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extraosseous soft - tissue uptake of technetium-99 m methylene diphosphonate ( tc-99 m mdp ) can occur in number of occasions . cancer patients those undergoing bone scintigraphy will have abnormal uptake , which should be differentiated from benign and metastasis in a planar bone scan . single - photon emission tomography - computed tomography ( spect / ct ) help in localizing uptake to the muscle hematoma is not reported yet . a 79-year - old man with prostate cancer and coagulation disorder was referred for a bone scan because of left shoulder pain . a bone scan was performed to assess for any skeletal involvement , especially in the shoulder . a total of 20 mci ( 740 mbq ) mdp was injected intravenously and imaging was performed 3 h later using a large field of view , dual headed gamma camera fitted with a low - energy , high - resolution collimator . anterior whole - body images showed intense uptake in the left axilla [ figure 1 ] . spect ct of the chest [ figures 2 and 3 ] was performed to rule out whether the uptake is in the humerus , but it showed a hematoma in the left brachialis muscle , which he developed due to his coagulation disorder . a hematoma was confirmed on fine - needle aspiration and resolved spontaneously over the next 4 - 5 weeks . follow - up bone scan carried out after 6 months showed resolution of uptake in the left axilla [ figure 4 ] . technetium-99 m methylene diphosphonate whole body bone scan showing increased uptake noted in the left axilla ( arrow ) and no other site of metastasis coronal computed tomography images showing hematoma in the left brachialis muscle fused coronal single - photon emission tomography - computed tomography images localises tracer uptake to the hematoma in the left brachialis muscle follow - up technetium-99 m methylene diphosphonate whole body scan shows resolution of uptake in the left axilla after 6 months localization of bone imaging agents like tc-99 m mdp and tc-99 m hydroxymethylene diphosphonate has previously been described in abdominal and pelvic hematomas . extraosseous soft - tissue concentration of these radiotracers in the chest has also been reported in soft - tissue hematoma , a benign intrapulmonary calcified focus , squamous cell carcinoma of the pleura and pulmonary alveolar microlithiasis . proposed mechanism leading to increased extraosseous tc-99 m mdp uptake include extracellular fluid expansion , enhanced regional vascularity and permeability , diminished lymphatic or venous removal from the affected area , and elevated tissue calcium concentration . tissue damage from inflammation , infection or physical trauma results in localized hyperemia , edema or calcium ( and hemosiderin ) deposition based on their pathophysiologic characteristics . because of advent of spect ct , it is possible to localize exact site of tracer uptake and characterize the lesion to guide further management . spect / ct localizing the uptake to the hematoma in the left brachialis muscle help in ruling out metastasis .

we report a case of 79-year - old male with prostate cancer and coagulation disorder presented with left shoulder pain . he underwent bone scintigraphy to rule out metastasis , which showed intense foci of tracer activity in the left axilla . hybrid single - photon emission tomography - computed tomography ( spect / ct ) of the shoulder region localized tracer uptake to the left brachialis muscle hematoma .

inflammatory myofibroblastic tumor ( imt ) is rare and characterized by spindle cell proliferation with inflammatory cell infiltration . because of its cytological features and infiltrative nature , it may be difficult to distinguish histologically from malignant sarcomatous lesions . a 36-year - old male was referred to our hospital for further examination of a bladder tumor . cystoscopy revealed a broad - based tumor 40 mm in diameter ( fig 1 ) . he had a medical history of hyperlipidemia , diabetes mellitus , asthma , and bipolar disorder . the hematological and biochemical data showed no abnormal findings without elevation of hba1c of 8.4% . the tumor markers were also within normal limits ( cea 1.4 ng / ml , ca125 12 u / ml , ca199 7 u / ml ) . magnetic resonance imaging ( mri ) showed a 40 25-mm mosaic bladder mass of high intensity on diffusion images ; the tumor was suspected to have invaded the muscle ( fig 2 ) , but computed tomography revealed no distant metastasis . histologically , the urothelium showed no atypia . in the submucosa , spindle cells proliferated in interlacing fascicles or storiform arrays with inflammatory cell infiltration . immunohistochemically , the spindle tumor cells were strongly positive for anaplastic lymphoma kinase ( alk ) and smooth - muscle actin , weakly positive for cytokeratin ae1/ae3 and p53 but negative for desmin . based on these findings , the tumor was diagnosed as imt . the patient has not experienced recurrence in the 10 months since resection of the bladder tumor . the hematological and biochemical data showed no abnormal findings without elevation of hba1c of 8.4% . the tumor markers were also within normal limits ( cea 1.4 ng / ml , ca125 12 u / ml , ca199 7 u / ml ) . magnetic resonance imaging ( mri ) showed a 40 25-mm mosaic bladder mass of high intensity on diffusion images ; the tumor was suspected to have invaded the muscle ( fig 2 ) , but computed tomography revealed no distant metastasis . histologically , the urothelium showed no atypia . in the submucosa , spindle cells proliferated in interlacing fascicles or storiform arrays with inflammatory cell infiltration . immunohistochemically , the spindle tumor cells were strongly positive for anaplastic lymphoma kinase ( alk ) and smooth - muscle actin , weakly positive for cytokeratin ae1/ae3 and p53 but negative for desmin . based on these findings , the tumor was diagnosed as imt . no adverse perioperative events were observed . the patient has not experienced recurrence in the 10 months since resection of the bladder tumor . imt also known as postoperative spindle cell nodule , pseudosarcomatous fibromyxomatous tumor , and reactive pseudosarcomatous response involve only inflammatory cells . these tumors have been observed in any organ , including the lung , liver , and kidney . the most frequently reported symptom is gross hematuria followed by urinary pain , dysuria , and increased urination frequency . the tumor has been observed in a wide range of ages , from around 30 to 50 years , with an equal balance of genders . although the causes of this tumor have long been believed to be urinary tract infection , surgical invasion , diabetes mellitus , and immune disorders , a number of idiopathic cases have also been reported [ 4 , 5 ] . in our case , the patient had diabetes mellitus . in this case , the tumor size was around 4 cm in diameter . reported imts were around 25 cm in most cases , but 1 case showed 37.5 cm [ 1 , 4 ] . due to the risk of local recurrence , complete resection is recommended . on the other hand , grossly , imt shows a variety of forms , but in most cases , the tumor adopts a nonpapillary form with a rounded surface . on mri , the tumor typically shows low intensity on t1-weighted imaging and high intensity at the surface with low intensity inside on t2-weighted imaging . histologically , imt is characterized by proliferation of myofibroblastic spindle cells and inflammatory cell infiltration . the most important entities in differential diagnosis are sarcomatoid urothelial carcinoma , leiomyosarcoma , and rhabdomyosarcoma because of the similarity of histological findings . finding cytological atypia and atypical mitotic figures and immunostaining with alk are useful to differentiate imt from other malignant spindle cell tumors [ 1 , 9 ] . although there have been no reports of distant metastasis , intravesicle recurrence was reported after transurethral resection . partial bladder resection is required after transurethral resection . however , in cases of benign tumors , total cystectomy should not be performed due to the risk of misdiagnosing them as sarcomatoid carcinoma .

a 36-year - old male was referred to our department for further examination of asymptomatic gross hematuria emanating from a bladder tumor . cystoscopy revealed a broad - based tumor 40 mm in diameter . urinary cytology was negative . preoperative magnetic resonance imaging suggested a muscle invasive tumor . transurethral resection was performed , and the pathological findings revealed an inflammatory myofibroblastic tumor . we herein report a rare case of bladder inflammatory myofibroblastic tumor .

mycosis fungoides ( mf ) is a cutaneous t cell lymphoma ( ctcl ) characterized by infiltration of skin with patches , plaques and nodules composed of t - lymphocytes . it has various stages , premycotic , patch , plaques , nodules , tumours and erythroderma . tumour demblee is a variant of tumour stage , which develops from normal skin without prior patch or plaque stage . a 55-year - old hindu male , tobacco farmer by occupation , presented with multiple infiltrated plaques and nodules of 3 months duration over the face and scalp . the nodules started from ears and spread all over the face and scalp , increasing in size and number . patient had a history of severe itching episodes for past three years which were not relieved by antihistaminics . there was history of episodes of fever , weight loss , anorexia , and nausea for the past 2 months . multiple infiltrated plaques and nodules with few erosions and foul smelling superficial ulcers were present over face and scalp . the infiltrated skin over forehead , nose and ear lobules and loss of eyebrows gave a leonine face appearance [ figures 1 and 2 ] . the nodes were discrete , non - tender , mobile , and firm in consistency . loss of hair was seen on scalp , eyebrow , and axillary region . nodules plaques and erosions over face investigations revealed a hemoglobin level of 8.6% gm and the erythrocyte sedimentation rate ( esr ) of 110 mm / hour . chest x - ray , lymph node aspiration cytology and bone marrow examination did not reveal anything abnormal . ultrasonography of abdomen and pelvis and computed tomography ( ct ) scan of head and neck , chest , abdomen , and pelvis were normal . histopathological examination of the excision biopsy from a nodule over face showed a lymphocytic infiltrate in the papillary dermis and around the hair follicle and pilosebaceous unit . epidermotropism was noted with formation of well defined pautrier 's microabscess at places [ figure 4 ] . biopsy showing epidermotropism ( h and e , 40 ) biopsy showing clusters of atypical lymphocytes within the epidermis ( pautrier microabscesses ) ( h and e , 400 ) immunohistochemistry showed positive cd3 and lca markers as and cd 30 and cd 20 negativity . he termed it mycosis fungoides because of the resemblance of the lesions to mushrooms . in 1885 , vidal and brocq described mycosis fungoides d emblee for a patient presenting with skin tumours not preceeded by patch or plaques . in this type of mf mf is the most common type of ctcl and accounts for almost 50% of all primary cutaneous lymphomas . however other lymphoproliferative disease also involve the skin including ki-1 + anaplastic large cell lymphoma , peripheral t - cell lymphoma , cutaneous b - cell lymphoma , adult t - cell leukaemia/ lymphoma , t - cell lymphoid leukaemia and cutaneous hodgkin 's disease . incidence of mf has been estimated to range from 0.06 to 0.1 per 10,000 cancer cases per year in the usa . the term tumour d emblee is now falling into disrepute and these tumors may , in fact , be pleomorphic cd 30 negative cutaneous t - cell lymphoma ( peripheral t - cell lymphoma ) , which have undergone large cell transformation . many of these cases are likely to be classified by immunophenotyping as various types of non - mf t - cell lymphoma or even b - cell lymphoma of the skin . such type of mf d emblee has been reported rarely in past.[1214 ] many cases described as the demblee variant in the past may have represented other types of lymphomas . the cd 30 negative large ctcl and small/ medium sized pleomorphic ctcl have been described in literature to be presenting with tumors without prior or concurrent patches or plaques along with histological presentation sometimes similar to that of mf . the cd 30 negative large ctcl ( 5 year survival of 15% ) has a poor prognosis compared with small/ medium sized pleomorphic ctcl ( 5 year survival of 60% ) . usually the mean interval between appearance of skin lesions and definite diagnosis by histopathology is approximately 6 years , however , in our case it was only 3 - 4 months . the patient was treated with chop regimen [ cyclophosphamide , hydroxydaunorubicin ( doxorubicin ) , oncoverin ( vincristine ) , prednisone ] plus methotrexate . taking into account that this case of tumour d emblee also showed typical histopathological changes along with cd30 negativity and the eventual death of the patient within short span of time after the diagnosis , it is possible that the patient had cd 30 negative large ctcl , which could not be confirmed owing to limited resources in our hospital set up . this case is reported because of an acute and masquerading presentation of mycosis fungoides reiterating the fact that ctcl can pose an enormous diagnostic challenge .

mycosis fungoides is a cutaneous t - cell lymphoma characterized by infiltration of skin with patches , plaques , and nodules composed of t - lymphocytes . it is the most common type of cutaneous t - cell lymphoma and accounts for almost 50% of all primary cutaneous lymphoma . tumour d emblee is the term used for the patient presenting with skin tumors not preceded by patches or plaques . we report a rare case of mycosis fungoides d emblee variant with tumors of only 3 months duration without any preceding skin lesions .

we describe one patient who was affected by an and presented high level increase of serum liver enzymes , along with sever thrombocytopenia . a 14-year - old boy with an was admitted in the pediatric psychiatric emergency department of alzahra hospital with impaired electrolyte levels , bradycardia , hypotension , liver dysfunction , and thrombocytopenia . a ten - time increase in liver enzymes and thrombocytopenia were observed on admission . after two months of treatment , improvement of initial clinical symptoms and recovery of liver enzymes and thrombocytopenia after the treatment suggested that liver dysfunction and thrombocytopenia may be observed in an patients and should be taken care of by physicians . a 14-year - old boy with an 8-month history of an referred to our outpatient clinic ( department of pediatrics , alzahra hospital ) . because of his physical condition ( weight loss , bradycardia , imbalanced electrolytes , hypothermia , hypotension , and lung and liver dysfunction ) we decided to hospitalize him ( figure 1 ) . a male patient with anorexia nervosa . on admission to the psychiatric unit , his body weight and body mass index ( bmi ) were 31 kg and 13.2 , respectively . in addition , his liver enzymes were high , and his platelet decreased as shown in table 1 . other causes of acute liver dysfunction such as hepatotoxic drugs , alcohol , cocaine and viral hepatotoxic diseases were evaluated and then ruled out . we started to treat the patient with conservative management including stabilizing electrolytes by serum therapy and nourishment using a high calorie diet . a marked decrease in serum transaminase and an increase in platelet count were observed with a gradual normalization of all the biochemical parameters within one months of hospitalization . he started eating and his electrolytes got balanced and his family became happy about his recovery . therefore , he was discharged after one months of hospitalization and successfully continued his rehabilitation program on an outpatient basis . this was one of the uncommon cases of an with a high level increase ( 10 times more ) of liver enzymes and sever thrombocytopenia . minor degrees of liver injury have been reported in up to 40% of patients with an.13 although the mechanism of liver injury in an has thought to be due to protein - calorie malnutrition of the kwashiorkor type accompanied with fatty changes , this has not been rigorously demonstrated and the mechanism is still unknown.1314 in an , malnutrition has been reported to cause thrombocytopenia along with liver dysfunction.2 one report has described temporal changes in liver enzyme levels , platelet count , and thyroid peroxidase ( tpo ) levels in a patient with an.3 acute liver failure with a massive increase of serum liver enzyme may be a sever , though relatively uncommon , complication caused by severe malnutrition such as that secondary to an.46 as reported in the literature , serum transaminases do not reach such high values during the refeeding syndrome.7 to avoid complications of refeeding syndromes,7 nutritional rehabilitation is started with a low - energy oral and parental nutrition ( 25 kcal / kg body weight ) . therefore , follow up of serum liver enzymes should be part of our evaluation to prevent the uncommon but serious risk of acute liver failure . our case report showed an an patient with increased level of liver enzymes about 10 times more than normal range , as well as severe thrombocytopenia , which is uncommon . therefore , it is concluded that physicians should be aware of high level increase of liver enzymes and severe thrombocytopenia which may occur in an .

background : anorexia nervosa ( an ) is a difficult - to - treat psychosomatic disease . very few cases of acute liver failure associated with an have been described . we describe one patient who was affected by an and presented high level increase of serum liver enzymes , along with sever thrombocytopenia . then , we discuss the possible etiopathogenic factors.methods:a 14-year - old boy with an was admitted in the pediatric psychiatric emergency department of alzahra hospital with impaired electrolyte levels , bradycardia , hypotension , liver dysfunction , and thrombocytopenia.results:a ten - time increase in liver enzymes and thrombocytopenia were observed on admission . after two months of treatment , the levels were within the normal range.conclusions:improvement of initial clinical symptoms and recovery of liver enzymes and thrombocytopenia after the treatment suggested that liver dysfunction and thrombocytopenia may be observed in an patients and should be taken care of by physicians .

aggressive angiomyxoma was first reported as a distinct variant of myxoid neoplasms in the female vagina and pelvis by steeper and rosai . these tumors mostly occurs in 3 to 5 decade of life and 95% in females . these lesions have a predilection for female pelvic soft parts , slow growth , frequent recurrences , and are characterized histologically by a predominantly myxoid stroma and an abundance of thin and thick walled vascular channels . this is a deep soft tissue tumor , which as the name suggests , may have a locally aggressive course . most tumors occur in women and are large , usually greater than 10 cm , slowly growing , and painless . the most common location is in the perineal region and may exert pressure on adjacent organs . no . a 8332 came to our opd on 05.08.05 with chief complaints of growth in the vulva - 2 month , bleeding from the growth - 1 month , irregular period - 6 month . no history of htn , dm , tb . tubectomy was done a year ago . on examination , gc is fair , pallor + , no palpable ln . no organomegaly , others nad , groin- nad . local examination of the vulva revealed a 8 5 cms pedunculated growth [ figure 1 ] having its thick pedicle of about 1.5 cm thickness hanging from the clitoreal region slightly on the left side [ figure 2 ] . p / r- nad . clinical presentation growth coming out from the clitoreal region on investigation , hb % - 9.8 gm% , abo gr.- o + ve , rbs- 101 mg / dl , rft - wnl , lft - wnl . pap smear - nad , cxr - nad , usg ( w / a ) nad . she was planned for wide excision of the vulval growth ; accordingly it was done under sa on 18.08.05 [ figure 3 ] . on sectioning , the mass had focally infiltrating margins and a rubbery glistening grey / white surface [ figure 4 ] . post op hpe revealed aggressive angiomyxoma [ figures 5 and 6 ] , cut margins negative . ihc studies revealed desmin and vimentin + ve , er , pr + ve and s100 protein negative . she is under regular follow - up , and doing well for the last 5 years . hpe shows thin epidermis and underlying hypo cellular myxoid tissue containing blood vessels of various calibers high power view showing hyaline thickening of blood vessels aggressive angiomyxoma is a rare , benign neoplasm that can be mistaken both clinically and on microscopy for several other conditions , it should be included as a differential diagnosis for any vaginal mass . it is important to diagnose this condition because the tumour is locally infiltrative and requires wide excision and follow up . it occurs mainly in the female pelvis , vulva , or perineum , though some cases are described in men . some authors believe that it is the only possible treatment , but surgery is often radical and can be mutilating , with massive blood loss . it also requires postoperative intensive care monitoring , and the recurrence rate after surgery remains high even if negative margins are obtained at the initial resection . a retrospective review has shown that patients having positive margins were as likely to have recurrence as those with negative margins . immunohistochemistry of the tumor cells revealed diffuse immunoreactivity for estrogen receptors , progesterone receptors , vimentin , and cd34 . no expression of s-100 protein , bcl-2 protein , cd117 ( c - kit gene product ) , epithelial membrane antigen , desmin , or h - caldesmon could be demonstrated .

aggressive angiomyxoma is a rare , benign neoplasm occurring in 3rd to 5th decade of life that can be mistaken both clinically and on microscopy for several other conditions , it should be included as a differential diagnosis for any vaginal mass . these lesions have a predilection for female pelvic soft tissues , slow in growth , and are characterized histologically by a predominantly myxoid stroma and an abundance of thin and thick walled vascular channels . this is a deep soft tissue tumor , which as the name suggests , may have a locally aggressive course . most tumors occur in women and are large , usually greater than 10 cm , slowly growing , and painless . standard of care treatment for angiomyxoma has been surgery . some authors believe that it is the only possible treatment , but surgery is often radical and can be mutilating , with massive blood loss .

atrial septal defects ( asd ) are congenital deficiencies of the atrial septum , most commonly occurring in the fossa ovalis and referred to as secundum defects as they result from failure of development of the septum secundum.1 failure of the development of the septum primum results in partial atrio - ventricular septal defects and these are the second commonest . the venosus defects are the least common and arise at the junction of the sinus venosus and the primitive atrium ; when situated close to the superior vena cava they are often associated with anomalous drainage of the right pulmonary veins and when the occur close to the inferior cava there is often override of the cava in relation to the atrial septum . large defects allow substantial left to right shunting , resulting in volume overload of the right heart and pulmonary vascular tree.2 untreated asds may cause a variety of complications . these include the eventual development of pulmonary hypertension that is initially reversible , but may later become irreversible , atrial arrhythmias and paradoxical embolisation with organ infarction . asds may close spontaneously in childhood.2 persistent defects with pulmonary to systemic flow ratios ( qp / qs ) of > 1.5 are operated before school age or whenever a diagnosis is made if this occurs later.3 significant residual asds after surgical closure have been documented in up to 17% of patients at catheterisation,4 and currently , this figure is down to 2%.3 a variety of devices for transcatheter closure of asds have been developed and offer an alternative to surgical treatment.5 we present a patient who had surgical closure of asd , with a second defect that was overlooked . she presented with atrial flutter ; electrophysiological studies showed that she had a slow - slow atrioventricular nodal re - entry tachycardia which degenerated into atrial flutter . slow pathway ablation was carried out at the base of the triangle of koch . during the procedure , an inferior atrial defect was diagnosed and successfully closed with an amplatzer aso ( atrial septal occluder ) device . the patient ( female ) had had surgery for asd at 34 years of age at a tertiary referral centre where a two by three cm defect was closed by direct suture . she represented four years later with palpitations due to atrial flutter and ablation was undertaken . atrioventricular nodal re - entry tachycardia was found and slow pathway ablation was carried out . during the procedure , the ablation catheters persistently passed from right to left atrium indicating the presence of an atrial communication . a left upper pulmonary angiogram showed a significant defect low in the interatrial septum very close to the junction of inferior vena cava and right atrium with no inferior margin ( figure 1 ) . balloon sizing using the aga medical sizing balloon measured the stretched diameter at 19 mm ( figure 2 ) . a 19 mm amplatzer aso device was successfully deployed across the defect under transoesophageal echocardiography and fluoroscopic guidance ( figures 3 and 4 ) . right atrial angiography ( figure 5 ) and transoesophageal echocardiography confirmed complete occlusion of the defect and with no impairment of flow through the inferior cava . transthoracic echocardiography and cxr on the following day confirmed good device placement and ecg was also normal . the amplatzer device has been used to close a wide variety of asds , ranging from defects in children , to persistently patent foramen ovale with presumed paradoxical embolism in older individuals.6 the device has also been used for palliation in complex congenital heart disease.7 around 70% of asds are amenable to trans - catheter closure and the amplatzer device is the most commonly used because of ease to deliver and deploy , retrievability , and a wide range of size from 4 to 40 mm . those asds not suitable for transcatheter closure include venosus ones with anomalous pulmonary venous drainage , very large defects , insufficient septal length to accommodate the device and poor margins , especially posteriorly and inferiorly . although this case had no inferior margin , it was possible to secure the device straddling the top end of the inferior cava and the atrial wall . as the septum secundum had been surgically closed , this part of the septum was firm and the device could , therefore , be secured superiorly so that inferiorly the device could be stabilised where the septal margin was deficient . this report highlights the need to fully assess the atrial septum both before and during surgery or intervention as multiple asds can be missed particularly if situated in unusual positions . some cases generally considered unsuitable for catheter closure can still be dealt with by intervention under certain circumstances . although , atrial flutter or incisional atrial tachycardia occur after atrial surgery , it is important to remember that other arrhythmia substrates may be responsible .

we present a patient who had transcatheter closure of a low atrial septal defect which was overlooked during surgical closure of a secundum atrial septal defect . the residual defect was detected during ablation for atrial flutter , and was closed successfully during the same procedure with an amplatzer atrial septal occluder ( aso ) device .

the course of the three major nerves crossing the elbow is quite consistent , yet in some instances variations are encountered particularly if the elbow has deformed following previous episode of fracture and surgery . we present here a case of entrapment of radial nerve in the bone without any signs of nerve palsy resulting from an old supracondylar fracture of the humerus . a 23-year - old male patient presented with cubitus varus deformity of the left elbow . the patient developed the deformity following some fracture around elbow in the childhood at the age of 8 years that was managed conservatively in plaster cast after closed reduction . on examination , the boy had 15 of cubitus varus deformity , full range of elbow movements , and no distal neural deficit . radiograph showed an oblique joint line suggestive of varus deformity and evidence of old healed remodeled fracture line . two foramina of 3 - 4 mm diameter were seen on anteroposterior view on a vertical plane . the distal hole had a sharp margins while proximal had indistinct margins , similar holes were seen in oblique view [ figure 1 ] . ( a ) anteroposterior and ( b ) lateral radiographs of the elbow showing two foramina marked with black arrows this child was undertaken for lateral wedge corrective osteotomy at elbow , the lateral approach to the elbow between the flexor and extensor compartments was used to expose the site of osteotomy . when the perisoteum from the anterior surface of the lower humerus was lifted , some anomalous structure entering into the bone was noticed on the medial side of the supracondylar region . on further dissection it looked like neural tissue [ figure 2 ] , and was thought to be the median nerve . we attempted to make a window into the bone and free the nerve but it was seen that the nerve was severely entrapped in the bone and on our repeated attempts to remove it , it got transected . we planned to explore all the three nerves at the elbow to ascertain the identity of the nerve as its course was very aberrant . post operatively the function of both ulnar and median nerves was normal , but there was radial nerve palsy [ figure 2a and b ] . ( a ) per - operative clinical photograph showing entrapped nerve in the bone and ( b ) the damaged radial nerve after attempts to remove it by cutting the bone the elbow was mobilized after 1 month . at 2 months all implants were removed and tendon transfers for radial nerve palsy , namely , pronator teres to extensor carpi radialis brevis , palmaris longus to extensor pollicis longus , and flexor carpi radialis to extensor digitorum communis was done . with extensive physiotherapy , it is very unusual to find the radial nerve to be entrapped in the callus . one such case was reported by symeonides et al.3 duthie1 has described a case of radial nerve palsy of long standing after a fracture of the shaft of the humerus in which the nerve was found to be enclosed in an osseous tunnel that was evident in the radiographs . roaf2 referred to a case of median nerve paralysis of late onset after dislocation of the elbow with fracture of the medial epicondyle , which during healing created a tunnel ensheathing the nerve . in both cases the nerve palsy indicated the correct diagnosis , which was supported by the radiographic findings . in our case no such palsy existed and this led us to take it as a usual case . this case is interesting because it had no preoperative nerve palsy , the unusual position of the osseous tunnel and the high risk of division or severe damage to the nerve . we feel that before embarking on a reconstructive operation for post - traumatic cubitus varus , it is essential to examine the radiographs carefully for the presence of foramina suggestive of nerve entrapment , and if suspected , always explore the radial nerve at an early stage in the procedure .

entrapment of a nerve in the callus of a healing fracture is not a common entity , but it does exist . the entrapment usually presents without neurological deficit . it is difficult to suspect the radial nerve injury if we need to operate on the same site . we present a case of entrapment of radial nerve in the callus of a supracondylar humerus fracture with cubitus varus deformity . the surgery for correction of the deformity led to the damage of the nerve . in retrospect a careful assessment of the x - rays showed two 3 - 4 mm diameter holes . awareness of this finding would have given us sufficient indication of nerve entrapment to prevent this mishap .

endophytic actinobacteria have a capacity to produce numerous secondary metabolites with a mass of biological activity , such as antibiotics , antitumor and anti - infection agents , plant growth promoters and enzymes , and may promote plant establishment under adverse environmental stresses . introducing such bacterial strains to plant tissues can result in increased plant growth , usually due to suppression of plant pathogenic microorganisms . it seems to be pivotal for obtaining a healthy microfloral balance within plants , soil appearing to be an important and moderating source of bacterial endophytes . recently , our group has isolated from a carrot sample from xinjiang uyghur autonomous region ( china ) a novel species of paenibacillus dauci sp . 100608 = jcm30283 ) , which can produce potential antimicrobial substances playing the part of endophytic actinobacteria . comparisons with 16s rrna gene sequences as shown in fig . 1 revealed that the novel strain had the highest similarity to paenibacillus hunanensis fel05 ( 97% ) . however , the phylogenetic distances from recognized species ( fig . 2 ) indicated that p. dauci sp . nov . is not affiliated to any of these recognized species . we can therefore conclude that this strain represents a novel species of the genus paenibacillus . what 's more , high nitrogenase activity , strong antagonism against plant pathogenic fungi , extensive carbon source utilization , and stress resistance were also uncovered . in consequence , investigation of the genetic information and characteristics of p. dauci knowledge of the genome sequence and bioinformatics will be of great help in this regard . here we present the draft genome sequence of strain p. dauci h9 obtained using the illumina hiseq 2000 system , which was performed by shenzhen bgi . tech . the reads were assembled with soapdenovo , , the version is 2.04 , and the sequence was annotated using the rast annotation server ( fig . sequencing was performed based on the paired - end strategy of 473 reads to produce 790 mb of filtered sequences , representing a 126-fold coverage of the genome . the sequence of paenibacillus algorifonticola xj259 is 5,449,237 bases with a g + c content of 46.5% , which was assembled into 26 contigs and 19 scaffolds . it contains 4766 open reading frames ( orfs ) , 77 trna genes , and 1 rrna gene ( table 1 ) identified by glimmer 3.02 , genemark , trnascan - se , and rnammer . according to the genomic analysis of strain p. dauci , we analyzed 36 orfs related to antibiotic metabolic process . additionally , 12 orfs were also discovered related to trehalose , which makes us believe that it could be related to the shock - resistant mechanism since the trehalose is regarded as a molecular chaperone . what 's more , the biosynthesis of vitamin b was annotated in the strain p. dauci as there were 19 orfs related to vitamin b12 production and vitamin b6 metabolism . further studies will be performed to confirm their functions , and a complete genome sequence will be included in the future to reveal the unique molecular characteristics of strain p. dauci . this whole genome shotgun project has been deposited at ddbj / embl / genbank under accession number laqq00000000 . the version described in this paper is the first version , with accession number laqq01000000 . the authors declare that there is no conflict of interest on any work published in this paper .

paenibacillus dauci sp . nov . , a new kind of endophytic actinobacteria , is separated from the inner tissues of carrot sample , which forms intimated associations with carrot acting as biological control agents . here we report a 5.37-mb assembly of its genome sequence and other useful information , including the coding sequences ( cdss ) responsible for biological processes such as antibiotic metabolic process , antimicrobial metabolism , anaerobic regulation and the biosynthesis of vitamin b and polysaccharide . this novel strain can be a potential source of novel lead products for exploitation in the field of pharmaceutical , agriculture and industry .

it was recently revealed that one quarter of paediatric intensive care beds in holland are closed and that many critically ill children have to be transferred to receive care . problems organizing paediatric intensive care exist in most health care systems . if we are to avoid crises such as this then we have to solve two fundamental problems : the way in which we staff the intensive care units with nurses ; and the lack of information that we have regarding the service that we are trying to commission . first , they are usually required to have specific higher postgraduate training in order to work at a basic grade . such training may not enhance their pay as compared with other nurses in other disciplines . second , their career structure is pyramidal , which limits the opportunities for individual progression and increases the appeal of lateral career moves into less stressful environments such as community nursing or ( in the uk ) national health service direct . from the nurse 's perspective , salary progression is usually linked purely to administrative responsibility and often fails to recognise significant additional practical and intellectual skills , such as intensive care training itself or additional experience ( e.g. in techniques such as haemofiltration or extracorporeal membrane oxygenation ) . even when additional recurrent funds are identified to commission a paediatric intensive care service , it can thus prove prohibitively difficult to open intensive care beds . furthermore , when service provision is inadequate , problems with recruitment suffer from negative reinforcement . centralization of care in large high volume units enables the best return from any limited resource , and it is tempting to assume that nurses will be the same as any other resource in this respect . nurses are unlikely to commute large distances to find work in intensive care in preference to a local change in specialty . effective planning and commissioning of a paediatric intensive care service requires close audit of activity , which we lack . in many cases the capacity of a paediatric intensive care service can be described in terms of the number of physical bed spaces present , but this does not reassure us that the beds are accessible . variations in patient dependency , the numbers of nurses available and their skill mix all have to be taken into account when deciding whether a bed can be used at a given time . even knowledge of the number of accessible beds tells us nothing about the amount of work being done . such information can only be gained by looking at patient flow ( admission rate , duration of stay , occupancy , readmission rate ) and intervention rates . even then , information regarding quality of care is lacking . a limited view of the quality of care ( its effectiveness ) can be inferred from standardized mortality ratios generated using mortality prediction models . however , the use of mortality data in this way has been questioned in paediatric intensive care , where survival rates are greater than 90% and morbidity may be of increased relevance because of the potential longevity of survivors . most literature and research using standardized mortality is based on the performance of individual units or groups of units . from an epidemiological perspective , however , it is preferable to know what happened to every child from a defined population who received intensive care ( irrespective of where it was provided ) and whether a lack of resources meant that some children were denied intensive care . there is evidence that increasing numbers of children are receiving or are expected to receive intensive care . in the uk ( or at least in birmingham ) this is occurring without a change in the intubation rate , implying that the change could represent partial resolution of an asserted shortage . where there are ample resources there is a tendency to provide high dependency care and ' observation ' on the intensive care unit , whereas triage otherwise limits this tendency . hence , when great variation in the incidence of intubation is observed within or between health care systems , one can infer variation in resource provision . the greatest concern must be when refused admissions occur in units with high intubation rates . the appropriateness of intensive care admission or intervention ultimately still has to be judged on a case review basis . the development of the mortality prediction model ' pim ' ( paediatric index of mortality ) has involved a collaboration that has , among others , incorporated all paediatric intensive care delivered in australia . the epidemiological superiority of these data will increase the influence of the conclusions drawn from it . in the uk , where we have long suffered from similar problems to those currently affecting holland first , this is being achieved through a study designed to assess the relevant mortality prediction models , which is to include morbidity ( united kingdon paediatric intensive care outcome study , ukpicos ) . the study has recruited all the major providers of paediatric intensive care in the uk . second , the english department of health has commissioned a continuous audit of paediatric intensive care to follow on from that study called ' picanet ' ( paediatric intensive care audit network ) , which will include the successful severity model . hence , commissioners will have access to comparative , risk adjusted , performance data on which to make their decisions .

problems with commissioning paediatric intensive care stem both from difficulties in recruitment and retention of nurses , and from incoherent or nonexistent national audit . pyramidal career structures and patterns of remuneration that concentrate on administrative responsibility over clinical skills underlie the former , whereas poor audit conceals variations in both service quality and demand . epidemiologically superior data are required if we are to solve commissioning problems . we need to know what happened to every child from a defined population receiving intensive care and whether a lack of resources means that some children are denied intensive care .

the index patient , a 26-year - old woman , was admitted to the infectious disease ward of a university hospital with a temperature of 40c and myalgias 3 days after she returned from a 3-week trip to cambodia and thailand . she was discharged in good condition after the fever subsided . on the day of admission of the index patient ( day 0i ) , a nurse sustained a needlestick injury with a hollow needle that had been used for drawing blood from the index patient . the needlestick resulted in a bleeding puncture wound that was immediately treated with an antiseptic . the index patient did not report any high - risk activity for hiv or hepatitis b virus , and the nurse had been immunized against hepatitis b virus . therefore , no specific postexposure prophylaxis was performed . the nurse had previously been in good health and had not traveled outside germany in the preceding 12 months . four days after the needlestick , headache , myalgias , and arthralgias developed in the healthcare worker , for which she took ibuprofen . seven days later , when she was experiencing an intense headache and noticed a macular rash on her trunk , she sought treatment from a local doctor ( day 0n ) . physical examination showed bilateral cervical lymphadenopathy . on day 2n , she visited our service , where dengue virus infection was diagnosed by using a light cycler ( roche diagnostics , mannheim , germany ) polymerase chain reaction ( pcr ) method . her symptoms lessened gradually over the course of 4 weeks , and she was on sick leave for 5 weeks . the time frame of the respective clinical presentation and the virologic results of the index patient and the nurse are shown in the figure ; laboratory data are presented in the table . time line of the signs , symptoms , and diagnostic tests in the index patient ( i ) and nurse ( n ) . ig , immunoglobulin ; eia , enyzyme immunosorbent assay ; pcr , polymerase chain reaction ; nd , not done . serologic studies were performed with the panbio dengue immunoglobulin ( ig ) m capture enzyme - linked immunosorbent assay ( elisa ) and panbio dengue indirect igg elisa ( panbio ltd . , brisbane , australia ) ( 3 ) ; arbitrary units relative to a simultaneously measured calibrator > rna was prepared from 140 l of serum by using the qiaamp viral rna mini kit ( qiagen , hilden , germany ) , according to the manufacturer s instructions . to detect specific dengue virus rna , we adapted a taqman - reverse transcription ( rt)-pcr ( 4 ) to detect any of the four serotypes by using the following : degenerated forward primer ( den fp ) , reverse primer ( den rp ) ; and probe ( den p ) : den fp 5aaggactagaggttakaggagaccc3 , den rp 5ggccytctgtgcctggawtgatg3 and the probe den p 5 fam - aacagcatattgacgctgggaragacc - tamra-3 . rt - pcr conditions for the light cycler ( roche diagnostics ) were : rt at 61c for 20 min , activation at 95c for 5 min , and 40 cycles of pcr at 95c for 15 s , 60c for 60 s. we used the rna master hybridization probes kit ( roche diagnostics ) with 500-nm primers and 200-nm probes . the kit includes an aptamer - blocked thermus thermophilus dna polymerase , which performs rt and , once the aptamer drops out at activation , hotstarts pcr amplification . this is the fourth reported case , to our knowledge , of nosocomial dengue virus transmission ( 57 ) and the first in which taqman rt - pcr was used to provide evidence of nosocomial transmission before the detection of an antibody response . the index patient had acquired a dengue virus infection in southeast asia and experienced typical symptoms . in particular , she was febrile on admission , when the needlestick injury of the nurse occurred . in the health care worker who sustained the injury , cephalgia and myalgias developed after an incubation period of 4 days . a typical rash appeared after 11 days , when she also had a severe headache . the absence of fever , the most common sign of dengue fever , is likely due to the administration of ibuprofen . however , the healthcare worker was on sick leave for 5 weeks with resulting socioeconomic consequences . the diagnosis was confirmed in both cases by both seroconversion and detection of dengue viral rna by taqman rt - pcr ; the latter gave positive results in both cases 3 and 6 days , respectively , before serum specimens were shown to contain antibody . dengue viremia is known to correlate well with the presence of fever ( 8) , which was the case in the index patient . our report illustrates the potential of percutaneous nosocomial transmission of dengue viruses . this risk is likely to increase with the increase in the number of dengue infections imported to countries where dengue viruses are not endemic

recent transmission of dengue viruses has increased in tropical and subtropical areas and in industrialized countries because of international travel . we describe a case of nosocomial transmission of dengue virus in germany by a needlestick injury . diagnosis was made by taqman reverse transcription polymerase chain reaction when serologic studies were negative .

