for 2 days . he did not have any neurological symptoms , abdominal pain , nausea , vomiting , change in bowel movements , or loss of appetite or weight . he did not have any history of recent surgery , central nervous system disorders , malignancy , or known pulmonary disease . on examination , he had a temperature of 102.4f , heart rate 120/min , respiratory rate 24/min , blood pressure 110/60 mmhg without orthostatic vital signs , and oxygen saturation 96% on room air . laboratory examination revealed a serum sodium of 122 meq / l ( 135 - 145 ) , blood urea nitrogen ( bun ) 11 mg / dl ( 8 - 24 mg / dl ) , creatinine 1.35 mg / dl ( baseline 1.2 - 1.3 ) , plasma osmolality 276 mosm / kg ( 280 - 290 ) , urine specific gravity of 1.029(1.002 - 1.030 ) , urine osmolality 777 mosm / kg , urine sodium 63 meq / l , thyroid - stimulating hormone ( tsh ) 3.011 iu ( 0.5 - 5.0 mu / l ) , and random serum cortisol 20.2 g / dl ( 7 - 25 g / dl ) . the chest x - ray did not show any infiltrate , consolidation , or mass . the nasal swab polymerase chain reaction was positive for influenza a. urinary antigens for legionella , mycoplasma , and streptococcus were negative . a diagnosis of siadh was made and his hyponatremia was corrected gradually in 3 days with fluid restriction o less than 800 ml / day . at 2 weeks thus , a careful history to rule out other causes like malignancy , pulmonary conditions , central nervous system lesions , and medications is essential in the evaluation of any patient suspected with siadh . it has been reported in many pulmonary infections including asthma , atelectasis , acute respiratory failure , and pneumothorax . influenza has been implicated as a cause of siadh previously , but there is no published data regarding the actual incidence of siadh in these patients . our patient was diagnosed with siadh based on : hypoosmolar hyponatremia;urine osmolality > 100 mosm / kg;urine sodium concentration > 40 meq / l;euvolemic state ; andnormal renal , thyroid , and adrenal function . hypoosmolar hyponatremia ; urine osmolality > 100 mosm / kg ; urine sodium concentration > 40 meq / l ; normal renal , thyroid , and adrenal function . failure of improvement of serum sodium with intravenous normal saline further confirmed the diagnosis of siadh . although the exact pathogenesis for siadh in influenza is unknown , it is thought to be related to the secretion of proinflammatory cytokines . interleukin ( il)-2 , il-6 , il-1 , and tumor necrosis factor ( tnf)- have been reported to stimulate parvocellular and magnocellular neurons to secrete more adh ; thus causing siadh . fluid restriction is the main treatment modality in siadh , with a suggested goal intake of less than 800 ml / day . further treatment options depend on the severity of hyponatremia and the presence of other related symptoms . in the presence of severe or symptomatic hyponatremia , hypertonic saline goal should be to raise serum sodium less than 10 - 12 meq / lin 24 h to ovoid the potential complication of osmotic demyelination with rapid correction . oral salt tablets and loop diuretics may also be added if optimum response is not seen with fluid restriction alone . our patient 's siadh was thought to be secondary to influenza , which was treated with oseltamivir and led to steady improvement in the patient 's serum sodium levels . in conclusion , clinicians should be cognizant of the association between influenza and siadh to allow for accurate diagnosis and treatment of this condition . further studies are needed in future to find out the incidence and pathogenesis of siadh in patients with influenza . although treatment depends on the severity of hyponatremia and associated symptoms , fluid restriction remains the cornerstone of therapy .

context : syndrome of inappropriate secretion of antidiuretic hormone ( siadh ) is a common cause of hyponatremia . although it has been associated with different pulmonary infections , there have been only few case reports describing the association of siadh with influenza.case report : we report a case of siadh in a patient with influenza who was successfully treated with fluid restriction.conclusion:it is essential for clinicians to be aware of the association between influenza and siadh .

