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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 .