cranioplasty is performed for calvarial defects due to the facts that this region is vulnerable to trauma , calvarial defects may cause cerebral atrophy and convulsions or for cosmetic purposes7,10,12 ) . improvement of neurological deficits , control of convulsions and partial prevention of cerebral atrophy are achieved after these operations12,14 ) . edwards and ousterhout4 ) advocated autogenous bone graft being the most appropriate cranioplasty material for children and adolescents however allogreft material was emphasized as the ideal graft for adults3,5 ) . one of the most important complications of cranioplasty is late infection or foreign body reaction mimicking infection2,3,7,14 ) . infections are usually seen 3 - 10 months after the cranioplasty operations3,7 ) however late infections presenting 20 years after cranioplasty operations as seen in our case are very rare . a 43-year - old male patient was admitted to our hospital with the complaint of purulant discharge from the right temporal inscission site for one year . twenty days after craniectomy , cranioplasty had been performed to craniectomized region with allograft material . laboratory examination revealed normal levels of erythrocyte sedimentation rate ( 5 mm / h ) , c - reactive protein ( 0.2 mg / l ) and white blood cells ( 7.910/l ) . in cranial computed tomography ( ct ) scan , allograft cranioplasty material and calcified tissue together was seen as hyperdense area ( fig . 1a ) . in cranial mri scan , allograft cranioplasty material together with calcified and fibrotic tissue thereunder was seen ( fig . ; white - yellow coloured tissue layer was seen on the surface of cranioplasty material ( fig . after removal of the cranioplasty material ; calcified , fibrotic and white - yellow coloured tissue layer 5 mm in thickness was seen in epidural area ( fig . there was no physical change in cranioplasty material after removal of surrounding tissues ( fig . 2c ) . cranioplasy is performed to cranial defects for functional and cosmetic purposes5,7,12,14 ) . in craniectomized patients ; scalp herniates towards brain through defect and makes irritation to brain by means of atmospheric pressure leading to cerebral atrophy and convulsions . improvement of neurological deficits , control of convulsions and partial prevention of cerebral atrophy are achieved after cranioplasty in these patients12,14 ) . in our case infection rates are higher in patients previously operated for cranioplasty or another cranial operation and whose previous operations include frontal sinus3,7,13,14 ) . infective complications are higher when time passing between craniectomy and cranioplasty is not long enough6,9,11,13 - 15 ) . in our case , the time interval between craniectomy and cranioplasty is only 20 days which is not long enough and thought to be facilitating infection . no statistical significance was found between the infection rates and size of cranioplasty material used , choice of allograft or autograft , the prophylactical antibiotic used , age , sex , site and duration of operation14 ) . edwards and ousterhout4 ) advocated that autograft is the ideal cranioplasty material for children and adolescents while allograft material was emphasized to be more appropriate for adults and previously infected patients3,5,7 ) . the previously used cranioplasty material in our case was allograft and we replaced it with allograft material again . cheng et al.3 ) emphasized that neither negative culture of infected material rules out infection nor positive culture certainly indicates it . the culture of purulant discharge and removed graft with surrounding reactive tissues were negative in our case but we still diagnosed the case as late cranioplasty infection . detection of air bubbles and dural contrast enhancement in cranial ct are not signs of infection due to the fact that these findings are detected in infected as well as uninfected patients ( 1 ) . for this reason , the most reliable indicator of infection is the clinical presentation of the patient as always instead of imaging techniques and laboratory findings only . in our case , infection of cranioplasty presented 20 years after the operation which is very rare in the literature . however , possibility of this late complication should be appreciated and that follow - up period after cranioplasty operations should not be short considering late cranioplasty infections .

cranioplasty is performed using autograft and allograft materials on patients to whom craniectomy was applied previously due to the facts that , this region is open to trauma and the scalp makes irritation and pressure onto the brain paranchyma causing brain atrophy and convulsions . dramatical improvement of neurological deficits , control of convulsions and partial prevention of cerebral atrophy are achieved after these operations . one of the most important complications of cranioplasty is late infection . here , we report a 43-year - old male patient admitted with the history of purulant discharge from the right temporal incission site for one year to whom cranioplasty had been performed with allograft material 20 days after craniectomy which had been performed in 1989 . allograft cranioplasty material was removed and cranioplasty was performed using new allograft material with the diagnosis of late cranioplasty infection .

hemangiopericytoma is a mesenchymal tumor that occurs most commonly in the soft tissues of the upper and lower extremities , pelvis , and retroperitoneal space and seldom in visceral organs ( 1 ) . due to its vascular origin transarterial embolization is a procedure which can be performed prior to surgery of highly vascular tumors in order to avoid perioperative bleeding . although there are a few reports ( 3 , 4 ) of preoperative embolization of hemangiopericytomas , to our knowledge , there has been no report to apply a preoperative embolization of a primary hemangiopericytoma of the rib . a 62-yr - old man was admitted to our department with the complaints of progressive dyspnea , an aching chest pain on the right side , malaise and anorexia with weight loss on 4 december 2001 . his medical history was noteworthy for diabetes mellitus type ii , a 10-pack year history of smoking , and a moderate history of alcohol . on physical examination , a chest roentgenogram on admission demonstrated a large , indistinct opacity on the peripheral region of the right lower zone associated with blunting of the right lateral costophrenic sulcus . computed tomographic ( ct ) scans of thorax revealed a homogeneous mass expanding the right seventh rib and invading into the adjacent lung , and a right sided pleural effusion ( fig . histopathologic examination of the pleural biopsy specimens were reported as chronic pleuritis . to clearly identify the mass , a ct - guided , core needle biopsy was performed . the ultrasonography and ct of the abdominopelvic region , magnetic resonance imaging of both upper and lower extremities and ct of the cranium were reported as normal . preoperative angiography showed hypervascularization of the tumor from the right 7th and 8th ( fig . 2 ) , and also from 9th intercostal arteries . we performed embolization with polyvinyl alcohol ( pva ) particles . firstly , we embolized arterioles within the tumor for which we used pva , 250 m in size . then , embolization of the feeding arteries of the tumor was done with pva , 750 - 1,000 m in size . complete resection of the mass with 7th , 8th , and 9th rib with a surgical margin of 5 cm and a wedge resection of the adjacent lung was done . macroscopic evaluation of the resected tumor revealed an encapsulated and lobulated mass located posteriorly to the 6th to 9th ribs . microscopic evaluation of the tumor revealed a solid mesenchymal mass composed of indistinct fusiform to rounded cells arranged around slit - like and branching thin - walled vessels ( fig . immunohistochemically tumor cells stained positively for vimentin and focally for cd-34 , and negatively for cytokeratin , smooth muscle actin , s-100 and cd-31 . hemangiopericytomas , that are believed to be derived from the vascular pericyte , rarely originate from ribs , although they can be found in any region which contains pericytes ( 5 ) . but , it may be asymptomatic and may be detected as an abnormal shadow on a chest radiography film ( 3 ) . the radiographic appearance is that of a mass on the lateral chest wall ( 6 ) . rarely , it may reach a huge size occupying two thirds of one hemithorax ( 7 ) . in our case , thorax ct revealed that a large indistinct opacity on the peripheral region of the right lower zone on chest radiography was a homogeneous mass expanding the right seventh rib . microscopically the tumor consists of numerous vascular spaces of variable size and shape separated by aggegates of tightly packed oval to spindle - shaped cells with bland nuclei . mitotic figures and nuclear atypia are variable in number and degree ( 6 ) . in our case , microscopic evaluation of the tumor revealed a solid mesencymal mass composed of indistinct fusiform to rounded cells arranged around slit - like and branching thin - walled vessels . gomori silver impregnation method revealed a dense reticulin meshwork confirming the perivascular distribution of tumoral cells . the results of immunohistochemical studies were consistent with the diagnosis ( 8) . because hemangiopericytomas are highly vascular tumours , because the choice of treatment for primary ones is surgery , and because some authors ( 3 , 5 ) reported massive bleeding during the operation of hemangiopericytomas , we performed transarterial embolization preoperatively in order to prevent or decrease perioperative bleeding ( 3 ) . and then , the patient underwent a right thoracotomy during which there was no any significant bleeding . because the recurrence rate was reported as 50% ( 7 , 9 ) , long - term follow - up is necessary for the patient . in our case finally , our case report has two important features : 1 ) primary hemangiopericytoma of the rib is an extremely rare tumor ; 2 ) preoperative embolization of a primary hemangiopericytoma of the rib have not been reported heretofore .

primary hemangiopericytoma of the rib is extremely rare and only a few cases have been reported . a 62-yr - old man presented with an aching chest pain and dyspnea . thoracic computed tomography revealed a homogenous mass expanding the right seventh rib . a diagnosis of hemangiopericytoma was established by percutaneous needle biopsy . preoperative embolization of the feeding vessels of the tumor was performed in order to prevent perioperative bleeding . there was no significant bleeding during the surgery , where complete resection of the tumor with 7th to 9th ribs with a surgical margin of 5 cm was performed . postoperative course was uneventful and there has been no recurrence for thirteen months . to our knowledge , there has been no report to apply a preoperative embolization of a primary hemangiopericytoma of the rib .

as result of improved surgical techniques and newer immunosuppressive regimens contributing significantly to better graft survival , exocrine pancreas transplantation remains the standard treatment of choice for patients with diabetes mellitus complicated by end - stage renal disease . histological assessment continues to play an important role in the diagnosis of graft complications after pancreas transplantation , especially for evaluating allograft rejection where histopathology is still considered the gold standard . a review elaborates on the current types of pancreas transplants and focuses on the patterns of allograft injury that are encountered in posttransplantation pancreas biopsies along with the pertinent differential diagnoses . in addition to optimal histological assessment , as in any other organ transplant setting , clinical information including indication and duration of transplant as well as other serologic work - up must be taken into consideration during clinical decision making for optimal graft outcome . several lines of laboratory and clinical evidence suggest that in a carefully selected group of patients , long - term glycemic control and allograft function are similar to that observed for pancreas transplants performed for type 1 diabetes . the first successful pancreas transplantation in conjunction with a simultaneous kidney transplantation ( spkt ) was performed by kelly and lillehei from the university of minnesota in 1966 . one of the alternative options to spkt for type i diabetics with renal failure is sequential transplant of a living donor kidney followed by a deceased donor pancreas transplant ( pancreas after living donor kidney transplant , palk ) . adults ( age 18 - 59 years ) with type i diabetes who were waitlisted for kidney - pancreas and received a spkt or palk between 2000 and 2007 were now studied . of 11,966 patients who received a kidney transplant , 807 received a palk and 5580 received a spkt . median time to pancreas from kidney transplant was 336 ( 25 - 75 % : 185 - 602 days ) days . average hospital stay for spkt recipients was 13 15 days , whereas for palk recipients was 6 4 days and 10 8 days for kidney and pancreas transplants , respectively . after controlling for confounding factors , patients receiving palk had better patient survival ( hr 0.52 ; 95 % confidence interval 0.39 to 0.70 ) and kidney survival ( hr 0.48 ; 95 % confidence interval 0.39 to 0.60 ) but worse pancreas survival ( hr 1.37 ; 95 % confidence interval 1.16 to 1.62 ) compared with spkt . thus , among those who were waitlisted for a kidney - pancreas transplant , 53 percent received a kidney - pancreas transplant . of those who received a kidney - pancreas transplant , 87 percent patients underwent spkt and 13 percent underwent palk . it was found an inferior pancreas graft survival and longer total transplant hospitalization in palk . pancreas transplantation provides the best glycemic control option for diabetes mellitus but is associated with significant morbidities related to infectious disease . it was performed a retrospective study of a cohort of consecutive pancreas transplantation recipients in whom pancreas transplantation was performed from 1998 to 2006 ( n=216 ) and followed up them until 2008 . data regarding infections , rejection , infection chemoprophylaxis , graft failure , absolute lymphocyte counts , and mortalities were collected . simultaneous pancreas and kidney , pancreas transplantation alone , and pancreas after kidney ( pak ) transplantations were performed in 42 , 67 , and 107 patients , with a mean age at transplantation of 47 , 41 , and 44 years . of the simultaneous pancreas and kidney , pancreas transplantation alone , and pak transplant recipients , 55 percent , 37 percent , and 59 percent were men . overall , 63 percent developed a serious infection during the median follow - up of 6.4 years . mean ( range ) number of infectious episodes was 2.3 ( 1 - 12 ) , with mostly bacterial infections both within ( 68 % ) and after 1 year ( 78 % ) . incidence of bacterial and viral infections was greatest in the first 3 months after transplantation . bladder exocrine drainage was significantly associated with higher risk of infection ( hazard ratio 2.5 ) . infection within the first 3 months after transplantation was related to higher mortality after the first 3 months ( hazard ratio 3.19 ) . absolute lymphocyte counts was significantly associated with the risk of first infections and bacterial infections . therefore , the incidence of infections after pancreatic transplantation was 63 percent and mostly bacterial .

a pancreas transplant is a surgical procedure to place a healthy pancreas from a donor into a patient whose pancreas no longer functions properly . exocrine pancreas transplantation remains the standard treatment of choice for patients with diabetes mellitus complicated by end - stage renal disease . the use of pancreas transplantation for type 2 diabetes mellitus is an emerging concept . a pancreas transplant is often done in conjunction with a kidney transplant . even if pancreas transplantation provides the best glycemic control option for diabetes mellitus , it is associated with significant morbidities related to infectious disease . the present article provides with a review of pancreatic transplantation .

a 71-year - old man visited us with a chief complaint of a 1-year history of a mass in the right scrotum . the patient had a 15-year - history of stroke and hypertension , for which he was receiving medical treatment . the patient also had an 8-year - history of hypertensive end - stage renal disease , for which he was receiving hemodialysis three times a week . on the physical examination at the time of admission , a hard , painless mass was palpated in the right scrotum that could not be differentiated from the testis . on hematology , tumor markers such as alpha - fetoprotein , beta - human chorionic gonadotropin , and lactate dehydrogenase were all found to be normal . scrotal ultrasonography showed a giant mass of 12 cm in size in the right scrotum . abdominal computed tomography scans showed a solid , contrast - enhanced mass in the right scrotum . we suspected that a tumor had developed in the scrotum and made an incision in the right scrotum with the patient under spinal anesthesia . we identified a tumor that was definitely separated from the right testicle and excised it . the removed tumor was 13106 cm in size and had an oval shape ; it was encapsulated and its cross - section was composed of white mucoid components . the sporadic presence of a solid part was confirmed , but there was no concurrent necrosis or bleeding inside . small and medium - sized blood vessels were shown under light microscopy . in the adjacent area , two months postoperatively , the patient is currently being followed up in an outpatient setting and has had no local recurrence . embryologically , various tissues such as the epithelium , mesothelium , and other tissues are derived from the mesoderm in the scrotum . for this reason , these tumors have different biological characteristics , for which a differential diagnosis between benign and malignant tumors and an accurate diagnosis can not be easily made . of the tumors occurring in the scrotum , angiomyofibroblastoma was first described by fletcher et al in 1992 , which is a tumor that occurs rarely in the reproductive system of middle - aged women . it particularly occurs in the vulva , labium major , vagina , areas around the clitoris , and perineal region . despite a lower rate of local recurrence , it has histopathological characteristics that are similar to those of cellular angiofibroma and infiltrative angiomyxoma . histopathologically , there is a mixed presence of hypocellular or multi - cellular regions and the cellular morphology is diverse . besides , there is also a mixed presence of spindle - shaped cells , satellite cells , epithelioid cells , and locally polygonal cells . these cells are arranged around the blood vessels or epithelioid - shaped regions and are accompanied by the clear presence of myofibroblastic differentiation . eight cases have been reported in the vulva of female patients in korea . to date , however , no cases have been reported in male patients . compared with the angiomyofibroblastoma - like tumors that occur in women , those occurring in male patients are seen in elderly people and have immunohistochemical differences . histopathologically , the cellular matrix of an angiomyofibroblastoma - like tumor is more dense and is abundant with collagen . immunohistochemically , in more than half of the reported cases , tumor cells are positive for cd34 and are various for desmin . however , they are negative for s-100 protein . in the present case , because of the presence of histopathological characteristics that are similar to those of angiomyofibroblastomalike tumors , a differential diagnosis of infiltrative angiomyxoma can not be easily made . an accurate diagnosis is therefore mandatory . to date , only a small number of cases of angiomyofibroma and infiltrative angiomyxoma have been reported . it is assumed , however , that local surgical removal will be sufficient for a complete recovery . angiomyofibroblastoma - like tumors occurring in male patients have not been reported in korea until now , and their incidence is extremely low . despite the presence of benign findings on histopathology , in cases in which such tumors occur in the scrotum , both a surgical removal and a histopathologic examination are mandatory for a differential diagnosis . furthermore , in cases of infiltrative angiomyxoma , for which the histopathologic findings are similar , a meticulous monitoring of local recurrence is essential . an appropriate follow - up observation of the long - term clinical course after the surgery is also essential .

various tumors can occur in the scrotum . of them , angiomyofibroblastoma - like tumors are very rare mesenchymal tumors . angiomyofibroblastoma - like tumors can not be easily differentially diagnosed from other malignant tumors invading the male genital tract on the basis of clinical characteristics and imaging study . therefore , surgical removal and a histopathologic diagnosis must also be performed .

chorea is the ceaseless occurrence of rapid , jerky , dyskinetic , involuntary flicking movement of hands , face , and other parts of body . huntington 's disease ( hd ) and drugs account for more than 50% of such patients . basic pathology involved in chorea and other hyperkinetic movements is damage to various parts of basal ganglia that ultimately leads to disturbances in neurotransmission . in chorea , there is degeneration of gamma aminobutyric acid ( gaba ) secreting neurons in the caudate nucleus and putamen of basal ganglia . the normal inhibition by gaba neurons is lost in globus pallidus , and substantia nigra resulting in over activity of excitatory transmitters causing the distortional movements . phenytoin sodium is an anti - seizure drug widely used for generalized tonic clonic seizures . few cases have been reported to cause hyperkinetic movements by various anti - seizure drugs . here , we report a case of phenytoin induced chorea in a child possibly due to interaction between anti - seizure drugs . a 3-year - old female patient weighing 10.5 kg was admitted in pediatric ward of sir takhtsinhji general hospital , bhavnagar , gujarat , with complaint of low grade fever for three days and convulsions with frothing , involuntary micturition , and altered sensorium for one hour . patient was treated with injection lorazepam ( 0.04 mg / kg ) followed by injection phenytoin ( 5 mg / kg ) intravenously to control the seizures . all investigations like total leukocyte count , differential leukocyte count , liver function tests , renal function tests , random blood sugar , and cerebrospinal fluid ( csf ) examination were normal except hemoglobin ( 9.0 g / dl ; reference value : 12.0 to 18.0 g / dl ) , positive c - reactive protein ( crp ) , and ionized calcium ( 1.01 mmol / l ; reference value : 1.16 to 1.32 injection phenytoin ( 5 mg / kg / day ) and injection phenobarbital ( 5 mg / kg / day ) intravenously were given for five days and tablet clobazam ( 0.75 mg / kg / day ) was given for three days to control seizures . injection acyclovir ( 40 mg / kg / day ) and injection methyl prednisolone ( 2 mg / kg / day ) were started as empirical therapy on 5 day . from 6 day , syrup phenytoin ( 30 mg/5 ml ) , 4 ml , 12 hourly , and syrup phenobarbital ( 20 mg/5 ml ) , 6 ml , 12 hourly , were started after stopping injectable anti - seizure drugs . on the 8 day , patient developed involuntary , continuous , uncontrolled , jerky movements of head and upper limbs , which was diagnosed as chorea . there was no family history of hd and diagnosis of viral encephalitis was not confirmed so it was suspected as drug induced chorea with phenytoin being an offending agent . patient was having an attack of convulsions two days after stopping phenytoin ; hence , sodium valproate ( 15 mg / kg / day ) was added to treatment . naranjo 's scale showed that the relationship between phenytoin and chorea was probable . according to modified schumock and thornton 's criteria , this reaction was probably preventable and modified hartwig and siegel 's scale showed that the reaction was moderately severe ( level 3 ) . chorea and hyperkinetic movements are the rare side effects of phenytoin . in this case , recovery on de - challenging the phenytoin therapy and normal laboratory investigations are in favor of diagnosis of the phenytoin induced chorea . normal ct - scan report after emergence of reaction has ruled out any structural damage to basal ganglia . involuntary movements caused by phenytoin are mainly related to its high plasma concentration ( 40 - 50 prolonged phenytoin therapy or its high plasma concentration is related with increased dopaminergic and serotonergic activity in basal ganglia that may be considered as a cause of chorea . phenytoin toxicity depends on the route of administration , duration , exposure , drug interaction , and dosage . drugs that alter the functions of these enzymes can place the patient at risk of toxicity . addition of clobazam to the patients who had been taking maximum tolerable dose of phenytoin is reported to result in its intoxication . though , both are enzyme inducers , they may increase plasma concentration of each other by competitive inhibition of their metabolism . acyclovir decreases plasma concentration of phenytoin due to interference in absorption . in our case , acyclovir was started parentrally on 5 day and is less likely to affect the plasma level of phenytoin . use of phenytoin along with clobazam and phenobarbital may have resulted in increased plasma concentration of phenytoin due to an interaction between them which may have caused the reaction . combined use of phenytoin and lamotrigine has been reported to cause the hyperkinetic movement disorder . a possible interaction between phenytoin , phenobarbital and clobazam may have resulted in chorea in this case . it is important that therapeutic drug monitoring should be done and drug interactions should be kept in mind especially when two or more anti - seizure drugs are prescribed . early detection and withdrawal of suspected drug in such cases can help to prevent further harm to the patient .

a 3-year - old female patient developed chorea possibly due to an interaction between phenytoin , phenobarbital and clobazam used for generalized tonic clonic seizures . phenytoin withdrawal resulted in recovery within 24 hours . post reaction computerized tomography ( ct)-scan of brain was normal . combined use of anti - seizure drugs and interactions between them may be responsible for the reaction . therapeutic drug monitoring is important while prescribing two or more anti - seizure drugs .

short anagen syndrome ( sas ) is a recently recognized congenital disease clinically characterized by persistently short fine hair since birth , due to a decreased duration of the anagen phase . the common complaint is that the hair does not grow long and that it has never been cut . only a few cases have been published in the literature , mainly in caucasian blond - haired girls . although some authors claim that short anagen is rare , others believe that it is just under - recognized . we here present a case of sas in a hispanic , dark - haired girl . a healthy hispanic 3-year - old girl presented with a history of short hair since birth . the mother reported that there was excessive shedding and poor hair growth , and that the girl had never needed a haircut . the patient was well- developed and did not present any abnormality except for short , dark , and thin hair [ figures 1 and 2 ] . note the short length hair in a 3-year - old child telogen hair with tipped point dermoscopy of pulled hairs showed 4.7 cm long telogen hairs with tipped points , which indicates that the hair had never been cut . short anagen hair syndrome , as the name indicates , is a condition where the anagen phase is shortened and subsequently there is an increase in the number of telogen hairs . the disease is congenital and is thought to be sporadic , even though familial cases have been reported which may suggest an autosomal dominant inheritance . clinically , although the hair shaft is normal without signs of breakage the patients are not able to grow long hair and present with increased shedding . the condition is usually benign , nevertheless associations with tricho - dental syndrome , synchronized pattern of scalp hair growth , and micronychia have been reported . the characteristic clinical image and the finding of short ( less than 6 cm long ) telogen hairs with a tipped point at the pull test or trichogram makes the diagnosis . the main differential diagnosis has to be made with loose anagen syndrome , which also presents with short hair , but the hair is shed during anagen . treatment is not necessary as this condition tends to improve after puberty , however improvement with minoxidil and cyclosporine has been reported . for the exception of a case reported in an african - american patient , three others in caucasians with dark brown hair , and one in an asian patient most cases have occurred in caucasians with fine blond hair . to our knowledge , based on a search of pubmed , ( lilacs ) latin american and caribbean health sciences literature , and google scholar from 1999 to the present , using the terms short anagen and sas as key words , this is the first case published in a hispanic dark - haired girl in the english medical literature .

short anagen syndrome ( sas ) is a condition in which hair does not grow long . it usually perceived by parents in children around 2 - 4 years of age . it is a benign disease of the hair cycle . the condition is relevant from the standpoint of differential diagnosis with loose anagen syndrome . we report a case of sas in a hispanic 3-year - old girl .

nineteenth and twentieth century biology was completely based on misleading ideological imposition that living entities are particular states of matter and in that era biologists have only made several attempts to deny the living organism of its veracity as an immortal soul , in favor of genes , molecules , atoms and so on . twenty first century biology realizes that living entities ( animate objects ) do things , which are intentional and purposeful ( internal teleology ) and nonliving objects ( inanimate objects ) have things done to them ( external teleology or design ) . from bacterial antibiotic resistance we can see that even the tiny bacterium displays the sign of great intelligence ( natural genetic engineering ) . unlike inanimate objects , all living cells ( and all living organisms ) create and maintain order . to create and maintain this order every cell has to work like a tiny chemical factory , performing many millions of reactions every second . thus , the proponents of creationist movement/intelligent design argue that an intelligent being is necessary for the creation / design of factory ( example of external teleology ) from the basic elements or parts . this is a more reasonable argument as compared to the imprudent materialistic view that the cell / life is a product of mere accumulation of inert chemicals . however , vednta philosophy is not based on creationist movement/intelligent design or reductionistic materialistic views . according to vednta philosophy an organic whole ( life comes from life or every cell comes from a cell biogenesis ) and an organic whole ( prna ) can not come from the mechanical and chemical additive sum of the parts ( khanda ) . caetano - anolls completely missed this main point , which the paper life and consciousness it is empirically observable that every day sun rises in the east and hence it is logical to conclude that the first sun rise was in the east. there is no problem , if someone wants to dedicate his whole life to do a rigorous scientific research to prove the opposite first sun rise was in the west. the problem arises when keeping such illogical views in mind someone wants to critique those who have the conviction on the obvious vedntic explanation that independent supreme cognizant being is the source of everything is founded on 2 scientifically verifiable axiomatic facts : ( 1 ) life comes from life , and ( 2 ) matter comes from life . consciousness arises from consciousness , or life comes from life . where there is life there is consciousness . consciousness does not originate from that which is unconscious or impersonal , and life is not a product of insentient matter . the conception that life comes from life ( biogenesis ) is the only scientific idea that has ever been verified by experiment and observation . matter comes from life are 2 scientifically observable deductions from vednta . on the other hand , materialism ( life originates from matter ) is an unverified ideological presupposition that has no scientific or observation - based evidence to support it . for a detailed critique of darwinian objective evolution of bodies and abiogenesis ( material origin of life ) , and a further elaboration on vedntic view for soul hypothesis , consciousness and subjective evolution of consciousness one can refer author 's recent paper why biology is beyond physical sciences? , the published book chapter and the article sorry , darwin : chemistry never made the transition to biology.

abstractthe author would like to thank professor gustavo caetano - anolls from department of crop sciences , university of illinois for his interest in his work . we may sometimes observe that there is a noticeable difference between the anecdote people narrate about the implications of a scientific paper and the real conclusion of the paper . prof . gustavo caetano - anolls 's response1 is an ideal example of the same , where he has tried to make great hay about the implications of the article life and consciousness the vedntic view.2 the vedntic view subscribes neither to the views of creationist movement/intelligent design , nor it supports some splendid anti - science proposal . vedntic view refutes the dominant reductionistic view of life in modern biology by proposing a viable alternative concept of organic whole and thus serves a scientific critique to the nescience ( avidy ) that is practiced on the name of science .

involvement of the central nervous system ( cns ) in patients with carcinoma of the uterine cervix is rare and published studies state that only 1% of patients with cervical carcinoma develop cns metastases . most of the reports in the literature on cns metastases from cervical carcinoma are metastases to cerebral or cerebellar parenchyma . meningeal metastases from the uterine cervix with histological variants of squamous cell carcinoma , adenocarcinoma , adenosquamous cell carcinoma and neuroendocrine carcinoma have been reported . metastasis to the dura is less frequent and cervical carcinoma metastatic to dura is extremely rare . in this report , we describe a case of isolated pachymeningeal metastases ( dural metastases ) from squamous cell carcinoma of the uterine cervix with involvement of dura as well as the optic nerve . a 50-year - old woman presented to our hospital with the chief complaint of bleeding per vaginum for 2 months . she also complained of severe headache , which had worsened in the weeks preceding presentation . pelvic examination revealed a bulky , friable growth in the cervix and a presumptive diagnosis of carcinoma of the cervix was made . no neurological defects were detected and ophthalmic evaluation revealed a normal fundus with no impairment of ocular movement . routine haematological evaluation revealed low haemoglobin levels ; the rest of the parameters were normal . as part of the routine work up , ultrasound scan of the abdomen and pelvis was performed . had increased in severity , contrast enhanced computed tomography ( ct ) scan of the brain was performed ( fig . a lobulated enhancing lesion was also seen in the left orbit involving the dural surface of the optic nerve ( fig . no lesions were seen in the cerebral or cerebellar parenchyma nor was there any cerebral oedema , mass effect , or midline shift . cerebrospinal fluid ( csf ) was obtained for cytological analysis and this revealed the presence of malignant squamous cells , thus confirming the diagnosis of pachymeningeal metastases . figure 1(a ) ultrasound image showing the mass in the cervix ; ( b ) contrast enhanced ct showing enhancement along the falx cerebri ; ( c ) contrast enhanced ct showing a lobulated mass in the left orbit involving the optic nerve . ( a ) ultrasound image showing the mass in the cervix ; ( b ) contrast enhanced ct showing enhancement along the falx cerebri ; ( c ) contrast enhanced ct showing a lobulated mass in the left orbit involving the optic nerve . brain metastases from squamous cell carcinoma of the uterine cervix are uncommon and isolated dural metastases extremely rare . carcinomatous meningitis occurs when cancer cells gain access to csf pathways , travel to cns sites , settle there and grow . the proposed routes for metastases to get access to the dura include perineural , perivascular , and haematogenous spread or through direct invasion from bony deposits . an isolated case of meningeal metastasis secondary to advanced squamous cell carcinoma has been reported . describe the cytological features of meningeal metastases from cervical squamous cell carcinoma . in both cases , contrast enhanced ct and gadolinium enhanced magnetic resonance ( mr ) imaging techniques have been used in the diagnosis of leptomeningeal metastases and all neuroimaging features of the disease have been discussed in detail . gadolinium enhanced mr is superior to contrast enhanced ct in detecting meningeal abnormalities when most of the enhancement lies against the skull vault.calvarial metastases from cervical carcinoma inducing a dural tail adjacent to the tumour have also been studied using gadolinium enhanced mr imaging . gadolinium enhanced mri studies of carcinomatous meningitis secondary to large cell cervical neuroendocrine carcinoma have shown diffuse pachymeningeal enhancement . benign conditions may cause leptomeningeal ( pia and arachnoid ) enhancement with a similar appearance to leptomeningeal metastases and these include infective and inflammatory meningitis , and iatrogenic causes ( surgery and chemotherapy ) . in contrast , carcinomatous meningitis causes pachymeningeal enhancement that is intense and linear , and thickening of the meninges along the inner surface of the calvarium , falx or tentorium without extension into the cortical gyri and basal cisterns . in our case , contrast enhanced ct exhibited thickening of the dura and intense linear enhancement along the falx cerebri suggesting pachymeningeal metastasis . the enhancing mass in the left orbit all these features are suggestive of pachymeningeal metastasis from squamous cell carcinoma of the uterine cervix involving the dural covering of the brain and optic nerve . methotrexate ( mtx ) is the most commonly used intrathecal chemotherapeutic agent for the treatment of carcinomatous meningitis from cervical carcinoma in addition to radiation therapy .

abstractthis report describes the case of a 50-year - old woman with carcinomatous meningitis from squamous cell carcinoma of the uterine cervix . ultrasound showed an irregular hypoechoic mass in the cervix . contrast enhanced computed tomography imaging revealed intense linear enhancement along the falx cerebri suggestive of pachymeningeal metastasis with involvement of the optic nerve . to our knowledge this is the first reported case of imaging features of isolated metastatic dural involvement from cervical carcinoma . moreover , this is the first case of its kind in which dural involvement was diagnosed at presentation in a locally confined tumour .

an 81-year - old woman recognized pruritic scaly erythemas on the scalp 2 months before the visit to our hospital . her medical history included nephrosis syndrome that had been treated with oral cyclosporine 100 mg / day for 8 years . the results of routine blood work before the onset of skin eruptions had been normal . although the head erythemas appeared to be seborrheic dermatitis ( sd ) , the lesions did not respond to topical steroidal lotion . when she visited our hospital , the eruption had disseminated to the trunk and extremities , resulting in generalized erythroderma ( fig . laboratory tests showed white blood cells 13,900/l ( normal 3,5009,800 ) , hemoglobin 11.9 mg / dl ( normal 11.315.5 ) , platelets 271,000/l ( normal 155,000365,000 ) , eosinophils 19.0% , atypical lymphocytes 2.0% , lactate dehydrogenase 517 iu / l ( normal 176353 ) and soluble interleukin-2 receptor 1,510 u / ml ( normal < 550 ) ; human t - lymphotropic virus type i antibody was negative . a skin biopsy of the erythema of the trunk showed that lymphocytes and eosinophils had infiltrated dominantly to the superficial perivascular space . 2 ) . polymerase chain reaction and flow cytometry of the skin specimens failed to detect malignant cells . however , atypical lymphocytes ( basket cells ) were detected in the peripheral blood and bone marrow ( fig . 3 ) . flow cytometry of the blood and bone marrow specimens showed that malignant cells were positive for cd2 , cd3 , cd4 , cd5 , cd7 , cd25 and cd45ra . positron emission tomography - computed tomography revealed abnormal enhancement of axillary and inguinal lymph nodes and bone marrow . we consulted a hematologist and peripheral t cell lymphoma not otherwise specified ( ptcl - nos ) , stage iv according to ann arbor was diagnosed . ptcl can cause sd - like dermatitis that gradually develops into auto - sensitization dermatitis . as chemotherapy was dismissed considering her age , we administered fexofenadine 120 mg / day and oral prednisolone 20 mg / day so as to alleviate erythroderma and pruritus . we added pregabalin 50 mg / day according to the recommendation by yosipovitch , which reduced pruritus dramatically . the amount of daily oral steroid was tapered to 5 mg over 4 months , maintaining remission of cutaneous symptoms . few publications have described sd as a paraneoplastic syndrome in cases with lung cancer and lymphoma [ 4 , 5 , 6 ] . the diagnosis of paraneoplastic syndrome usually requires concurrent onset and parallel course with malignancy at least . although we could not confirm whether the severity of the sd would parallel that of ptcl , sd seems to be a paraneoplasia since the onset of the sd coincided with that of ptcl and the sd was resistant to ordinary topical therapy . although the mechanisms of pruritus as well as the antipruritic effect of anticonvulsive agents are not clear , they probably inhibit central itch pathways . in this case , simple sd and subsequent auto - sensitization dermatitis were suspected at first . however , the sd was too resistant to ordinal therapy and developed to erythroderma . complete blood count revealed the presence of lymphoma that became an important clue to diagnosis .

seborrheic dermatitis is an inflammatory eruption that tends to distribute on the sebaceous areas of the body and is rarely described as a paraneoplasia . here we report a case with a responsive seborrheic dermatitis - like eruption of the head which resulted in generalized erythroderma . intensive examinations detected concurrent malignant lymphoma .

robust data assessing the value of procalcitonin ( pct ) for monitoring treatment response in abdominal sepsis are rare , so the study of jung and colleagues published in the previous issue of critical care is most welcome . they concluded that a decrease of pct to 0.5 ng / ml lacked sensitivity to predict treatment response and a decrease of at least 80% from its peak failed to accurately predict treatment response . the value of the study is limited by the small number of patients included , the single - center approach and its observational character . nevertheless , it is to date among the best available evidence we have for these critically ill patients . international databases show that one in four cases of severe sepsis or septic shock is caused by intra - abdominal infection . abdominal sepsis is not just a single disease , but comprises a group of different entities . almost 90% of all intra - abdominal infections are so - called secondary peritonitis and require a primarily surgical approach ( 87% of patients had surgical intervention in the study of jung and colleagues ) . secondary peritonitis consists of community acquired and postoperative nosocomial forms , the latter one following a previous surgical intervention ( anastomotic insufficiency following anterior rectum resection ) . tertiary nosocomial peritonitis is a persistent intra - abdominal infection without a surgically treatable focus , but this point is difficult to assess without an uncontributive reoperation proving that the patient indeed has a tertiary peritonitis . primary inadequate and inappropriate antibiotic regimens for both forms of nosocomial peritonitis are associated with substantially worse prognostic outcome for patients with intra - abdominal infections and result in substantial increases in health care costs . the difficulties associated with abdominal sepsis are complicated by uncertainty about surgical control of the source of the sepsis . do we have any reliable parameters that enable us to decide whether to perform a relaparotomy or not ( in the jung and colleagues study about 20 out of 101 patients required a relaparotomy ) ? an analysis of all investigated markers , including pct , failed to detect specific parameters that can be used under these difficult conditions . current guidelines recommend administration of broad - spectrum antimicrobials within 1 hour of the diagnosis of severe sepsis or septic shock . this recommendation is based on the evidence that delaying antimicrobial therapy in patients with sepsis- related hypotension is associated with increased mortality . pct has been evaluated over recent years as to whether it can be used to detect the presence of different types of infection , treatment failure or adverse outcome . the promising initial publications reporting the results of using serial serum pct concentrations to guide duration of antibiotic therapy in patients with community - acquired pneumonia have only partially been confirmed in critically ill patients . a recent randomized multicenter trial enrolling critically ill patients with mainly respiratory tract infection showed that duration of antibiotic therapy can be reduced by a mean of 2.7 days without impact on mortality . but unfortunately , pct had no influence on the duration of antibiotic therapy in patients with intra - abdominal infections . smaller randomized studies show that significant pct - guided reduction of antibiotic exposure can safely be accomplished in patients with severe sepsis and septic shock and in surgical patients with sepsis . more recently , it has been suggested that pct may be of value as a prognostic marker . daily measurements of pct in a general icu population in a recent large multicenter randomized study were associated with increased use of antibiotics and duration of mechanical ventilation . this commentary has been written by an abdominal surgeon and an intensivist , representing the two disciplines most frequently involved in the treatment of an important subgroup of critically ill patients . in this war against the high mortality from abdominal sepsis , surgeons and intensivists are brothers in arms . the study of jung and colleagues indicates that pct is still a valuable weapon in this war - but far from being the magic bullet .

the ideal management of infection includes not only the early identification and start of effective therapy but also the correct categorization of non - infected patients in order to avoid unnecessary use of antimicrobials . the availability of a specific and sensitive test for the presence of infection is of paramount importance to improve the prudent use of antimicrobial therapy . procalcitonin ( pct ) has been evaluated over recent years as to whether it can be used to detect the presence of different types of infection , allows reduced duration of antibiotic therapy , or predicts treatment failure or adverse outcome . in the previous issue of critical care , jung and colleagues report about the monitoring of treatment response in abdominal sepsis by repetitive determination of pct .