most commonly they arise from cells lining of the central canal within the spinal cord and present as intramedullary tumor . a 59-year - old woman complained of pain in neck over the past 6 years . about 10 months before , she came to us ; she noted pain in her back which was radiating down the lower limbs to the little toes . as a result , she has to stop after walking a little while . she also started experiencing fear of fall when walking . on examination , her triceps were weak , especially on left . magnetic resonance imaging ( mri ) scan of spine showed lobulated , conglomerate and discrete idem tumors from d4 to l3 vertebral bodies . they were hypointense on t1w and hyperintense on t2w [ figure 1a - c ] . ( a - c ) are t2 weighted sagittal magnetic resonance imaging of spine showing multiple intradural extramedullary tumors in dorso - lumbar region . ( d and e ) are t1 weighted postcontrast sagittal and axial images respectively showing areas of the tumor enhancement on the basis of mri image , we suspected lymphoma , and hence we decided to excise the cervical tumor for histology . on opening the dura , two separate pale brown , mildly vascular and fleshy tumors were seen deep to the arachnoid , one above the other . they were seen to be adherent to the spinal cord but did not expand it . they were not continuous but consisted of separate tumors one above the other as in the neck . we removed two more tumors and as in the neck , found them adherent to the spinal cord without expanding it . postoperatively , the patient showed some improvement in her lower limbs and she could walk without fear of fall . the above finding was suggestive of suggestive of low - grade ependymoma [ figure 2a and b ] . ( a 10 and b 40 ) hematoxylin and eosin ( h and e ) stained images showing radially arranged ependymal cells with fibrillary processes . pseudorosettes are seen with no mitotic activity six weeks after the operation , she was treated by radiotherapy with 28 fractions of 1.8 gy - the total dose being 50.4 gy . at follow - up of 11 months , patient is doing well . though 20 cases of purely idem ependymomas have been reported in the literature , in most of these cases , single lesion was found . reported cases of multiple primary idem ependymoma in a first report of idem ependymoma in 1951 , cooper et al . so in glial tumors presenting as idem lesions : there is a lack of an apparent infiltration into the central nervous system.there is an absence of a primary neoplastic process within the brain or spinal cord.the tumors show encapsulation , are located along the neuraxis and are frequently association with congenital anomalies . there is an absence of a primary neoplastic process within the brain or spinal cord . the tumors show encapsulation , are located along the neuraxis and are frequently association with congenital anomalies . these criteria are ependymomas usually arise from the ependymal cells lining the ventricles and central canal of the spinal cord . however , idem ependymomas may arise from heterotopic ependymal cell rests were left in the idem space when the neural tube closed . as with typical intradural ependymomas , idem ependymomas occur irrespective of age but are most common in the third to fifth decades of life . the overall prevalence of the majority of intradural ependymomas among males and females is equal , but , in multiple idem ependymomas are common in males [ table 1 ] . most spinal idem ependymomas affect the thoracic spine in contrast to intramedullary ependymomas , mainly located at the cervical spinal cord and the conus medullaris . neither the presenting symptoms nor the imaging features of idem ependymomas are different from other common idem tumors like schwannoma or meningioma . therefore , mostly they are mistaken for schwannoma or meningioma and diagnosis is delayed . though radical excision is recommended for ependymomas in general and near total resection is advisable for single idem ependymoma , it seems to be unrealistic and risky in cases of multiple idem ependymomas . in all the reported cases , decompression of the lesion causing mass effect was carried out followed by radiation in 2 cases and chemo - radiation in a single case . though role of radiation in such cases is controversial , biopsy of the symptomatic lesion followed by radiation seems to be the most rational option of this rare entity . a biopsy of the most symptomatic lesion followed by radiotherapy perhaps represents to be the most preferable option .

spinal ependymoma commonly presents as an intramedullary tumor . we present a rare case of multicentric intradural extramedullary spinal ependymoma . a 59 years old female presented to us with spastic quadriparesis for 10 months . magnetic resonance imaging of the spinal cord showed discretely located enhancing tumor masses from at c1-c2 , c6-c7 , and d4 to l3 level . subtotal resection of the symptomatic tumor at c6-c7 and d7-d9 was done . the patient underwent radiotherapy with 50.4 gy . at follow - up of 11 months , patient is doing well . the relevant literature is reviewed .

strongyloides stercoralis is a human intestinal nematode that is considered a common parasitic disease in tropical and subtropical areas . it is endemic in southeast asia , africa , west indies , south america , bangladesh , and pakistan . the ability to replicate in the human host permits autoinfection of s. stercoralis leading to chronic infection . hyperinfection occurs when the parasite load increases and the rhabditiform larvae penetrate the bowel mucosa and finally reaches the organs normally involved in pulmonary autoinfection cycle ( gi tract , peritoneum , and lungs ) . dissemination is defined as larva migrating to end organs not usually involving the normal life cycle of the parasite such as brain and skin . there are very few case reports of hyperinfection or disseminated s. stercoralis infection in immunocompetent patients . we present a case of hyperinfected s. stercoralis infection in an adult male patient presenting with respiratory symptoms . a 48-year - old farmer from eastern part of coastal india presented to the emergency department with complaints of low - grade fever for 15 days , cough with expectoration for 10 days , and gradually increasing breathlessness for 5 days . the patient was suffering from cough with expectoration and breathlessness on and off for the past 2 years . he was neither a diabetic nor a hypertensive . at the time of admission , the patient was confused , irritable , cyanosed , and tachypneic . his pulse rate was 120/min , blood pressure was 90/60 mm of hg , temperature was 101 f , respiratory rate was 30/min , and oxygen saturation was 78% . hb - 8.8 gm / dl , tlc - 10.8 10/cmm , dc - p 72% , l 22% , e 4% , and absolute eosinophil count - 480/cmm , tpc rbs was 96 mg / dl , bun - 28 mg / dl , serum creatinine - 1.2 , serum na - 128 mmol / l , serum k - 3.9 mmol / l . abg analysis revealed ph - 7.44 , paco2 32 mm hg , pao2 67 mm hg , bicarbonate 24 a provisional diagnosis of bronchopneumonia , and septic shock was made , and the patient was shifted to icu . blood and sputum were sent for aerobic culture along with sputum gram stain and zn stain before starting the antibiotic . chest x - ray at the time of admission revealed bilateral interstitial pattern of opacities [ figure 1 ] . on the 2 day , he developed ards and was put on mechanical ventilator . x - ray chest showing features of ards while examining the gram stain and zn stain smears of sputum , plenty of larvae were seen [ figure 2 ] . on wet mount , plenty of actively motile larvae of s. stercoralis were found [ figures 3 and 4 ; videos 1 and 2 ] . s. stercoralis rhabditiform larvae in sputum on zn staining s. stercoralis larvae on wet film observation of sputum sample motile rhabditiform larvae of s. stercoralis on wet film observation of sputum . rhabditiform larva of s. stercoralis in stool sample of patient the patient 's condition gradually deteriorated inspite of adding oral ivermectol and intravenous imipenam . s. stercoralis is a unique intestinal nematode causing chronic asymptomatic infection , hyperinfection , and dissemination due to its ability to produce autoinfection in the intestine and due to penetration of the perianal skin by the filariform larvae . hyperinfection and dissemination syndrome usually occur in immunocompromised patients includes those undergoing steroid therapy or chemotherapy , and those with hematologic malignancy , kidney and bone marrow transplant , hiv infection , and hypogammaglobulinemia . hyperinfection and dissemination syndrome has a very high mortality rate ( up to 87% ) . complications of hyperinfection and disseminated disease include bacterial and fungal infections , sepsis , and meningitis . secondary bacterial infection occurs because of the leakage of gut flora from an ulcerative bowel mucosa or as a result of bacteria carried on the surface of the larvae when they migrate into the host 's circulation . therefore , blood cultures commonly grow escherichia coli , klebsiella pneumoniae , proteus mirabilis , pseudomonas , and enterococcus fecalis . s. stercoralis hyperinfection has been documented in immunocompetent patients very rarely . a case has been documented from puducherry in an elderly male who presented with fever , cough , breathlessness , and pain abdomen who responded to oral ivermectol . a study from sgpgims documented 15 cases of strongyloidiasis ( 7 in immunocompromised and 8 in immunocompetent patients ) . but , eosinophilia is often absent in hyperinfection syndrome , as in our case . in conclusion , besides showing gastrointestinal symptoms , it may mimic acute exacerbation of underlying copd or new - onset asthma and be complicated with gram - negative bacteremia . therefore , stool and sputum examinations are important when the clinical picture is suspicious for s. stercoralis hyperinfection .