histologically it can be categorized as one of five histologic subtypes : capillary , cavernous , venous , arteriovenous or mixed . case reports describe hemangiomas of the chest wall arising from intercostal muscles ( intramuscular , intercostal ) or from the medullary canal of the rib ( bone hemangioma ) . we describe a patient with an intercostal venous hemangioma presenting as a chest wall tumor , for which resection of the chest wall was successfully accomplished . a 36-year - old male was admitted to the clinic of thoracic surgery for a slowly progressing chest mass and six - month pain of the thoracic spine and left chest . there was no medical history of trauma of the chest wall and no oncological disease . during clinical examination a slowly growing soft resistance located dorso - laterally in the range of the seventh to ninth rib on the left chest chest magnetic resonance ( mr ) imaging showed a well - bordered tumor of the left chest wall , with a size of 9.5 x 9 x 3 cm with calcifications , overgrowing to the seventh and eighth intercostal space ( fig . the patient underwent surgery . a complete resection of the tumor with the left seventh , eighth and ninth ribs and their intercostal muscles was successfully accomplished ( fig . microscopically , structures of benign vascular lesions corresponding to intramuscular venous hemangioma with numerous phleboliths were found in adipose tissue and striped muscle in the resected chest wall . the patient was discharged on the seventh postoperative day , and presently , ten months after the operation , he is doing well , without any evidence of local recurrence . coronal t2-weighted mr images of the intercostal hemangioma of the chest wall ( a ) and enhancement by contrast media ( b ) reconstruction of the chest wall with used polypropylene mesh ( a ) . intramuscular hemangiomas occur most often in people under 30 years of age and show no sex predilection . generally they are considered to be congenital , but factors such as chest trauma or repetitive bruises may play a role in development of intramuscular hemangioma [ 2 , 3 ] . patients with intercostal hemangioma clinically may present with palpable mass of the thoracic wall , soft - tissue bulging , pain or a combination of these signs and symptoms . intercostal hemangioma should be included in the differential diagnosis of primary soft tissue chest wall tumors , such as fibromas , lipomas , giant cell tumors , neurogenic tumors , desmoids , soft tissue sarcomas , connective tissue tumors and metastatic tumors . conventional radiography hemangiomas may be seen as an ill - defined soft - tissue mass . regional ribs may show periostitis , trabecular coarsening and cortical changes such as thickening , thinning or erosion . computed tomography ( ct ) of the chest localizes and characterizes chest wall hemangioma , its effect on adjacent structures and it can also reveal phleboliths . a preliminary diagnosis may be established by mr examination , when classic mr findings are present : tumor mass of low or intermediate signal intensity in t1-weighted images and a high signal intensity in t2-weighted images ( vascularity is manifested as a high signal intensity ) . invasive diagnostic techniques , such as open or percutaneous ( ct - guided or echo - guided ) needle biopsy are also available , but needle biopsy of hemangioma may cause bleeding . in the case of big hemangiomas , a preoperative embolization of hemangiomas with the aim to minimize the risk of intraoperative complications like excessive bleeding , intercostal hemangiomas are managed by complete surgical chest wall resection with clean surgical margins . the next decision about skeletal reconstruction posterior defects that lie above the fourth rib and are covered by the scapula do not need to be reconstructed . the choice of synthetic prosthetic material depends on the location of the defect , its size and surgeon 's preference and experience . in conclusion presumptive diagnosis was based on mr , resection was performed for definitive diagnosis and treatment .

the authors describe a case of a 36-year - old patient who had six months pain of the thoracic spine and left chest . a soft slowly growing resistance was present on the dorso - lateral side of the left chest wall , in the range of the seventh to ninth rib . according to the medical history , the patient did not have any prior trauma and malignancy . a well - defined tumor of the left chest wall with calcifications , which grew to the seventh and eighth intercostal space , was present on computed tomography ( ct ) and magnetic resonance ( mr ) scans . the patient underwent resection of the tumor with the chest wall and reconstruction with polypropylene mesh . histologically , it was a venous hemangioma , one of very rare tumors of the chest wall .

myxoma is the most common benign cardiac primary tumors , accounting about 50% of cardiac tumors and is more prevalent among females . because of different size of myxomas and their location in the different chambers of heart , patients with atrial myxoma usually present with cardiovascular symptoms such as heart failure and pulmonary hypertension , secondary to mitral valve obstruction . constitutional symptoms of atrial myxoma include weight loss , fatigue , fever , clubbing , anemia , orthopnea , and acute pulmonary edema . on the other hand , myxomas may cause life - threatening cardiac symptoms , e.g. , syncope , requiring emergency surgery . two - dimensional echocardiography is the primary diagnostic imaging , not only as a complement to conventional echocardiography in the assessment of left atrial myxomas but also as a method of differentiating such masses from extra - cardiac tumors compressing the atrium . echocardiography is a helpful method that can determine the tumor size , shape , and mobility . here she dropped during the second prostration in prayer and decreased her mental state , with no prior history of syncope , shortness of breath , or chest pain . she had no significant past medical history , but she had a positive family history of early cardiovascular disease . at presentation , the patient was afebrile and had normal vital signs ( heart rate 80 bpm , blood pressure 110/70 mmhg , oxygen saturation 97% while breathing room air ) and jugular venous pressure ( jvp ) was normal . a 12-lead electrocardiogram revealed normal sinus rhythm with nonspecific minor st - t abnormalities . on cardiac examination , a transthoracic echocardiogram ( tte ) was performed which showed the presence of a pediculated mass in the left atrium , with an appearance suggestive of atrial myxoma , that was prolapsed through the mitral valve towards the left ventricle by changing patient 's position [ figure 1a c ] . ( a - c ) transthoracic echocardiography : chambers view showing a large mobile left atrial mass prolapsing through mitral valve the patient was referred for urgent surgery . she recovered without major complication and was discharged . at 2-year follow - up , she remains with excellent cardiac function . myxoma is the most common primary benign cardiac tumor . despite the fact that they can be discovered unexpectedly in asymptomatic patients , myxomas usually present with nonspecific signs and symptoms . depending on myxomas locations and their association with the heart structures , they can provide symptoms . tumors that origins from the left atrium , especially if mobile and large , may result in symptoms similar to mitral stenosis due to obstruction of atrio - ventricular blood flow . these symptoms include : exertional dyspnea , paroxysmal nocturnal dyspnea , orthopnea , fatigue , and syncope . in our patient , the tumor plop of myxoma is a protodiastolic murmur that is heard 80 to 150 ms after s2 . tumor plop may be mistaken for an opening snap , and tumor obstruction of the valve leads to a diastolic murmur . the central nervous system ( cns ) symptoms usually call for computed tomography ( ct ) or magnetic resonance imaging ( mri ) scan of the brain to exclude embolization or an aneurysm formation , which is sometimes associated with myxomas . it has been suggested as prudent to perform mri scan of the brain in all cardiac myxoma cases to exclude central nervous system ( cns ) manifestations . in our patient , transthoracic echocardiography reported a mobile and pedunculated mass in the left atrium , which was attached to the interatrial septum . the mass prolapsed into the left ventricle across the mitral valve , resulting in a mitral valve obstruction . recently , the diagnosis of cardiac tumors has improved enormously , and echocardiography has become a choice screening tool for cardiac tumors . the location of the myxoma in the left atrium and its origination from the atrial septum are chief clues for the diagnosis . thus , it is very important to recognize the location of the tumor during echocardiography . as reported in other studies , tte is usually sufficient to make the diagnosis , but if the results are suboptimal , transesophageal echocardiogram ( tee ) should be employed . in conclusion , echocardiography is likely to be a valuable diagnostic tool in patients who have had a cardiac mass . besides , it also offers the cardiologist and cardiovascular surgeon the chance of more accurate pre- and intra - operative assessment of cardiac masses .

cardiac myxoma is the most frequent benign tumors of heart . a 37-year - old woman dropped during the second prostration in prayer and decreased his mental state , with no prior history of syncope . on cardiac examination , there was an early diastolic sound that was compatible with a tumor plop . a transthoracic echocardiogram was performed which showed the presence of a pediculated mass in the left atrium , with an appearance suggestive of atrial myxoma . atrial myxoma can appear with non - specific symptoms . the best diagnostic method for myxoma is echocardiography that has a high sensitivity

the initial manifestations are neurologic in 40% of patients , hepatic in 40% and psychiatric in 15% of patients . wd is an autosomal recessive condition characterized by inability of the liver to transport and store normally absorbed dietary copper , resulting in abnormal deposition of copper in the basal ganglia , eyes , liver and other tissues . in 1912 , kinnier wilson published a description of 12 patients who presented with extrapyramidal motor disease and , on autopsy , demonstrated softening of the lenticular nucleus and cirrhosis of the liver . he further noted that these patients exhibited emotionalism , and 2 of his 12 patients presented with schizophrenic - like psychoses . scheinberg and sternlieb wrote that 1025% of patients with wd initially present with psychiatric symptoms . psychiatric symptoms in wd may range from major depression , mania , and anti - social behavior to psychosis . g. d. , a 32-year - old unmarried gentleman born of non - consanguineous parents , presented with personality change and behavioral disturbances since the last 6 months . the behavioral disturbances were in the form of emotional liability , aggressiveness and disinhibition and delusions . he had past history of jaundice at 18 years of age which resolved in 3 months . physical examination at the time of the admission revealed a kf ring obvious on naked eye examination and risus sardonicus . higher mental function examination revealed impaired attention span 7 days of week forward and 2 days of a week backward , and he was able to comprehend two - stage axial commands . he lost three points in orientation to time , two points in orientation to place , five points for calculation , one point in construction and one point in recall . he had impaired abstract thinking and could not explain the meaning of a given proverb . complete blood count ( cbc ) was normal ; total bilirubin : 0.6 mg% ; direct bilirubin : 0.15 mg / dl ; total protein : 8.2 g / dl ; albumin : 4.8 g / dl ; globulin : 3.4 g / dl ; serum glutamic oxaloacetic transaminase ( sgot ) : 35 iu ; serum glutamic pyruvic transaminase ( sgpt ) : 22 iu ; alkaline phosphatase : 84 the 24-hour urinary copper was significantly elevated , i.e. 635.52 g / day ( normal 32 - 64 g / day ) . usg abdomen revealed liver parenchymal disease with minimal free fluid in the abdomen along with splenomegaly . for the severe agitation and restlessness , he was given injection haloperidol 5 mg i m in bid doses for 2 days haloperidol was replaced with quetiapine 25 mg tablet which was increased to bid over the next 2 weeks . after 2 weeks of inpatient treatment with antipsychotics and sedatives , his behavior was controlled . the patient was started on penicillamine 250 mg daily which was gradually increased to 250 mg five times a day supplemented with pyridoxine 40 mg daily . wd is an autosomal recessive disease characterized by inability of the liver to transport and store normally absorbed dietary copper , resulting in abnormal deposition of copper in the basal ganglia , eyes , liver and other tissues . he had emotional lability , disinhibition and was severely agitated , restless with delusional thoughts . since the psychiatric symptoms in wd are generally mild , patients may not present with these symptoms . of the 108 patients , only 9 ( 8.3% ) manifested severe psychiatric symptoms that required admission . among these patients , only one patient developed bipolar disorder that began some months before the onset of neurologic disorder . our patient presented with severe neuropsychiatric symptoms and had tremors on examination which were present since 5 years . a high degree of suspicion and early detection of wd is critical because early initiation of chelation therapy can prevent a catastrophic outcome .

wilson 's disease ( wd ) is a relatively rare disease of copper metabolism . the diagnosis is often missed initially . the presentation is usually neurologic or hepatic , seen in 40% of patients . psychiatric presentation of wd is reported in only 15% of patients . we present a 32-year - old patient with severe psychiatric manifestations . on examination , he had mild rest and postural tremors and a kf ring was seen . serum ceruloplasmin was low and 24-hour urinary copper was elevated . the patient responded to penicillamine , lorazepam and quetiapine , and is being followed up .

informed consents were signed by each patient before cardiac electrophysiology procedure . after ceasing of antiarrhythmic drugs for more than five halflife periods , paul , mn 551179983 , usa or japan lifeline co. , ltd , tokyo 1400002 , japan ) were , respectively , inserted into right ventricular apex and coronary sinus ( cs ) through right femoral vein and left subclavian vein . programmed cs stimulation with extrastimuli was used for inducing tachycardia . the selection of the target sites for ablation was determined by the shortest av / va interval during sinus rhythm , avrt , or right ventricular apex pacing with a 4mm standard tip ablation catheter . the energy of rfca was delivered by power of 35w and maximum temperature of 65c . a 62yearold man without structural heart disease was referred to our institution because of the longstanding episodes of palpitation . the standard 12lead electrocardiogram showed frequent pvcs , and no other baseline abnormality was found ( fig . 1b ) , and ventricularatrial infusion was located at cs 56 which was also confirmed by rv pacing ( fig . delivery of radiofrequency energy with an ablation catheter ( 35 w , 5060c , 60 sec ) at the target site resulted in ventricularatrial disassociation with right ventricular apex pacing , and no avrt could be induced after ablation . surprisingly , the spontaneous pvcs also disappeared . to confirm the origination of the pvcs , mechanical stimulation ( fig . 1d ) the ablation catheter a little further into the left ventricle were used to compare the morphology of spontaneous and induced pvcs . as shown in the figures , the patient has been free from the same pvcs without any medications during 6month followup . ( a ) premature ventricular contractions shown by the standard 12lead electrocardiogram ; ( b ) tachycardia ; ( c ) intracardiac electrogram of ablation target ; ( d ) premature ventricular contractions with mechanical stimulation at ablation site ( a ) and pacing at ablation site ( b ) . a 54yearold man without structural heart disease presented a history of recurrent palpitations of 2 years was admitted to our laboratory . the morphology of pvcs was very similar with the qrs waves within preexcitation electrocardiogram . during electrophysiology examination , it was revealed that the ventricular insertion was located at left posterior septum where local potential advanced surface qrs waves for about 20 ms with obvious qspattern unipolar potentials ( fig . ablation at this site blocked the accessory pathway with preexciting conduction and also eliminated the pvcs at the same time . the patient has been free from the same pvcs without any medications during a followup period of 9 months . ( a ) preexcitation syndrome and frequent premature ventricular contractions shown by the standard 12lead electrocardiogram ; ( b ) intracardiac electrogram of ablation target . radiofrequency catheter ablation has been established as an effective and reliable treatment of pvcs for decades 1 . in general , most of the pvcs originate from the ventricular outflow tract or left ventricular inferoseptal site 2 . less commonly , pvcs can originate from the mitral annulus 3 , the tricuspid annulus 4 , purkinjefascicular network , left ventricular papillary muscles , and the moderator band in the right ventricle 5 . usually , the pvcs and ventricular tachycardia originating from the valve annulus can be located by the accessory pathway 's algorithm based on their electrocardiogram characteristics and be compared with the target site pacing after ablation 6 . the anatomic relationships of accessory pathways and ventricular muscle may cause disturbance of electrical activity of focal cardiac muscle cells in specific patients . during the accessory pathways ablating , the abnormal ventricular insertion which caused focal electrical abnormality the intracardiac electrogram confirmed that both accessory pathways and pvcs originating from the same site of the heart . as report above , the morphology of pacing induced pvcs was almost the same as spontaneous ones . however , the exact mechanism of this phenomenon is still unknown . however , reports of individuals with pvcs originating from the same anatomic sites as accessory pathways were rare . possibly there are some underlining mechanism and network between pvcs and accessory pathway which could not be recognized at this time .

key clinical messageradiofrequency catheter ablation has been used for treating cardiac arrhythmias , such as premature ventricular contractions and accessory pathway . we report two cases with successful ablation of leftsided accessory pathways and premature ventricular contractions from mitral annulus with one ablation . to our knowledge , no similar reports have been found so far .

idiopathic eruptive macular pigmentation ( iemp ) is a rare skin disorder characterized by the presence of asymptomatic , brown pigmented macules that involve the face , trunk and proximal extremities in children and adolescents . the first description of this condition was given by degos et al . , these hyperpigmented macules gradually resolve over months or years without any residual pigmentation or scarring . we report a case of a 10-year - old girl who fulfilled all the criteria for this entity . a 10-year -old girl presented with asymptomatic brown macules over the trunk and proximal extremities , of three months duration . they progressively increased in number and size over a period of one month and became stable . the cutaneous examination showed multiple dark brown , discrete , round to oval macules and mildly elevated pigmented lesions over the anterior and posterior trunk and proximal extremities sparing the palms and soles [ figures 1 and 2 ] . the individual lesion was 1 - 3 cm in diameter and the elevated lesions had a velvety appearance on the surface [ figure 3 ] . the routine blood , urine and stool examinations , liver function , renal function and thyroid function tests revealed no abnormality . biopsy from elevated lesion on back showed acanthosis , moderate papillomatosis and uniformly prominent melanin in the basal layer of the epidermis with normal number of melanocytes [ figure 4 ] . no new lesions or change in preexisting lesions was seen at six months of follow - up . dark brown discrete macules over the anterior trunk and proximal extremities characteristic macules on back velvety appearance of pigmented lesions acanthosis , papillomatosis and increased melanin in the basal layer ( h and e , 45 ) iemp is a rare skin disorder characterized by asymptomatic , brown macules involving the neck , trunk and proximal extremities . though the first case was reported around 30 years back , the exact etiology and pathogenesis is still not known . , in 1996 summarized the criteria for the diagnosis of this condition , namely ( a ) eruption of brownish - black , discrete , nonconfluent , asymptomatic macules involving the neck , trunk and proximal extremities in children and adolescents , ( b ) absence of any preceding inflammatory lesions , ( c ) no previous drug exposure , ( d ) basal layer hyperpigmentation of the epidermis with dermal melanophages without any basal cell damage or lichenoid infiltrate , and ( e ) normal mast cell counts . the youngest and oldest case reported in the literature is that of a one - year - old and a 50-year - old . the largest series of ten cases and nine cases have been described by jang et al . the differential diagnosis of iemp includes post - inflammatory hyperpigmentation , fixed drug eruption , urticaria pigmentosa , lichen planus pigmentosus and erythema dyschromicum perstans . iemp can be differentiated from these conditions by taking proper history and doing skin biopsy study . histopathologically , iemp shows acanthosis , basal layer hyperpigmentation of the epidermis with dermal melanophages without any basal cell damage or lichenoid infiltrate and normal mast cell count . some authors believe that iemp may be related nosologically to confluent and reticulate papillomatosis ( crp ) and eruptive acanthosis nigricans because both these conditions show histological findings of pigmented papillomatosis similar to our case . however , the clinical features and etiopathogenesis of these conditions are quite different . it is important to consider iemp in the differential diagnosis of pigmentary lesions as iemp is a self - resolving condition . the treatment of this condition is not required as spontaneous resolution of iemp is expected in a few weeks to few years . in our case , topical steroid was started for the first two weeks to speed up thinning of elevated velvety lesions but without any benefit . to include papillomatosis as one of the diagnostic criteria , more reports of iemp with papillomatosis

we present a case of an otherwise healthy 10-year - old girl who presented with asymptomatic brown macules over the trunk and proximal extremities , of three months duration . the cutaneous examination revealed multiple , dark brown , discrete , round to oval macules and a few mildly elevated lesions over the trunk and proximal limbs . the individual lesion was 1 - 3 cm in diameter and a few showed velvety appearance over the surface . darier 's sign was negative . the histopathological study from the velvety lesion showed acanthosis , papillomatosis and increased melanin in the basal layer . the upper dermis showed sparse perivascular infiltrate of lymphocytes without any dermal melanophages . it fulfilled the criteria for idiopathic eruptive macular pigmentation with additional histological finding of papillomatosis .

currently anti - tnf agents are widely used for cutaneous and systemic autoimmune diseases . for dermatologists most common indications for anti - tnf use are psoriasis and psoriatic arthritis . we describe a case of scedosporium apiospermum infection in a patient receiving long - term treatment with etanercept , a tnf- inhibitor . s. apiospermum is a ubiquitous filamentous fungus found in soil , polluted water , and contaminated ambient air in hospital isolation rooms . in immunocompromised patients , increasing reports of s. apiospermum infection in the past few years suggests that s. apiospermum is an emergent opportunistic pathogen . infectious diseases including tuberculosis , atypical mycobacteria , histoplasmosis , coccidioidomycosis , and various opportunistic infections in patients receiving tnf - a inhibitors have been reported in the literature and postmarketing surveillance . a pubmed search resulted in one report of scedosporium infection as a complication of infliximab therapy for ankylosing spondylitis . to the best of our knowledge , this is the first reported case of s. apiospermum infection in a patient receiving etanercept . neither he had active psoriasis lesions , but he had pitting and ridging on nails . after extensive workup , we narrowed our differential diagnosis to ankylosing spondylitis and psoriatic arthritis . he was started on methotrexate because of continued neck and lower back pain with morning stiffness . in 2004 , etanercept was initiated at the dose of 50 mg / week and sulfasalazine was discontinued . he did remarkably well with etanercept in respect to back pain and morning stiffness . in 2008 as he was receiving an anti - tnf agent , we actively pursued investigation for opportunistic and rare infectious agents . a flexible endoscopic examination of the sinuses demonstrated mucopurulent ethmoid disease . tissue specimens of the right and left nasal turbinates and nasal washes were sent for evaluation and culture . the tissue isolates showed chronic inflammatory edematous respiratory tissue without any significant pathology in the underlying bones and gms stains showed no evidence of fungus . however , cultures of the specimen from the sphenoid sinuses returned positive for s. apiospermum . a mri of head and sinuses did not demonstrate any evidence for invasive rhinocerebral fungal disease . we consulted our infectious disease colleagues and the patient was started on voriconazole 200 mg bid . follow - up mri and ct of the brain and sinuses did not show any evidence for sinusitis or invasion of the adjacent anatomical structures . as there was no histopathological or radiological evidence for invasive fungal infection we felt comfortable to continue etanercept . the patient has continued to take both etanercept and methotrexate for more than 1 year with no signs of re - infection or complication . scedosporium apiospermum has been associated with mycetoma , keratitis , endophthalmitis , osteomyelitis , and brain abscesses . a wide range of pulmonary manifestations exists , ranging from simple colonization as seen in patients with cystic fibrosis to fungus ball formation in patients with cavitary lesions and invasive disease , simulating aspergillosis . as the clinical presentation of scedosporium infection , including fever , cough , and dyspnea is nonspecific , diagnosis can be based on cytology , histopathology , and isolation of the fungus in culture . culture confirmation is important as the histological appearance and clinical presentation of s. apiospermum are difficult to distinguish from that of the aspergillus species on pathological examination . in a case report of three lung transplant patients , mean - time from specimen collection to positive - culture identification for sputum culture was 4.5 days compared to 9.5 days with bronchoalveolar lavage culture . in our patient , positive culture was identified in 10 days . s. apiospermum has been shown to have intrinsic resistance to many anti - fungal agents , including fluconazole and amphotericin b , the traditional antifungal of choice for disseminated hyalohyphomycoses . much of the data on the treatment of s. apiospermum pertains to the use of voriconazole . a retrospective review of 107 patients treated for scedosporium infection with voriconazole showed 57% of patients achieved a successful response after a median of 103 days of therapy . in vitro studies have demonstrated that voriconazole is more active against s. apiospermum than either itraconazole or amphotericin b. the optimal choice and duration of therapy remain unknown . surgical debridement or drainage for limited disease in combination with antifungal therapy , as was done successfully with our patient , is recommended now .

patients on anti - tnf therapy are at increased risk for rare opportunistic infections . here we are reporting a case of scedosporium apiospermum infection in a patient treated with anti - tnf for 5 years . patients on anti - tnf need close follow - up and clinicians should be suspicious for atypical infections in these immunocompromised hosts .

neurocysticercosis is the most common parasitic infection of central nervous system and result from infection with the intermediate stage of taenia solium . in india , cysticercosis is highly prevalent and cns involvement is seen in 60%90% of infested patient . cerebrum and cerebellum are common sites but may involve brainstem , basal ganglion , thalamus , and lateral sinus . seizures are the commonest presenting feature in majority but can present with headache , focal deficits , hydrocephalus , and raised intracranial pressure . we report a case of pontomedullary neurocysticercosis presenting with left vi and vii cranial nerve palsy of lower motor neuron type and contralateral hemiplegia , i.e. , millard gubler syndrome , which is not reported till date . a 7 year girl presented in outpatient department with history of vomiting and deviation of angle of mouth to right side for 3 days . there was no history of fever , headache , seizures , altered sensorium , diplopia , nasal regurgitation of feeds , trauma , ear discharge , rash , recent vaccination , and history of contact with an open or treated case of tuberculosis . examination of patient revealed palsy of vi and vii cranial nerve of left side with right - sided grade iii / v weakness , upper motor neuron type , of upper and lower limbs . her right - sided babiniski 's sign was positive with exaggerated deep tendon reflexes on same side . his complete blood count cbc , x - ray chest , blood glucose , electrolytes , liver and renal function tests were normal . mantoux test was negative at 72 h. cerebrospinal fluid study showed cells 8/mm protein ; 48 mg / dl , and glucose was 68 mg / dl . contrast - enhanced computed tomograph ( cect ) of cranium revealed single - ring enhancing lesion , with eccentric dot and perilesional edema at pontomedullary area of brain stem suggestive of inflammatory granuloma with possibility of neurocysticercosis [ figure 1 ] . magnetic resonance imaging ( mri ) of brain showed a well - defined ring enhancing lesion with thick rim noted in pontomedullary area of brain stem [ figure 2 ] , which appeared hypointense on t1-weighted and hyperintense on t2-weighted images . flair images showed suppression of internal signal with mild perilesional edema ; further suggestive of neurocysticercosis in its colloidal - vesicular stage . coronal cect image showing solitary ring enhancing lesion , with eccentric scolex , in pontomedullary area mri of cranium showing thick cyst wall enhancement with mild perilesional edema , depicting colloidal vesicular stage of cysticercosis in pontomedullary area patient was administered 20% mannitol ( 1 gm / kg / dose i.v . 8 hourly for 48 h ) , dexamethasone ( 0.5 mg / kg / day for 2 days ) , and then prednisolone 2 mg / kg / day along with acetazolamide at 75 mg / kg / day . on 3 day of steroid , oral albendazole at 15 mg / kg / day steroid was stopped after 7 days and patient was discharged on oral albendazole which was to continue for 28 days and advice of physiotherapy . at discharge , there was no vomiting but deviation of angle of mouth and right - sided weakness persisted . she was called for follow - up after 15 days and found to have no deviation of angle of mouth and weakness . patient is doing well at 1 and 3 months of follow - up with no clinical evidence of cranial nerve palsy and hemiparesis . unusual manifestations are stroke , visual loss , ataxia , dystonia , dementia , and hydrocephalus . intraventricular ( 5%10% ) and meningeal cysticerosis are associated with hydrocephalus , signs of meningeal irritation , and raised intracranial pressure . we here report a case of neurocysticercosis presenting as left vi and vii cranial nerve palsy of lower motor neuron type and contralateral hemiplegia , i.e. , millard gubler syndrome , which is unreported in literature . ct scan and mri are useful in anatomical localization of cysts , but mri cranium is more sensitive in picking up active lesions . our case fulfilled the imaging absolute diagnostic criteria ( histologic demonstration of the parasite from biopsy of a brain or spinal cord lesion , cystic lesions showing the scolex on ct or mri , and direct visualization of subretinal parasites by funduscopic examination ) . therefore , all patients with multiple cysts should receive treatment with steroid to reduce intracranial pressure and edema ; thereafter cysticidal drug , i.e. , albendazole . our patient improved and became asymptomatic with steroid treatment and albendazole . recognizing this clinical entity would avoid unnecessary antituberculous treatment and surgical intervention . cysticercosis is common in tropical countries including india but neurocysticercosis of brain stem is rare .

neurocysticercosis is a common childhood neurological illness in india . a variety of presentations have been reported in the literature , including weber syndrome . neurocysticercosis , manifesting as millard gubler syndrome , have not been reported in literature . therefore , we report a child presented to us with millard gubler syndrome due to pontomedullary neurocysticercosis and was treated successfully .

bloodstream recurrent infections have been reported for a great variety of opportunistic bacteria , with coagulase - negative staphylococci being the most common . the majority of the relapsing sepsis infections are either catheter related or are caused by indwelling devices that serve as an excellent solid phase for sticky biofilms , the source for transient bacterial translocation into the vessel lumen . molecular fingerprinting , as well as biochemical analysis and serotyping have shown that the majority of the sepsis episodes might be caused by the same strain even when adequate antimicrobial therapy is provided . taking into account the multistrain and multispecies complexity of biofilm , it remains unclear why sepsis episodes are often caused by exactly the same strain and what kind of leads this strain may have compared to other altogether , the patient experienced seven episodes of e. coli bacteraemia in just over a year . all the episodes can be considered as relapses caused by the extended - spectrum -lactamase ( esbl ) strain or by the ampc hyperproducer . finally , the focus of these bloodborne infections was found in his spleen and pancreas cauda , which was resected . of interest , the underlying disease , autoimmune pancreatitis of type 1 with igg4 hyperglobulinaemia , had probably contributed to the formation of the cyst that harboured infection . a 47-year - old man came to finland as a refugee from southeast asia . in the immigration health inspection , he was diagnosed with a toxocara canis infection and treated with mebendazole . soon after arrival , he complained of epigastric pain and fever ; he was diagnosed with acute pancreatitis , which was treated conservatively . pancreatitis episodes , often complicated with septicaemias , recurred several times during the following years . three years after the first pancreatic episode , the patient was hospitalized again for fever and multiple liver abscesses . drainage of abscesses was not feasible because of the small size of the multiple abscesses and the challenging anatomic site . an infection of the pancreatic duct stent was suspected , and the stent was removed . instead , toxocara canis serology remained positive , compatible with his early infection . during the following months , the patient was hospitalized several times for recurrent pancreatitis and relapsing episodes of sepsis . abscess formation continued even though the patient received various antimicrobials ( table 2 , table 3 ) . in addition to resection of the pancreatic cauda , the enlarged spleen was removed , and cholecystectomy was performed . histopathologic examination of the pancreas revealed extensive fibrosis , multiple cysts ( 12 cm in diameter ) and inflammatory cells such as neutrophils , macrophages , lymphocytes and plasma cells that were partly immunopositive for igg4 . the hilum of the spleen revealed purulent inflammation , but the splenic parenchyma and gallbladder were structurally normal . computed tomographic scan revealed numerous degenerative cystic lesions in the spleen that most probably had formed as a result of prolonged bacterial infection ( fig . 1 ) . a pseudocyst filled with a grey fluid was found between the pancreatic cauda and the spleen . all other tissue cultures were negative in bacteriologic , mycobacteriologic , virologic and parasitologic examinations . these findings finally confirmed suspected end - stage chronic autoimmune pancreatitis associated with the igg4 syndrome . during convalescence , the patient had a relapse of esbl e. coli sepsis but recovered completely . three other e. coli isolates ( table 1 ) had an ampc phenotype and were negative for ampc genes ( cit , dha , mox , fox , ebc , acc ) , thus apparently overproducing the chromosomal ampc . in order to investigate the clonality of the strains the culture isolates were analysed with pulsed - field gel electrophoresis using a protocol based on pulsenet for e. coli ( http://www.cdc.gov/pulsenet/pathogens/ecoli.html ) . briefly , genomic dna was digested with xbai ( new england biolabs ) , and separated in a chef dr iii ( bio - rad ) . the esbl isolates were found to be the same strain ( one- to two - band differences in the banding patterns ) . the ampc overproducers were also similar ( a one - band difference in one isolate ) ; however , they were different from the esbl clone ( fig . 2 ) . soon after the surgical intervention , our patient experienced a new episode of esbl sepsis a complication that might have been avoided if previous bacteriologic data had been taken into account so perioperative carbapenem prophylaxis could have been implemented . the reported case emphasizes that the primary prevention of bloodstream relapses caused by gram - negative bacteria is the surgical elimination of the focus of infection . being encapsulated in a cyst , the bacteria are well protected against the bactericidal action of antimicrobials even in organs with good vascularization such as the pancreas . relapses of bacteraemia with enterobacteria can occur in patients with underlying gastrointestinal or autoimmune disorders , as in our case . these episodes can be caused by resistant bacteria , which should be considered during perioperative protection after the first sepsis episode .

bloodstream recurrent infections have been reported for a variety of opportunistic bacteria . these are often either catheter related or are caused by indwelling devices . a case of relapsing sepsis with two escherichia coli strains carrying extended - spectrum -lactamase and derepressed ampc genes is reported . the patient had seven episodes of bloodstream infections within 1 year and was diagnosed with chronic autoimmune pancreatitis and igg4 hypergammaglobulinaemia . abscesses were found in his spleen and pancreas cauda , which was finally resected . relapses of bacteraemia with resistant enterobacteria should be considered during perioperative protection . surgical removal of the infective focus could be curative .

the prospective investigation by engstrm and colleagues in a previous issue of critical care sets out to determine if apneic oxygenation via a pharyngeal catheter during endotracheal intubation would prevent or increase the time to life - threatening hypoxemia in an animal model with acute lung injury . in this investigation , eight anesthetized piglets with induced lung collapse were randomized to receive either 10 l of oxygen per minute via a pharyngeal catheter or no oxygen . the investigators found that pharyngeal oxygenation markedly prolonged the time to severe systemic arterial oxygen desaturation , defined as oxygen saturation ( spo2 ) of less than 60% . emergency endotracheal intubation in the critical care unit and in the emergency department can be fraught with complications . difficulty with oxygenation can be challenging in the critically ill as they have much less reserve and are more prone to desaturate during the brief apneic period that occurs while the patient is being intubated . traditionally , patients typically do not receive supplemental oxygen as attempts are made to pass the endotracheal tube through the vocal cords . in one prehospital study , for example , it was found that among 54 trauma patients who had been intubated following a rapid sequence induction technique , 57% experienced significant desaturation with a median duration of 160 seconds . the specific premise of the current investigation by engstrm and colleagues was to use an animal model involving induced acute lung injury in order to demonstrate that even in underlying conditions at greater risk for life- threatening hypoxemia , the oxygen desaturation can be minimized by using the pharyngeal catheter supplemental oxygen technique . one limitation of the study was that the authors chose a threshold saturation level that was markedly low ( 60% ) . in other studies of critically ill adults , ' severe hypoxemia ' was defined as a spo2 of less than 80% and ' hypoxemia ' was defined as a spo2 of less than 90% . it would be helpful to know when the piglets ' spo2 fell below 90% , a point at which traditional concerns for hypoxia during intubation typically begin for most clinicians . though less contentious , the investigators chose a continuous 10-minute period of apnea as their cutoff point for desaturation . one prospective cohort study of endotracheal intubation attempts in critically ill adults demonstrated that 10.3% of intubations did require 10 or more minutes to achieve . however , these patients had multiple intubation attempts in which they were ventilated with a bag - valve - mask ( bvm ) between intubation attempts . accordingly , it is likely that none of these patients had a continuous 10-minute period of prolonged apnea . several reports in the anesthesia literature support the use of nasopharyngeal oxygenation following pre - oxygenation in human subjects , but all in relatively healthy , cooperative persons . for example , teller and colleagues conducted a randomized placebo controlled trial in 12 uncomplicated patients undergoing endotracheal intubation during scheduled surgery . an 8 fr catheter was inserted through a nasal airway and insufflated with oxygen ( 3 l / minute ) . they found that the arterial oxygen saturation ( sao2 ) never fell below 97% during the entire 10 minutes of apnea . how the results of these studies would then translate to critically ill human subjects undergoing emergent intubation remains to be seen , particularly among those with underlying pulmonary impairment . it makes intuitive sense that if one provides supplemental oxygenation using a method that allows simultaneous intubation procedures to take place , the time to desaturation would be prolonged , and the experimental evidence certainly supports that contention . although the presence of a pharyngeal catheter may provide a barrier to obtaining a good seal when using modern bvm devices , it appears ( as observed with previous studies ) that such a device could be rapidly replaced whenever the bvm is removed . overall , the authors succeeded in demonstrating the benefits of pharyngeal oxygen administration in reducing the risk of desaturation during intubation in the presence of acute lung injury using an animal model . although the study design implemented in the current investigation would be difficult to repeat in human subjects , this study supports the intuitive contention that pharyngeal oxygenation should be considered during emergent intubation of critically ill patients , particularly during periods of apnea . severe life - threatening hypoxemia is a well - known adverse consequence of emergent intubations and any reasonable measure used to minimize this risk is a reasonable conclusion . the authors should be congratulated for taking this first step in the methodical process of proper evidence - based approaches in clinical care of the critically ill .

critically ill patients requiring emergent endotracheal intubation are at risk for life - threatening hypoxemia during the intubation procedure , particularly when the patient is apneic and not receiving any supplemental oxygen . in a current study , engstrm and colleagues investigated the effect of nasopharyngeal oxygenation in eight anesthetized pigs with induced acute lung injury . the investigators confirmed , even in this model , that pharyngeal oxygenation significantly prolonged the time to desaturation during periods of apnea . recognizing the limitations of directly extrapolating these experimental results to critically ill human subjects , the findings do support the contention that , until proven otherwise , nasopharyngeal oxygenation should at least be considered as one technique to diminish hypoxemic complications in very sick patients , particularly those with underlying pulmonary impairment .