s. stercoralis infection is very common in south east asian countries including india . chronic infection is very common with symptoms of diarrhea , abdominal pain , nausea , vomiting , anemia , and cough . hyperinfection and dissemination usually occur in immunocompromised patients with symptoms mimicking asthma , copd , or aseptic meningitis . very few cases of hyperinfection and dissemination have been documented in immunocompetent patients . we report this case for its rarity and future references .

relevant studies were identified through medline , embase , cochrane library , scopus , and clinicaltrials.gov electronic databases and hand - searched from inception through december 2014 . prospective and retrospective observational cohort studies examining the association between statin use ( on hospital admission or previous users ) and the outcomes of bacteremic patients were included . the outcome of interest was overall hospital mortality at the longest follow - up at each single study . copenhagen : the nordic cochrane centre , the cochrane collaboration , 2014 . a p value of < 0.05 was considered statistically significant . study - specific risk ratios were calculated and combined using random - effects model meta - analysis . between studies the overall hospital mortality was 15.36% ( 139/905 ) in patients on statin versus 22.28% ( 1481/6648 ) in patients not on a statin ( odds ratio = 0.49 ; 95% confidence interval = 0.300.81 ; i = 69% , p = 0.005 ) [ figure 1 ] . quality analysis showed that all the included studies were of high or moderate quality ( 16.67% high and 83.33% moderate scores ) . in previous studies , statins have inconsistently been shown to improve mortality among septic patients . our study showed that statin treatment in bacteremic patients was associated with significantly lower mortality rates . the optimum dose and type of statin ( hydrophilic vs. lipophilic ) and the mechanism by which statins potentially halt the inflammatory cascade remains an area of further study . large , well designed , randomized controlled trials are warranted to provide more conclusive knowledge and potentially change clinical practice .

background : statins modify inflammatory cell signaling during the immune response to infection . this has been considered as a pleotropic effect . effects of statins in inflammatory conditions such as bacteremia have been found to be controversial.aims:we examined the effect of statins on the mortality of bacteremia patients.materials and methods : major databases were searched for the pertinent clinical trials.results:six cohort studies comprising 7553 patients were included . hospital mortality was lower ( 15.36% vs 22.28% ) in patients on statin.conclusions:there may be a potential role of statins in similar inflammatory and infective conditions .

intralobar pulmonary sequestration ( ilps ) with an anomalous systemic arterial blood supply represents a mass of nonfunctioning parenchyma surrounded by visceral pleura ( 1 , 2 ) . unlike extralobar sequestration , radiographically demonstrated calcification in the ilps has been reported in some case series , but primary sequestration associated with typical hamartoma signs is really rare and has been described only once ( 3 , 4 ) . in this report , we present a rare case of giant hamartoma originated from primary ilps in a 39-year - old woman who had intracranial cholesteatoma . a 39-year - old woman with an abnormal mass in the right cerebellopontine angle was referred to neurosurgery department of our hospital . a giant mass in the right thoracic cavity was detected accidentally by x - ray in a routine preoperative screening process . subsequent thoracic computed tomography scan demonstrated a complex lesion ( size 15.1 12.3 15.7 cm ) occupying more than two - thirds of the thoracic cavity on the right side . the blood supply to the area of the lesion was from a systemic artery arising from the abdominal aorta , with venous drainage through the inferior pulmonary vein , suggesting an ilps ( figure 1 a - 1c ) . three months later , an open thoracic surgery for the intrathoracic lesion was performed under general anesthesia . intraoperatively , lesion appeared hypervascular , because of abundant systemic vascularization ( figure 2 a ) . the massive lesion was compressing the right lung and there was no communication between the tracheobronchial tree and sequestered lesion . based on the findings of 3d ct angiography , we explored the aberrant artery at the bottom of the chest and carefully ligated it with an absorbable silk suture . after the pulmonary ligament had been completely divided , the lower pulmonary vein was found to be widened . the lesion was adherent to adjacent pulmonary vein branches and was not easily dissected . to avoid major intraoperative blood loss , pathologic analysis showed a predominant fatty differentiation with fibroblastic , chondroid and osseous differentiation making the rest ( figure 2b - 2d ) . the postoperative recovery was uneventful and the patient was discharged from the hospital on the eighth postoperative day . ilps is usually diagnosed later than extralobar sequestration ( els ) , being found in childhood or adulthood when the patient presents with an infection ( 5 ) . up to 15% of patients , particularly in adult population , are asymptomatic when the sequestration is discovered incidentally ( 6 ) . in our case , the sequestration surrounded by visceral pleura , characteristically receives its blood supply from a systemic artery with venous drainage through pulmonary veins and was consistent with ilps . the lesions of ilps may be solid , fluid or hemorrhagic or may contain mucus . primary sequestration associated with typical hamartoma signs final histology was pulmonary hamartoma with predominantly adipose and cartilage differentiation , which is an unusual complication originated from primary sequestration . pulmonary hamartoma is a rare lung neoformation , usually symptomless and discovered incidentally , of a probable dysontogenetic origin with prevailing cartilaginous tissue and adult onset age ( 7 ) . in a series of 24 patients , gabrail and zara ( 8) concluded that pulmonary hamartomas are frequently accompanied by other developmental abnormalities and benign tumors . however , the entity described ( pulmonary hamartoma syndrome ) seems to be distinct from well - established multiple hamartoma syndrome ( cowden s syndrome ) . many interesting features characterize the case report : histopathological nature of the pulmonary hamartoma , the typical vascular structure related to intrapulmonary sequestration and intracranial cholesteatoma as shown by neurosurgery operation . . the combination of sequestration , hamartoma and cholesteatoma may be only an incidental combination , but this could indicate both possibilities as hamartomatosis change on underlying sequestration or sequestration associated with hamartomatosis syndrome .