a 58-year - old male presented with a lesion on the medial aspect of left lower eyelid near the punctum . he had a small elevated nodular swelling at the margin of the eyelid for the past two decades . there was a gradual increase in the size of the swelling for past 4 years , however , during past 6 months it became more visible associated with discomfort , itching , and a noticeable mass . physical examination revealed a solitary 2 cm 2 cm size brownish firm fleshy growth with hyperkeratotic surface covered with crusts in some areas , involving the skin of the left lower eyelid [ fig . 1 ] . it did not involve the underlying deeper tissues also and there was no regional lymphadenopathy . fleshy growth with hyperkeratotic surface covered with crusts in some areas , involving the skin of the left lower eyelid the mass was excised along with a 3 mm margin of healthy skin , and the resultant skin defect was repaired with a median frontoglabellar pedicle skin flap . the final pathologic diagnosis of excision biopsy specimen confirmed syringocystadenoma papilliferum . on gross examination , skin covered tissue measuring 1.3 cm 1.1 cm 1 cm . this showed a nodular lesion 0.7 cm in its greatest axis 0.3 cm away from the nearest peripheral surgical cut margins . on microscopic examination , section showed a nodular lesion lined by epidermis with varying degree of papillomatosis [ fig . 2 ] . these were lined by two rows of cells . the luminal row consisted of columnar cells with evidence of active decapitation secretion and outer row of cells composed of small cuboidal cells . on gross examination , skin covered tissue measuring 1.3 cm 1.1 cm 1 cm . this showed a nodular lesion 0.7 cm in its greatest axis 0.3 cm away from the nearest peripheral surgical cut margins . on microscopic examination , section showed a nodular lesion lined by epidermis with varying degree of papillomatosis [ fig . 2 ] . these were lined by two rows of cells . the luminal row consisted of columnar cells with evidence of active decapitation secretion and outer row of cells composed of small cuboidal cells . syringocystadenoma papilliferum is a rare benign tumor that is believed to be derived from the apocrine or the eccrine sweat glands . in a recent report , immunohistochemistry proved the apocrine nature of the benign , noncystic lesion by virtue of its nuclear androgen receptor and cytoplasmic gross - cystic disease fluid protein-15 positivity , along with its smooth muscle actin - positive myoepithelial layer . this is predominantly a childhood tumor ; however presentation at a later stage like our case has been described in literature . in half of those who are affected , it is present at birth , and in a further 1530% , the tumor develops before puberty . the lesion is frequently misdiagnosed as basal cell carcinoma or cyst or squamous cell carcinoma . in a series of 14 patients , this is unlike other benign eyelid lesions , where histopathological diagnosis confirms clinical diagnosis in 95.9% cases . tumor is usually described as a skin colored to pink , hairless , firm plaque of grouped nodules or as a solitary nodule . cauliflower like , verrucous , papillary , hyperkeratotic , or sometimes moist fleshy excrescences have also been described . most of the lesions develop and enlarge slowly , although a few can increase to significantly within a short period . the plaque type that presents a hairless area of the scalp is commonly associated with a sebaceous nevus of jadassohn . in about one - third of the case , appearance of the lesion in the face and neck region is seen in the linear type ; however , a solitary nodular type shows predilection for the trunk . syringocystadenocarcinoma papilliferum is a malignant counterpart of syringocystadenoma papilliferum . the diagnosis is clinically suspected and histologically confirmed . ulceration or a rapid enlargement of an existing tumor is indicative of a malignant transformation . we were suspicious in the index case because of the recent increase of size . in about one - tenth of cases of syringocystadenoma papilliferum squmaous cell carcinoma may also develop , but much less frequently . because of this , surgical excision is the treatment of choice . in our case , excision of the tumor was done followed by repair of skin defect with median frontoglabellar pedicle skin flap .

syringocystadenoma papilliferum can rarely affect eyelid skin . the lesion is frequently misdiagnosed as basal cell carcinoma or cyst or squamous cell carcinoma . we are presenting a case that was clinically diagnosed as basal cell carcinoma of eyelid but was later histologically diagnosed as syringocystadenoma papilliferum .

hen eggs are common food widely acceptable by people around the world , either rich or poor . not only treated as a main dish and used as an ingredient in cooking and bakery , hen eggs can be made into yolk oil ( generically known as dn yu , lun yu , lun jng , dn hung yu or j z yu ) . yolk oil is popular in japan and korea , and among chinese people ( including chinese people from the mainland china , taiwan , hong kong , malaysia , etc ) . in japan , yolk oil products with trademark can be purchased over the counter from pharmacies or cosmeceutical stores . in taiwan and china , most of these products can be purchased from homemade market or traditional chinese herbal shops , mostly without a brand . yolk oil is described in the well known chinese medical encyclopedia flora sinensis ( bn co gng m ) as a remedy for every diseases , with specific indications in skin sore and ulcer on head and mild fever with diarrhea in children ( boym , 1956 ) . nowadays , yolk oil is widely used as a complimentary medicine for treating or preventing heart diseases , especially in japan current methods for obtaining yolk oil include heating and chemical extraction , or a combination of both . it is generally believed among yolk oil users and chinese medicine practitioners that yolk oil made from heating ( yoheat ) method , mostly by using the traditionally wok , is more effective than yolk oil made from laboratory based chemical extraction ( yoext ) . the yolk is dried in oven or on the wok , and then continuously heated and fried without cooking oil , until yellowish or slightly charred yolk oil effuses . the oil is then collected and stored for further use . also , it is generally thought that charred yolk oil ( cyo ) is more effective than the yellowish yolk oil as a medicine . however , whether yolk oil should be extracted at yellowish or charred state , remains an argument . the opponents argue that cyo may contain carcinogens and thus the threat of cancers can not be ignored , while the supporters claim that the toxicity of carcinogens is equalized by other good components of the oil , or the black materials in the oil are harmless something else . indeed , kato et al ( 1990 ) detected at least 7 heterocyclic amine mutagens in cyo branded samples . the worrying part of cyo is that heating method can simply be done in kitchen , and drug safety issues may not be taken into account in the heating process . an improvement of the heating method for avoiding the formation of heterocyclic amines is warranted . lipids are the main components in egg yolk , including triglycerides ( 65% ) , phospholipids ( 29% , out of which 86% are phosphatidylcholine and 14% phosphatidylethanolamine ) , cholesterol ( 5% ) , and free fatty acids ( < 1% ) . there have been very few literatures attempting to analyze the compositions of yoheat , and thus it is unclear which components are potentially effective to human health and diseases . only a very small number of publically available modern scientific literatures have reported the effects of yoheat in human health and diseases . among these , lin et al reported the effects of yoheat in reducing lipid levels using rodent models ( lin et al , 2004a ; lin et al , 2004b ) . the three experimental groups in the hamster model were fed with 2% acidic fraction oil , 4% of acidic faction oil and 2% of neutral fraction oil in their basal diets for 6 weeks , respectively , while the two experimental groups in the rat model were fed with 2% and 4% of yolk oil in their basal diets for 7 weeks , respectively . the authors showed that yoheat reduced liver total cholesterol in rats ( lin et al , 2004a ) and triglycerides in hamsters ( lin et al , 2004b ) . a yoext , al721 , has been reported to reverse the brain membrane hyperviscosity and , concomitantly , markedly reduce , or even completely abolish the withdrawal symptoms precipitated by naloxone in morphine - addicted mice ( heron et al , 1982 ) . the compound has been shown to reduce htlv - iii infectivity in human peripheral - blood lymphocytes ( salin et al , 1985 ) . a study design comparing the effects of yoheat and yoext in cellular and animal models may reveal essential information on the usefulness of the yolk oil . because heart diseases have become common diseases around the world , it is expected that an easy - to - make complimentary medicine like yolk oil may become even more common in the next few decades . although generic information on yoheat can be obtained from commercialized companies ( e. g. , http://www.tezukuri-ranyu.jp/ ) or books published by user groups ( nomoto , 1989 ) , there is an obvious need to verify the treatment effects , production methods and guidelines and safety of yoheat by evidence based studies .

yolk oil is common in asia . according to the flora sinensis , yolk oil is a multipurpose medicine , with specific dermatological and fever indications . nowadays , it is generally used as a complimentary medicine for heart diseases . yolk oil can be made from heating or chemical extraction method . it is generally believed that yolk oil made from heating ( yoheat ) method is more effective as a medicine than that from extraction ( yoext ) . the technical details of the heating method remain an issue of argument , including the degree of char and the threat of carcinogens formed during the heating process . most yolk oil related studies used yoext as research material . nevertheless , animal studies have showed that yoheat reduced triglycerides and total cholesterol in rodent liver . it is expected an easy - to - make complimentary medicine like yoheat may become even more common and thus evidence based studies should be conducted to verify its pharmacological effects and safety .

hereditary gingival fibromatosis ( hgf ) first reported by goddard and gross in 1856 , is a rare , benign , nonhemorrhagic , fibrous enlargement of gingiva . it seems to be a slowly progressive keratinized gingival overgrowth with various degrees and it is genetically heterogeneous and can occur in either autosomal dominant ( common ) or recessive forms . hgf can potentially interfere with speech , lip competence and mastication resulting in both esthetic and functional problems . this condition is generally diagnosed alone or occasionally in association with a number of syndromes , such as zimmerman - laband syndrome , rutherford , and ramon syndromes . since exact etiology and pathogenesis of hgf has not been yet established , therefore , there is a need for further research regarding genetic inheritance of hgf . attempts should also be made to find out various preventive measures and implementation of different treatment modalities to limit or eradicate hgf and associated complications such as esthetics , speech and functional problems as much as possible . a 14-year - old male [ figure 1 ] , accompanied by his parents , reported with the complaint of swollen gums , presented with gradual and progressive gingival enlargement of both jaws from the age of 7 years [ figure 2a c ] . the enlargement had led to incompetent lips , poor esthetics and also hindered speech and mastication . intra - oral examination revealed fibrotic enlargement of gingiva involving both upper and lower arches . his current health condition and mental state were considered normal . during the evaluation of his family history , the patient 's mother demonstrated similar intra - oral features in the form of gingival enlargement , involving to various extents , the maxilla as well as the mandible with no syndromic association [ figure 3 ] . biopsy sample was taken and sent for histopathological examination showing stratified squamous epithelium with long slender rete pegs , connective tissue and dense collagen stroma [ figure 4 ] . on the basis of the histopathological findings and positive family history the diagnosis of hgf was made with no syndromic association . in the treatment enlarged , gingival overgrowth was surgically removed [ figure 5a and b ] ( gingivectomy ) and patient was referred to department of orthodontics and dento - facial orthopedics for correction of malocclusion . ( c ) preoperative facial view left side intraoral view of mother histopathological specimen showing stratified squamous epithelium with long slender rete pegs , connective tissue and dense collagen stroma ( a ) peroperative view of mandibular jaw . ( b ) peroperative view of maxillary jaw postoperative healing was good and desired crown lengthening was achieved . patient 's speech and masticatory problems were completely resolved with gain of adequate functional ability . esthetics was significantly improved in terms of gingival appearance after surgical excision of hypertrophied gingival tissue . patient was put in the follow - up program at 1 , 3 , 6 months interval followed by after 1 and 2 years . there was no recurrence of the disease even after 2 years follow - up [ figure 6a c ] . syndromes that have been occasionally associated with hgf are zimmerman - laband syndrome ( defects of bone , ear , nail and nose , accompanied by hepatosplenomegaly ) , murray - puretic - drescher syndrome ( multiple dental hyaline tumors ) , rutherfurd syndrome ( corneal dystrophy ) , cowden syndrome ( multiple hamartomas ) and cross syndrome ( hypo pigmentation with athetosis ) . in this case , a thorough evaluation of the patient revealed no association with any of the clinical features associated with the above syndromes . the present case reported as hgf . this case is diagnosed as gingival fibromatosis due to hereditary and autosomal dominant with occurrence of enlargement in successive generation from mother to son and support with other evidence by histopathological findings . various types of treatment modalities have been employed for the excision of the enlarged gingival tissues , including of conventional surgery , electrosurgery , an apically positioned flap and lasers . in the present case , reports about recurrence rates are contradictory so the postoperative long - term benefit of periodontal surgery can not be predicted . some reports in severe cases of hgf , full - mouth - tooth clearance has been advocated , and they suggest that the condition does not recur if the teeth have been extracted . in the literature , one case has been reported that there is less chance of recurrence if the gingivectomy is delayed until the permanent dentition is in place . in our case report , there was no recurrence of the disease even after 2 years follow - up .

hereditary gingival fibromatosis ( hgf ) is a rare hereditary condition characterised by slow , progressive , nonhemorrhagic , fibrous enlargement of gingiva caused by increase in sub - mucosal connective tissue component . this paper presents a case report of a 14-year - old male suffering from hgf with positive family history . after through clinical examination , routine blood investigation was advised . all the parameters were within normal physiological limits . surgical excision of enlarged gingival mass was planned after meticulous scaling and root planning . patient was recalled 1-week after surgery . postoperative healing was good and desired crown lengthening was achieved with significant improvement in speech and masticatory problems . there was no recurrence of the disease even after 2 years follow - up .

the recent study by burri and colleagues examined the usefulness of arterial blood gases ( abg ) in the diagnosis and prognosis of 530 dyspneic patients with abg drawn upon presentation to the emergency department . the study was a retrospective analysis of prospectively collected data performed at a single center . they concluded that abg can not be used to distinguish between pulmonary and other causes of dyspnea . prior to the introduction of automated blood gas analyzers , blood po2 and pco2 could be obtained only by laborious and often inaccurate laboratory methods , such as gas tonometry and van slyke manometric extraction of plasma total carbon dioxide . improvements in electrode technology came with the development of the astrup ph electrode , the stow / severinghaus - type pco2 electrode and the polarographic oxygen clark electrode . although pulse oximetry has largely superseded the use of arterial po2 ( pao2 ) , the ease by which abg can now be measured has made this test de rigueur in the workup of dyspneic patients . we agree with burri and colleagues in that pao2 values serve mainly to triage and to guide treatment , rather than to differentiate among the causes of dyspnea . except for anxiety hyperventilation , it is difficult to rely solely on abg to identify a specific clinical syndrome . the poor predictive value of pao2 in diagnosing patients with pulmonary embolism is well known . in the pioped i study of patients with angiographically proven pulmonary embolism and no prior cardiopulmonary disease , 26% had pao2 > 80 mmhg . the probability of diagnosing an acute pulmonary embolism based on changes in pao2 did not achieve statistical significance . burri and colleagues also report that arterial ph was a significant predictor of short - term and long - term outcome . multiple physiological buffers act to preserve the concentration of hydrogen ions in blood within a relatively small range . decreases in arterial ph are likely to reflect severe impairments or even exhaustion of systemic compensatory mechanisms in patients with acute dyspnea . the predictive value of the arterial ph in dyspneic patients noted by burri and colleagues supports this hypothesis . burri and colleagues propose the use of venous blood ph in the initial evaluation of acute dyspnea , based on data from several single - center studies reporting relatively close limits of agreement ( -0.11 to + 0.04 ) between arterial ph and venous blood ph . one must keep in mind , however , that muscular activity or regional microcirculatory alterations could result in misleadingly low regional ph values in septic or agitated patients . substituting venous blood ph for arterial ph in the evaluation of dyspneic patients is an appealing notion , but one that requires testing in multicenter , prospective clinical studies . until these studies corroborate the equivalence between arterial and peripheral venous blood gases , or until non - invasive techniques to monitor arterial pco2 and ph become available , we shall continue to support the use of abg in the initial evaluation and treatment of patients with acute dyspnea . abg : arterial blood gases ; icu : intensive care unit ; paco2 : arterial partial pressure of carbon dioxide ; pco2 : partial pressure of carbon dioxide ; po2 : partial pressure of oxygen .

arterial blood gases ( abg ) are obtained commonly in dyspneic persons presenting to emergency departments . the study by burri and colleagues found that the information contained in abg fails to distinguish between pulmonary and other causes of dyspnea . on the other hand , arterial ph was highly predictive of icu admission and outcome . until large clinical studies show equivalence between peripheral venous and abg , we will continue to advocate the use of abg in the evaluation of acute dyspnea .

a 64-year - old female was diagnosed with thyroid cancer in 2004 and was treated by thyroidectomy . during follow - up , blood free t4 levels were increased and an i-131 whole body scan was performed . 1 ) . additional chest computed tomography ( ct ) showed a 1.2-cm - long nodule at the left lower lobe , which matched the location in the i-131 scan results ( fig . 2 ) . a thoracoscopic approach was first attempted , but failed due to adhesion of left upper lobe . thus , a thoracotomy was performed . a 1-cm - long nodule surrounded by pulmonary tissue was observed next to the inferior pulmonary vein . a blood vessel branching off from the pulmonary vein and going through the nodule was also observed . the blood vessel was ligated , excised , and isolated from the inferior pulmonary vein . endogia ( covidien , mansfield , usa ) was then used for wedge resection of the nodule ( fig . it was identified as ectopic thyroid tissue , but it was not observed to be malignant ( fig . 5 ) . the patient 's chest tube was removed on day 5 after surgery , and the patient was discharged on day 10 without other complications . the thyroid migrates from endodermal protrusion of the first and second pharyngeal arch at 3 weeks to 7 weeks of gestation . a thyroglossal duct forms along the descending path of the thyroid and undergoes atrophy during the embryonic stage . during this development , abnormal migration of the thyroid causes it to be misplaced , which is known as ectopic thyroid . the prevalence of ectopic thyroid is 1 in every 100,000 to 300,000 in the general population and 1 in 4,000 to 8,000 in patients with thyroid disease . ectopic thyroid is mostly symptomless , but can have various symptoms based on the size and location . in particular , when located inside or around the trachea , the patient may experience aphagia , hoarseness , dyspnea , or a foreign body sensation as the size increases . however , most cases of ectopic intrapulmonary thyroid are symptomless , as in this case study . it is observed through radiation screening and ct scans and is reported to cause dry cough , dyspnea , hemoptysis aphagia , and superior vena cava syndrome . in addition , it is reported that orthotropic thyroid coexists in all cases of intrapulmonary thyroid . radiologic examinations for diagnosis include ct , magnetic resonance imaging , tc-99 m , i-131 , and i-123 . blind bronchoscope aspiration and real - time ultrasound aspiration have been used to obtain samples for histological diagnosis . a differential diagnosis of ectopic intrapulmonary thyroid includes thyroid cancer metastasis , thymoma , neuroma , and germ cell tumor . among ectopic thyroid cases , prior to ectopic intrapulmonary thyroid treatment , the patient 's age , presence of orthotropic thyroid , symptoms due to nodules and their severity , thyroid hormone level , and malignancy potential need to be considered to perform surgical or medical treatment . depending on the position of the tissue , sternotomy or thoracotomy can be performed for surgical treatment . also , thoracoscopic treatment can also be considered . in conclusion , ectopic thyroid occurs due to early developmental differentiation problems and can be positioned in different locations based on thyroid development . it is usually symptomless , but can cause symptoms depending on its location , size , and malignance . this case reports a patient with a history of thyroid cancer and abnormal thyroid function . surgery was performed in order to determine malignancy , and to diagnose and treat the ectopic thyroid .

an ectopic thyroid is caused by abnormalities in migration of the thyroid during development and rarely occurs in the thoracic cavity or the abdominal cavity . we report the case of a 64-year - old female who had abnormal findings from a thyroid hormone test during follow - up after thyroid cancer surgery . based on the radioisotope diagnostic test , an ectopic thyroid inside the thoracic cavity was suspected . through surgical treatment , the patient was diagnosed with ectopic intrapulmonary thyroid . ectopic intrapulmonary thyroid is reported to be very rare and the case is described along with a literature review .

complete transposition of the penis and scrotum is an uncommon congenital malformation of the external genitalia in which the scrotum is located cephalic to the penis . there have been described fewer than 20 cases of complete penoscrotal transposition ( cpst ) with an intact scrotum.[36 ] most of the reported cases of cpst are sporadic . cpst is often characterized by major and sometimes life - threatening associated malformations involving the urogenital , cardiovascular , intestinal , and skeletal systems . a 3.6 kg newborn boy was noted at birth to have a complete transposition of the external genitalia . a 3.5-cm - long , hypospadic and hypoplasic penis arose from the perineum , just above the anus and beneath a normal scrotum with both normal testis inside [ figure 1 ] . external genitalia before surgery at 18 months , we performed the first surgical procedure achieving penis advancement to the level of the scrotum [ figure 2 ] . external genitalia after the first surgical procedure when he was 30 months old , we performed the second procedure advancing the penis without the urethra , achieving a satisfactory position of the penis above the scrotum and a scrotal hypospadias [ figures 3 and 4 ] . in a third surgical procedure external genitalia before the second surgical procedure external genitalia after the second surgical procedure after this three - stage procedure , we achieved a satisfactory penis position and excellent cosmetic results [ figure 5 ] . fewer than 20 cases have been reported in the literature.[137 ] the embryological sequence responsible for this malformation remains unclear ; however , it has been suggested that an abnormal positioning of the genital tubercle in relation to the scrotal swellings during the critical fourth to fifth week of gestation could affect the migration of the scrotal swellings . during normal development scrotal swellings migrate inferomedially during the 911 week , and fuse in the midline caudal to the penis by the 12 week of gestation . as chadha et al . suggested , the phallic tubercle is intrinsically abnormal and affects the corporal bodies development explaining the flaccid and hypoplasic penis . others suggested that a failure of labioscrotal migration due to a unilateral or bilateral gubernaculum defect leads to anomalies such as incomplete , complete transposition or ectopic scrotum . it has been suggested that many cases reported as penile agenesis may actually represent cases of concealed cpst . some reviews report a high incidence of associated urogenital malformations such as flaccid penis , hypospadias , urethral atresia , or bifid scrotum . renal abnormalities such as renal agenesis , ectopic pelvic kidney , or dysplastic kidneys are the most frequent extragenital malformations associated . reported other less frequent abnormalities : mental retardation ( 60% ) , imperforate anus ( 33% ) , central nervous system abnormalities ( 29% ) , preaxial limb defects ( 24% ) , and congenital heart disease ( 19% ) . the presence of a multicystic pelvic kidney in the case that we report advocates that review . there is not any description of the technique for correction and results of these so severe cases of pst . , we tried to advance the penis to the level of scrotum without disconnecting the urethra from the corpora cavernosa . in the second procedure , it was necessary to disconnect the urethra from the corpora cavernosa to achieve the penis position above the scrotum . extreme penoscrotal transposition with severe hypospadias and chordee is difficult to differentiate from penile agenesis with a midline skin tag anterior to the anus . in both cases , the penile reconstruction and repositioning are often unsatisfactory and female sex reassignment , unlike ethically controversial , may be a prudent therapeutic in selected cases . we think that surgical correction is possible in selected cases by achieving a satisfactory penis position and excellent cosmetic results .

complete penoscrotal transposition ( cpst ) with an intact scrotum is a rare anomaly in which the scrotum is located cephalic to the penis . it is the most severe degree of malformation of a spectrum of abnormalities in scrotal development . there are few cases reported in the literature , and there are few descriptions of the technique for correction and results . we describe a new case of cpst and its sequential correction .

statistical significance , most often defined as a p value of < 0.05 , simply means that an observed quantitative difference would occur by chance < 5% of time and does not necessarily imply biological significance . in the nonparametric analysis of survival data , the order of the events rather than the timing of the events is the basis for assessing differences between treatment groups . for example , if all mice in group 1 die before the mice in group 2 , the results will be statistically significant regardless of whether the group 2 mice die 1 h later or 1 month later or not at all . thus , in an experiment in which all deaths occur within a day or two but animals are monitored to determine precise survival times , group differences could be statistically significant but not biologically relevant . with this in mind , it has become apparent that in many recent publications in various highly respected journals , animals were monitored for survival multiple times a day or even hourly to obtain statistically significant results . these experimental settings allowed statistically significant results to be obtained even when the differences in survival time were clearly of limited biological significance . for example , in many studies , deletion of a particular gene led to a 1-day decrease or increase in the median time to death with a p value as low as < 0.001 . this could happen if all mice in a treatment group , for example , were kept in the same cage or were monitored as a group . to elaborate on this systematic problem , we generated three sets of hypothetical data that were designed to compare the efficacies of vaccination for protection against viral challenge . each data set consisted of two experimental groups ( mock - treated mice and vaccinated mice ) , and each group consisted of five mice ( fig . 1 ) . for the first set of data , both groups of mice were monitored once a day and all the mice died 10 days after viral challenge . this yielded a p value of 1 , hence not rejecting the null hypothesis and not indicating any efficacy of vaccination ( fig . for the second data set , the same experiment was conducted except that the mice were monitored on an hourly basis . in this case , a difference of 1 h median time to death was observed between the two groups ( fig . in this example , all the mice died around the same time , but in the mock - treated group , all mice died before any of the mice in the vaccinated group died . alternatively , it could be that all the mice in the mock - treated group were assessed before the vaccinated mice , so that there was a temporal delay in data gathering . in either case , the null hypothesis in this instance was clearly rejected ( p = 0.0027 ) and could be used to argue that indeed the vaccination was effective in providing significant protection . given the clustering of deaths observed , however , the results may have been due to nothing more than a cage effect , with no biological significance . 1c had a difference of 100% in survival rates between the mock - treated group and the vaccinated group , with at least 10 more days of protection than the results shown in fig . this is because the log rank test considers only the order in which the animals die . thus , from these hypothetical data sets , it is apparent that the use of statistical significance in survival analyses could be extremely deceptive . the biological effect , i.e. , duration of protection , clearly needs to be assessed along with the statistical significance of the data . a mismatch between statistical significance and biological significance could be a red flag for a poorly designed study that measures something other than treatment efficacy . two groups of mice ( 5 mice per group ) were either mock treated or immunized with vaccine x and were challenged with a lethal dose of virus . survival of the infected mice was monitored either daily ( a ) or hourly ( b ) . p values were derived by the kaplan - meier log rank test using graphpad prism 4 software . statistical analyses gave identical p values for panels b and c ; however , it is clear that biologically significant protection was seen only in panel c. pbs , phosphate - buffered saline . the intent of this article is to serve as a reminder that statistical and biological significance should never be used interchangeably in survival studies that attempt to predict protective efficacy . in our opinion , for acute infections that cause death in 7 to 10 days , a 3-day difference in survival is the minimum value that would warrant further development . on the other hand , a 3-day difference in survival would be biologically irrelevant for chronic infections such as tuberculosis , in which desired differences would be weeks , months , or even years . nevertheless , we along with others ( 1 , 2 ) appreciate that defining particular quantitative changes as biologically or clinically significant is subjective , context dependent , and sometimes obscure . we suggest that the biological outcome from the experiment be considered first and then statistics applied to determine if the results are likely to be due to chance . in this process , it should be remembered that a cutoff p value of 0.05 is relative ; a p value of 0.1 indicates that a particular result would occur by chance 10% of the time . it is hoped that these considerations will assist investigators in focusing more on the most promising outcomes in preclinical disease models and increase the impact of experimental results on development of effective cures or vaccines in humans .

abstractin most preclinical disease models , survival analyses are the gold standard for measuring the efficacy of medical interventions such as therapeutics or vaccines . in these analyses , treatment regimens that promote the survival and/or reduce the morbidity of experimental subjects ( e.g. , mice ) are tested for efficacy . although these analyses appear to be relatively straightforward , there are associated caveats regarding interpretation of the results that we wish to discuss in this editorial . of particular concern is overinterpretation of the biological significance of survival data based on statistical significance rather than durability of protection .

our patient presented with accelerated silicosis starting as gradually progressive shortness of breath for about 1 year , progressing to chronic type 1 respiratory failure . this was followed by development of full blown mctd , with combined features of rheumatoid arthritis , scleroderma and systemic lupus erythematosus with severe arthritis , myositis and joint contractures . this was a case report of a 32-year - old stone crusher presented with gradually progressive breathlessness , initially on exertion and later , also at rest for 1 year . at the same time , he also noticed raynaud 's phenomenon involving the fingers and toes . over the next 6 months , he developed a gradual binding down of the skin over the dorsa of hands , forearms , face and leg . the patient also had severe joint pains predominantly involving all joints of the hands , including the wrist joint and the knees bilaterally . patient had been working as a stone crusher for the past 6 years . on examination , the patient had diffuse hyperpigmentation , visible respiratory distress with a respiratory rate of 34/min with mild pallor . arterial blood gas analysis revealed type 1 respiratory failure with pao2- 54 mmhg , ph - 7.38 , paco2- 38 mmhg . testing for immune markers revealed antinuclear antibody ( ana ) positive-9 ( if assay ) , anti - double stranded - deoxyribonucleic acid positive , anti - scl70 igg antibody positive 86 u / l , anti - u1 ribonucleoprotein ( rnp ) antibodies positive in high titers , anti - cyclic citrullinated peptide and rheumatoid factor positive . contrast enhanced computed tomography of the chest was suggestive of diffuse intra and interlobular septal thickening with fibrosis and randomly situated nodules [ figure 1 ] . transbronchial lung biopsy was compatible with silicosis and revealed focal interstitial fibrosis interspersed with pigment laden macrophages and refractile material . low dose prednisonolone ( 20 mg od ) was given in view of the arthritis . methotrexate at a dose of 25 mg weekly was also started along with proton pump inhibitors and physiotherapy . his hypoxia has also improved on therapy , but he continues to be on supplemental oxygen . some patients have features of more than one rheumatic disease and thus do not fit into traditional classification . patients with combination of clinical finding similar to those of systemic lupus erythematosus , progressive systemic sclerosis , polymyositis , rheumatoid arthritis and with unusually high titers of circulating ana with specificity for nuclear rnp are considered to have mctd . hypotheses implicating modified self - antigens and/or infectious agents in the pathogenesis of mctd have been advanced , but none have been proven yet . crystalline silica ( quartz ) particles less than 1 are the most pathogenic in silicosis . this constitutes a permanent stimulus for the fibroblasts , which increase their production of collagen leading to cutaneous sclerosis , vascular occlusion and pulmonary fibrosis , which explains the myriad clinical features of scleroderma and mctd .

silica exposure has been implicated with the development of various connective tissue diseases . we report a case of 32-year - old stone crusher who developed silicosis with mixed connective tissue disorder ( mctd ) 6 years after exposure to silica . this association of silicosis with mctd has never been reported from the indian subcontinent , although the problem of this pneumoconiosis remains rampant . this rare association urges us to report this case .

trochlear nerve palsy may be clinically characterized by vertical diplopia , incomitant hypertropia that increases upon head tilt toward the paralyzed site ( positive bielschowsky 's test ) , excyclotropia , and head tilt . the differentiation between acutely acquired palsy vs. the decompensation of a congenital palsy is important for an accurate diagnosis . the presence of acute unilateral trochlear nerve palsy with claude bernard - horner syndrome represents a rare clinical condition . in a review of 215 cases of trochlear nerve palsy examined over a period of 23 years , the current report describes a patient with trochlear nerve palsy associated with claude bernard - horner syndrome and contralateral hemiparesis , with onset following a hypertensive crisis . a 35-year - old caucasian woman with a history of chronic headache and systemic arterial hypertension was admitted with sudden acute intense bitemporal headache , diplopia , dysarthria , and left hemiparesis . the patient 's blood pressure was lowered with antihypertensive drugs , including sodium nitroprusside , and she regained consciousness the next day . a neurological examination showed right trochlear nerve palsy , slight ipsilateral claude bernard - horner syndrome ( fig . 1 ) , and left hemiparesis . at rest , the patient presented cyclovertical diplopia when her head was tilted down and to the right . magnetic resonance imaging ( mri ) of the brainstem and cerebellum , acquired on the sixth day , showed multiple small areas localized mainly to the pons and mesencephalon that were distinguished by t1 and t2 hyperintense signals and no contrast enhancement ( fig . an mri in the fourth week showed remission of the previous lesions ; the patient was asymptomatic at that time and returned to her daily activities . the most frequent causes of trochlear nerve palsy are traumas , surgical injuries , tumors , demyelinating and inflammatory diseases such as meningitis and cysticercosis . brainstem stroke represents a rare cause of trochlear nerve palsy , in which infarcts may be extensive or restricted to the microvascular territory [ 4 , 5 ] . the patient presented in the current report developed sudden - onset clinical manifestations associated with arterial hypertension . these clinical features were suggestive of a vascular etiology , which was supported by the neuroimaging findings ( fig . 2 ) . most likely , small bleedings at the brainstem and cerebellum occurred as consequence of increased blood pressure . this clinical picture has previously been described in patients with trochlear nerve palsy [ 5 , 6 , 7 ] . the right - side claude bernard - horner syndrome and left - side hemiparesis observed in this patient may be related to the right - side pons lesion that was observed ( fig . in addition , the right - side trochlear palsy was possibly a result of the left dorsal mesencephalic lesion ( fig . after exiting the trochlear nucleus , which is ventrolateral to the cerebral aqueduct , the nerve fascicles course posteroinferiorly around the cerebral aqueduct and decussate in the dorsal midbrain [ 1 , 5 ] . therefore , in the current patient , the involvement of the trochlear nerve must have occurred before the decussation , resulting in contralateral palsy . the literature also contains descriptions of contralateral trochlear nerve palsy with ipsilateral horner 's syndrome . guy et al . describe nuclear or fascicular involvement of the trochlear nerve prior to decussation in the superior medullary velum and impairment of the adjacent sympathetic fibers . in the current report , the multiplicity of lesions observed in the patient likely was responsible for the unusual clinical presentation . in the case presented here , progressive improvement was observed , and the patient was asymptomatic at the end of the fourth week . similar outcomes have been described in patients with trochlear nerve palsy related to minor vascular lesions . however , there is not sufficient evidence to draw definitive prognostic conclusions in this rare situation [ 3 , 4 , 6 ] .

the association of unilateral trochlear nerve palsy with claude bernard - horner syndrome represents a rare clinical condition . we present the case of a patient with this unusual presentation . the investigation performed implicated cerebrovascular disease as the underlying cause of the condition in this patient .

acute urticaria is caused by various factors including foods , chemical agents , infections , and insect bites . when a clinician is trying to determine the cause of a patient 's urticaria , it is important to ask about the patient 's food intake , possible chemical agent exposure , and symptoms that may indicate an infection . here , we report the cases of five patients with acute urticaria . although four of the patients did not describe experiencing a bee sting at their presentation , the subsequent examination detected anti - bee - specific ige antibodies . the ages of the five japanese patients ranged from 33 to 86 years ( median : 61 ) . the onset of urticaria was 614 days ( median : 10 ) after a bee sting . all five patients presented at our hospital in the 3-month period from july to september . only one patient had a local skin reaction at the sting site , 2 days before the onset of urticaria . the type of bee involved was paper wasp in three cases and yellow jacket in two cases . venom - specific iges for paper wasp , yellow jacket and honeybee were examined in four cases . the three patients stung by a paper wasp were positive for paper wasp and yellow jacket but not for honeybee . the urticaria was well controlled by a type 2 antihistamine antagonist in three patients ; the other two patients required oral prednisone . although most anaphylactic reactions caused by insect stings occur shortly after the sting , they occasionally have a delayed onset . in the study by the american academy of allergy and immunology committee , there were only three patients in whom the reaction started more than 48 h after the sting in the recorded 2,219 patients with allergic reaction by insect sting . so , it may be difficult to suspect bee sting as cause of allergic reaction if it shows a delayed onset . four of our five patients took no notice of a relationship between their acute urticaria and their bee sting history . importantly , an examination detected ige antibodies for bees in all four examined cases with a cross - reactivity between paper wasp and yellow jacket in three of them . a history of a bee sting should thus be part of the medical interview sheet for patients with acute urticaria , especially in the summer to early autumn . if a patient has incurred a bee sting within 2 weeks prior to his or her presentation , an examination of ige for bees may help prevent a severe bee - related anaphylactic reaction in the future . moreover , individuals who are stung by a bee should be advised that their antibodies for bees should be examined if a general or local eruption with pruritus occurs within approximately 2 weeks after the sting . a question is raised regarding the mechanism of late onset of acute urticaria in our cases . reisman and livingston reported 10 patients with allergic reactions 12 weeks after bee stings . four of them had serum sickness - type reactions with joint swelling , arthralgia and urticaria , three had only generalized urticaria , two had severe symptoms of anaphylaxis with urticaria and the remaining one had a large local swelling . all patients had venom - specific ige and four had serum venom - specific igg which relates to serum sickness reaction . however , sickness - type reactions were observed only in one of four patients with venom - specific igg . reisman and livingston suggested that the late reaction ranges from typical anaphylaxis to serum sickness , probably related to simulation of ige antibodies and subsequent reaction with persisting venom antigen . although the mechanism of late onset of acute urticaria without rapid reaction is unclear , our cases might show delayed urticaria caused by a reaction of the bee antigen - specific ige antibody to the antigens remaining in the body , after the first sensitization . it suggests that bee antigens can remain for 12 weeks in the body after a bee sting , because the bee antigen - specific ige antibody can not react without bee antigens .

here we report the cases of five patients with a late onset of acute urticaria after a bee sting . the ages of the five japanese patients ranged from 33 to 86 years ( median : 61 ) . all patients had no history of an allergic reaction to bee stings . the onset of urticaria was 614 days ( median : 10 ) after a bee sting . although four of the patients did not describe experiencing a bee sting at their presentation , the subsequent examination detected anti - bee - specific ige antibodies . so , we think a history of a bee sting should thus be part of the medical interview sheet for patients with acute urticaria , and an examination of ige for bees may help prevent a severe bee - related anaphylactic reaction in the future .

seborrheic keratosis ( sk ) is an extremely common benign epidermal proliferative lesion , which is prevalent in all races . most lesions are found on the trunk , face , scalp , and the extremities , although they can occur anywhere on the body except the palms and soles . the most common appearance is that of a very superficial verrucous plaque which appears to be stuck on the surface , varying from dirty yellow to black in color . giant lesions are very rare , and their location on the genital area is rarer still , with no more than 10 published cases . we report here a case of multiple giant sk lesions located on the genitals and the adjacent areas . a 59-year - old man presented with large dark coloured growths over his lower abdomen , genitalia and the adjoining areas of 10 years duration . the disease started as small elevations over the penis and left groin . over the next few years , new lesions appeared over the adjacent areas and grew in size to attain the present dimensions . the patient initially had local discomfort , occasional pain and irritation over the affected sites , but he was otherwise in good health . examination revealed multiple , brownish black to black nodules , plaques , and tumors with lobulated , irregular , greasy surface [ figure 1 ] . in some areas , the lesions had erythematous moist erosions over the surface [ figure 2 ] . the lesions were distributed over the pubic area , penis , scrotum , groins , upper thigh , perineum , and the perianal areas . some lesions were discrete , while the others were confluent , giving rise to large plaques . histopathological examination of multiple biopsy specimens showed similar features of hyperkeratosis , papillomatosis and acanthosis with proliferation of basaloid cells containing multiple horn cysts [ figure 3 ] . large , blackish growths with verrucous , lobulated surface over the pubis , penis , scrotum , groin , and upper thigh large , warty , lobulated tumors over the perineum , groin and upper thigh . some areas are reddish , with eroded surface histopathology showing hyperkeratosis , acanthosis with basaloid cells , papillomatosis and horn cysts within the acanthotic epidermis ( h and e , 100 ) based on the clinical and histopathological findings , a diagnosis of giant seborrhoeic keratoses was made and the patient was referred to plastic surgery department for further management . sks are common benign lesions , which usually present with multiple pigmented papules and plaques with a stuck on appearance . lesions are rarely more than 3 cm in diameter and occur most often on trunk , face , and extremities , particularly over the sun exposed areas . the lesions tend to increase in number and size with advancing age . morphologic variants of sk include the common flat type , skin tag like , stucco keratosis , dermatosis papulosa nigra , inverted follicular keratosis , and melanoacanthoma . large , often polypoidal lesions have been reported to occur on the genital / perigenital area on rare occasions . multiple giant pedunculated lesions over the penis of 20 years duration , perianal polypoidal lesions , and large perigenital lesions complicated by myiasis have been reported in the past . however , such extensive involvement as in our case with lesions over the pubic area , genitals , scrotum , perineum , thigh , and perianal areas has not been documented previously . giant sk may have to be differentiated from condyloma acuminata , melanoma , and buschke lwenstein tumor . condyloma acuminata or genital warts usually involve the glans and shaft of the penis and the perianal area , but may affect the adjoining skin . the lesions are usually skin colored to brownish , have a rough surface with filiform projections and lack the greasiness of the surface typical of sk . buschke lwenstein tumor is a locally aggressive verrucous carcinoma that typically starts on the prepuce and slowly grows into a cauliflower like mass . melanomas are darkly pigmented , show irregularity of border and color with frequent ulceration , bleeding and local lymph node involvement . several histological subtypes are generally recognized : acanthotic , hyperkeratotic , adenoid ( reticulated ) , clonal , irritated , inverted follicular keratosis , and melanoacanthoma . of these , the acanthotic subtype is the most common variant . the acanthotic type , as in our case , demonstrates hyperkeratosis , marked acanthosis with basaloid cells , papillomatosis and presence of horn cysts or pseudocysts . the cause of genital sk is as yet unknown , but there may be a possible role of chronic friction . formation of in situ carcinoma and basal cell carcinoma has been documented rarely in acanthotic sk . the common flat type of sk may be left alone or may be treated with liquid nitrogen cryotherapy , curettage , shave excision , or light electrodessication . the large and extensive lesions as in our case , however , need surgical excision and plastic reconstruction .