the radiologic features of intralobar pulmonary sequestration ( ilps ) have been describe and include the identification of a feeding systemic artery with venous drainage through pulmonary veins . primary sequestration associated with typical hamartoma signs is really rare and has been described only once . we describe a patient with ilps whose radiographic findings were unusual for two reasons . first , computed tomography ( ct ) demonstrated a bulky mass in the pulmonary sequestration . the size of lesion and histopathology made it an unusual presentation . final histology study demonstrated pulmonary hamartoma with predominantly adipose and cartilage differentiation , which is an unusual complication originated from ilps . another sign also explains the second unusual feature , intracranial cholesteatoma , occurring concurrently with ilps .

in a previous issue of critical care , prowle and colleagues describe the results of a cohort study in which incidence and attributable mortality of bloodstream infection ( bsi ) were investigated in university - affiliated hospitals . the cohort included 6,339 patients with an icu stay > 72 hours , of which 330 developed an icu - acquired bsi . mortality associated with bsi was 41.2% and thereby substantially higher compared to patients without bsi ( 22.5% ) . after adjustment for confounding covariates , bsi remained an independent risk factor for death ( hazard ratio 2.9 , 95% confidence interval 2.4 to 3.5 ) . the study by prowle and colleagues , however , goes beyond impact estimates for patients who are affected by this infectious complication . the investigators linked the attributable risk of death to the incidence of bsi , which was approximately 5% in this cohort . the authors state that , taking into account the low incidence , the overall impact of nosocomial bsi on the total study population was small as it only caused a decrease in overall survival of approximately 1% . as such , the study by prowle and colleagues is remarkable as it evaluates the deleterious impact of bsi in bacteremic patients and in the overall icu cohort . for what concerns the impact for patients with bsi , the study results concur with those of other investigators who found dramatic excess mortality rates , albeit that some researchers reported attributable mortality rates of non - significant proportions [ 2 - 4 ] . within certain confidence limits , all of these estimates might match reality as clinical outcomes are multifactorial and variable depending on the specific characteristics of the study cohort . more unusual and controversial is to express the excess mortality of bsi for the overall population . even in a situation where substantial excess mortality was noted in the bacteremic cohort , the deleterious impact appears to be of minor importance when using the overall cohort as denominator . as the authors themselves point out , survival benefit of untargeted interventions to prevent bsi is hardly feasible , and any claims of improved survival from interventions to reduce bsi must therefore be interpreted cautiously . as bsis hardly affect overall mortality , huge trials in prevention are necessary to demonstrate benefits in mortality . as already mentioned , mortality always is a product of many components . also , plenty of studies , including the present one by prowle and colleagues , show that bsis do result in a significant excess risk of death . it seems appropriate , therefore , that infection rate in itself , and not mortality , is the best suited outcome variable . the data provided by prowle and colleagues show that , for interventional studies in infection prevention , study power should be calculated as a function of a predefined reduction in infection rate , rather than decreased mortality . vice versa , study results of such trials indicating a reduced infection risk but without difference in mortality should not be taken as a justification of non - adherence , on the condition that associated costs are not excessive . although mathematically correct , the approach of considering the impact of bsi on population level calls for some vigilance . by diluting the effect of infection even though prowle and colleagues clearly do not enlighten their study results with this purpose , the present data could be used as an argument to minimize the problem and a reason not to invest in infection prevention . in this way , the consequences of many other severe complications can be downgraded to apparently negligible proportions . for example , acute kidney injury with need for renal replacement therapy is well - known to be one of the strongest risk factors for death in patients with severe burn injury . acute kidney injury occurs in approximately 3% of severely burned patients and is associated with a mortality rate of about 30% . based on these figures , it can be calculated that acute kidney injury increases mortality by only 0.9% ( from 4.85% to 5.75% ) . this example illustrates how the impact of complications can be diminished by alterations in denominator . the study by prowle and colleagues demonstrates that assessing the impact of bsi should preferably be performed on the patient group affected as many other icu patients have only a very low risk profile for the acquisition of nosocomial bsi . diluting the impact of infection to the overall population , however , illustrates that infection prevention studies should use infection rates as endpoints , as proving substantial benefits in survival does not seem to be achievable .

mortality associated with nosocomial bloodstream infection is multifactorial . source of infection , etiology , age , underlying disease , acute illness , and appropriateness of antimicrobial therapy all contribute to the final outcome . as such , estimates of mortality attributable to bloodstream infection may differ largely according to the presence or absence of risk factors in distinct patient populations . the adverse effect of nosocomial bloodstream infection for the individual patient is substantial , with about a doubling of the risk of death . yet , in settings with a high standard of care in terms of infection prevention and control , the occurrence rate of bloodstream infection is relatively low and therefore its impact on overall icu mortality rather limited . as a consequence , untargeted interventional studies focused on infection prevention should use occurrence rate of infection rather than mortality as outcome variable .

carcinoma of the gallbladder is more common in women and usually seen in patients older than 50 years of age . it is more common in the white population than the black and in western countries than the mediterranean . although areas of squamous differentiation is seen in adenocarcinoma , pure primary squamous cell carcinoma is rarely reported and accounts for less than 1% of all gallbladder malignancies . some researchers have stated that squamous cell carcinoma originates from pre - existing squamous metaplasia of the gallbladder epithelium , while others concluded that it originates from squamous differentiation of neoplastic cells of adenocarcinoma . we present a pure case of squamous cell carcinoma with some areas of squamous metaplasia in the vicinity of the invasive tumor . another purpose of this case presentation was to emphasize on the vague clinical presentation of gallbladder carcinoma . a 70-year - old man presented with acute onset right upper quadrant abdominal pain and fever since two days prior to admission . liver function tests showed total protein : 7.2 g / dl , alb : 4.1 g / dl , alt:40 iu , ast : 38 iu , alkaline phosphatase : 150 iu , total bilirubin : 2.3 mg / dl , and direct bilirubin : 1.8 mg / dl . abdominal ultrasonography showed thickened gallbladder wall without gallstone in favor of acute acalculus cholecystitis . with the presumptive diagnosis of acute cholecystitis , the patient received supportive care and antibiotics . gross examination of the gallbladder revealed an ill - defined infiltrating creamy white mass in the body of the gallbladder measuring 322 cm with focal exophytic configurations ( figure 1 ) . gross appearance of the squamous cell carcinoma shows the infiltrative tumor and a focal fungating configuration . microscopic examination of the mass showed well differentiated keratinized squamous cell carcinoma invading full wall thickness to the serosal surface ( figures 2 and 3 ) . the mucosa showed mature squamous metaplasia in the vicinity of the tumor ( figure 4 ) . the tumor lacked any glandular differentiation . in the follow - up visits all examinations were negative for the primary origin of the squamous cell carcinoma and the patient was well in a follow - up period of 6 months . this figure shows well differentiated keratinized squamous cell carcinoma is invading through the wall of the gallbladder ( h&e100 ) . this figure shows areas of extensive keratinization is shown in invasive squamous cell carcinoma ( h&e400 ) . this figure shows mature squamous metaplasia of the gallbladder mucosa is shown in the vicinity of the tumor ( h&e400 ) . adenocarcinoma is the most common histological subtype of gallbladder cancer constituting about 90 - 95% of the cases . although areas of squamous differentiation are seen in some reported cases , pure squamous cell carcinoma of the gallbladder is very rare . traditionally it has been said that adenosquamous and squamous cell carcinomas have very poor prognosis . however , currently it is important to differentiate adenocarcinoma with squamous differentiation from pure squamous cell carcinoma because of the better prognosis of the latter . pure squamous cell carcinoma of the gallbladder grows slowly , is usually localized and rarely metastasized . on the other hand adenosquamous carcinoma is aggressive and metastasizes widely . the mean age of the patients with squamous cell carcinoma was 65 years and only 13% of patients were suspected for carcinoma preoperatively . the etiology and pathogenesis of squamous cell carcinoma is not well understood ; however , two important presumptive causative possibilities are gallstones and parasitic infestation . another important pathogenetic clue for squamous cell carcinoma is the metaplasia - dysplasia - carcinoma sequence . most of the cases with squamous cell carcinoma show some degrees of atypical epithelial change adjacent to the invasive tumor . gupta and co - workers reported a case of primary squamous cell carcinoma presenting as acute cholecystitis . the patient was operated on after 12 hours and cholecystectomy showed wall thickening with multiple gallstones . other researchers reported a case of primary squamous cell carcinoma of the gallbladder in an elderly lady with infiltration to the adjacent hepatic parenchyma . rai and colleagues concluded that pure squamous cell carcinoma of the gallbladder was less aggressive than adenocarcinoma . this type of carcinoma should be suspected when the lesion reaches a large size without metastasis . we presented a 70-year - old man diagnosed as having acute cholecystitis based on clinical examinations and ultrasonographic findings . in our case the subtle clinical presentation could be in favor of the less aggressive behavior of pure squamous cell carcinoma of the gallbladder in comparison with adenocarcinoma or adenosquamous variants , which was reported in some previous studies .

squamous cell carcinoma of the gallbladder is rare and constitutes only 0.5 - 3% of all malignancies of this organ . most of the reported cases have had a component of adenocarcinoma . we report a 70-year - old man who presented with acute onset right upper quadrant pain . he operated on based on a presumptive diagnosis of acute cholecystitis according to clinical and ultrasonographic findings . histopathological examination of the infiltrating mass of the gallbladder revealed well differentiated keratinized squamous cell carcinoma invading full wall thickness . thorough evaluations revealed no other primary site for the tumor . pure primary squamous cell carcinoma of the gallbladder is rarely reported . clinicians and pathologists must be aware of its vague clinical presentations .