seborrheic keratosis ( sk ) is a very common benign epidermal proliferation that is prevalent in all races . most commonly occurring on the trunk , face , scalp , and the extremities , they can occur anywhere on the body except the palms and soles . the most common appearance is that of a very superficial verrucous plaque which appears to be stuck on the surface . giant lesions are very rare , and their location on the genital area is rarer still . we report here a case of multiple giant sk lesions in a 59-year - old man .

we use density functional theory ( dft ) to compute the effects of substitutional al , b , cu , mn , and si solutes , and octahedral interstitial c and n solutes on the lattice parameters and elastic stiffness coefficients cij of bcc fe . the purefe.csv file contains the computed lattice parameter , magnetic moment , cij , and the derivatives of the cij with respect to lattice parameter for pure fe . the computational methodology we developed in ref . calculates a strain - misfit tensor for each solute which determines changes in the lattice parameter and volumetric contributions to the derivatives of the cij with respect to solute concentration . we also compute chemical contributions from each solute to the derivatives of the cij with respect to solute concentration . the sum of the volumetric and the chemical contributions gives the total derivatives of the cij with respect to solute concentration . the soluteeffects.csv file contains the diagonal components of the solute strain - misfit tensors and their average values , the volumetric and chemical contributions to the cij derivatives , the sum of the two contributions , and direct calculations of the total derivatives that encompass both contributions . we compute the solute data using 222 ( 16 atoms ) , 333 ( 54 atoms ) , and 444 ( 128-atom ) supercells . the calculation details , including the exchange - correlation functional , pseudopotentials , and all numerical convergence parameters used in generating the data , are given in ref . . the vasp input files incar and kpoints , and output files contcar , outcar , and oszicar for all the calculations are stored in the nist dspace repository ( http://hdl.handle.net/11256/67 ) , along with the analyzed data stored in the purefe.csv and soluteeffects.csv files . the repository also stores unix shell scripts we developed for calculating the data in the csv files from the raw vasp output files . the fundamental quantities necessary for computing strain misfit tensors and elastic stiffness coefficients are the numbers of atoms in the computational supercells , lattice parameters , applied strain magnitudes , and stresses . the scripts compute the elastic stiffness coefficients from derivatives of stress with respect to strain , approximated using a standard four - point central finite - difference formula . table 1 , table 2 list the properties contained in the purefe.csv and soluteeffects.csv files , respectively , along with identifying tags that label the properties in the files and their units .

we present computed datasets on changes in the lattice parameter and elastic stiffness coefficients of bcc fe due to substitutional al , b , cu , mn , and si solutes , and octahedral interstitial c and n solutes . the data is calculated using the methodology based on density functional theory ( dft ) presented in ref . ( m.r . fellinger , l.g . hector jr . , d.r . trinkle , 2017 ) [ 1 ] . all the dft calculations were performed using the vienna ab initio simulations package ( vasp ) ( g. kresse , j. furthmller , 1996 ) [ 2 ] . the data is stored in the nist dspace repository ( http://hdl.handle.net/11256/671 ) .

although the indications for cholecystectomy in the presence of polypoid lesions in adults have been established , they remain to be clearly defined in children because of the limited experience . we report an unusual case of a polypoid lesion of the gallbladder in an adolescent boy , which was successfully treated by laparoscopic cholecystectomy . a 14-year - old male presented with a four - month history of recurrent right upper quadrant abdominal pain . the initial episode , which began suddenly and persisted for three days , had been severe enough to warrant admission to the hospital . after his discharge from the hospital , the pain recurred once a week , and sometimes lasted for several days . physical examination at our institution ( westchester county medical center ) revealed inconsistent right upper quadrant tenderness with an occasional positive murphy 's sign . all laboratory results were normal , including complete blood cell count , liver function tests and serum amylase . initial ultrasound of the gallbladder done at a community hospital had revealed the presence of multiple small gallstones . a repeat ultrasound examination demonstrated a 3 mm polypoid lesion in the body of the gallbladder , close to hartmann 's pouch ( figure 1 ) . computerized tomography of the abdomen was normal , and failed to demonstrate the polypoid lesion in the gallbladder . histological examination revealed a benign 2 mm adenomatous polyp in the body of the gallbladder , close to the hartmann 's pouch ( figure 2 ) . after cholecystectomy the patient 's symptoms completely disappeared . he has remained well and pain - free after two years of follow - up . polypoid lesions of the gallbladder have been the subject of controversy in the medical literature . the most accepted classification was proposed by christensen and ishak , who classify the lesions as benign tumors , pseudotumors , and malignant neoplasms . over 90% of the polyps adenomas of the gallbladder account for only 1% of all lesions , but they are important because of their potential transformation to invasive carcinoma . it is characterized by late diagnosis and extremely poor prognosis with five - year survival of less than 5% . the importance of early diagnosis is paramount in these cases , since the only survivors have been reported following early cholecystectomy . polypoid lesions are mainly composed of heterotopic tissues , the most common one being ectopic gastric mucosa , followed by ectopic pancreatic and thyroid tissue . in our search of the literature we did not find any reports of adenomas of the gallbladder in children . for diagnostic purposes , ultrasound seems to have the best sensitivity and specificity . computerized tomography with oral cholecystographic enhancement has been reported to be successful in equivocal cases . in the present case computerized tomography failed to demonstrate the polyp . in the adult population , accepted indications for cholecystectomy in the presence of polypoid lesions of the gallbladder include polyps over 10 mm in diameter , patient age over 50 years , sessile polyps , associated gallstones , possibility of malignancy and the presence of symptoms regardless of the size of the polyp . the experience with polypoid lesions of the gallbladder in children however , because the presence of these lesions in the gallbladder of children has been associated with acalculous cholecystitis and because the long - term effects of their presence in the gallbladder are unknown , we currently recommend cholecystectomy in all children with such lesions . laparoscopic cholecystectomy , which is now well accepted as a safe procedure in the pediatric population , even in small children , should be the procedure of choice unless there are specific contraindications for its use .

polypoid lesions of the gallbladder in children are rare . we report a case of a gallbladder polyp in a 14-year - old boy who presented with recurrent right upper quadrant abdominal pain . ultrasound examination of the abdomen revealed a polypoid lesion of the gallbladder . his symptoms resolved after laparoscopic cholecystectomy . histological examination of the gallbladder demonstrated a benign adenomatous polyp . although the experience with polypoid lesions of the gallbladder in children is limited , we currently recommend cholecystectomy because these lesions are associated with acalculous cholecystitis , and because their long - term effects are unknown .

unilateral s - shaped anomaly with a contra lateral normal kidney has been reported sparsely in the literature . herein we present perhaps the first case of bilateral presentation with associated pelviureteric junction obstruction on the left and renal stones on the right side . sixteen - year - old male patient presented to us with left dull aching flank pain . intravenous urogram ( ivu ) showed an excretory kidney on right side with three radiopaque shadows apparently outside the pelvicalyceal system [ figure 1 ] . a retrograde pyelogram showed an s - shaped kidney on the right side with the upper calyces pointing laterally and the medial calyces pointing medially [ figure 2 ] . on the left side computed tomography scan showed bilateral s - shaped kidneys with the upper calyces pointing posterolaterally and the lower calyces pointing anteromedially . on the left side severe cortical thinning and non - excretion of contrast were noted [ figure 3 ] . a 99m - dtpa acid scan revealed right s - shaped renal anomaly with a non - functioning kidney on the left side . as the patient was symptomatic on the left side we proceeded with left renal exploration . the left kidney was found to have s - shaped renal anomaly with two separate set of calyces oriented in opposite directions with a common pelvis and ureter . ivu with right renal stones in s - shaped kidney retrograde pyelogram showing s - shaped kidney ct scan of bilateral s shaped kidneys the common s - shaped kidney reported in the literature is a fusion anomaly where the contra lateral kidney crosses to fuse with its mate leaving the opposite renal fossa empty . this is theorized as a ureteral phenomenon with the developing ureteric bud wandering to the opposite side and inducing differentiation of the contra lateral nephrogenic analge . in contrast the s - shaped renal anomaly reported in our case has been reported in the literature albeit with a normal opposite kidney . as ivu denotes near normal course of distal ureter we do not consider the defect at the ureteral bud origin . the ct urogram and rgp vividly demonstrate the collecting system anatomy in which the obtuse angulation of major calyces is noted , this could explain the near separation of two moieties and resultant development of this type of kidneys , so we propose a defect in the dichomotous branching of the ureteral bud as the cause of this anatomy in which the first ureteric division was at a greater angle then normal resulting in large spatial separation of the two units with subsequent normal branching , with spatial separation providing enough space for both the kidneys to develop . a similar embroyological hypothesis accounts for supernumeray kidneys . a second ureteral bud or a branching from the initial bud is considered a necessary step . alternatively , the nephrogenic analge may divide into two metanephric tails , which separate entirely when induced to differentiate by the separate or bifid buds . the s - shaped renal anomaly may be at an earlier stage where complete separation does not occur . a differential diagnosis of bilateral supernumerary kidney was considered but the presence of single pelvis and ureter ruled out the possibility . a concomitant pujo caused renal loss on the left side and an association between the two conditions may be present .

a bilateral s - shaped kidney is a rare anomaly in which both the kidneys are in their normal position , in contrast to the commonly reported s - shaped fusion anomaly , in which the contralateral kidney crosses the midline to fuse with opposite kidney leaving the ipsilateral renal fossa empty . here we present the diagnosis and management of a case of bilateral s - shaped renal anomaly with associated left pelviureteric junction obstruction and nonfunctioning kidney and right renal stones . left kidney was managed by open nephrectomy and right kidney by pnl .

the complexity of choosing a particular treatment for an individual patient while keeping her informed about the relevant options and considerations keeps increasing as personal genetic information becomes more commonly available . this is leading clinicians and patients to question their role in the decision - making process . for example , what role should patients take in choosing between alternative treatment options , in particular when the benefits and risks of each option are not crystal clear ? to what extent should clinicians share their own hesitations about the best treatment choice , exposing their patients to the incomplete knowledge about each alternative ? how should clinicians take such decisions without exposing patients to superfluous stress when current knowledge about the advantages and drawbacks of available therapy options is far from complete ? these questions , and the doctor 's dilemma , have long been the topic of public discourse . over 800 years ago , maimonides , a prominent jewish philosopher and practicing physician , wrote that ' the risk of a wrong decision is preferable to the terror of indecision ' . although this remains as true as ever , should we not be asking what role patients have in taking a treatment decision - even when current knowledge is incomplete ? such questions seem to be more pertinent as we enter the age of personal genomes , when an individual 's pharmacogenomic data may affect their choice between treatment options [ 1 - 3 ] . can patients comprehend complex diagnostic information and act on it when they face a choice between alternative therapeutic options , based on their personal genomic data ? in other words , should patients be made aware of the fine details of current medical knowledge , including the gaps in it , when crucial treatment decisions have to be made ? inevitably , some of those decisions may later turn out to have been the wrong ones for them . wendy lorizio and colleagues have examined this charged issue in a real - world personalized medicine scenario by following the treatment choices of 235 breast cancer patients currently taking or planning to take tamoxifen for prevention of cancer recurrence and who were offered the cyp2d6 genotyping test . their study is a fine example of our current knowledge limitations : at the time of conducting their cyp2d6 genotyping and follow - up patients survey ( march 2008 to may 2010 ) , most published studies , based on retrospective data , indicated that individuals having a cyp2d6 poor metabolizer genotype ( predictive of complete lack of the enzyme activity ) were less likely to benefit from tamoxifen for the prevention of breast cancer recurrence . however , more recent meta - analysis and studies cast doubt about the relevance of cyp2d6 genotypes for breast cancer recurrence in tamoxifen - treated patients . thus , it could well be that a similar study taking place today would find other results , namely that patients would be less likely to change from tamoxifen to another drug following genotyping . as long as no consensus has been reached on the effect of cyp2d6 genotypes on the efficacy of tamoxifen for preventing breast cancer recurrence , monitoring the serum level of endoxifen , its active metabolite , seems the most appropriate biomarker for adjusting tamoxifen dosages . including this biomarker as a decision making tool in breast cancer therapy seems to be justified at our currently incomplete state of knowledge . moreover , it will remain a valuable biomarker once endoxifen itself , currently in clinical trials , is eventually approved as a drug . the study by lorizio et al . found that 46% ( 6 of 13 ) of the breast cancer patients prescribed tamoxifen and genotyped as poor cyp2d6 metabolizers elected to change their medication to another drug within the following 6 months . this crucial treatment decision , while obviously taken along with their attending physicians , must have been affected by their participation in the informational session held by the researchers before the genetic testing , in which the results of studies examining the effects of cyp2d6 genotypes on breast cancer recurrence were presented . notably , the authors found that about half the patients had previous knowledge about the relevance of cyp2d6 genotypes for tamoxifen therapy , with the source of this knowledge being their nurses or clinicians , the medical literature or the general media ( internet , tv and newspapers ) . yet it seems that performing the genotyping tests and learning about their results in a medical setting affected the decision on switching treatment . this study does not examine the extent to which the decision about changing the medication was driven by the patients or their clinicians . the genotyping results were transferred to patients through their attending physicians , who did not receive specific recommendations along with the laboratory results . it would have been of interest to also interview the clinicians and find out about their role and considerations in taking this decision ; however , this would require a larger study , as in this one only 13 patients of the 235 who were genotyped were found to be cypd6 poor metabolizers . however , this study illustrates that when genotyping relevant to drug response is carried out in a clinical setting along with informing patients about the test implications in advance of the testing , a decision about medication change followed for about half the patients whose test results indicated ( at that time ) that they were unlikely to benefit from tamoxifen . this study conveys important insights for moving personalized medicine forward : offering patients pharmacogenetic testing in the clinical setting along with an educational session on the test relevance for their medication choices is an effective route for taking informed treatment decisions . . the challenge will be to keep medicine participatory and patients fully informed when medicine and personal genomes meet - which may not be as far away as it seemed just a decade ago .

informing patients about risks and benefits of alternative treatment options and choosing between them is becoming a bigger challenge as knowledge about the relationship between the individual 's genetic profile and the efficacy and safety of available medications accumulates . putting personalized medicine into practice requires new modes of information sharing and decision making by patient and physician . this is illustrated by a case study on treatment choices of breast cancer patients following genotyping for cyp2d6 , recently published in genome medicine.see research article : http://genomemedicine.com/content/3/10/64

artificial vaginas are designed to imitate the female sex organ and to achieve this , they are made out of a soft material , lubricated , and sometimes heated . further , the artificial vaginas are made for medical research purposes , animal breeding , or as a sex toy for erotic stimulation . the internal artificial vagina ( iav ) usually permits semen sampling , as well as mating ability evaluation among animals . iavs of male - to - female transsexuals ' are constructed by penile skin invagination . in females with vaginal agenesis an artificial vagina for the purposes of human sexual stimulation is essentially an aid to human masturbation , and it is designed to simulate the sensation of sexual intercourse . it will often have moving parts such as vibrators that increase stimulation . in this instance , a middle - aged male was found dead in his bathroom with an artificial vagina in situ . wife of the deceased heard that her 46-year - old husband was shouting in the bathroom around 6 pm . the door of the bathroom was forced open and the deceased was found lying unconscious . he had been brought to a tertiary care hospital of sri lanka within half an hour , but was pronounced dead on admission . he was a carpenter by profession and had no history of any significant illness including diabetes mellitus , epilepsy , or on long - term treatment , but was a chronic smoker . after removing the sarong , it was evident that the penis was inside an artificial sex toy , an in situ artificial vagina [ figures 1 and 2 ] . on inspection of the artificial vagina , evidence of ejaculation was not apparent , and the laboratory report for seminal or sperms was negative . there was no history of previous similar practices , and the wife was not aware about this apparatus . in situ artificial vagina the artificial vagina complicated atheromatous plaques were found mainly in the infrarenal part of the aorta . the heart was 350 g in weight , and the lumen of the left anterior descending artery was pinpoint [ figure 3 ] , the right coronary and left circumflex branches showed more than 75% narrowing . the left ventricle was hypertrophied , and fibrotic areas were found in the anterior , lateral , and posterior walls . the lumen of the anterior descending artery was pinpoint the cause of death was ischemic heart disease due to coronary artery atherosclerosis . ( a ) no evidence of violence , ( b ) toxicology tests were negative , ( c ) histopathology re - confirmed the cause of death , and ( d ) ischemic heart disease could have been precipitated due to indulging abnormal sexual activity using an artificial vagina . usually , the artificial vagina for human sexual stimulation has a realistic or close to realistic appearance with a sleeve , where the penis can be inserted . however , in this case , such sleeve was not found and did not simulate the real appearance of female vulva . ischemic heart disease is the most common cause of sudden death , and the coronary atheroma is the most common contributor . pin - hole lumen was due to concentric narrowing of the coronary arteries due to atheroma . the left ventricular hypertrophy could have been due to a condition such as hypertension that may have been left unknown due to masking by another nonsignificant illness , ignorance , misinterpretation , or rationalization . in the presence of fibrotic areas with all the three coronaries that were narrow , the autopsy findings were compatible with the cause of death ; ischemic heart disease due to coronary artery atheroma . ischemic heart disease precipitates due to relative ischemia and due to transient risk factors such as exertion , psychological stress , heavy meal , and sexual activities . in this circumstance , the presence of an in situ artificial vagina suggests that the deceased would have been practicing an abnormal sexual activity , and it could have caused relative ischemia and the death of this person . since this special device was left hidden under the sarong , it had not been removed by the relatives before the admission . had it been removed before admission , this circumstance could not be ascertained . this is the first reported case in the forensic literature of a man being pronounced dead with an artificial vagina in situ . removal of such devices before admission to hospitals could be the reason why such incidents do not come to light .

artificial vaginas are designed to imitate the female sex organ . this is the first reported case in the forensic literature of a man being pronounced dead with an artificial vagina in situ . a middle - aged man was found unconscious in a bathroom when the door was forced open and was pronounced dead on admission . autopsy revealed that the penis was inside an artificial vagina . there were no injuries , but there were left ventricular hypertrophy , myocardial fibrosis , and narrow coronaries . the cause of death was ascertained as ischemic heart disease due to coronary atherosclerosis and the comments included were no evidence of violence , and ischemic heart disease could have been precipitated due to abnormal sexual activity . if removal of artificial vagina was done before the admission , this circumstance could not have ascertained . removal of such devices before admission to hospitals could be the reason why such incidents do not come to light .

the numerous anecdotal reports of catastrophic medical equipment failure in close proximity to electromagnetic field emitters ( such as mobile phones or other wireless devices ) have recently been supported by formal studies . add to this growing literature database by reporting the effects of electromagnetic interference ( emi ) produced by newer generation mobile phone signals on medical devices commonly used in an intensive care unit ( icu ) . based on a high ( 43% ) rate of emi - related incidents at a median distance of 3 cm , they reasonably conclude that mobile phone use in critical care units should be restricted to the usual 1 m distance from the critical care bedside . these investigators used a worst case scenario in their study design , simulating electromagnetic ( em ) fields at the maximum signal strength generated by mobile phones and intentionally targeting poorly shielded locations on the tested medical devices . the high rate of hazardous incidents that they found may not represent what would be expected from routine mobile phone use . other studies reporting on the susceptibility of commercial medical devices to emi in real life ( as opposed to laboratory ) environments using reasonable distance restrictions have found fewer clinically relevant emi events [ 3 - 5 ] . although van leishout 's data can be interpreted as supportive of the use of mobile phones 94% of hazardous events occurred at a distance of 30 cm or less the danger of relying on a 1 m restriction is highlighted . the catastrophic failure of a ventilator at a distance of 3 m from a mobile phone signal raises serious concerns about industrial standards , as the authors note in their conclusions . industrial standards for life - supporting medical devices ( international electrotechnical commission [ iec ] standard 60060 - 1 - 2 ) fall substantially short of achievable standards for example , for military equipment ( mil - std-461 ) . almost a decade ago , the institute of electrical and electronics engineers ( ieee ) committee on man and radiation noted that technology existed to protect most medical devices from radiofrequency fields much more intense than the iec standards , and that shielding , grounding and filtering , were not costly when incorporated into the initial device design . despite that , and in the face of growing evidence of emi in the literature , there have been no substantial changes to emi susceptibility standards for medical devices in the last decade . newer generation wireless devices are rapidly expanding into frequency spectrums not covered by current standards for medical devices , necessitating more frequent reevaluation of those standards . hospitals rely on manufacturers ' stipulated adherence to emi standards , typically based on third - party susceptibility testing of a small number of sample devices . electromagnetic susceptibility of an individual medical device may vary due to poor quality control during construction . compliance with standards can not be guaranteed , which may explain why some devices fall below the food and drug administration ( fda ) standard when tested in hospital environments . regardless of the potential risks , wireless technology is becoming increasingly prevalent in the critical care environment . hospitals are routinely using wireless solutions for patient monitoring , data collection , and enhanced communication . several companies are now offering wireless solutions for electronic - icu applications , using either their own proprietary networks , or ' piggybacking ' on existing hospital networks . a new generation of transport monitors and external defibrillators offers wireless transmission to hospital telemetry systems . current data suggest that wireless area networks ( 802.11 ) and bluetooth systems do not carry a risk of emi with medical devices . however , the rapid development of new wireless telecommunication technologies makes much of the current literature obsolete . with each new generation of wireless technology , information technologists and medical engineers must determine the impact on existing hospital network infrastructure and medical devices . there are those that argue that the intangible benefits of improved communication using wireless devices far outweigh the small risk of a hazardous event from emi . as wireless devices become less expensive and consequently more prevalent we are also seeing increasing use of data transmission ( email , web access ) in addition to voice communication , by staff and visitors . increased awareness of the risks of emi , by staff , patients and visitors , is essential to ensure sensible use of wireless devices . there are other aspects of electromagnetic interference that may need to be considered , such as bandwidth competition by medical devices employing the same local wireless networks , or between medical devices and personal wireless products . as restrictions on the use of wireless technology are relaxed , increased vigilance and testing of new wireless devices and their transmission networks is essential , in our own hospital environments with our own equipment . emi = electromagnetic interference ; em = electromagnetic ; fda = food and drug administration ; icu = intensive care unit ; iec = international electrotechnical commission ; ieee = institute of electrical and electronics engineers .

wireless communication and data transmission are playing an increasing role in the critical care environment . early anecdotal reports of electromagnetic interference ( emi ) with intensive care unit ( icu ) equipment resulted in many institutions banning these devices . an increasing literature database has more clearly defined the risks of emi . restrictions to the use of mobile devices are being lifted , and it has been suggested that the benefits of improved communication may outweigh the small risks . however , increased use of cellular phones and ever changing communication technologies require ongoing vigilance by healthcare device manufacturers , hospitals and device users , to prevent potentially hazardous events due to emi .

sinus of valsalva aneurysm ( sva ) is a rare cardiac anomaly and is involved in less than 1% of cardiac operations.1 ) most patients with unruptured svas are asymptomatic ; however , a ruptured sva results in a devastating course and causes various clinical manifestations such as aortic regurgitations or arrhythmic disorders . acute coronary syndrome may occur with compression of the coronary artery2 ) or severe acute aortic regurgitation . we present a case of a ruptured sva mimicking acute myocardial infarction ( ami ) , without either significant coronary artery compression or aortic regurgitation . a 39-year - old male patient presented with chest discomfort and dyspnea that had lasted for 12 hours . a grade 3/6 diastolic murmur was auscultated at the left third intercostal space , and an electrocardiogram showed mild st segment depression on precordial leads ( fig . the creatine kinase mb ( ck - mb ) , troponin t , and serum creatinine levels were 208.4 ng / ml ( reference value , < 5 ng / ml ) , 2.54 ng / ml ( reference value , < 0.1 ng / ml ) , and 4.1 mg / dl , respectively . transthoracic echocardiography ( tte ) showed slightly reduced left ventricular systolic function ( ejection fraction , 51% ) with apical akinesia and mild aortic regurgitation ( grade 1 ) . the pattern of apical akinesia was dissimilar to that associated with the apical ballooning caused by stress - induced cardiomyopathy . the patient had unstable vital signs , and his echo window was very poor due to severe obesity ; a thorough echocardiographic study was impossible . emergency coronary angiography was planned under the impression of ami , but cardiac arrest occurred immediately before coronary angiography . coronary flow was within normal limits , and there was no evidence of plaque disruption or thrombosis . cardiac catheterization showed elevated right ventricular and pulmonary artery pressure ( peak , 55 mmhg ) . subsequent transesophageal echocardiography ( tee ) revealed shunted flow from the sva of right coronary cusp to the right atrium and grade 1 aortic regurgitation ( fig . exposure of the ascending aorta and right atrium revealed a sva on the right coronary cusp , which had ruptured to the right atrium ( fig . after successful direct closure of the rupture site , intraoperative tee result did not showed shunted flow or aortic valve dysfunction . preoperative multiple organ failure ( mof ) was aggravated despite intraaortic balloon pump with a high dose of cardiotonics and continuous renal replacement therapy . electroencephalography showed that severe cerebral injury might have been caused by the prolonged preoperative cpr . most cases of ami , with svas , are associated with a left sinus origin and compression of the left coronary artery.3 ) another hypothesis is that aortic regurgitation and a left - to - right shunt lead to a severe coronary oxygen supply - demand mismatch , causing myocardial ischemia.4)5 ) in this case , sva originated from the right sinus , and there was neither significant aortic regurgitation nor compression of the coronary artery . the initial tte study did not yield a correct diagnosis because of a poor echo window and the patient 's lack of cooperation in facilitating a thorough examination . even with the indefinite findings of the electrocardiogram , primary coronary angiography was mandatory owing to the regional wall motion abnormality and the markedly elevated cardiac enzyme levels . the possible mechanisms of myocardial infarction , without coronary compression or severe aortic regurgitation , are as follows : acute , severe shunt from the aorta to the right heart causing systemic hypoxia and flow insufficiency to the coronary artery , and decompensation , with left ventricular dysfunction , caused by myocardial infarction - aggravated systemic and myocardial ischemia . although unruptured svas are mostly asymptomatic , fatal complications such as right ventricular outflow obstruction , malignant arrhythmias , and acute coronary syndrome can occur in ruptured svas . acute , massive left - to - right shunts can cause myocardial infarction and rapidly progressive mof , without definite obstruction of coronary blood flow or severe aortic regurgitation . with the experience of this case , the possibility of sva rupture should be considered in cases of ami without significant coronary obstruction ; careful echocardiographic evaluation is needed .

we present a rare case involving a ruptured sinus of valsalva aneurysm ( sva ) and acute myocardial infarction in a 39-year - old male patient . coronary angiography showed normal findings ; however , the patient showed remarkably elevated levels of cardiac enzymes and decreased left ventricular function with apical akinesia on transthoracic echocardiography . transesophageal echocardiography revealed shunt flow from the sva to the right atrium without significant aortic regurgitation . preoperative cardiac arrest was managed by cardiopulmonary resuscitation , and surgical repair was performed by closing the entrance of the aneurysm . however , the compromised hemodynamic status was not reversed by surgery .

eosinophilic esophagitis ( eoe ) is a commonly recognized pediatric condition that has emerged as a disorder increasingly affecting adults . although eoe has been documented in all ages , races and genders , the typical eoe patient is an adult male with prior history of atopy . eoe is characterized by chronic , immune / antigen - mediated esophageal dysfunction with eosinophil - predominant inflammation . incidence rates of eoe have increased over the past decade beyond what would be expected by increased recognition alone [ 1 , 2 ] . food impaction , chest pain , upper abdominal pain , symptoms of gastroesophageal reflux disease ( gerd ) and globus have also been reported in some adults with eoe [ 5 , 6 ] . new consensus recommendations released in 2011 established a minimum peak value of 15 eosinophils / hpf as a requirement for a diagnosis of eoe with few exceptions . additionally , due to an increasing prevalence of proton pump inhibitor - responsive esophageal eosinophilia , therapeutic trials of proton pump inhibitor or ph monitoring were recommended to aid in distinguishing eoe from gerd . studies have demonstrated both clinical and histologic response to ( 1 ) strict elemental diet , ( 2 ) diet restriction based on allergy testing , and ( 3 ) diet restriction based on eliminating the more common food allergens . corticosteroids have also been proven to be effective in treating eoe , however clinical and histologic features are known to return with discontinuation of therapy . here we report the case of a 24-year - old female who was diagnosed with eoe with an atypical presentation . a 24-year - old woman was referred to our care in march 2011 with a 3-year history of persistent hiccups and mild , intermittent dyspepsia . her symptoms began with episodic mild chest discomfort lasting one minute followed by bouts of hiccups . over time , the hiccups progressed to up to 10 episodes per day . she had no prior medical history other than one admission for renal calculi , and her only prescription was birth control pills . she had no history of allergy and no known family history of illness as she was adopted . six months before our evaluation she was treated empirically with ranitidine with no relief of her symptoms . she underwent esophagogastroduodenoscopy ( egd ) , which demonstrated trachealization of the esophagus , and biopsies from the distal esophagus showed significant eosinophilic infiltration . she was subsequently placed on a 6-week course of high - dose omeprazole ( 40 mg twice daily ) , with minimal relief of her symptoms . a follow - up egd showed persistent trachealization and esophageal eosinophilia ( peak eosinophil count of 23/hpf ) consistent with a diagnosis of eoe ( fig . her symptoms improved substantially within 1 week , with hiccups occurring fewer than 2 times per week . a repeat egd while on treatment demonstrated resolution of trachealization , and biopsies showed histologic remission of eoe ( peak eosinophil count of 5/hpf ) . fluticasone was subsequently discontinued , but the patient developed recurrent hiccups within a few days . they are an involuntary spasmodic contraction of the diaphragm and intercostal muscles , resulting in sudden inspiration and closure of the glottis . multiple causes of hiccups have been described , including gastric or esophageal distention due to overeating or carbonated beverages , phrenic nerve irritation , central nervous system disorders , metabolic , postoperative and psychogenic disorders , medication side effects and reflux esophagitis . the pathogenesis is unclear , but one proposed mechanism suggests that esophageal receptors send impulses via the vagal nerve to respiratory motor neurons , resulting in hiccups . eoe is a chronic , immune / antigen - mediated esophageal disease characterized histologically by eosinophil - predominant inflammation and clinically by symptoms related to esophageal dysfunction . due to overlapping clinical features , the diagnosis of eoe requires distinction from gerd with a trial of a proton pump inhibitor or with ph monitoring . esophageal eosinophilia led to the initial suspicion of gerd and the initiation of acid - modifying therapy . our patient achieved minimal relief with an h2 blocker or proton pump inhibitor , suggesting that hiccups were unlikely related solely to gerd . by contrast , the patient 's clinical , endoscopic and histologic response to topical steroid therapy supports an association between hiccups and eoe and suggests that eoe be considered in the differential diagnosis of patients with refractory hiccups . the international gastrointestinal eosinophil researchers ( tigers ) concept award ( support to p.a.b . and j.l . ) .

eosinophilic esophagitis ( eoe ) is a chronic esophageal disease increasingly recognized in adults for its gastrointestinal manifestations . this paper discusses a young woman with eoe who presented with persistent hiccups and intermittent dyspepsia . the patient was initially treated with trials of both h2 blocker and proton pump inhibitor . however , her hiccups resolved only after treatment with topical fluticasone . a repeat upper endoscopy while on steroid treatment demonstrated both histologic remission of eoe and resolution of esophageal trachealization . our patient 's clinical course supports an association between hiccups and eoe , suggesting that eoe be considered in the differential diagnosis of patients with refractory hiccups .

adenomatoid tumors , although rare , are the most common tumors of the paratesticular tissues , accounting for approximately 30% of all paratesticular tumors . in men , they are located in the epididymis , testicular tunicae , and rarely , the spermatic cord with most arising in or adjacent to the lower or upper pole of the epididymis . although benign in nature but because they are difficult to differentiate from testicular malignancy these men are often subjected to radical orchiectomy . recently , some authors have tried to define the imaging characteristics of these tumors but since these tumors are rare and experience is limited imaging is still not considered as diagnostic . we report a case that was diagnosed on the basis of clinical suspicion , biochemical investigations , fine - needle aspiration cytology findings and radiological tests and thereby high orchiectomy could be avoided . a 52-year - old male presented with complaints of a painless nodule in right scrotal sac for last 2-years that was gradually but very slowly increasing in size . there was no history suggestive of urinary infection , genitor - urinary tuberculosis or epididymo - orchitis . examination revealed a pea - sized firm , well - marginated , smooth swelling present at the lower pole of testis but that could not be separated with epididymis . scrotal ultrasonography revealed a solid mass at the lower pole of right testis that was relatively hyperechoic as compared to the testicular parenchyma [ figure 1 ] . scrotal mri revealed a well - defined lenticular lesion at lower part of right testis . the lesion displayed signals isointense to slightly hypointense on both t1- and t2-weighted images with adjacent hypointense band . fine - needle aspiration from the mass revealed absence of malignant cells . in view of long clinical history , negative tumor markers , findings typical of adenomatoid tumor on sonography and mri , as reported previously , and absence of malignant cells on cytology local excision was performed under local anesthesia through inguinal incision . at exploration scrotal ultrasonography shows a solid mass at the lower pole of righttestis that was relatively hyperechoic as compared to the testicular parenchyma scrotal mri shows a well - defined lenticular lesion at lower part of right testis . the lesion displays signals isointense to slightly hypointense on both t1 and t2-weighted images with adjacent hypointense band most of these tumors have been present for several years and uniformly behave in a benign fashion . cellular atypia and local invasion have been observed occasionally . nonetheless , because of the long history of these tumors and benign nature surgical excision is adequate . a practical problem faced by clinicians is to differentiate this condition preoperatively from the much commoner testicular malignancy so as to avoid high inguinal orchiectomy especially in younger men . because of the adenomatoid tumor does not produce any characteristic pattern on ultrasound that would allow it to be distinguished from malignant testicular tumors because they can be hypo , hyper or even isoechoic as regards the adjacent parenchyma . it provides additional morphological evidence to allow precise localization of the origin of the mass , may also show contrast - enhancement features that enable further confidence of a benign diagnosis , and may allow conservative management . however , in our case we were able to diagnose this condition after thorough evaluation and thereby could conserve the testis .

paratesticular tumors are rare tumors that are difficult to diagnose preoperatively and therefore , many patients are subjected to inguinal orchiectomy . however , radical orchiectomy can be avoided as the diagnosis of paratesticular tumor can be made on the basis of clinical suspicion , findings of tumor markers and radiological tests .

calcinosis cutis is the pathologic deposition of insoluble calcium salt in the skin and subcutaneous tissue . it is classified into four main subtypes : dystrophic , metastatic , idiopathic , and iatrogenic . dystrophic calcinosis cutis follows inflammation , infection , connective tissue diseases , and so on . complications of acne vulgaris such as calcinosis cutis are rarely reported previously in the literature . a 55-year - old man who is a diagnosed case of obstructive sleep apnea ( osa ) presented with symptoms of sinusitis for a period of 15 days . a computed tomography ( ct ) scan was done to confirm the diagnosis of sinusitis . however , ct scan showed multiple soft tissue calcification distributed all over the face mainly in the region of distribution of acne vulgaris suggestive of calcinosis cutis [ figure 1 ] . the patient was given antibiotics and supportive treatment for sinusitis after which he recovered completely . he reported that he had severe acne vulgaris in his adolescence for which he did not take any treatment . on retrospective questioning however , the patient also had multiple skin - colored papules of various sizes ranging from pin head to maximum of 5 mm over the face predominantly on cheeks [ figure 2 ] , nose , and forehead for a period of 25 years . the plasma calcium , phosphate , vitamin d , and parathormone levels were within normal range . however , all other hematological and biochemical investigations including complete blood count and peripheral smear , liver , kidney function tests , and urine microscopy were normal . antinuclear antibody , rheumatoid factor , p- and c - anca , anti - topoisomerase , anticentromere antibodies , and hiv serology were negative . computed tomography scan showing multiple soft tissue calcification distributed all over the face mainly in the region of distribution of acne vulgaris suggestive of calcinosis cutis a punch biopsy from the acne scars on the face showing areas of small calcific deposits in the upper - to - mid dermis a punch biopsy was done from the acne scars on the face , which showed areas of small calcific deposits in the upper - to - mid dermis . multiple skin - colored papules of various sizes ranging from pin head to maximum of 5 mm over the left cheek it is caused by abnormal follicular hyperkeratinization and overproduction of sebum by the sebaceous gland . acne vulgaris affects nearly 80% of the population between 12 and 25 years without gender , ethnicity , or race prevalence differences . the pathophysiology of acne vulgaris includes increased sebum production , follicular hyperkeratinization , proliferation of propionibacterium acnes , and production of inflammation . usually calcinosis cutis presents as multiple , hard , whitish papules , plaques , or nodules . it is known to occur in a variety of disorders and classified into four subtypes according to its etiology : dystrophic , metastatic , iatrogenic , and idiopathic . the term dystrophic calcinosis is used for calcification associated with infection , inflammatory processes , cutaneous neoplasm , or connective tissue diseases . it is the most common type of ectopic calcification and develops around localized tissue damage , with no alterations of calcium or phosphate metabolism . in contrast , metastatic calcification is characterized by abnormal calcium and/or phosphate metabolism that leads to the precipitation of calcium in cutaneous and subcutaneous tissue . medical intervention can cause tissue damage or disturbances in calcium and phosphate metabolism , leading to soft tissue calcification in some cases known as iatrogenic calcinosis cutis . in a normal tissue , ectopic deposits of calcium salts develop when the calcium phosphate product in plasma exceeds 70 mg / dl . however , in a damaged tissue the following pathogenic phenomena may play a role increased intracellular calcium concentration , denaturation of proteins that preferentially bind phosphate , genetic mutations of elastic fibers and collagen , and increased g - carboxyglutamic acid . calcinosis cutis is a rare disease , so there are no controlled clinical trials on its treatment . various medical and surgical modalities have been found to be beneficial but none has been accepted as standard . medical management include warfarin , bisphosphonates , minocycline , ceftriaxone , diltiazem , aluminum hydroxide , probenecid , intralesional corticosteroids , and intravenous immunoglobulin . surgical modalities include curettage , surgical excision , carbon dioxide laser , and extracorporeal shock wave lithotripsy . our patient had a history of acne lesions during puberty , following which scar lesions were present on his face . however , despite an extensive search no relationship was found between osa and calcinosis cutis . thus , it is concluded that dystrophic calcinosis cutis can develop rarely secondary to acne vulgaris .