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

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

in the lips assay , ia-2 ( amino acids 601979 ) was cloned into the pren2 mammalian expression vector downstream of the renilla luciferase ( ruc ) reporter ( 35 ) . monkey kidney cells ( cos1 ) in a 100 mm dish were transfected , and 48 h later , the cells were sonicated , clarified by centrifugation , and the extract ( enough for 1,500 assays in duplicate ) used without further purification . total luciferase activity in the extract was measured in a luminometer and adjusted so that each reaction contained 1.0 10 light - forming units per 0.1 l of extract . the extract was then incubated with 1.0 l of sera for 1 h at room temperature in a total volume of 100 l , transferred to 96-well filtration plates containing 7 l of 30% suspension of protein a / g beads ( pierce biochem ) , and incubated for an additional hour . the a / g beads with the captured antibody luciferase labeled ia-2 complexes were washed using a biomek - fx workstation , renilla luciferase substrate ( promega , madison , wi ) was added , and the light - forming units were determined in a microplate luminometer ( berthold technologies , bad wildbad , germany ) . in the rip assay , performed as previously described ( 6 ) , the same intracellular portion of ia-2 used in the lips assay was cloned into a pgbkt7 vector ( clontech , mountain view , ca ) , and the ia-2 protein was produced by in vitro transcription / translation in the presence of s - methionine . ia-2 autoantibodies were detected by liquid - phase radioimmunoprecipitation using 20,000 cpm of radiolabeled ia-2 . a total of 100 sera from patients with newly diagnosed type 1 diabetes who had been previously screened for ia-2 autoantibodies by rip were selected on the basis of the counts precipitated , from very high to moderate and low to negative . a total of 100 sera from age - matched nondiabetic individuals served as the control ( 6 ) . a serum was scored as positive if the precipitated cpm exceeded the mean + 3 sd of the control subjects . sera from diabetic ( n = 100 ) and control subjects ( n = 100 ) were screened for ia-2 autoantibodies by rip assay . only one of the control subject sera fell outside the 3 sd range , whereas 90% of the diabetic subject sera exceeded the 3 sd range of the control subject sera ( fig . the coefficient of variation ( cv ) for duplicate samples of the diabetic subject sera was 5.0% . none of the control subject sera fell outside the 3 sd range , whereas 85% of the diabetic subject sera exceeded the 3 sd range of the control subject sera ( fig . comparison of the rip and lips assays revealed a high correlation , with a 0.805 coefficient of determination ( r ) ( fig . evaluation of the 5 diabetic subject sera that were negative by the lips assay but positive by the rip assay showed that 3 of the 5 negative sera were at the very borderline of positivity ( fig . receiver operating characteristic analysis showed that the areas under the curves for ia-2 by rip and lips were not statistically different ( p = 0.120 ) ( fig . from these experiments , we concluded that there was no significant difference in sensitivity or specificity between the lips and rip assays . first , because it uses luminescence rather than radioactivity , it lends itself better to most clinical laboratories and can be easily automated . second , because the preparation of the protein does not require in vitro transcription / translation , the protein can be prepared at a fraction of the cost of the rip assay . third , because the recombinant protein is fused with a luminescence marker , it does not need to be externally labeled or laboriously separated from the other proteins in the mammalian cell lysate , thereby eliminating the purification steps required for both bacteria - prepared proteins ( 7 ) used in solid - phase enzyme - linked immunosorbent assays . fourth , because the proteins are made in mammalian cells , they may undergo a variety of processing and posttranslational modifications that do not occur when they are prepared via in vitro transcription / translation and , therefore , may more truly reflect the natural state of the autoantigen . it will be of interest to see if this increases detection and/or sensitivity when other autoantigens , prepared in mammalian cells , are screened for autoantibodies . our findings suggest that the lips assay may be of practical value at the clinical level for the detection of autoantibodies not only for diabetes , but also for other autoimmune diseases . however , as with all new assays , lips requires validation with a large number of sera and comparison with rip in a diabetes autoantibody standardization program workshop .

objective insulinoma - associated protein 2 ( ia-2 ) is a major autoantigen in type 1 diabetes , and ia-2 autoantibodies are routinely detected by a liquid - phase radioimmunoprecipitation assay . the present experiments were initiated to develop a new assay that does not require the use of radioisotopes or autoantigens prepared in bacteria or by in vitro transcription / translation.research design and methods ia-2 luciferase fusion protein was expressed in mammalian cells and assayed for autoantibodies by liquid - phase luciferase immunoprecipitation.resultsour study showed that there was no significant difference between the luciferase immunoprecipitation and the radioimmunoprecipitation assays in sensitivity and specificity , and comparison of the two assays revealed a high correlation coefficient ( r2 = 0.805).conclusions the luciferase system offers a robust , inexpensive , nonradioactive method for the detection of autoantibodies to mammalian cell prepared ia-2 and could be of practical value at the clinical level .

it was a prospective , non - randomized , interventional case - series study of patients with large macular holes . all patients in the study had idiopathic large macular holes as determined by bio microscopy and optical coherence tomography ( oct ) imaging . exclusion criteria were macular holes of < 700 m and macular hole due to other causes . demographic and clinical data were collected for all patients , including age , sex , best - corrected visual acuity ( bcva ) and intraocular pressure . slit - lamp bio microscopy of the anterior segment and fundus with + 90 d was also done . the diagnosis of macular hole in all patients was confirmed using spectral - domain oct . the follow - up was done at day 1 , day 7 , 1 month , 2 months and 6 months . final bcva was recorded and complete ophthalmic evaluation with oct imaging was done during all the visits . all patients underwent 23 g three - port pars plana vitrectomy with posterior vitreous detachment induction using triamcinolone acetonide . brilliant blue dye assisted ilm peeling was done and instead of completely removing the ilm , a remnant of ilm attached to the margins of the macular hole was left in place and inverted into the hole after trimming with cutter . all patients underwent 23 g three - port pars plana vitrectomy with posterior vitreous detachment induction using triamcinolone acetonide . brilliant blue dye assisted ilm peeling was done and instead of completely removing the ilm , a remnant of ilm attached to the margins of the macular hole was left in place and inverted into the hole after trimming with cutter . demographic data and variables were analyzed [ table 1 ] . there were a total of five patients . the mean minimal linear diameter of the macular holes was 811.4 m ( 728 - 995 m ) [ figs 1 , 3 , 5 ] . mean bvca pre - operatively was 1.22 log - mar units ( 1.10 - 1.22 log mar units ) . post - operatively , mean bcva was 1.10 log mar units ( 1.0 - 1.52 log mar units ) . improvement of visual acuity was registered in all patients ( 100% ) [ figs . 2 , 4 , 6 ] . there were no intraoperative or post - operative complications . demographic and clinical profile of patients pre - operative optical coherence tomography of patient one post - operative optical coherence tomography of patient one pre - operative optical coherence tomography of patient three post - operative optical coherence tomography of patient three pre - operative fundus photo of patient one post - operative fundus photo of patient one the improvement in technique and development of finer instrumentation in vitreo - retinal surgery has significantly improved the surgical outcome of macular holes in terms of anatomical and functional success . the vitrectomy for treatment of macular hole study group showed a clear benefit in closure rates and final visual acuity with surgery versus observation for stage iii and iv macular hole . the single most reliable factor affecting the surgical outcome following surgery is the size of the hole . a number of studies have established that the mld of the hole is closely related to the rate of anatomic success . also , it has been shown that the most favorable outcomes for visual recovery were associated with better initial visual acuity . among all the different techniques for macular hole surgery , the one with the most positive effect on final outcome is vitrectomy with ilm peeling , in order to release tangential forces acting on the macular hole ( mh ) . in addition to promoting hole closure , peeling of the ilm also reduces the probability of its reopening . dye assisted technique is safe and useful in visualizing the ilm , leading to the performance of successful peeling of ilm with minimal damage to the retina . brilliant blue selectively stains the ilm and can be safely used for staining the ilm . the peeled - off ilm contains mller cell fragments which can induce gliosis and helping in closure of macular hole . thus , if a segment of peeled - off ilm is left attached , it may provoke gliosis both inside the retina and on the surface of the ilm . michalewska et al . observed closure of the macular hole by a thin membrane with an appearance consistent with the ilm . our study found that the closure rate of macular hole following this technique was 100% and the functional outcome were also better . but , a larger study group and longer follow - up period is required to further evaluate this method .

we are presenting the initial results of inverted internal limiting membrane ( ilm ) flap technique for large macular hole . five eyes of five patients with large diameter macular hole ( > 700 m ) were selected . all patients underwent inverted ilm flap technique for macular hole . anatomical closure and functional success were achieved in all patients . there was no loss of best - corrected visual acuity in any of the patients . inverted ilm flap technique in macular hole surgery seems to have a better hole closure rates , especially in large diameter macular holes . larger case series is required to assess the efficacy and safety of this technique .

a 44-year - old male was visited for back pain and mass around left buttock . he had a medical history that included a diagnosis of pulmonary tuberculosis , from which he had recovered completely 20 years previous . he was under medication from a local clinic and pharmacy for 1 month prior to visiting the hospital due to cold symptoms and lower back pain . vital signs on visit were blood pressure at 130/80 mmhg , heart rate at 72 beats / minute , respiratory rate at 18/minute and body temperature was 38.3. the mass was painful and palpated on the left buttock area , and is seen as a reddish skin color around the anterior superior iliac spine ( fig . laboratory investigations on admission were the following : white blood cell count was 16,660/mm , hemoglobin was 10.5 g / dl , platelet count was 631,000/mm , c - reactive protein was 21.9 mg / dl , and erythrocyte sedimentation rate was 120 mm / hour . abdominal computed tomography ( ct ) and magnetic resonance imaging ( mri ) showed a large psoas abscess in retroperitoneal space and abscess on left lower quadrant anterior abdominal wall ( fig . 2 ) . based on a diagnosis of psoas abscess , the patient was given ciprofloxacin and metronidazole as an empirical injection , then an incision and drainage was performed . ciprofloxacin and metronidazole were injected for an additional 7 days after this procedure , however streptococcus agalactiae and streptococcus aginosus were cultured . a skin defect , 4 3 cm in size , developed around left anterior superior iliac spine . ten days post discharge , the patient experienced fecal discharge from the local flap site ( fig . the patient underwent an operation for enterocutaneous fistula , which was performed by the department of general surgery . during the surgical procedure , a tumor mass was found in the descending colon and was adherent to the retroperitoneum . the tumor had ruptured spontaneously and formed enterocutaneous fistula track , but there were no peritoneal seeding . the histopathologic results of the fistula track and capsule of abscess were granulation tissue with acute suppurative inflammation without tumor cell . reported cases of psoas abscesses have been attributed to tuberculous diseases of the spine , infective spondylitis , crohn 's disease , and diverticulitis.3 ) the incidence of perforated colon cancer ranges from 3% to 10%.4 ) development of intra - abdominal abscess from spontaneous rupture of colon cancer is very rare , having an incidence of 0.3 - 0.4%.1,2 ) the psoas muscle is a retroperitoneal structure lying outside the endoabdominal fascia , such that it is protected from intra - abdominal muscle.5 ) similar to this case , a psoas abscess from colon cancer usually has been preceded by perforation of cancer and commonly with fistula formation . abdominal ct is useful in diagnosis and mri helps in judgment of abscess location , determination of lesion boundaries , and the spread to surrounding soft tissue . in this case , the patient was relieved of symptoms from the psoas abscess by routine incision , drainage and antibiotic therapy in this case . however , the wound culture from the operation was positive for s. agalactiae and s. aginosus which are unusual findings from this location . this led the authors to doubts about the original diagnosis of an uncomplicated psoas abscess and prompted the taking of abdominal ct and mri . we discovered that the patient 's intra - abdomen was connected with retroperitoneum and fecal discharge , which were observed on the local flap . during the operation under enterocutaneous fistular impression , we found a ruptured tumor mass in the descending colon , which had adhered and connected to the retroperitoneum . the case report concerned a thigh abscess with perforated colon cancer ; the route by which the abscess spread from abdominal sources were by 2 means in this case : one was the direct soft tissue extension of infection from the extraperitoneal portion of colorectum ; the second was the extension of infection into the other site via naturally occurring defects in the abdominal wall.6 ) as previously described , perforated colon cancer is rare . fistular formation is uncommon and occurs only in approximately 15% of all perforated colon cancers.7 ) in this case , abscess and fistula of perforated colon cancer were coexistent . it must be recognized that ruptured colon cancer can be a rare cause of psoas abscess . if the result of wound culture is an uncommon strain or normal flora of bowel and the patients have continuous wound problem , surgeons should consider spontaneous rupture of colon cancer as part of the differential diagnosis in these cases .