acne vulgaris is a common dermatological disease commonly affecting the adolescent and young adults . it is characterized by the presence of pleomorphic skin lesions such as comadones , papules , pustules , and nodules . the common complications are postacne hyperpigmentation and scarring causing psychological impact . calcinosis cutis is the pathologic deposition of insoluble calcium salt in the skin and subcutaneous tissue . calcinosis cutis following acne vulgaris is rarely reported in the literature . we report a case of calcinosis cutis in acne vulgaris in a 55-year - old man .

participants consisted of 4 students who attended two special education schools at the elementary level . all students were diagnosed as having adhd , and their age range was between 9 to 11 years . three of the four students were diagnosed with a combined type of adhd , and one person was diagnosed to have the hyperactive impulsive type by a child psychiatrist . the researcher directly observed the inattentive behaviors ( such as inattention to teacher and materials , not following through instructions , leaving seat ) of the participants in the classroom . inattentive behaviors of participants ( target behaviors ) were observed during two sessions each week ( each session lasted 30 minutes ) . all target behaviors were recorded using duration per occurrence recording procedure , and percentages of the behaviors were calculated . self - monitoring of attention was used as a cognitive - behavioral technique for increasing self - control in the participants . the programs included the following components : self - monitoring cues tape : an audiotape including tones or beeps at irregular intervals . when a student first begins to use self - monitoring , the pre - recorded tones are essential for his / her success ( 5 ) . a self - monitoring card : it includes a self - assessment question ( was i paying attention ? ) and spaces in which participants indicate being off - task or on - task when the tones sound . percentages of inattentive behaviors in experimental phases during self - monitoring , students were engaged to work in classroom assignments or follow their teacher 's instructions ( 5 ) . the desired goal of self - monitoring was to achieve self - control in classroom situation and to work without external cues features ( tape and card ) . thus , during self - monitoring sessions , external cues were phased out , and students were expected to control their off - task behaviors internally . the results indicated that the percentages of off - task or inattentive behaviors in the classroom situation reduced as a result of the self - monitoring program . this decreasing trend from baseline to the intervention phase is displayed for all the four participants . levels of inattentive behaviors in the follow - up are approximately similar to the intervention , and are lower than the baseline phase ( particularly for the first and fourth participants ) . during self - monitoring , students were engaged to work in classroom assignments or follow their teacher 's instructions ( 5 ) . the desired goal of self - monitoring was to achieve self - control in classroom situation and to work without external cues features ( tape and card ) . thus , during self - monitoring sessions , external cues were phased out , and students were expected to control their off - task behaviors internally . the results indicated that the percentages of off - task or inattentive behaviors in the classroom situation reduced as a result of the self - monitoring program . this decreasing trend from baseline to the intervention phase is displayed for all the four participants . levels of inattentive behaviors in the follow - up are approximately similar to the intervention , and are lower than the baseline phase ( particularly for the first and fourth participants ) . direct observation of inattentive behaviors in a school- based special education situation showed that the behaviors reduced in the intervention phase of a single - subject experimental design . however , maintaining the treatment effects was difficult for the participants . based on the results of this study , two important points should be considered : firstly , increased effectiveness of self - monitoring technique was only observed in the context of the intervention phases and not in the follow - up phases . in other words , secondly , individual differences are important in accepting treatment . from a practical perspective , the findings of this study indicate that self - monitoring techniques can be applied for students with adhd in school - based special education settings . with respect to the short - term effectiveness of self - monitoring technique , continued treatment for adhd is needed so that parents and teachers could understand the outcomes of each approach . lastly , it should also be noted that parent management training ( 6 , 7 ) is an important factor to be considered in cbt techniques .

beneficial effects of stimulants on core symptoms of attention deficit hyperactivity disorder ( adhd ) have been reported in several studies . behavioral interventions have also been proposed as empirically supported interventions for adhd . although cognitive - behavioral therapies ( cbt ) have been criticized for the lack of evidence - based data , some studies have indicated the positive effects of cbt techniques on children with attention deficit hyperactivity disorder ( adhd ) . this article reports the effects of self - monitoring technique , as a cbt technique , on inattentive behaviors of children with adhd .

zoon 's balanitis or balanitis circumscripta plasmacellularis is a benign chronic disease of unknown origin . zoon 's balanitis , unlike some other inflammatory penile dermatoses , is generally not thought to be a precursor for neoplasia . we herein report the case of an uncircumcised man , who developed clinically and histopathologically evident squamous cell carcinoma of the penis in an area affected by zoon 's balanitis . a 71-year - old uncircumcised man presented with a 3-month history of extremely painful genital sores associated with swollen foreskin and dysuria , not preceded by any flu - like symptoms . the patient reported that he has suffered from zoon 's balanitis for 12 years , confirmed by a histopathological examination . he treated the condition with topical corticosteroids with relative improvement and paid periodic visits for 7 years ; after that he stopped performing any follow - ups . clinical examination revealed a well - demarcated , highly indurated , glistening erythematous plaque ( about 3 cm in diameter ) on the glans and adjacent preputial mucosa . a 3-mm punch biopsy of the glans was performed showing typical features of a moderately differentiated squamous cell carcinoma ( nests of atypical cells with abundant eosinophilic cytoplasm and large vesicular nucleus ) ( fig . zoon 's balanitis is characterized by a solitary red - orange plaque of the glans and prepuce . although the etiology is unknown , different factors have been reported to be involved in its genesis ( local infections , poor hygiene , heat , friction , and constant rubbing ) . histopathologic examination demonstrate an inflammatory infiltrate of predominantly plasma cells , atrophy of epidermis , spongiosis , tortuous dermal blood vessels , and exocytosis of inflammatory cells [ 2 , 3 ] . it is generally considered to be a benign condition , and its association with malignancies has been rarely reported . in 1999 , a case of penis carcinoma arising in a patient with zoon 's balanitis was described by joshi , implying that this inflammatory lesion could be a premalignant condition or could contribute to the development of squamous cell carcinoma . after this report , the hypothesis that zoon 's balanitis may be followed by penile carcinoma or premalignant lesions started to arise . in 2001 , bunker claimed that there were zoonoid changes in clinical and histological features in some cases of lichen sclerosus , lichen planus , bowenoid papulosis and penile cancer . these zoonoid changes could suggest that zoon 's balanitis per se is a premalignant condition . recently , starritt and lee reported a case of erythroplasia of queyrat of the glans on a background of zoon 's plasma cell balanitis . the hypothesis of the possible association between zoon 's balanitis and penile cancer could also be linked to the concept of inflammation as a cofactor in carcinogenesis . in 1863 , virchow noted a connection between inflammation and cancer and sustained that this link may have implications for cancer prevention and treatment . therefore , prevention of penis carcinoma is possible , including early detection and relative treatment of risk factors ( phimosis , inflammatory conditions , multiple sexual partners , and hpv infections ) and precancerous lesions [ 9 , 10 ] . this case highlights the importance of frequent follow - ups for zoon 's balanitis ; topical treatment , such as corticosteroids and calcineurin inhibitors [ 4 , 5 , 7 ] , may be important to prevent the development of a secondary carcinoma . in case of resistance to topical treatments , circumcision should be recommended because it could be curative and also protective against penile carcinoma .

zoon 's balanitis or balanitis circumscripta plasmacellularis is a chronic disease of unknown origin . this condition usually manifests in middle - aged or elderly uncircumcised men . although of unknown etiology , different factors have been reported to be involved in its genesis ( local infections , poor hygiene , heat , friction , and constant rubbing ) . it is generally considered to be a benign condition , and its association with malignancies has been rarely reported . we report the case of an uncircumcised man , who developed clinically and histopathologically evident squamous cell carcinoma of the penis in an area affected by zoon 's balanitis .

the case we present here is about a 22-year - old female patient referred to the department of conservative dentistry and endodontics with the chief complaint of pain in the left lower back tooth for the past 2 days . her medical history was noncontributory and she gave a dental history of root canal treatment was done in that tooth before 2 months in a dental clinic . on clinical examination , it was found access opening was done in a grossly decayed left mandibular second molar . the treatment was continued by complete caries excauation and canal exploration after rubber dam isolation . on microscopic exploration of the floor of the pulp chamber a canal re is an extra third root in mandibular molars present on the lingual side , which is shorter in length than other two roots . however , here , it is seen on buccal side called as rp . on careful exploration on mesial root , presence of three canals after working length estimation done [ figure 1 ] , all the canals were enlarged until 20 size k file and biomechanical preparation was completed by protaper rotary systems . all three mesial canals were enlarged until f1 , distal canal until f3 and the extra third root on buccal side until f2 with copious irrigation of saline simultaneously . then the master cones checkup were done as shown in figure 2 . then the final irrigation was done with 17% ethylenediaminetetraacetic acid , 3% sodium hypochlorite and by saline . canals were dried with paper points and obturated with gutta - percha cones of respective sizes with kerr sealer . figure 4 shows the post obturation magnified view of floor of the pulp chamber showing the five canals with rp in middle . working length determination post obturation radiograph microscopic image of floor of pulp chamber showing type b rp the mandibular molars usually have two roots with two canals in mesial roots and one canal in distal root . it is more common that mandibular molars having four canals with two in mesial and distal root viz . the first molar . however , recent studies shows there are more chance for a 3 canal in mesial and distal root as middle mesial and middle distal , respectively . this presence in second molar is very rare but , recently few studies of ryan et al . and jain reported with cases of five or six canals in mandibular first molars only . the isthmus connecting the mesiobuccal and lingual or distobuccal and lingual is debrided and left uninstrumented in most of the cases . however , on careful exploration of this isthmus a third canal with a separate path of exit can be seen in many of the cases as reported by deepalakshmi et al . in their four cases . here , in this case of 37 with three mesial canals , all three files and gp points went until full working length independently without any fusion at the apex to exit as one . it seems that in all three canals , there will be isthmus communicating them in between laterally as it travel , these lateral connections were debrided completely with 3% sodium hypochlorite and sealed by the root canal sealer . re is an extra third root in mandibular molar , which is shorter than the mesial and distal roots ; seen in distolingual corner like a distolingual canal in the floor of the chamber . the rp occurrence rate is about 0% , 2% , and 5% in mandibular first , second and third molars respectively . carlsen and alexandersen described two different types of rp : type a : rp in which the cervical part is located on the mesial root complex ; type b : rp in which the cervical part is located centrally , between the mesial and distal root complexes , an additional cusp was present on the buccal side . the complex root canal anatomy stresses the operator to observe the canal morphology with care without underestimating it and missing the extra root and roots canals , which can occur in any cases as a rare finding . thus , the success of endodontics lies in the careful exploration of the canals and debridement of it .

mandibular first molar commonly has two roots , the mesial and the distal root . surprisingly in some mandibular first molar has an unusual extra third root in between mesial and distal root . this extra root is the most commonly seen in lingual side and is called as radix entomolaris . if this extra root is seen on the buccal side , it is termed as radix paramolaris ( rp ) , which is a very rare phenomenon . recently , various case report studies has shown the presence of third canal in the mesial and distal roots of mandibular molars . they are named as middle mesial and middle distal canal , respectively . here , we present a case report of mandibular second molar showing three canals in the mesial root and a rp .

he reported chronic non - productive cough , weakness for the preceding three weeks , loss of appetite , and weight loss of about ten kilograms in six months . the interview and the medical history documentation indicated that he was suffering from diabetes type 2 , paroxysmal atrial fibrillation , hypertension , chronic renal failure grade 3 , and from generalised atherosclerosis . at age 45 it was located in segment 6 of the right lung , with diameter of 4.5 cm and lysis in the centre . in addition , the ct revealed in the enlarged lower pulmonary vein and in left atrium of the heart an hourglass - shaped structure with dimensions 5.4 1.6 cm . the results of laboratory tests of serum revealed the elevation of d - dimers ( 791 ng / ml ) and c - reactive protein concentration ( 37 mg / l ) . in bronchofiberoscopy the additional longitudinal echo ranging from right pulmonary vein ostia to the mouth of mitral valve was recorded b ) the loss of contrast in the left atrium and thickening of the pulmonary vein . after cardiothoracic consultation the patient was qualified for surgery . in the first stage sternotomy with extracorporeal circulation was performed . we incised the left heart atrium and revealed a pale pink tumour , which we removed completely from the atrium and from the final section of the right lower pulmonary vein . in intraoperative cytology of the tumour imprints the pathologist found non - small cell lung carcinoma cells . we decided to perform a right - sided thoracotomy in the second stage with right lower lung lobectomy and mediastinal lymphadenectomy . 2c the incised right pulmonary vein is shown with its wall infiltration forming the beginning section of the cardiovascular part of the tumour . a ) intracardiac part of the tumour just before the resection and ( b ) just after the resection . c ) right lower lobe the pulmonary vein is cut and the infiltration of the vein wall is shown . in the final examination of the tumour the pathologist diagnosed mixed heterogeneous lung cancer ( squamous cell and non - small cell endocrine ) in stage iiia . there are very few cases of lung cancer extension via the pulmonary vein into the left atrium of the heart [ 2 , 3 ] . they can be diagnosed by use of transoesophageal echocardiograms , magnetic resonance imaging , and ct scan [ 1 , 3 ] . most of those tumours show rapid growth and comprise a large mass in the lung parenchyma . resection of the intra - atrial mass seems to be a life - threatening procedure because the patient may die from cardiac inflow obstruction and sudden cardiac arrest or massive tumour embolism involving the major organs [ 2 , 4 , 5 ] . the possibility of systemic tumour embolisation should be considered in patients with large , central tumours and particularly those that abut the pulmonary veins [ 4 , 5 ] . computed tomography with contrast allows the detection of the spread of lung cancer through the vessels into the heart cavity . malignant lung tumours penetrating into the cavity of the heart can be , in some cases , radically removed . in this case , the tumour did not infiltrate the left atrium of the heart but only grew into its light through the lower pulmonary vein ( iiia t3n1m0 stage ) . the rapid progression of the tumour in the presented case ( the floating part of the tumour in the atrium grew 1 cm in a week , as seen by comparing ultrasound examinations of the heart ) rapid multidisciplinary collaboration of the two centres enabled fast and efficient qualification procedure .

computed tomography is performed in every patient before lung tumour resection . the presented case realises how important it is to perform this study with contrast . in a 75-year - old male we detected a tumour ingrowing from the right lung through the right lower pulmonary vein into the left atrium of the heart . the patient was qualified for primary sternotomy with extracorporeal circulation and resection of the intracardiac part of the tumour . in the second stage , right - sided thoracotomy was performed , and right lower lung lobectomy was done . mixed heterogeneous lung cancer was diagnosed ( squamous cell and non - small cell endocrine ) in stage iiia . the perioperative period was uncomplicated . the patient , due to renal failure , was not eligible for adjuvant chemotherapy . if the patient were qualified for lobectomy based directly on computed tomography without contrast , there would have been a high risk of perioperative death due to embolic incidents and heart failure . effective multidisciplinary collaboration allowed us to avoid this sort of complication .

enema administration has been a common practice worldwide for several centuries for the treatment of chronic constipation and for preparation of patient for a diagnostic test or a surgery . it seldom causes so prolonged lower gastrointestinal bleed that requires massive blood transfusion and rarely requires colectomy . we report an unusual complication of herbal enema in the form of severe ileo - colitis with persistent massive lower gastrointestinal bleed immediately after administration of enema for the treatment of chronic constipation . the bleeding was refractory to conservative treatment and was managed with emergency total laparoscopic colectomy . a 57-year - old male patient presented with persistent massive bleeding per rectum for one month that developed immediately after administration of herbal enema by a religious quack for the treatment of chronic constipation . he was admitted at some other hospital for the same complaint and was managed conservatively with oral glucocorticoid , 5-aminosalicylate preparation , metronidazole , entofoam ( hydrocortisone acetate ) and sucralfate enema . he had history of 48 units of blood transfusions during the course of conservative management to raise the haemoglobin above 8 mg / dl , but the condition did not improve and the patient was referred to our centre for further management . on clinical examination , the patient was pale , had tachycardia ( pulse , 136/min . ) and hypotension ( systolic blood pressure , 70 mmhg ) . colonoscopy revealed extensive ulcerations and friability of entire colon , more on left colon and ileal intubation also showed multiple ulcerations [ figure 1 ] . cect of abdomen showed distended small and large bowel with no air - fluid level . endoscopic view : ulcerations and friability of colonic mucosa we gave the patient a trial of conservative management because the condition was not permissible to withstand a major abdominal surgery . conservative management did not work and once again patient developed massive lower gastrointestinal bleed bringing haemoglobin down to 4.9 g% . patient was planned for emergency laparoscopic total colectomy . on laparoscopy , there was evidence of mild ascites , thick oedematous inflamed and friable large bowel and distal 30 cm of ileum . large bowel was very friable and developed 3 small inadvertent perforations by bowel holding grasper during dissection and manipulation of colon [ figure 2 ] . the patient developed hyponatremia and paralytic ileus in early postoperative period that were managed conservatively . oral liquids were started on postoperative day ( pod ) 3 and after that stoma started functioning . drains were removed on pod5 and patient was discharged on pod 7 with advice of restoration of bowel continuity after 8 - 10 weeks . majority of the population of india is seemingly unaware of the potential hazards associated with herbal medications and of the limited knowledge and diagnostic skill of those who are prescribing such type of treatments . contrary to the widespread belief that because it is natural it is safe , herbal therapy probably carries major risks and produces more serious side - effects than any other form of alternative medicine . the common natural ingredients used in enemas are aloe , coffee , garlic and milk thistle . other types of enemas include the ones made with mineral water , epsom salt , glycerin , vinegar , bark of the marula tree , fruit of the cucumis africanus , various wild herbs , industrial thinner , turpentine , undiluted dettol , ginger , pepper or soap . the injurious side - effects of herbal enema vary from mild abdominal discomfort and self - resolving haemorrhagic proctocolitis to severe colitis . most of the time , colitis responds conservatively and rarely require blood transfusion and colectomy . herbal enema induced massive lower gastrointestinal bleed is a life threatening clinical condition usually refractory to conservative management as in our case . nowadays , the indication for surgery is mainly limited to acute , uncontrollable , and recurrent forms of lower gastrointestinal bleed . there are few studies in literature that address the feasibility of laparoscopic colectomy in emergency conditions . marcello et al reported in their case - control study comparing laparoscopic total colectomy for acute colitis with a matched open colectomy group that laparoscopic total colectomy is feasible and leads to a faster recovery . the mortality rate from a subtotal colectomy in emergency setting is approximately 20% in most collected series , because of the reluctance of surgeons to perform a subtotal colectomy early and defer it till desperate circumstances arise . on the basis of surgical outcomes of this patient and literature support , we need for spreading awareness regarding the potentially disastrous adverse effects of herbal medications prescribed by quacks and advocate early intervention in such type of severe ileocolitis with massive rectal bleed .

various colonic side - effects of herbal enema have been reported in literature ranging from mild abdominal discomfort to self - limiting haemorrhagic colitis . it rarely requires blood transfusion or subtotal colectomy . we report a 57-year - old male patient developing severe ileo - colitis with persistent massive rectal bleeding immediately after herbal enema administration for the treatment of chronic constipation and was resistant to conservative management . patient was managed successfully with emergency total laparoscopic colectomy . post - operative recovery of the patient was excellent .

brainstem vascular malformations can be classified as arteriovenous malformations , venous malformations , cavernous malformations , or capillary telangiectasias . on pathological examination , capillary telangiectasias are a distinct type of vascular malformation , characterized by multiple thin - walled vascular channels , interposed between normal brain parenchyma . it has been postulated that telangiectasias are acquired lesions , caused by other underlying venous anomalies . , numerous case reports of presumed brainstem capillary telangiectasias have appeared ; usually pathological confirmation is absent . the fact that most capillary telangiectasias are found incidentally on mr imaging confirms the suggested clinically benign course in general , although a histopathologically proven , clinically aggressive case in an infant has been described . we performed a pubmed search of the literature and found 26 cases to date [ 58 ] . all but one of these cases were thought to be symptomatic , including symptoms of vertigo , tinnitus , hearing loss , ataxia , limb paresthesias , and monocular ptosis . basilar - type migraine , previously called basilar migraine or bickerstaff migraine , is a migraine variant first described by bickerstaff in 1961 . being a very rare migraine variant , the exact incidence and prevalence are unknown . although various criteria for the diagnosis have been applied over the years , fully reversible symptoms resulting from brainstem dysfunction are essential for the diagnosis . a recent study found the median age of onset to be 17 years and a female - to - male ratio of 3.8:1 . an 18-year - old woman presented to the outpatient clinic with a history of unilateral headaches , accompanied by phonophobia , but no photophobia , nausea , or vomiting . these headaches had increased in frequency over the last 6 months from once per year to about three times per week , typically lasted several hours , and were alleviated by sleep . the headache was frequently preceded by visual symptoms , such as flickering or black spots , in both visual fields . the patient had not used painkillers for these attacks , because in her opinion , these headaches were not severe enough to justify the use of medication . furthermore , this patient experienced a single episode of vertigo , followed by sudden loss of consciousness with a duration of about 10 min . no jerks , urinary incontinence , or tongue bite were present . on regaining consciousness , no confusional state was present , but patient noted the most terrible headache ever . several days later , an attack of vertigo without hearing loss occurred , with alternating paresthesias in all limbs , followed by the same terrible headache . for these a clinical diagnosis of basilar - type migraine was made , since the patient fulfilled the international headache society ( ichd - ii ) criteria . magnetic resonance imaging ( mri ) showed focal areas of hyperintensity in t2-weighted spin echo images , hypointensity in t2 * -weighted gradient echo images , and enhancement in postcontrast t1-weighted images ( fig . 1 ) . the diagnosis was revised to secondary headache attributed to cranial vascular disorder ( ichd - ii 6 ) , since one of the criteria for basilar - type migraine is that it can not be attributed to another disorder . she was treated with propranolol 80 mg per day as prophylactic treatment and acetaminophen 1,000 mg during attacks . during follow - up , she reported excellent response to the propranolol , with no new basilar - type migraine attacks for 12 months.fig . 1postcontrast axial and sagittal t1 , arrows pointing towards mr - suggested capillary telangiectasia postcontrast axial and sagittal t1 , arrows pointing towards mr - suggested capillary telangiectasia although no pathologic confirmation is available in our patient , we believe the radiological abnormality found on mri to be a capillary telangiectasia . this is supported by the absence of significant changes in a follow - up mri scan . the association with clinical symptoms remains unproven , although a clinical picture of peculiar attacks of prolonged loss of consciousness due to pontine telangiectasia has been described in the literature . another paper describes a case of basilar - type migraine associated with calcifications in the pontine tegmental nuclei . as this case illustrates , mr imaging of the brain should be considered if a rare cause of primary or secondary headache is suspected on clinical grounds . follow - up imaging seems only to be warranted in presumed symptomatic lesions , although the added value remains debatable , since no therapeutic interventions are available . regarding preventive treatment for basilar - type migraine , some experts prefer divalproex - sodium or verapamil instead of propranolol because of the concern of limitation of compensatory vasodilatory mechanisms . in our opinion no contraindication for propranolol exists in this patient because of the assumed causal relationship between the capillary telangiectasia and her clinical symptoms . with respect to acute treatment , there seems to be consensus against triptans because of concern over the potential for cerebral vasoconstriction and the uncertainty of the mechanism of basilar - type migraine , although evidence proving this causality is lacking . in conclusion , with this case report we provide some further evidence that pontine capillary telangiectasia might cause a clinical picture resembling basilar - type migraine .

a case of presumed pontine capillary telangiectasia in an 18-year - old woman with a clinical diagnosis of basilar - type migraine is reported . since both are very rare diagnoses , this case provides some evidence to suggest that pontine capillary telangiectasia might cause a clinical picture resembling basilar - type migraine .

statins are a very widely used class of medication and controlled studies have demonstrated clear benefits with respect to cardiac disorders and also stroke and cognitive function . because of this there are moves toward their use in primary prevention of atherosclerosis ( 1 ) . the literature includes numerous reports of cognitive dysfunction ( 2 ) even though their occurrence was not borne out as a general effect in the controlled trials ( e.g.3 ) . however the previously published reports have not mentioned aphasia or dysphasia as a specific side effect except as part of a much wider and more serious problem ( 4 ) . despite this a general search of the internet however as at the 30th march 2011 the australian register of drug adverse reactions records six cases of aphasic disturbance with atorvastatin , one with rosuvastatin and two with simvastatin ( goodwin , personal communication ) . this case is presented as a reasonably well documented occurrence of dysphasia associated with the use of atorvastatin and rosuvastatin and a consideration of some of the factors that might be involved in both the genesis of the syndrome and the absence of documented reports . mrs . x. y. a 58-yr - old caucasian woman , presented for medicolegal examination on the 14th of april 2010 with regard to a compensation claim involving allegations of harassment at work producing anxiety and depression . at the time of her initial presentation for treatment her general practitioner had noted that her blood pressure was higher than usual and had prescribed the statin lipitor ( atorvastatin ) 10 mg per day together with indapamide 2.5 mg per day . x. y. reported that she had developed problems in " word finding " in that her speech would be interrupted because she would be unable to find a word to describe an object . x. y. had ceased the lipitor after a few days and said that her symptoms had resolved quite quickly . she had seen her doctor four weeks later and the doctor had noted " had symptoms of haziness and confusion with the lipitor tablets so patient had stopped them . nil symptoms since then . claims x. y. had been commenced on crestor ( rosuvastatin ) 5 mg daily while continuing on indapamide . x. y. was continuing to take indapamide 2.5 mg per day . a review of mrs . x. y. 's investigations indicated that a the time she had been prescribed lipitor her total cholesterol was 6.1 mm ( hdl 1.27 , ldl 3.77 ) , trigycerides 2.34 mm and fasting glucose 5.8 mm . x. y. had developed dysphasia as a direct side effect of the use of simvastatin . that this is likely to have been a generic statin effect is supported by the recurrence of milder symptoms on rosuvastatin and their remission on its cessation . using the method of attribution recommended by naranjo and colleagues the greater effect resulting from the rosuvastatin is likely to reflect the co - incident prescription of indapamide as both drugs are metabolised through the cyp 450 3a4 pathway whereas rosuvastatin is metabolised via the cyp 450 2c9 pathway ( 6 , 7 ) . there is clear evidence that aphasia can be included in the syndrome of mitochondrial encephalopathy ( melas ) ( 8) but in this case there is no history of other mitochondrial dysfunction such as muscle weakness . wagstaff and colleagues ( 2 ) suggest that inhibition of membrane synthesis may affect the neuronal membrane . this is supported by baker and tarnopolsky ( 9 ) who also suggest that decreased ubiquinone ( co - enzyme q10 ) synthesis may lead to decreased atp production and reduced free radical scavenging , and by ihara and colleagues who report that the cerebral pathology occurring in their melas patients reflected damage at a cellular rather than vascular level ( 6 ) . it may be that speech requires a selective increase in neuronal metabolism and is therefore a vulnerable function . slow cyp 450 metabolisers are likely to have proportionately higher blood levels and there may also be a genetically determined increased sensitivity to lower ubiquinone levels within the mitochondria in some patients ( 11 ) . given the history of the episodes in this patient and the comments written in the attending practitioners notes it would seem that other episodes of similar syndromes may be more common than reported . i subsequently have had one further patient retrospectively report transient cognitive symptoms on a statin . accad ( 12 ) notes that one of the problems in the use of statins is the immediacy of side effects and the long delay of benefits . however another problem would seem that there tends to be a " one size fits all " approach and that because of the substantial overall benefits of statin use significant side effects are masked in large trials . some greater attention to the group reporting side effects may demonstrate significant markers such as cyp 450 slow metabolising that would allow prediction of the at risk group as well as defining specific genetic abnormalities in cerebral lipid metabolism such as those reported by hollingworth and colleagues ( 13 ) . also this particular case draws attention to a need for greater awareness of possible drug interactions through the cyp 450 system amongst primary care physicians .

this paper presents a case of reversible dysphasia occurring in a patient prescribed atorvastatin in combination with indapamide . a milder dysphasia recurred with the prescription of rosuvastatin and was documented on clinical examination . this resolved following cessation of rosuvastatin . the case highlights both a need for a wider understanding of potential drug interactions through the cyp 450 system and for an increased awareness , questioning and reporting of drug side - effects .

sympathetic innervation of the eye is a third - order neuron pathway which emerges from the hypothalamus and runs along a well - known route before reaching the eye [ 1 , 2 , 3 ] . the third - order neuron is located in the superior cervical ganglion dividing itself into two branches which innervate the mller 's muscle of the eyelids , lacrimal gland , iris dilator muscle , facial sweat glands and the small skin vessels [ 1 , 2 , 3 ] . horner 's syndrome , also called oculosympathetic paresis , results from any lesion that interrupts the sympathetic neuronal pathway from the hypothalamus to the eye . it manifests ipsilaterally to the lesion , consisting mainly of miosis , slight ptosis and enophthalmos , but can present other findings [ 1 , 2 , 3 ] . horner 's syndrome can be caused by many benign and malignant conditions [ 1 , 2 , 3 , 4 ] . neoplasia is the most common cause and accounts for 3560% of all cases [ 2 , 3 , 4 ] . the purpose of this paper is to present the case of a woman with a left cervical mass corresponding to a t - cell - rich b - cell non - hodgkin lymphoma that manifested horner 's syndrome due to a sympathetic third - order neuron lesion at diagnosis . to our knowledge , this is the first case of horner 's syndrome secondary to a lesion in the post - ganglionic level of the sympathetic pathway in a non - hodgkin lymphoma . a 35-year - old woman was admitted with a cervical lymphadenopathy which had progressively grown over the last 3 months . it consisted of a coalescent group of hard lymph nodes that infiltrated adjacent tissues and skin , posteriorly located on the left side of the neck ( fig . simultaneously she presented ipsilateral miosis , slight superior eyelid ptosis , and enophthalmos typical for horner 's syndrome ( fig . the ocular phenylephrine 1%-test revealed minimal dilatation in the normal right pupil and pronounced dilatation in the left affected pupil ( fig . ct scan of the neck confirmed a lymphadenopathy that occupied the carotid and paravertebral spaces . thoracic ct scan did not show any tumor in the mediastine or left lung apex . cervical tumor biopsy revealed a t - cell - rich b - cell non - hodgkin lymphoma [ immunohistochemistry : 100% large lymphocytes cd20(+ ) ; 40% large lymphocytes cd45(+ ) ; background lymphocytes cd3(+ ) ; cd15( ) ; cd30( ) ; alk-1( ) ] . as liver and bone marrow were both compromised but without b symptoms , the tumor was classified as stage iva by the ann arbor staging system , and she was treated with 6 cycles of r - chop . until present , the patient has been receiving salvage chemotherapy with ifosfamide , carboplatin and etoposide due to a relapse affecting the lungs occurring after 2 years of complete clinical remission . as soon as she reaches the second remission , she will undergo an autologous bone marrow transplant . we found a small number of papers citing or describing horner 's syndrome related to non - hodgkin lymphomas [ 5 , 6 , 7 , 8 , 9 ] . they were reported as tumors that primarily affected the intramedullary spinal cord ( c3-c6 ) , lung apex ( pancoast 's syndrome presentation ) [ 6 , 7 ] , the thyroid gland , or which were spread throughout the patient 's body including a supraclavicular lymphadenopathy . these published cases , however , seem to be the result of sympathetic neuronal pathway interruption in the first- or second - order neuron pathways [ 6 , 7 , 8 ] . in 1958 , giles and henderson cited a case of malignant lymphoblastoma that caused horner 's syndrome in one of their study patients . this tumor could correspond to a non - hodgkin lymphoma , but the sympathetic lesion level was not specified . according to danesh - meyer et al . , the phenylephrine test finding observed in our patient locates the lesion in the third - order neuron level ( post - ganglionic ) . this can be explained by the principle of denervation supersensitivity which occurs in the affected side . as the patient did not show hemifacial anhydrosis or flushing , it seems that the lesion specifically affected the third - order neural branch along the internal carotid artery . it is well - known that neck lymphadenopathy from any cause can result in horner 's syndrome . nonetheless , our paper illustrates a rare presentation of non - hodgkin lymphoma , mainly because it seems to be the first well - documented case of a third - order sympathetic neuron lesion caused by this kind of malignancy .

in this paper , we present the rare case of a patient with cervical lymphadenopathy diagnosed as a t - cell - rich b - cell non - hodgkin lymphoma that manifested horner 's syndrome due to a post - ganglionic sympathetic neuron lesion caused by the tumor .

it is a benign locally aggressive tumor usually involving the distal end of the femur , proximal tibia and distal radius in young adults . the main variables to be considered for planning treatment include the site of involvement and campanacci stage of the tumor . different treatment options are available which include intralesional curettage , extended curettage , wide resection and reconstruction . functional and oncological outcome of these treatment options varies widely , the predominant detrimental factor being tumor recurrence rate . reconstruction of endoprosthesis after wide excision of the tumor offers good short - term and mid - term functional and oncological outcomes as established by previous studies . this study was conducted to evaluate the long - term outcome of 11 patients with gct who underwent wide excision and customized endoprosthetic replacement . this study included 11 patients ( eight men and three women ) aged 2448 ( mean 32 ) years with primary gct of proximal femur campanacci stage - iii who were available for mean follow - up duration of 10.6 ( range 10.214 ) years . the definite diagnosis was established on histopathological confirmation with incisional biopsy . computed tomography scan of chest and bone scan none of the patients had pulmonary metastasis , and all the 11 patients had a solitary lesion in the proximal femur . these patients underwent wide resection of the tumor using postero - lateral approach to the proximal femur . the proximal femur was reconstructed using a customized , titanium , cemented endoprosthesis [ figure 1 ] . hip abductors , short external rotators and iliopsoas tendon were secured onto the prosthesis and hip capsule repair was performed . postoperative rehabilitation protocol included nonweight bearing and abduction splinting of the limb for 6 weeks followed by nonweight bearing crutch walking for another 6 weeks . once the hip abductors and quadriceps strength was regained weight bearing was allowed . long - term functional outcome was evaluated at minimum 10 years duration using revised musculoskeletal tumor society rating scale . ( a ) radiogragh showing giant cell tumor of proximal femur in a 34-year - old man . ( b ) magnetic resonance imaging showing giant cell tumor of proximal femur with soft tissue extension . there were no instances of prosthesis related complications like aseptic loosening or dislocation . at the end of mean 10.6 years six patients had good hip function without any restrictions , four patients had intermediate functional restriction whereas one had the recreational restriction of function . nine patients enthusiastically accepted the outcome of the procedure whereas two patients had satisfactory emotional acceptance . eight patients were walking without any support with unlimited walking abilities whereas three patients were using a cane for support while walking . the mean is revised musculoskeletal tumor society score was 26.8 out of 30 [ table 1 ] . traditional treatment of gct has been a difficult problem in orthopaedic oncology owing to high recurrence rates following conventional treatment with curettage or extended curettage . ideally treatment currently with improvement in reconstructive surgical techniques and availability of high quality biomechanically designed megaprosthesis , wide resection of tumor with proximal femur endoprosthesis replacement is being considered as a treatment option for campanacci stage - iii lesions in proximal femur with extensive osteolysis and soft tissue extension . it offers good local control of s with least recurrence rate and favorable functional outcome . the previous studies have shown satisfactory short- and mid - term functional and oncological outcomes . this study shows good long - term functional , and oncological outcomes of the procedure and hence the authors recommended as an endoprosthetic replacement for advanced gct of the proximal femur . furthermore , randomized control trials are required to established this modality as a standard treatment .

introduction : giant cell tumor ( gct ) of bone is locally aggressive benign tumor involving the epiphysis of long bones in young adults . various treatment options include intralesional curettage , extended curettage , wide resection , resection and reconstruction and amputation . the main variables to be considered for planning treatment include the site of involvement and campanacci stage of the tumor . functional and oncological outcomes of these treatment options vary widely , the predominant detrimental factor being tumor recurrence rate.aim:a study was conducted to evaluate the long - term oncological and functional outcome of patients with gct of the proximal femur that underwent tumor resection and endoprosthetic replacement.materials and methods : eleven patients with campanacci stage - iii gct of proximal femur who underwent wide excision of tumor and endoprosthesis replacement with a mean follow - up the duration of 10.6 years were assessed using standard proforma . the treatment outcome was evaluated using the revised musculoskeletal tumor society rating scale for the lower extremity.results:at mean follow - up the duration of 10.6 years , none of the cases had tumor recurrence , infection , prosthesis loosening or dislocation . all the patients were community ambulators among whom eight patients were walking without support while three patients were using a cane for support . the mean total musculoskeletal tumor society score was 26.8 out of 30 indicating the good outcome.conclusions:the authors recommend that wide resection and endoprosthetic replacement should be considered as a preferred treatment option for proximal femur gct as the functional , and oncological outcome is satisfactory with this modality of treatment .

munchausen syndrome is characterized by feigning physical symptoms to seek attention ; it was first reported by asher in 1951 . we report a case of cutaneous munchausen syndrome in a patient who self - inflicted trauma to a postoperative wound . a 50-year - old japanese woman consulted the emergency department of our hospital in august 2015 for bleeding due to an intractable postoperative wound on the lower abdomen ; the postoperative wound was owing to a laparoscopic cholecystectomy performed 1 year previously for acute cholecystitis . the wound was sutured and the patient consulted with the dermatology department 3 days later ( fig . , she presented with a painful ulcer ( diameter 6 cm ) on her right lower abdomen , and its suture had disappeared ( fig . she also presented with multiple scars , skin grafts on the extremities , and a missing left lower leg , the causes for all of which were unexplained ( fig . 2 ) . her white blood cell count , neutrophil number , platelet count , renal and liver functions , c - reactive protein level , and ch50 level were normal , except for the hemoglobin level ( 9.2 g / dl ; normal range 12.015.0 g / dl ) . negative results were obtained for cytoplasmic antineutrophil cytoplasmic antibodies , myeloperoxidase antineutrophil cytoplasmic antibodies , and anti - ss - a antibodies . a histology of the skin biopsy specimen from the margin of the abdominal ulcer did not show any specific findings such as pyoderma gangrenosum or vasculitis , although we had considered these as differential diagnoses . she had been presenting with repeated intractable wounds since she was a child , which resulted in the amputation of her left lower leg . although we asked her about the scar and amputation , she did not reveal any details . the previous surgeon who had performed the laparoscopic cholecystectomy 1 year before revealed that surgical wound dehiscence had occurred during her admission . after her medical records indicated that she had been admitted to the department of plastic surgery at our hospital for skin grafting of a leg ulcer 10 years before . during that admission , she refused to consult with the department of psychiatry , although the staff suspected mental disorders . therefore , we diagnosed her with cutaneous munchausen syndrome , although we could not determine how she had traumatized the postoperative wound . after vacuum - assisted closure ( vac ) therapy had been performed to prevent her from traumatizing the ulcer again , it rapidly became granulated and reepithelialized ( fig . soon after we had told her that we had diagnosed her with cutaneous munchausen syndrome , she discharged herself . munchausen syndrome is a disorder characterized by a triad of features : simulated illness , pathological lying , and nomadic living . people with this syndrome self - inflict numerous lesions , keep getting admitted to different hospitals , and feign acute illness , usually spectacular diseases ; and they willingly undergo invasive diagnostic procedures and risky therapies [ 3 , 4 ] . typical findings in cutaneous munchausen syndrome caused by the intracutaneous presence of foreign material are erythema , swelling , necrosis , and tissue breakdown , which present as ulcerations , abscesses , nodular panniculitis , and pyoderma gangrenosum [ 2 , 5 ] . most patients with cutaneous munchausen syndrome inject foreign materials into their skin and soft tissue ; however , our patient traumatized her postoperative wound . the diagnosis of munchausen syndrome , which can sometimes be fatal , is often difficult to make . also , hospital room and personal - belonging searches can provide evidence of methods for faking symptoms , and video monitoring or a bedside sitter can be helpful , as these techniques often reduce or eliminate symptom frequency during observation . however , searches and monitoring should be performed after approval has been granted from the institution 's legal counsel . diagnostic clues include cultured organisms from cutaneous wounds that are uncommonly found on the skin , usually on the nondominant side of the body [ 1 , 2 ] . cutaneous munchausen syndrome should be considered as a differential diagnosis when a patient 's skin lesions do not heal or when they repeatedly recur despite appropriate treatment , and if routine detailed examinations show negative or normal results .

a 50-year - old japanese woman consulted the emergency department of our hospital for bleeding due to an intractable postoperative wound on the lower abdomen ; the postoperative wound was owing to a laparoscopic cholecystectomy performed 1 year previously for acute cholecystitis . she presented with a painful ulcer on her right lower abdomen . she also presented with multiple scars , skin grafts on the extremities , and a missing left lower leg , the causes for all of which were unexplained . the results of her blood test were normal , except for the hemoglobin level . histology of the skin biopsy specimen from the ulcer did not show any specific findings . the previous surgeon who had performed the laparoscopic cholecystectomy revealed that surgical wound dehiscence had occurred during her admission . after a body restraint had been applied , the ulcer improved . medical records indicated that she had been admitted to the department of plastic surgery at our hospital for skin grafting of a leg ulcer . during that admission , she refused to consult with the department of psychiatry , al - though the staff suspected mental disorders . therefore , we diagnosed her with cutaneous munchausen syndrome . after vacuum - assisted closure ( vac ) therapy had been performed to prevent her from traumatizing the ulcer again , it rapidly became granulated and reepithelialized . munchausen syndrome is characterized by feigning physical symptoms to seek attention . patients self - inflict numerous lesions , keep getting admitted to different hospitals , and feign acute illness , usually spectacular diseases . vac therapy may be effective for preventing patients with cutaneous munchausen syndrome from traumatizing their wounds .

streptococcus minor was described in 2004 as a new species isolated from the tonsils of dogs , cats and cattle as well as from the intestinal tract of dogs . although staphylococci and streptococci are commonly involved genera in bite - infected wounds , no cases of human infection by s. minor have been reported in the literature . here a 51-year - old woman was admitted for a dog bite injury to her right hand . the patient s medical history revealed a urinary bladder cancer 3 years ago , currently in remission . she presented with inflammation , redness , heat and pus production at the bite wounds ( fig . 1 ) . clinically , the patient was afebrile ( temperature 36.6c ) , and no signs of systemic infection were observed . biologic investigations revealed an inflammatory syndrome with a c - reactive protein value of 46 mg / l ( normal value , < 5 mg / l ) associated with a light leukocytosis of 10.880 cells/l ( normal range , 4 to 10 10 cells/l ) . urgent surgery was proposed but was refused by the patient despite warnings of the risk of sepsis and necrosis . the wounds were washed with povidone iodine , and intravenous empiric antibiotic therapy was initiated ( cefazolin 2 g / d ) . one set of peripheral blood cultures ( including aerobic and anaerobic conditions ) was performed , and no growth was observed after 5 days of incubation . aerobic culture from pus wounds after 48 hours on columbia agar ( becton dickinson , franklin lakes , nj , usa ) yielded a pure growth of unpigmented , regular , translucent and -hemolytic colonies of gram - positive streptococcus . identification as streptococcus minor was achieved using matrix - assisted laser desorption / ionization time - of - flight mass spectrometry ( maldi - tof ms ; bruker daltonics , bremen , germany ) , with an excellent score of 2.428 . sequencing of 16s rrna gene ( 96ga3730 xl ; thermo fisher scientific life sciences , waltham , ma , usa ) confirmed the identification of s. minor with 100% of identity and demonstrated the usefulness of maldi - tof ms for identifying this organism . the antimicrobial testing showed susceptibility to penicillin , clindamycin , erythromycin and trimethoprim sulfamethoxazole . the patient left the hospital the same day and received 10 days of oral antimicrobial therapy with amoxicillin clavulanate acid at 850/125 mg three times a day . under this antibiotic regimen , five days later , patient examination revealed no clinical signs of infection or radiologic signs of bone injury . infections caused by s. minor are probably underestimated because of the organism s facultative anaerobic nature , requiring a co2-enhanced atmosphere , and the difficulty in identifying to the species level -hemolytic streptococci with current laboratory techniques . moreover , in contrast to other streptococci generally identified in zoonotic infection , such as streptococcus canis ( group g ) involved in several cases of septicaemia and one case of infective endocarditis , , s. minor does not react with lancefield groups a , c , d , f or g antisera . although the pathogenicity of this organism is still unknown , this case suggests that s. minor can lead to serious local infections . this study also demonstrates the usefulness of maldi - tof ms for identifying this organism . to our knowledge s. minor has never been isolated from humans but is part of the commensal flora from dogs , suggesting strong causality . unfortunately , in this case , the dog bite had occurred a while ago , and the dog was not available for further testing in order to compare the homology of both the patient s and dog s isolate strains and to confirm the origin and the pathogenicity of s. minor . further investigation on the oral dog flora and on s. minor s virulence factors is necessary to confirm its implication and elucidate its pathogenic mechanisms .

we report the first case of human infection caused by streptococcus minor in a 51-year - old immunocompetent woman admitted for dog bite injuries . at present , the role of streptococcus minor in bite wound infections is unknown . further studies on virulence factors are needed to elucidate its pathogenicity mechanisms .

myiasis is a term derived from the greek word myia , meaning invasion of vital tissue of humans or other mammals by fly larvae.[15 ] the term myiasis hope in 1940 , and since then , it has been used to designate infestation by the larvae.[68 ] myiasis was defined by zumpt as the infestation of live human and vertebrate animals by dipterous larva , which at least for a certain period feed on host 's dead or living tissue , liquid body substances or ingested food . a condition similar to myiasis was considered by the hindu mythology as god 's punishment to sinners . a 22-year - old male patient reported to the outpatient department of oral medicine with a primary complaint of worms in the mouth since 4 days . the medical history revealed that the patient was affected by cerebral palsy since birth [ figure 1 ] . clinical oral examination revealed an area of ulceration in the anterior palatal aspect of the mouth , accompanied by erythema , redness and bleeding on probing [ figure 2 ] . external profile of the patient intraoral photograph showing palatal swelling a total of 20 larvae were grasped gently and taken out with the help of tweezers after application of turpentine oil . out of these , only three were viable . these were then taken to department of parasitology where they were identified as larvae of the common housefly . histopathological examination of the incisional biopsy specimen revealed dense inflammatory infiltrate comprising chiefly lymphocytes in the connective tissue stroma . this parasitic infestation frequently occurs in rural areas , infecting livestock and pets such as dogs and cats . after the fly lays eggs in the dead and decaying tissues , the larvae hatch in about 810 hours , soon after which they burrow into the surrounding tissues ; and in this stage , there will be tissue inflammation ensuing discomfort , which makes the patient consult a doctor . the opening of the burrow is usually kept patent with induration of the marginal tissues , and is raised forming a dome - shaped warble . they position their heads down so that the posterior spiracles could become exposed to the open air to make respiration possible . after the young larvae penetrate the skin of the host , they take 812 days to develop into the prepupal stage and then leave the host to pupate . while in human skin the most common anatomic sites for myiasis are the nose , eye , lung , ear , anus , vagina and , more rarely , the mouth . incidence of oral myiasis as compared to that of cutaneous myiasis is less as the oral tissues are not permanently exposed to the external environment . it has been reported among epilepsy patients with lacerated lips following a seizure , incompetent lips and thumb sucking habits , advanced periodontal disease , at tooth extraction sites and patients with tetanus with mouth propped open to maintain their airway . the stage of larvae lasts for 68 days during which they are parasitic to human beings . the larvae have backward directed segmental hooks with which they anchor themselves to the surrounding tissue . they are photophobic and tend to hide deep into the tissues for a suitable niche to develop into pupa . this unusual type of gingival myiasis may occur in an unconscious or sleeping person when the mouth is left open . periodontal disease of the oral cavity , with pockets , provides a perfect environment for the eggs to hatch and for the larvae to grow in the warm and moist conditions . histological examination of tissue has been reported to show evidence of dense inflammation , dystrophic calcification , and foreign bodies compatible with features of abscess . the standard treatment of myiasis is manual removal with hemostatic or clinical pincers , associated with or without the administration of topical asphyxiation drugs , which forces the larvae to come out . it is important to remove all the larvae , otherwise the cavity does not heal properly and can also become chronically infected . various substances ( ether , chloroform , olive oil , calomel , iodoform , phenol mixture ) have been recommended ; however , they were found to produce controversial results . ivermectin , a semi - synthetic macrolide antibiotic , is found safe for human use as proposed by shinohara et al . and osorio et al . in some cases to conclude , myiasis affects mostly the uncovered body areas where oviposition is easily carried out . it frequently affects low socioeconomic level individuals with poor hygiene habits and unhealthy patients with psychiatric disorders , diabetics , and immunocompromised patients . undoubtedly , preventive approach measures , including basic health care , hygiene , access to primary health service , and safe water and drainage , are fundamental to prevent cases such as this one .

myiasis is a relatively rare condition arising from the invasion of body tissues or cavities of living animals or humans by maggots or larvae of certain species of flies . it is an uncommon clinical condition , being more frequent in underdeveloped countries and hot climate regions , and is associated with poor hygiene , suppurative oral lesions ; alcoholism and senility . its diagnosis is made basically by the presence of larvae . the present article reports a case of oral myiasis involving 20 larvae in a patient with neurological deficiency .

paraganglioma is a rare neuroendocrine neoplasm that may develop at various body sites like abdomen , thorax , head and neck . majority of paragangliomas develop in abdomen while mediastinal paraganglioma is a rare mediastinal tumor.12 posterior mediastinum is the commonest site for mediastinal paraganglioma while anterior mediastinal localization is unusual.13 most paraganglioma are asymptomatic and present as painless mass . endoscopic ultrasound ( eus ) features of retroperitoneal paraganglioma have been described4 while that of mediastinal paraganglioma have not been described . in this report we describe the eus features of mediastinal paraganglioma in a patient who presented with cough and chest pain without any neuroendocrinal symptoms . a fifty - six year old female presented with one month history of chest pain and cough . the patient was not hypertensive and did not give any history related to neuroendocrinal hormone over secretion . the mass was inverted triangular shape with bulging peripheries , situated between aorta and left pulmonary artery . the mass was hypervascular in the center and the interface between the mass and vessels described was intact and there was no lymphadenopathy ( fig . 1 - 3 ) . eus - guided fine needle aspiration ( eus - fna ) was done using a 22-g needle ( echotip , cook corporation ) . slides were prepared and the material was air dried as well as alcohol fixed before sending for cytopathological evaluation ( fig . 4 , 5 ) . good material was obtained on eus - fna , but three experienced cytopathologists gave three different reports ; final diagnosis of paraganglioma was only made on thoracoscopic biopsy and immunohistochemistry . mediastinal paraganglioma is a rare mediastinal tumor.12 it constituted 0.3% of all mediastinal tumors in the series described by cesar et al.1 while no case of mediastinal paraganglioma was found out of 57 eus - fna done for mediastinal masses by zeppa et al.2 majority of thoracic paragangliomas occur in posterior mediastinum . out of 16 cases of thoracic paragangliomas reported by cesar paragangliomas arise from parasympathetic or sympathetic ganglia located in ap window or posterior mediastinum.34 diagnosis of asymptomatic paraganglioma on any imaging modality is difficult . on fna cytology , it is difficult to give final diagnosis.4 in our patient also the tumor could be finally diagnosed only upon thoracoscopic biopsy and immunohistochemistry and the tumor was positive for chromogranin , synaptophysin and neuron specific enolase . eus features of mediastinal paraganglioma are not described while only in one case eus features of retroperitoneal paraganglioma are reported.2 the situations in retroperitoneum and mediastinum are different . retroperitoneum is a potential big space where tumor can grow freely to any size and can assume any shape while there is little space in mediastinum for tumor to grow and tumor may assume a particular shape . in the present case , there were certain features which were highly suggestive of paraganglioma . it is inverted triangular shape with base of the triangle lying superiorly , because there is sufficient space in ap window where tumor can grow , and apex lying inferiorly , because the tumor has to grow in between the vessels . besides , there were other features such as rich vascularity of the tumor , bulging peripheries , no invasion of vessels and absence of lymphadenopathy . we analyzed our 50 cases of various mass lesions involving ap window and subcarinal space , and in none of the cases such typical eus features were seen . growth in between the vessels without invasion of vessels was a typical feature of benign paraganglioma . when such appearance is seen on eus imaging , diagnosis of paraganglioma is quite likely and eus - fna may be risky and may not provide final diagnosis .

endoscopic ultrasound ( eus ) features of mediastinal paraganglioma have not been described . in this paper , we report a female patient presented with cough and chest pain without any neuroendocrinal symptoms . final diagnosis of mediastinal paraganglioma was made on thoracoscopic biopsy and immunohistochemistry after eus - guided fine needle aspiration . eus features of mediastinal paraganglioma are described .

it is an aggressive neoplasm that arises from the remnants of the dental lamina and dental organ ( odontogenic epithelium ) and patients usually present late in life after the tumor has achieved considerable size , to cause facial disfigurement . 70% of ameloblastomas develop in the molar - ramus region of the mandible and are occasionally associated with an unerupted third molar teeth . radiographically an ameloblastoma can be a unilocular or multilocular radiolucent lesion with a honeycomb or soap bubble appearance . there are three forms of ameloblastomas , namely peripheral , unicystic , and multicystic tumors . multicystic ameloblastoma is common and represents 86% of all the cases . our patient was a 42-year - old female with a history of swelling in the left mandibular region that had been present for the four - and - a - half years . physical examination demonstrated a non - tender , left mandibular lesion measuring approximately 15 17 12 cm with normal overlying skin [ figures 1 and 2 ] . panoramic and posterior - anterior ( pa ) skull radiographs revealed a well - defined , large , expansile , multilocular radiolucent lesion , involving the entire hemimandible with medial displacement of the teeth [ figures 3 and 4 ] . an axial computed tomography ( ct ) scan of the mandible showed a well - defined , large , multilocular , expansile radiolucent lesion with erosion , cortical destruction , and thinning of the posterior border of the left ramus of the mandible [ figure 5 ] . fine needle aspiration cytology ( fnac ) of the lesion was performed , which yielded straw - colored fluid . subsequently , the patient underwent incisional biopsy of the left mandibular mass confirming the diagnosis of plexiform ameloblastoma . it was predominantly composed of epithelium arranged as a tangled network of anastomosing strands , enclosing cysts of various sizes , suggestive of plexiform ameloblastoma . after confirmation of the diagnosis , the patient underwent left hemimandibulectomy [ figures 6 and 7 ] . the excised mass was sent for histopathology examination , which further confirmed the diagnosis of plexiform ameloblastoma [ figure 8 ] . . a submental view of the patient demonstrates a left mandibular mass with its lateral and inferior extension . an orthopantomograph ( opg ) demonstrates a large multilocular , expansile lesion causing thinning of the cortical plates involving the whole of the left hemimandible . a posterior anterior ( pa ) skull radiograph reveals a multilocular expansile lesion of the left mandible , with medial displacement of the involved teeth . a non - contrast computed tomography ( ct ) axial view through the left mandible demonstrates multiple locules , with expansion and thinning of both the cortical plates , and perforation along the posterior border of the left ramus . photograph of the gross appearance of the mass , measuring 14 15 10 cm . photomicrograph demonstrates a plexiform ameloblastoma predominantly composed of the epithelium arranged as a tangled network of anastomosing strands , enclosing cysts of various sizes . the radiographic appearance of an ameloblastoma varies from characteristic soap bubble loculations , to unicystic and multicystic radiolucencies , to subtle appearances such as expanded follicles of erupting teeth . the most common location is the posterior mandible associated with impacted teeth and follicular cysts , causing expansion of the cortical plates with scalloped margins and perforations with resorption of the involved teeth in advanced stages . radiographically an ameloblastoma may be mistaken for an odontogenic keratocyst , aneurysmal bone cyst , fibrosarcoma , or a giant cell tumor . ameloblastoma is characterized by the proliferation of epithelial cells arranged on a stroma of conjunctive vascular tissue in locally invading structures that resemble the enamel organ at different stages of differentiation . diverse histological patterns have been described in the literature and include follicular , plexiform , acanthomatous , papilliferous - keratotic , desmoplastic , granular , vascular and those with dentinoid induction . the term plexiform refers to the appearance of anastomosing islands of odontogenic epithelium in contrast to a follicular pattern . the epithelium displayed a stellate , reticulum - type appearance , arranged as a tangled network of anastomosing strands , enclosing cysts of various sizes . in conclusion , although ameloblastoma is one of the most common odontogenic tumors , its final diagnosis can only be confirmed with a histopathological examination . radiographically , ameloblastoma of the mandible can mimic other tumors of the mandible , such as , the odontogenic keratocyst , aneurysmal bone cyst , fibrosarcoma , or a giant cell tumor . a high index of suspicion of ameloblastoma will help triage the patients for further appropriate management .

ameloblastoma is a common and aggressive odontogenic epithelial tumor . it has an aggressive behavior and recurrent course , and is rarely metastatic . ameloblastoma represents 1% of all tumors and cysts that involve the maxillomandibular area and about 10% of the odontogenic tumors . it is primarily seen in adults in the third to fifth decade of life , with equal sex predilection . radiographically , it appears as an expansile radiolucent , with thinned and perforated cortices , and is known to cause root resorption . as it shares common radiographic features with other lesions such as the giant cell tumor , aneurismal bone cyst , and renal cell carcinoma metastasis , a definitive diagnosis can only be made with histopathology . we present an extensive case of plexiform ameloblastoma of the mandible in a 42-year - old female patient .

the hantavirus cross - sectional survey was carried out april through may 2006 in the municipality of uberlndia , minas gerais , at an average altitude of 863 m ( 1855s,4816w ) ( figure ) . a randomized and stratified ( sex and age ) sample was collected from the entire rural area and from the south sector of the municipality s periurban area . the term periurban refers to a residential area on the outskirts of the city that is in close contact with the rural area . the participants answered a questionnaire that included demographic information ( sex , age , place of birth , and address ) and questions relating to hps risk factors ( type of dwelling , exposure to rodents at home or work , labor activity , risk activities , history of severe pneumonia , and direct contact with hps patients ) . blood samples were collected by venipuncture , centrifuged , and sent to the laboratory of hantaviruses and rickettsioses at the oswaldo cruz foundation , rio de janeiro , brazil , for analysis . we screened serum samples by elisa for hantavirus - specific immunoglobulin g using a recombinant antigen of the nucleocapsid protein of araraquara virus , produced in escherichia coli and supplied by the virus research unit of the university of so paulo , brazil , according to the procedure previously described ( 2 ) . all positive serum samples were retested ; only those that had 3 elisa - positive results at > 1:400 dilutions were considered positive . the mann - whitney u and fisher exact / binomial tests for 2 proportions were applied for comparison among medians and proportions , respectively , using epi info 3.3.2 ( www.cdc.gov/epiinfo ) and biostat 5.0 ( www.biostat.org ) software . the 400 study participants comprised 200 rural and 200 periurban residents ranging in age from 12 to 76 years ( mean = 41 years ) . the 8 rural area antibody - positive samples were from male farmers ( table 1 ) . presence of antibody was significantly associated with male sex , older age class , and potential risk activities ( table 1 ) . although all case - patients reported exposure to rodents or their excreta , this exposure was not statistically significant ( table 1 ) . in the periurban area , the presence of antibody was associated with age but not with sex , risk activity , or exposure to rodents ( table 1 ) . the mean age of seropositive persons from periurban and rural areas was similar ( p = 1.0 ) . the relationship between antibody and sex depended on urban vs. rural residence ( p = 0.02 ) . three antibody - positive persons in the rural zone and 2 in the urban zone reported a history of pneumonia , albeit without complications . * clearing land , farming , working in pastures or cellars , or cleaning sheds barns , or other outbuildings . the largest number of cases occurred among periurban residents , but the highest cumulative incidence was among rural residents ( table 2 ) . nevertheless , rural and periurban areas did not differ significantly in either prevalence or incidence . rural versus periurban . determined by using 2-tailed fisher exact or binomial tests for 2 proportions . overall hantavirus antibody prevalence among periurban residents was 2.0% , with a higher prevalence among women ( 2.6% ) . in previous studies , the prevalence of hantavirus antibodies was higher in men ( 46 ) . this finding is similar to a situation reported in colombia , where all positive samples came from men engaged in rural activities ( 6 ) . these activities involve a high risk for infection by hantaviruses ( 7 ) . in this study , hantavirus positivity was found only in persons > 39 years of age , and the difference in the mean age of the participants in relation to positivity was significant . this fact might suggest a historic high - risk event to which the older age class , but not the younger age class , was exposed . high hantavirus antibody prevalence has been found in studies of some human populations in latin america ( 5,8,9 ) . the prevalence of araraquara virus reactive antibodies among the volunteers in this study demonstrates that transmission is not rare , reinforcing the hypothesis of the existence of mild disease or asymptomatic infections ( 10 ) . two hypotheses have been proposed : clinically mild disease or inapparent infections might result from differences in the nature of exposure ( e.g. , low inoculum or inefficient mechanism of transmission ) or genetic differences in immune response to infection , or they might indicate the circulation of > 1 hantavirus genotypes of greatly reduced virulence ( 10,11 ) .

a cross - sectional serosurvey was conducted to assess the proportion of persons exposed to hantaviruses in a virus - endemic area of the state of minas gerais , brazil . findings of this study suggested the presence of > 1 hantaviruses circulating in this region causing hantavirus pulmonary syndrome , mild disease , or asymptomatic infection .

most coronary artery origin abnormalities are incidentally determined during coronary angiography . in the adult population , its prevalence is reported to be approximately 0.3 to 1.3% in the largest registry.1 ) these abnormalities are usually asymptomatic and have no clinical significance . however , some cases of coronary artery abnormalities are related to severe life - threatening events such as myocardial ischemia , arrhythmia and acute myocardial infarction.2 ) we report an uncommon case of an anomalous origin of the left coronary artery ( lca ) , a single coronary artery , arising from the right sinus , with angina pectoris and palpitations . a 48-year - old woman presented with exertional angina and palpitations for a long time . she a had medical history of hypertension and dyslipidemia , and a family history of coronary artery disease . the exercise electrocardiogram showed dynamic changes with st - segment depression in the v 1 - 4 leads . the coronary angiography procedure was started with a lca cannulation attempt , but left anterior descending coronary artery and cx imaging was unsuccessful even though contrast was injected into the left coronary sinus . the right coronary artery was cannulated and visualized with a right judkins catheter . at this time the right judkins catheter was gently pull back and the left coronary arteries were clearly visualized ( figs . 1 and 2 ) . coronary ct angiography confirmed that the left coronary arteries arose from the right sinus of valsalva and that all three coronary arteries originated from the single sinus ( fig . the patient was managed with conservative treatment and has had no symptoms on clinical follow - up . coronary anomalies affect less than 1% of the general population . anomalous origin of lca from the right sinus of valsalva is the rarest anomaly , with a reported prevalence of 0.02 - 0.03% according to studies . the isolated origin of a single coronary artery is very rare , with an incidence of 0.04% to 0.23%.3 ) most of these coronary artery anomalies are generally asymptomatic ; however , some can cause severe potentially life threatening events . understanding anatomic coronary variations is important in determining anomalous origins that are related to sudden cardiac death.4 ) single coronary artery has been defined angiographically by lipton et al.5 ) according to the origin from the coronary artery . the modified lipton classification includes features such as the anatomical distribution , the ostial location , and the course of the transverse trunk . anomalous origin of the lca from the right sinus of valsalva is associated with sudden death in some cases ( 59% ) because an anomalous artery between two great vessels is related with acute myocardial infarction and sudden cardiac death.6 ) the acute angle of the ostium increases the risk of sudden cardiac death . the anomaly determined in our patient seemed to be potentially malignant , but without marked compression between the great arteries . the management of patients with an anomalous origin of coronary artery includes observation , medical treatment , coronary stent implantation and surgery repairment . however , in our case medical treatment was chosen due to the absence of compression of the coronary arteries by the great arteries , and the lack of acute ostial angulation . the patient was treated with a beta blocker and nitroglycerin because of the angina pectoris and palpitations , and she has remained asymptomatic for 1 year on follow - up . although cardiac catheterization is generally accepted as the gold standard for the evaluation of coronary anomalies , ct angiography has recently emerged as an effective and noninvasive method for performing imaging of the origin of the coronary arteries . in conclusion , the determination of the anomalous origin of the coronary artery and the cardiovascular system is of great clinical importance due to its severe life - threatening complications . the new imaging modalities that have emerged enable the accurate visualization of the anatomical configurations and the detection of structural malformations . most of the structural cardiovascular abnormalities are incidentally detected and are asymptomatic ; however , a few are potentially significant and can trigger sudden death .

anomalous origin of coronary arteries is generally asymptomatic and a rare disease . however , some cases can cause severe life - threatening events such as myocardial ischemia , arrhythmia , and acute myocardial infarction . we describe a case of a single coronary artery arising from the right sinus of valsalva in a 48-year - old female patient with a complaint of stable angina pectoris and palpitations . coronary angiography revealed that all three coronary arteries arose from the right sinus . coronary ct angiography confirmed that there was an anomalous origin of the left coronary artery arising from the right sinus of valsalva . the patient was managed with conservative treatment .

the ectodermal dysplasia represents a group of inherited conditions in which two or more ectodermally derived anatomic structures fail to develop . ectodermal dysplasias represent a large and complex group of diseases comprising of more than 170 clinical conditions . depending upon the presence or absence of sweat glands , it is divided into the hidrotic ( clouston syndrome ) and anhidrotic types . ( cst - syndrome i.e. christ- siemen - touraine syndrome and anhidrotic / hypohidrotic , ectodermal dysplasia being synonymous . ) in most cases , this disorder seems to show an x - linked pattern , with gene mapping to xq12-q13.1 ; therefore , a male predominance is usually seen . individuals affected by it show the triad comprising anhydrosis / hypohydrosis , hypotrichosis , and dental hypoplasia . hypodontia has been considered to be a multifactorial condition with genetic and environmental influences , and published opinions differ on the importance of each factor . larmour et al . , state that recent developments in molecular genetics are revealing the roles of the homeobox genes in the control of the complex epithelial / mesenchymal interactions that occur during dental development . those of particular interest for dental development are the muscle - specific homeobox genes , msx1 and msx2 . here is the case report of a 8-year - old male child with ectodermal dysplasia . the chief complaint of the patient was difficulty in mastication due to absence of maxillary and mandibular teeth . the patient experienced episodes of high fever , was intolerant to heat , and did not sweat . his i.q . , level was low , and it was evident when asked about schooling . other characteristics of ectodermal dysplasia , such as frontal bossing , saddle nose , reduced vertical dimension of face due to total anodontia were also noticed . child showing dry skin , sparse eyebrows , eyelashes , and scalp hair hands showing dystrophic ( thin and brittle ) nails feet showing dry skin and dystrophic nails intraoral examination revealed absence of teeth with thin alveolar crests [ figures 4 and 5 ] . complete anodontia of maxillary arch complete anodontia of mandibular arch occlusal and panoramic radiographs revealed no primary and permanent teeth [ figures 68 ] . in order to improve mastication and aesthetics , both upper and lower complete dentures were fabricated [ figure 9 ] occlusal view of maxilla occlusal view of mandible orthopantomogram ( opg ) showing complete anodontia post treatment photograph ectodermal dysplasia is one of the most important anomalies of interest to dental clinicians because of the absent or misshapen teeth . hypodontia is known as one of the major factors of ectodermal dysplasia and is almost always present . in severe cases , no teeth form . the absence of primary teeth ( true anodontia ) is a rare phenomenon . in this case , the patient 's history and clinical and radiographic examination revealed the absence of primary teeth . acikgoz et al . , and vieira et al . , also reported true anodontia of primary teeth . total anodontia denoted by complete developmental absence of teeth in both primary and secondary dentitions was reported pirgon et al . and pannu and singh . it is claimed that primary teeth must be present for the development of their permanent successors . there are no permanent teeth in the oral cavity of the patient , similar finding reported by vieira et al . the patient experienced episodes of high fever , was intolerant to heat , and did not sweat . child 's inability to perspire , more comfortable during cold weather , and absence of hair from the eyebrows with scanty eyelashes were also reported by gupta et al . and pannu and singh ( 2002 ) . short stature , underweight in relation to age and mental retardation were reported in accordance to case reported by gupta . management : to improve the appearance , mastication , and speech , the child was provided with maxillary and mandibular complete dentures similar to treatment provided by vierra et al . the dental team should be aware of the clinical presentation of ectodermal dysplasia in order to provide the correct guidance for functional , social , and psychological needs of the patients .

the hereditary condition known as ectodermal dysplasia is characterized by the absence or defect of two or more ectodermally derived structures . the most commonly observed forms of ectodermal dysplasia are the hidrotic and hypohidrotic types ; discrimination is based on the absence or presence of sweat glands . a case of 8-year - old male child with hypohidrotic ectodermal dysplasia with complete anodontia of primary as well as secondary dentitions is presented . the child had a short stature , low intelligent quotient ( i.q . , ) , and was underweight . the patient experienced episodes of high fever , was intolerant to heat , and did not sweat . he exhibited smooth and dry skin , sparse light - colored eyebrows . dental clinicians can be the first to diagnose ectodermal dysplasia due to the absence of teeth .

true metastases from solid tumors in lung , skin ( melanoma ) , gastrointestinal tract , kidney , testes , and endocrine glands are reported only in 0.2% of all surgical prostatic specimens and 2.9% of all male postmortems . lung is the most common primary site of metastases to the prostate . in all series direct spread of bladder carcinoma clinical context , morphological features , and immunohistochemical localization of prostate specific antigen ( psa ) are supposed to clarify the differential diagnosis between a secondary and a primary tumor . we report an unusual and rare case of secondary signet ring cell carcinoma ( srcc ) of prostate in which the clinical data pointed toward the diagnosis of a primary srcc . signet ring cell morphology was also not helpful as incidence of primary srcc was more than that of secondary srcc in prostate . immunohistochemistry ( ihc ) for psa not only proved the case to be a secondary srcc but also initiated the process for diagnosis of the occult primary malignancy in the patients stomach . a 74-year - old male patient presented with frequency of micturition , dysuria , and features of urinary outlet obstruction developing progressively over a period of last 3 months . he was a smoker , occasional drinker , and complained of no other features of clinical interest except infrequent dyspepsia . transrectal ultrasonography showed grade iii prostatomegaly measuring 5.54.24.8 cm ( 58 g ) , with suspicious hypoechoic areas in the peripheral zone and residual urine of 80 ml . serum total psa level was 9.71 ng / ml and free - to - total psa ratio was 10.8 . on digital rectal examination the prostate was elastic , slightly hard , painless , and with prominent retroprostatic sulci . cystoscopic examination found no primary abnormality of the bladder and extensive transurethral resection of prostate ( turp ) was performed under anesthesia with resultant specimen measuring 45 g. histopathology revealed nests and singly infiltrating poorly differentiated , hyperchromatic , pleomorphic adenocarcinoma cells majority of which were of signet ring morphology [ figures 13 ] . individual cells and cell nests were seen lying haphazardly among bundles of smooth muscle fibers and also within lymphovascular spaces but no perineural invasion , mucinous fibroplasia or glomerulations were noted . initial diagnosis of signet ring variant of invasive prostatic adenocarcinoma with gleason score 4 + 5=9 was thought of but ihc for psa [ figure 3 ( inset ) ] and carcinoembryonic antigen ( cea ) were simultaneously performed as primary prostatic signet ring cell adenocarcinoma is rare and it is mandatory to exclude other mucinous tumors of non - prostatic origin based on morphology and immunohistochemistry and if necessary using clinical information . the globoid optically clear cytoplasm of the signet ring cells were stained positively with alcian blue at ph 2.5 confirming the contents as acid mucin [ figure 1 ( inset ) ] . gastric endoscopic biopsy was subsequently performed 2 weeks after turp and histopathology showed infiltrating signet ring cell carcinoma of stomach . ( inset : same signet ring cells with positive alcian blue stain at ph 2.5 . ) signet ring cells lying haphazardly among bundles of smooth muscle fibers . some primary adenocarcinomas of the prostate will have a signet - ring - cell appearance , yet the vacuoles do not contain intracytoplasmic mucin . these vacuolated cells may be present as singly invasive cells , in single glands , and in sheets . only a few cases of prostate cancer have been reported with mucin positive signet ring cells . one should exclude other mucinous tumors of nonprostatic origin based on morphology and immunohistochemistry and if necessary using clinical information . immunohistochemical stain for psa is diagnostically helpful in distinguishing prostatic adenocarcinomas from other neoplasms secondarily involving the prostate and establishing prostatic origin in metastatic carcinomas of unknown primary . a minority of higher grade prostatic adenocarcinomas are psa negative , although some of these tumors have been shown to express psa mrna . some prostatic adenocarcinomas lose psa immunoreactivity following androgen deprivation or radiation therapy . in gastric signet ring cell carcinoma ( who classification ) more than 50% of the tumor consists of isolated or small groups of malignant cells containing intracytoplasmic acid mucin that stain with alcian blue at ph 2.5 . the present case once again underlines the fact that metastatic src carcinoma although rare should be considered as a differential before diagnosing a primary src carcinoma of prostate . a detailed clinical examination and special attention to any prior history of mild symptoms like dyspepsia might lead to the performance of an upper gastrointestinal endoscopy which can help in much earlier detection of a primary gastric tumor . the most important feature for differentiation in this case with an occult primary was psa immunostain supplemented by an alcian blue stain at ph 2.5 . dr . tapas moitra , associate professor , department of urology , north bengal medical college , sushrutanagar , darjeeling .

true metastases to prostate from solid tumors are reported only in 0.2% of all surgical prostatic specimens and 2.9% of all male postmortems . clinical context , morphological features , and immunohistochemical localization of prostate specific antigen ( psa ) are supposed to clarify the differential diagnosis between a secondary and a primary tumor . we report an unusual and rare case of secondary signet ring cell carcinoma ( srcc ) of prostate in which the clinical data and signet ring cell morphology pointed toward the diagnosis of a primary srcc . immunohistochemistry ( ihc ) for psa not only proved the case to be a secondary srcc but also initiated the process for diagnosis of the occult primary malignancy in the patients stomach .

both wild and captive reptiles are frequently affected by external parasites . of these , acarids ( ticks and mites ) are the most commonly encountered . the most commonectoparasite in captive snakes is the hematophagous snake mite ( ophionyssus natricis ) belonging to the macronyssidae family of the suborder mesostigmata ( 1 ) . unfed females are yellow - brown ; engorged females are dark red , brown or black . 1 ) . the engorged female leaves the host and deposits eggs in cracks and crevices . the eggs hatch in 14 days , developing through larva , protonymph and deutonymph stages to the adult . o. natricis has a worldwide distribution affecting mainly snakes and to a lesser extent lizards . infected snakes often exhibit lethargy , dysecdysis , pruritus , crusting dermatitis ( sometimes progressing to abscesses ) , and behavioral changes ( increased bathing time , rubbing against objects ) . the mite , which thrives in skin crevasses , acts as an irritant to the snake that can cause parasitic dermatitis , but often leads to increased , irregular shedding cycles ( 3 ) . o. natriciscan also attack humans , causing popular vesiculo - bullous eruption of the skin ( 4 ) . a 29 years old manworking in sari zoo , sari , mazandaran , iran , presented itchy papullar eruption of the skin ( fig . he had noticed small insects fixed on his skin and he had attempted to remove them , also large numbers of these same insects were on a python and its cage in the zoo . department of veterinary parasitology , veterinary faculty , islamic azad university , babol branch was asked to examine the python . the snake was a 2.95 m caramel burmese python snake and insects were collected from the snake and its glass cage in the zoo . the man who feeds and takes care of python with papullar rash was also examined and behavioral changes noticed such as , restlessness , irritation , anorexia , and short cycles of skin shedding in python history . samples were preserved in alcohol , and then made them transparent in lacto phenol in order to observe them under the light microscope . they were identified regarding to their morphological characteristics as o. natricis ( geravis , 1844 ) , a snake mite . for diagnosis confirmation , samples were sent to iran veterinary parasitology museum and deposited with accession number of 733 . o. natricis is a purely blood sucking parasite of snakes and is of worldwide distribution ( 5 , 6 ) . the diagnosis of snake mite infestation is usually straightforward : the parasites are easily identifiable with the naked eye or with a magnifying glass . snakes are uncommon pets but their popularity is increasing . when patients with unusual pets such as snakes or lizards present at dermatology clinics , o.natricis should be considered as a cause of dermatitis ( 7 ) .

ophionyssus natricis is a purely blood sucking parasite of snakes and of worldwide distribution . infected snakes often exhibit lethargy , pruritus , crusting dermatitis , and behavioral changes . ophionyssus natricis can also attack humans , causing popular vesiculo - bullous eruption of the skin . a 29 years old man working in zoo , sari , mazandaran , iran , presented itchy papullar eruption of the skin . he had noticed small insects fixed on his skin and large numbers of these same insects on a python and its cage in the zoo . regarding totheir morphological characteristics they were diagnosed as o. natricis ( geravis , 1844 ) , a snake mite . it is the first report of o. natricis from iran .