spontaneous rupture of colon cancer , combined with psoas abscess formation , is rare . a 44-year - old male visited for back pain and left buttock mass . abdominal computed tomography and magnetic resonance image revealed a large abscess in the left psoas muscle and in the left lower quadrant area . ten days after incision and drainage , a skin defect around the left anterior superior iliac spine remained . a local flap was performed using a superficial skin graft . ten days after the stitches had been removed , fecal discharge was observed around the anterior superior iliac spine at the flap site . an operation was performed by a general surgeon who had diagnosed this as a case of enterocutaneous fistula . operative findings included a ruptured tumor mass in the descending colon , which was connected to a retroperitoneal abscess . pathologic report findings determined adenocarcinoma of the resected colon . herein , we report a case of psoas abscess resulting from perforating colon cancer .

hamiltonian mapping demonstrates how the standard wham formalism can be modified and used to extrapolate information about a biased hamiltonian from the unmodified reference hamiltonian , h0(x ) , where x represents the molecular coordinates . wham is typically used along with umbrella sampling , in which a set of l additional restraining potentials , { v } = v1(x ) , ... , vl(x ) , are added to h0(x ) in order to enhance conformational sampling in rarely visited regions of phase space . in this case , the modified hamiltonian takes the form1where { } is the set of coupling parameters used for scaling individual biasing potentials , 0 = 1 , and h0(x ) = v0(x ) . then , for r independent simulations , each performed at a temperature t = 1/kb ( where kb is the boltzmann constant ) and with differing { } , the bias is removed by solving the following pair of wham equations self - consistently2and3 t may be constant or vary across the r simulations . ) is a particular value along a progress variable of interest , nm is the total number of configurations in the mth simulation , and nk({v}, ) is the histogram count of configurations with { v } and . finally , fm is related to the helmholtz free energy for the mth simulation . in contrast to standard wham , in the hamiltonian mapping framework , we proceed in the opposite direction ; we perform one or more simulations of the system under the original hamiltonian h0(x ) and then add a bias to the statistical averages computed from h0(x ) to examine thermodynamic behavior under a modified hamiltonian . for this scenario , eq 2 is recast as4essentially , the histogram counts nk now come from the sampling of h0(x ) , and the sum of the scaled restraining potentials in the denominator reduces to h0(x ) . briefly , in this model , each residue is represented by a single bead centered at the c position and with the mass of the corresponding amino acid . an additive potential describes the bonded and non - bonded interactions between the beads . virtual bonds and angles are defined by harmonic potentials with reference values determined by the c coordinates in the experimental structure . a potential for virtual dihedral angles is based upon backbone dihedral angle probability distributions from the protein data bank ( pdb ) for the 400 possible amino acid pairs and thus is independent of the specific topology of the system . residue pairs separated by three or more bonds interact through the following potential5where rij is the distance between residues i and j , ij corresponds to the distance between the two residues at which vij is minimum , and ij is the interaction strength at ij . residues located in close proximity in the experimental structure ( i.e. , forming a native contact ) interact favorably with ij values based on the statistical contact energies of miyazawa and jernigan , while residue pairs not in close proximity experience a slight repulsive interaction that takes the form of a typical 126 lennard - jones potential . further description of the go-like model and details of the simulation setup can be found in refs ( 25 ) and ( 8) , respectively . we further consider the non - bonded interaction potential ( eq 5 ) for native contacts between the idp and the receptor in tuning the model to match the experimental kd . for this set of intermolecular contacts , we scale the interaction strength , ij , by a factor so as to control the proportion of bound and unbound states throughout simulation . from the fraction of unbound states , pu , the kd is computed as6where [ protein ] is the concentration of protein in moles per liter ( 10 mol / l in the current study ) . a configuration is considered unbound if zero intermolecular native contacts are formed and if the distance between the centers of mass of the idp and of the target protein is greater than the cutoff for calculating the non - bonded interactions ( 25 ) . we also note that the strength of intramolecular contacts within the idp are tuned in a similar manner to reproduce the experimental estimate of residual helical structure in the unbound state .

molecular recognition by intrinsically disordered proteins ( idps ) plays a central role in many critical cellular processes . toward achieving detailed mechanistic understanding of idp target interactions , here we employ the hamiltonian mapping methodology , which is rooted in the weighted histogram analysis method ( wham ) , for the fast and efficient calibration of structure - based models in studies of idps . by performing reference simulations on a given hamiltonian , we illustrate for two model idps how this method can extrapolate thermodynamic behavior under a range of modified hamiltonians , in this case representing changes in the binding affinity ( kd ) of the system . given sufficient conformational sampling in a single trajectory , hamiltonian mapping accurately reproduces kd values from direct simulation . this method may be generally applied to systems beyond idps in force field optimization and in describing changes in thermodynamic behavior as a function of external conditions for connection with experiment .