urinary tract infections in diabetics are a common occurrence , and they may be complicated by the presence of gas producing organisms . emphysematous infection of the kidney is well known , but such infections are rare in the testis and epididymis . these infections are often referred to the surgeon , because of the likelihood of surgical intervention . both emphysematous pyelonephritis and epididymo - orchitis may not be detected clinically and ultrasound or computed tomography ( ct ) may be needed for the diagnosis . the presentation of epididymo - orchitis with gas bubbles in the scrotum is very rare , and one case that has been reported was secondary to seminal vesicle involvement by diverticulitis of the colon . . however , there are no case reports of emphysematous epididymo - orchitis caused by e. coli with a normal seminal vesicle . a 52-year - old man was brought to emergency with a 3-day history of pain and swelling in the left scrotum with fever [ figure 1 ] . clinical examination of the scrotum showed inflamed left scrotum and tender and enlarged left testis and epididymis . per rectal examination showed that the prostate was normal in size and consistency , with its upper limit just reachable . he gave a history of previous urinary tract infection , and the culture had shown e. coli . an ultrasound of the scrotum was done , which showed gas shadows in the left epididymis and testis with inflammation in the skin of the scrotum and fluid in the tunical sacs [ figure 2 ] . a ct scan of the abdomen and the pelvis showed the pockets of gas in the scrotum and testis , but the seminal vesicles and the sigmoid colon were normal [ figure 2 ] . clinical presentation with acute inflamed scrotum with per operative image showing destroyed testicular tunica and parenchyma radiology of the patient showing in clockwise sequence , gas bubbles in the testis and scrotum seen on ultrasound , ct images showing preserved fat planes around the seminal vesicles , gas bubbles seen in the scrotum and substance of the testis , and increased vascularity of the testis seen on doppler images the patient was taken up for surgery in view of the gas shadows in the testicular substance and poor response to clinical parameters after intravenous antibiotics . there was extensive inflammation in the scrotum with gas bubbles , extending through the tunica into the substance of the testis [ figure 1 ] . histopathology of the excised testis showed acute epididymo - orchtis with areas of necrosis and thrombosis in veins . fournier 's gangrene can involve the perineum with gas formation but classically spares the testis and epididymis . an online search revealed one case of emphysematous epididymo - orchitis , secondary to seminal vesicle involvement in diverticulitis of the sigmoid colon . however , our patient had normal outline of seminal vesicles with preserved fat planes and no evidence of diverticulitis on ct scan . pus from the testis cultured e. coli , which has been cultured previously in cases of emphysematous pyelonephritis but has never in emphysematous epididymo - orchitis . there is not much information available about the best modality for the treatment of this condition . initially , most cases merit high - dose broad - spectrum antibiotics till the results of culture sensitivity are available . aspiration of pus with a wide bore needle may be tried in early cases . as in case of emphysematous pyelonephritis diabetes mellitus could have a role in the pathogenesis of the condition as in emphysematous pyelonephritis . the differential diagnosis of a bright , highly reflective tissue interface on ultrasound of the testis , with distal acoustic shadow , can be either emphysematous infections like fournier 's gangrene or emphysematous epididymo - orchitis , or testicular shrapnel , testicular germ cell neoplasm , or testicular microlithiasis . ct scan can be a useful adjunct to the diagnosis . with the availability of ultrasound in most emergency departments , there is a case for applying the ultrasound probe on diabetic patients with an acutely inflamed scrotum to rule out emphysematous infection .

emphysematous epididymo - orchitis is a rare cause of an acute scrotum and is a surgical emergency . diagnosis is clinically difficult , and sonography with a high - frequency probe is useful to pick up gas shadows in the scrotal wall or testicular substance . a diabetic patient presented with fever , urinary tract infection , and an acute scrotal swelling . the patient needed orchidectomy and scrotal debridement . as in emphysematous pyelonephritis , this condition occurs in diabetics , and patients may need surgery . there is a need to perform sonography in all diabetic patients with an acutely inflamed scrotum , because detection of gas shadows makes surgical intervention more likely .

direct invasion or metastasis of malignant lymphoma in the middle ear is rare and the clinical features remain unknown [ 1 , 2 ] . we treated a case of non - hodgkin b - cell lymphoma ( nhbl ) in the middle ear presenting as recalcitrant otitis media and mastoiditis associated with transverse sinus thrombosis . the patient was diagnosed 6 years after the initial symptoms and was treated successfully with surgery and chemotherapy . we report the clinical characteristics of a rare case of nhbl in the middle ear and review the literature . a 57-year - old woman presented with chronic temporal headache and right tinnitus , and the symptoms gradually aggravated . conservative treatment continued at the local otolaryngology clinic based on a diagnosis of otitis media . slight consciousness disturbance , slight fever and auditory disturbance were noted 1 year after the initial symptoms , and the patient was referred to our department . neurological findings showed slight consciousness disturbance , and an audiometric hearing test demonstrated 30 db in the right ear , diagnosed as a mild hearing impairment . magnetic resonance imaging ( mri ) showed edematous brain swelling in the right temporal lobe and right tentorium and dural enhancement around the transverse sinus ( fig . mri showed a heterogeneous mass lesion in the right middle ear and mastoid air cells with dural enhancement around the lesion ( fig . she was diagnosed with recalcitrant otitis media invading the mastoid associated with transverse sinus thrombosis and was treated with antibiotics , hyperosmotic fluids , steroids and repeated external drainage of the middle ear . symptoms of temporal headache , auditory disturbance , slight fever and radiological findings of brain swelling did not disappear , and remission and exacerbation of these symptoms occurred repeatedly . consciousness disturbance occurred again , and chronic temporal headache gradually aggravated 5 years after the first examination in our department . mri revealed enlargement of the edematous swelling around the right transverse sinus , and the enhanced lesion was also enlarged ( fig . open drainage of the middle ear with mastoidectomy was performed 6 years after the initial symptoms . granulation had invaded the eardrum and stapes , and the auditory tube was also filled with granulation ( fig . pathological examination demonstrated diffuse proliferation , predominantly consisting of small to medium - sized lymphoid cells with slightly irregular nuclei ( fig . 1f ) , which were positive for cd20 , cd79 and bcl-2 , suggesting malignant lymphoma , b - cell type , classified as extranodal marginal zone b - cell lymphoma . computed tomography and blood and bone marrow evaluation did not show other lesions of malignant lymphoma , suggesting that the otitis media lesion was the primary lesion . she was treated with rchop ( rituximab combined with cyclophosphamide , doxorubicin , vincristine and prednisolone ) chemotherapy . malignant lymphoma can spread to all areas of the body , including the head and neck . involvement of the temporal bone as part of generalized lymphoma has been reported ; however , clinical evidence of temporal bone or middle ear involvement is unusual [ 3 , 4 , 5 , 6 ] . presentation with otoneurological signs prior to systemic involvement of a lymphoproliferative disease is also unusual . to our knowledge , only 10 cases of malignant lymphoma originating around the middle ear have been reported ( table 1 ) [ 1 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 ] . in the previous 10 reports , the lesion was located in the middle ear in 3 , internal in 3 , and external in 4 . facial nerve palsy was the most common initial symptom and mastoiditis was associated in about 50% of the cases . there was no direct invasion into the intradural region and no association with sinus thrombosis in 10 cases . our present case included the following marked characteristics : first , it was difficult to diagnose malignant lymphoma under the suspicion of intractable otitis media . second , transverse sinus thrombosis caused by dural invasion of a tumor or spread of otogenic infection manifested neurological symptoms . third , tentorial or dural enhancement adjacent to the transverse sinus did not decrease , and sinus occlusion continued even after remission . fourth , rchop chemotherapy was effective , and the lesion has not recurred for 4 years . infectious symptoms and dural enhancement showed repeated remission and abrogation under treatment for otitis media with antibiotic administration and drainage . there was a possibility that sinus occlusion induced by infection progression might abrogate venous circulation , resulting in brain edema in the early stage , and collateral venous flow might gradually develop during the progression of sinus occlusion . we treated a rare case of b - cell malignant lymphoma presenting with otitis media and mastoiditis associated with transverse sinus thrombosis . the authors report no conflicts of interest concerning the case report presented herein or the findings specified in this paper .

cerebral venous thrombosis as a manifestation of paraneoplastic angitis and otitis media , revealing non - hodgkin b - cell lymphoma ( nhbl ) , is extremely rare . a 57-year - old woman presented with headache , auditory disturbance and recalcitrant otitis media . magnetic resonance imaging showed brain edema in the temporal lobe and transverse sinus thrombosis . external drainage under antibiotic treatment was repeated based on a diagnosis of invasive otitis media and mastoiditis associated with infectious sinus thrombosis , but the condition deteriorated progressively . open surgery for otitis media was performed 6 years after the initial symptoms and after a tumorous lesion had been detected in the middle ear . pathological findings revealed nhbl . we report a rare case of nhbl presenting as otitis media and mastoiditis associated with sinus thrombosis , and a literature review .

a thorough understanding of root canal anatomy and morphology is required for achieving high levels of success in endodontic treatment . failure to recognize variations in root or root canal anatomy can result in the unsuccessful endodontic treatment . hence , it is imperative that the clinician be well informed and alerted to the commonest possible variations . hoen and pink in their analysis on teeth requiring re - treatment , found a 42% incidence of missed roots or canals . numerous reports of root canal variations in these teeth have been reported in the literature . vertucci in his series of studies conducted on extracted teeth , reported 2.5% incidence of a second canal . in the case of mandibular first premolars , it is normally a single - rooted tooth . the frequency of occurrence of two roots is 1.8% while three roots are reported to be present in 0.2%of cases . in single - rooted mandibular first premolars , these anatomic abnormalities are additional challenges , which begin at the case assessment and involve all operative stages , including access cavity design , localization , cleaning , and shaping of the root canal system . although preoperative radiography gives a two - dimensional image of a three - dimensional object , precise interpretation can reveal external and anatomic details that suggest the presence of extra canals or roots . the purpose of this clinical report is to describe an anatomic abnormality that was detected during routine root canal treatment in a mandibular first premolar . a 24-year - old male patient came to a private dental clinic with pain in the left lower back tooth . on radiographic examination preoperative radiograph revealed radiolucency involving pulp with respect to 34 [ figure 1a ] . diagnosis of acute irreversible pulpitis was made . also iopa revealed 34 having four roots . to confirm the presence of four roots two more radiographs one with distal angulation and the other with mesial angulation access was gained to the pulp chamber after administration of local anesthesia ( 2% lignocaine with 1:100000 epinephrine ) , under rubber dam isolation . to gain sufficient access to the canals , the conventional access opening was modified into one that was wider . after careful inspection , four canal orifices were located and patency was ascertained using a small size k - file ( kerr , orange , california ) . working length was established with the use of apex locator ( root zx , j. morita inc . ) ( a ) preoperative intraoral periapical radiograph ( straight angulation ) ( b ) preoperative intraoral periapical radiograph ( mesial angulation ) ( c ) preoperative intraoral periapical radiograph ( distal angulation ) ( a ) working length radiograph ( b ) postobturation radiograph ( c ) recall radiograph 1-year postoperatively the canals were cleaned and shaped with hand k - files and nickel titanium rotary protaper files ( dentsply maillefer , switzerland ) . the canals were sequentially irrigated using 5.25% sodium hypochlorite and 17% edta during the cleaning and shaping procedure . the canals were thoroughly dried and obturation was done using f2 pro taper gutta - percha and ah plus sealer ( dentsply , maillefer , switzerland ) . the post - endodontic permanent restoration was completed with composite ( 3 m espe dental products , st paul , mn ) [ figure 2b ] . a 1-year recall radiograph showed satisfactory healing and was advised to get this tooth crowned [ figure 2c ] . the presence of extra roots or canals in mandibular premolars is undoubtedly an endodontic challenge . clearly , these findings are clinically important as in a study at the university of washington assessing the results of endodontic therapy , the mandibular first and second premolars showed failure rates of 11.45% and 4.54% , respectively . conceivably , these findings could be due to the complex root canal anatomy of a large number of these teeth . a wide range of opinions are reported in the literature regarding the number of root canals , but there are very few reports on the variations in the numbers of roots that occur in mandibular premolars . accurate preoperative radiographs , straight and angled , using parallel technique are essential in providing clues as to the number of roots that exist . optimum opening of the access cavity is absolutely necessary . despite the existence of complicated dental anatomy , cautious use of rotary or hand nickel titanium files prepares the canals to a predetermined shape . there are many reports regarding four root canals in mandibular second premolar[1214 ] and five - canaled mandibular second premolar but four canals in mandibular first premolar is hard to find in the published literature . these discussions also validate an important consideration that must not be overlooked , that is , the anatomic position of the mental foramen and the neurovascular structures that pass through it , in close proximity to the apices of the mandibular first and second premolars . there are reports in the literature , of flare - ups in mandibular first and second premolars with associated paresthesia of the inferior alveolar and mental nerves . the failure to recognize the presence of extra root or canals can often lead to acute flare - ups during treatment and subsequent failure of endodontic therapy . successful and predictable endodontic treatment requires knowledge of biology , physiology , and root canal anatomy . the clinician should be astute enough to identify the presence of unusual numbers of roots and their morphology . a thorough knowledge of root canal anatomy and its variations , careful interpretation of the radiograph , close clinical inspection of the floor of the chamber , and proper modification of access opening are essential for a successful treatment outcome .

mandibular premolars have earned the reputation for having aberrant anatomy . the literature is replete with reports of extra canals in mandibular first premolars , but reports about the incidence of extra roots in these teeth are quite rare . this paper attempts at explaining a rare case of successful endodontic management of a four - rooted mandibular first premolar with diagnostic , interoperative and postoperative radiographic records along with a substantial data on the incidence of extra roots in these teeth . the standard method of radiographic appraisal was maintained as the criteria for determining the presence of extra roots .

pulmonary tuberculosis is divided into primary and post - primary types according to pathogenic and radiological features . pleural involvement is generally seen in the form of a pleural effusion , which can be a component of both primary and post - primary tuberculosis . empyema , residual pleural thickening and calcification are other forms of pleural tuberculosis involvement and are generally seen in association with parenchymal disease . in approximately two - thirds of cases , there is no associated parenchymal lesion on the chest radiograph ; yet tubercle bacilli are frequently found in biopsy specimens of pleural tissue . we report an unusual form of pleural tuberculosis demonstrated by pleuroscopy and computed tomography ( ct ) presenting with multiple pleural nodules and masses with large hemorrhagic pleural effusion and without any evidence of either parenchymal or lymphatic disease . a 68-year - old male was admitted with complaints of gradually progressive exertional dyspnea and dry cough of three months duration . he had pleuritic chest pain , low grade fever and weight loss for one month . his routine hemogram , urine examination , renal and liver function tests and coagulation profile were normal except raised erythrocyte sedimentation rate . chest x - ray was suggestive of large right - sided pleural effusion . at thoracentesis , it was a lymphocytic exudate ( total protein 3.4 g / dl , sugar 76 mg / dl , cholesterol 67 mg / dl , lactate dehydrogenase 253 iu / l , adenosine deaminase 9 polymorphs : 5% , lymphocytes : 92% , cytology negative for malignant cells , gram stain and afb smear negative ) . post - aspiration chest x - ray showed multiple irregular pleural masses [ figure 1 ] . ct of the chest revealed multiple different size masses involving the parietal as well as visceral pleura [ figure 2 ] . post taping chest x - ray shows multiple irregular pleural masses computed tomography ( ct ) chest shows multiple different size masses on parietal pleura as well as on visceral pleura a medical pleuroscopy was performed using a flexible bronchoscope placed through the chest tube . multiple pleural - based ( parietal as well as visceral ) masses of varying sizes were observed . histopathological examination of the pleural biopsy from a parietal pleural mass revealed epitheloid cell granulomas indicative of tuberculosis [ figure 3 ] . the major differential diagnostic considerations in a patient with multiple pleural nodules and masses are malignant mesothelioma , pleural lymphoma , hematogenous pleural metastases , malignant thymoma and on rare occasion sarcoidosis.[38 ] although pleural tb infection is thought to result from the rupture of a subpleural caseous focus within the lung into the pleural space , it may occasionally be as a result of hematogenous dissemination or contamination from adjacent infected lymph nodes . pleural infection in tuberculosis is usually characterized by an effusion in early stages , or by diffuse pleural thickening and adhesions often with calcification in long standing cases . pleural thickening may also result from chronic inflammatory conditions , for example , hemothorax , empyema , tubercular effusion , or recurrent pneumothorax , often with calcification . in our case the provisional diagnosis was a pleural neoplasm ( primary or secondary ) based on clinical , radiological and pleuroscopic findings . to our knowledge , pleural tuberculosis presenting with multiple pleural nodules and masses without parenchymal involvement or lymphadenopathy have been reported rarely in the standard english medical literature,[1113 ] but pleural tuberculosis presenting as multiple pleural masses with large hemorrhagic pleural effusion has not been reported . it should be considered in the differential diagnosis of pleural masses without radiographically visible parenchymal lung disease even when there is large hemorrhagic effusion . confirmation of the diagnosis with sputum smears , culture , or histology is mandatory since treatment is highly successful .

tuberculous involvement of the pleura usually presents as pleural effusion , empyema or pleural thickening . pleural tuberculosis presenting with multiple masses without parenchymal involvement or lymphadenopathy has been reported rarely in the english literature . we report a case of a 68-year - old male with unilateral pleural tuberculosis presenting as multiple different sized nodular masses evident on computed tomography ( ct ) of the chest with a large hemorrhagic pleural effusion , which initially raised a possibility of mesothelioma . pleuroscopy also revealed multiple pleural masses . pathological examination of the biopsy specimen showed multiple epitheloid cell granulomas confirming the diagnosis .

congenital lip pits are malformations that occur on the paramedial portion of the vermilion border of the lip . if it occurs along with cleft lip and palate , it is termed as vander woude 's syndrome . the other anomalies which may or may not be associated with syndrome are hypodontia , hypoplasia , ankyloglossia , high arched palate , limb anomalies , congenital heart defects , etc . most cases have been associated with a deletion of chromosome 1q32-q41 , but an extra chromosomal locus at 1p34 has been identified . lip pits may result due to notching of the lip at an early stage of development with fixation of the tissues at the base of the notch or it may result from a failure of complete union of embryonic lateral sulci of the lip . the surface opening of the lip may present as a circular or transverse slit or be located at the apex of nipple - like elevations . its diameter may be upto 3 mm and its depth can range from 1 to 15 mm . the problem associated with lip pits is exudation of mucous on the lower labial skin which is a source of embarrassment for the patient . other than the lip pits , the other intraoral features should also be properly looked for and treated simultaneously . the cleft lip and palate patients have various dental anomalies like hypoplastic , malformed , supernumerary , congenitally missing , and peg - shaped teeth . it is also important to identify and treat these anomalies at an early stage thus improving the esthetics and function of the patient . a 7-year - old male child reported to the department of pedodontics and preventive dentistry with a chief complaint of carious teeth . natal history revealed that he was delivered through a caesarean section . maternal history relieved no medications or illness during pregnancy . , it was seen that the patient was a treated case of unilateral cleft lip and palate , and two lip pits were present on the lower lip [ figures 1 and 2 ] . when the lip was compressed there was mucous secretion . intraoral examination revealed carious teeth with 16 , 26 , 36 , and 46 and root stumps with 55 , 64 , and 65 [ figure 3 ] . extraoral examination of the patient lip pits present on the lower lip intraoral examination of the patient ( preoperative ) : maxillary arch intraoral examination of the patient : anterior bite radiographic examination of the patient : opg the treatment planned was restoration of carious teeth followed by extraction of root stumps [ figure 6 ] . the patient was also advised to undergo orthodontic treatment and a cosmetic lip correction for the lip pits . it is important to diagnose these syndromes from oro facial digital syndrome and popliteal syndrome which manifests similar clinical features . these entities are allelic variants of the same condition . the other features which help to differentiate are as follows : orofacial digital syndrome shows cleft lobular tongue , digital malformation and mental retardation , whereas popliteal syndrome shows syndactly , digital reduction , and syngathia . because the symptoms of these children are limited and because the affected individuals have normal intelligence , this disorder should not be confused with non - syndromic cleft lip and palate . the treatment of such cases should be surgical excision of the labial and commissural pits if esthetics is a major concern . it should include total removal of the minor salivary glands that exude secretions at the base of pits to prevent formations of cysts and mucoceles . the treatment should be carried out in collaboration with plastic surgery , oral maxillofacial surgeons , and orthodontists . other treatments like cross bite corrections , maxillary expansions , restorations , and extractions should also be carried out . a multidisciplinary approach is very necessary to carry out the treatment thus improving the self - esteem of the patient at an early age . an early and proper diagnosis followed by a multidisciplinary approach is necessary to improve the self - esteem of the patient .

one of the most common developmental defects seen in south india is cleft lip and palate . among them a few are associated with lip pits and termed as vander woude 's syndrome . the early diagnosis of this rare syndrome is very necessary followed by a multidisciplinary approach . it is also necessary to differentiate this syndrome from the other syndromes which may present similar features . a case report of the same is presented here requiring a multidisciplinary approach for a functional and esthetically pleasing outcome .

horner 's syndrome , along with weakness and atrophy of upper limb , as well as anaesthesia to pain and temperature , is well recognized finding in patients with syringomyelia . few cases have been reported regarding isolated horner 's syndrome as a presenting manifestation of a chiari i malformation with syringomyelia . we report a 41 year old man with left side hemi hidrosis probably a part of horner 's syndrome who was found to have a chiari i malformation with holocord syrinx . a 41-year - old man presented in medicine ward with a complaint of neck and back pain and loss of sweating in right side of the body that had begun eight months before . there was no history of hypertension , diabetes , and immunocompromised status . on examination whole left side of body including face was dry , there was no evidence of sweating [ figures 1 and 2 ] . this test is described as drawing a metal spoon across the surface of the skin after adequate physical exercise . neurological examination was unremarkable with no limb weakness , wasting or numbness and temperature impairment on the side of anhidrosis . this was done to rule out any mass in the upper lobe of the lung which may present as horner syndrome . mri spine was performed which showed hyperintense signal ( red arrow head ) in t2-weighted sections extending whole spinal cord up to eighth thoracic cord level with herniation of cerebellar tonsil ( blue arrow head ) compatible with syringomyelia along with chiari i malformation [ figure 3 ] . dry left nipple with anhyrosis holocord syrinx up to 8 spinal cord level ( red arrow head ) , herniation of cerebellar tonsil ( blue arrow head ) syringomyelia is the development of a fluid - filled cavity or syrinx within the spinal cord . more than half of all cases are associated with chiari type 1 malformations in which the cerebellar tonsils protrude through the foramen magnum and into the cervical spinal canal . it may occur after a trauma , secondary to a tumor , craniocervical or intracerebral pathology or idiopathic . fibers originating in the cerebral cortex traverse the hypothalamus , and then cross in the medulla to the lateral horn of the spinal cord . these fibers leave the spinal cord to synapse in the sympathetic ganglia with neurons that innervate the sweat glands . thus , a cortical lesion will cause contralateral anhidrosis , a lesion in the medulla could result in contralateral or ipsilateral anhidrosis , and any lesion distal to the medulla will cause ipsilateral anhidrosis . slowly progressive tissue damage around the syrinx reaches the lateral horn , it will segmentally affect the sympathetic preganglionic neurons or adjacent structures . search for publications dealing with anhidrosis in syringomyelia there was lack of information regarding this . in our case probable hypothesis may be hypo activity due to autonomic disturbances because of progressive and irreversible damage to the sympathetic preganglionic neurons due to expanding syrinx . physicians should be aware of the different ways in which syringomyelia can present to ensure its early diagnosis . anhidrosis of the face and upper part of the body , segmental anhidrosis is reported in horner syndrome and syringomyelia but hemi hidrosis of the whole boy was unique in this case .

we present a 41-year - old man with chiari type 1 malformation and syrinx up to tenth thoracic level who presented with left side hemi anhidrosis . neurological findings of syrinx were absent in this case . though horner 's syndrome is reported , this report is probably first .

lymphoma , malign melanoma and rhabdomyosarcoma are the most common tumors that metastasize to the breast tissue . breast metastases in cases of leukemia are very rare and occur primarily in patients with acute myeloid leukemia . we report the conventional and advanced magnetic resonance imaging ( mri ) findings of unilateral breast involvement of all and review the literature . a 32-year - old woman with all under remission was admitted to the department of internal medicine in our institution . this patient was first diagnosed with all in june 2004 and was treated between june and december 2004 . the giant mass , involving the whole right breast at the time of presentation grew progressively in a period of 3 months . the mass and contralateral breast tissue was further evaluated with mri , diffusion weighted imaging ( dwi ) and mr spectroscopy . mri was done with a 1.5 tesla mr device ( signa hdx ; general electric , milwaukee , usa ) . the routine sequences were axial short ti inversion recovery ( stir ) , sagittal fast spin echo ( fse ) , fat saturated t2w , sagittal 3d vibrant ( postcontrast fat saturated t1w ) . we added dwi with b=0 and b=600 values and brease ( single voxel mr spectroscopy ) sequence . the giant right breast mass was hyperintense - isointense on precontrast fat saturated t1w images ( figure 1a ) and heterogeneously hypointense - hyperintense on stir and fat saturated t2w images ( figure 1b and 1c ) . in the vibrant sequence , there was a prominent enhancement of the solid components ( figure 1d and 1e ) . time - signal intensity curves obtained by post - processing were classified as type 2 ( figure 1f ) . the lesion was hyperintense on dwi ( figure 1 g ) , and hypointense in apparent coefficient diffusion ( adc ) maps ( figure 1h ) . the adc value was extremely low ( 3.1210 mm / sec ) representing prominent restricted diffusion . a prominent choline peak compatible with malignancy was detected at 3.2 ppm in the brease sequence ( figure 1i ) . there was no sign of chest wall invasion and the other breast was normal . with these findings cd34 ( + ) , tdt ( + ) , cd20 ( - ) , cd3 ( - ) , cd79 ( - ) , mpo ( - ) were found in immunhistochemical analysis . a new chemotherapy regimen was started , but unfortunately the treatment was not successful and the patient died . metastases to the breast from extramammary malignant neoplasms are unusual and were described first in 1903 . metastatic cancer to the breast is often discovered as a superficial solitary mass ( 85% ) , located in the upper outer quadrant ( 66% ) . metastases are frequently multiple and bilateral , but they are more commonly large , solitary tumors . metastatic breast leukemia is very rare and occurs primarily in patients with acute myeloid leukemia . the explanation of this ring - enhancement is reported due to the central necrosis and peripheral angiogenesis in the literature . malignant tumors , show attenuated diffusion on dwi , and the adc values are low secondary to high cellular density . choline takes part in cellular membrane turn - over and is a marker of cellular proliferation . in malignancy , the choline concentration increases as a result of both intracellular phosphocholine and high cellular density of the lesion . moreover , it was reported that high choline content was compatible with the increase of angiogenetic activity . in our case the extremely rare involvement of the breast in cases of leukemia can be the only complaint at initial presentation or seen as relapse . moreover , radiotherapy performed for breast malignancies can also cause acute leukemia in breast tissue . in a patient with a known malignancy , any enlarging breast mass , even one with a reassuring benign sonographic appearance must be investigated promptly , initially with fine - needle aspiration or core needle biopsy . breast metastases are usually associated with disease originating elsewhere , and the prognosis is generally poor .

breast metastases in cases of leukemia are rare . we aimed to report the conventional - advanced magnetic resonance imaging ( mri ) findings of unilateral breast involvement of acute lymphoblastic leukemia ( all ) and review the literature . a 32-year - old woman was first diagnosed with all in treated in 2004 . she did not continue the follow - up after 2008 . she was presented with a giant , progressive right breast palpable mass in 2010 . mass , contralateral breast tissue were evaluated with mri , diffusion weighted imaging and mr spectroscopy . with mri findings , lesion was evaluated as malignant , tru - cut biopsy revealed recurrence of all . lymphoma , malignant melanoma , rhabdomyosarcoma are most common tumors metastase to breast . breast metastases of leukemia are rare and occur primarily in patients with acute myeloid leukemia . secondary all breast involvement is uncommon . in a patient with malignancy , any enlarging breast mass , even with benign radiologic appearance , should be investigated carefully and metastasis should not be forgotten .

abnormal involuntary movements may appear in any part of the body , and can be embarrassing , distressing , disfiguring or dangerous . tremor is an involuntary rhythmic oscillation of one or more parts of body about a fixed plane in space . tremors are observed with the use of various drugs , including tricyclic antidepressants , monoaminooxidase inhibitors , antipsychotics , lithium , valproate , lamotrigine , antihistamines , thyroxine and nicotine . these tremors tend to disappear after withdrawal of the offending drug . in a young person receiving psychotropic medication , appearance of unilateral tremor is unusual and various diagnostic possibilities need to be kept in mind . in this report a 26-year - old young male , employed as a tailor , from rural background , presented with 6 months duration of symptoms suggestive of mania . at the time of admission , detailed clinical examination including bedside neurological examination revealed no abnormalities . he was prescribed risperidone 2 mg / day and diazepam 30 mg / day on the first day of admission . as he remained aggressive even after this sodium valproate 500 mg / day it was observed that he developed regular rhythmic movements of his neck and right hand , with no other extrapyramidal symptoms . for optimal control of his manic symptoms the dose of risperidone was increased to a maximum of 8 mg and valproate to 1400 mg on day 46 of his admission . trihexyphenidyl 2 mg / day was also added to his ongoing therapy , in view of tremors . however , these movements became more prominent involving the neck along with head and right upper limb . they were rhythmic and regular with 3 - 4 hz , and present at rest . the tremor used to disappear as the target was approached , thus did not cause any difficulty in eating or writing . as this symptom caused significant distress to the patient , valproate was stopped on day 60 . however , there was no improvement even after one week of this , and hence risperidone was also stopped . two weeks after stopping risperidone , there were no visible tremor at rest , but it would appear when he became emotionally disturbed . he was discharged on olanzepine ( 10 mg / day ) , which he tolerated well , and remitted completely from mania . the liver function tests showed raised liver enzyme -sgot which was 93iu ( 0 - 25 ) in the first week which returned to baseline subsequently . investigations for complete blood count , wilson 's disease , thyroid abnormalities and folic acid levels were normal . low serum vitamin b12 levels ( 41 pg / ml ; normal > 201 pg / ml ) and serum ceruloplasmin on lower side of normal range ( 25 microg / dl , normal range 25 - 63 microg/ dl ) were detected . the common causes for unilateral tremor include parkinson 's disease , wilson 's disease , neuropathic , familial essential tremor syndrome , holmes tremor and psychogenic tremor . rubral tremor is a special type of visible tremor appearing as flexion - extension movement at wrist and fingers present at rest and during action , not associated with bradykinesia or cogwheel rigidity and considered as a separate entity compared to holmes tremor . thus our patient had rubral tremor of right upper limb associated with tremor of the neck . cases of rubral tremor developing following exposure to fluphenazine and risperidone have been reported . however , both these cases had symptom or sign suggesting of structural brain damage , unlike in our case . the clinical examination and laboratory investigations ruled out other causes for the tremor and suggested a possibility of drug - induced tremor in this case . causality analysis using the naranjo algorithm suggested that risperidone was scored to be the probable causal agent . however , other contributory factors could have been vitamin b12 deficiency and the concurrent use of valproate . there is a suggestion that bipolar illness itself may increase risk for antipsychotic - induced movement disorder . furthermore , this patient 's nicotine use may have suppressed features of drug induced parkinsonism , causing tremors to dominate the clinical presentation . in a young person with a unilateral tremor of acute onset , drug - induced movement disorder must be considered among the diagnostic possibilities . the role of concurrent valproate therapy and vitamin b12 deficiency as suggested in this atypical case presentation require further elucidation . this case highlights the complexities involved in identifying drug induced movement disorders in patients receiving multiple psychotropic medications .

identification and management of drug - induced movement disorders is a clinical challenge , more so when the clinical presentation is atypical . a young male with acute mania was under treatment with sodium valproate and risperidone . he developed tremors of right hand and neck . these were present at rest and exacerbated by mental activity , when under observation and during voluntarily initiated activity . there were no associated extra pyramidal symptoms or cerebellar signs . investigations for other common causes of tremors did not reveal any evidence except for low value of serum vitamin b12 levels . the tremors persisted after the withdrawal of valproate , but resolved following the withdrawal of risperidone . it is a common dictum that drug - induced tremors are bilateral . this may not be true always as we found out in our case . these movements were probably induced by risperidone . this atypical presentation could be due to concurrent use of valproate and low serum vitamin b12 levels .

a 3-month - old girl child presented to us with a history of swelling on back since birth . she had a history of full term normal vaginal delivery with no significant family history . there was complete flaccid paralysis of right lower extremity with normal anal tone . on local examination , an initial diagnosis of a myelomeningocele was made and patient was referred for magnetic resonance imaging ( mri ) of neuraxis . mri spine revealed a bony spur at d11 level dividing the spinal cord into two halves suggesting pang type 1 split cord malformation ( scm ) or diastematomyelia . right hemicord , along with meninges and cerebrospinal fluid was herniating through the defect in posterior element of same vertebra forming a large hemimeningomyelocele [ figures 1 and 2 ] . t2-weighted sagittal ( a ) and coronal ( b ) magnetic resonance imaging of dorso - lumbar spine shows a hemivertebrae from d10 to d12 level along with a bony spur at d11 . continuation of left hemicord is appreciable in coronal view ( b ) t2 weighted axial image shows a bony spur dividing the cord into two halves ( a and b ) . herniation of right hemicord , meninges and cerebrospinal fluid is noted through the defect in posterior element , forming a large hemi - meningomyelocele ( c ) . two hemicords are visible below the level of herniation ( d ) which reunites at d12 level to form a single cord ( e ) based on clinical examination and mri a final diagnosis of scm type 1 with right hemimyelomeningocele ( hmm ) was made and patient was prepared for surgery . excision of bony spur along with microneurosurgical dissection and meticulous layered closure of myelomeningocele was achieved . according to pang 's unified theory of embryogenesis , the whole spectrum of split cord syndrome originates from one basic ontogenic error occurring around the time of primitive neurenteric canal closure . this basic error is the formation of accessory neurenteric canal between the amniotic cavity and the yolk sac . this abnormal fistulous connection bisects the notochord and the neural plate on approximately postovulatory day 18 . final appearance of matured scm depends on the ability of the embryo to heal around this abnormal fistulous connection aka endomesenchymal tract . according to pang et al . , formation of endomesenchymal tract before postovulatory day 21 gives rise to scm type 2 or diplomyelia , whereas formation of this tract after postovulatory day 30 gives rise to scm type 1 or distematomyelia . the formation of this tract between postovulatory day 21 and 30 gives rise to composite / mixed scm . each hemineural plate undergoes neurulation in which , the neural folds converge and fuse each other in relation to their respective hemi - notochords . this process of primary neurulation occurs between postovulatory days 2228 . in case of neurulation defect on one side , hmm or hemimeningocele myelomeningocele are frequently associated with chiari malformation diastematomyelia ( up to 45% in some reported series ) and other congenital vertebral defects such as spondylocostal dysostosis , jarcho - levin syndrome , klippel - feil anomaly and a wide range of syndromic malformation complexes , but true hemimeningocele , where a single hemicord fails to neurulate is rare . the neurological deficit in children with hmm is less severe than compared to myelomeningocele patients and is limited only to the side of exposed hemicord . this case report highlights the importance of detailed imaging of complete neuraxis in cases of spinal dysraphism for optimal neurosurgical management . second the rarity of this condition suggests that formation of the endomesenchymal tract and neurulation defect are two separate embryological events , and their coexistence at the same level is only by chance though more inputs are warranted in this regard .

variations in split cord malformation ( scm ) have been described earlier . however , a true hemimyelomeningocele ( hmm ) as only congenital malformation is extremely rare and is reported infrequently in published literature . we are reporting the case of a 3-month - old girl child who presented with a swelling on the lower back since birth . magnetic resonance imaging revealed a type 1 scm with right hemicord forming a hmm . precise diagnosis and thorough anatomical detail of dysraphism is essential for optimal , individualized neurosurgical management .

a 34-year - old male presented with proptosis of the left eye ( os ) in november 2014 since 2 years with occasional pain and blurred vision . best - corrected visual acuity was 6/6 , n6 right eye ( od ) , 6/18 with pinhole improvement to 6/9 , n10 ( os ) . axial proptosis was noted with hertel 's exophthalmometry measurement of 14 mm in the od and 20 mm in os . there were no ocular motility restrictions in either eye . slit lamp and fundus examination revealed normal anterior and posterior segments in both the eyes ( ou ) . computerized tomography scan of the orbit and brain in os revealed a retrobulbar mass , well delineated and intraconal in location , displacing the optic nerve medially [ fig . 1 ] . ( a ) computerized tomography scan of brain and orbit with intraconal orbital mass and ( b ) gross bluish black encapsulated cavernous hemangioma left sided lateral orbitotomy under general anesthesia was planned and carried out under proper consent . the specimen was sent to ocular pathology laboratory where encapsulated bluish black mass measuring ( 22.1 mm 16.18 mm 12.24 mm ) was documented [ fig . 1 ] . grossly , the tumor showed surface vascularity over the capsule . surface vessels were in different dimensions and were also seen piercing the capsule . after dissecting a small portion of capsule , numerous tecs were seen , some of which formed a pattern of endothelial podosome rosette which was documented . sprouting of tec and the blood vessels with intracellular gap junctions among the tecs was observed . endothelial cells on the surface of the blood vessels and tec were seen under high power objective illumination of microscope ( axioskop 40 with axiocam mrc camera ) . microscopic appearance showed capsulated vascular tumor with numerous dilated blood vessels of varying sizes filled with red blood cells and lined by endothelial cells . some of the endothelial cells showed sprouting of its extension , which were also documented under microscope [ figs . 2 and 3 ] . pericytes and fibrocytes with varied morphology were seen in intervening stroma . some of the lymphocytic collections were seen at the edges of the lumen of the blood vessels . all the microscopic findings were consistent with cavernous hemangioma , and interesting finding of surface blood vessel and tecs was similar to some of the established cell culture tumor model in vitro experimental pathology . immunohistochemistry ( ihc ) of the tumor showed cd31 , cd34 , actin , and vimentin positive . sprouting of end of small vessels in gross with suspected angiogenesis ( 400 , unstained specimen ) outgrowth of small twig of sprouting from endothelial surface of blood vessel ( h and e 400 ) sprouting angiogenesis is an enlargement of new capillary blood vessels arising out of preaccessible ones . it was long being discussed that how a new vessel could arise from the exiting one when the metabolic needs in the adjoining tissue is similar . it has been documented in various conditions such as neovascularization in diabetes , pannus in synovium of joints in rheumatoid arthritis , vascular system complications , and in tumor biology . in tumors , sprouting angiogenesis is not only seen in primary tumors but also in micrometastasis and obvious metastasis . in all these conditions , sprouting angiogenesis was seen in oxygen deficient area where angiogenesis starts with activation of endothelial cells by various growth factors that bind to the specific sites . extracellular matrix and bm surrounding the endothelial cells despoiled locally by activated factors . by the process of polarization , the migrating endothelial cells are created within the lumen , and immature blood vessels are formed . the entire development of angiogenesis is firmly prescribed by positive and negative regulators , the stability of which determined the level of ongoing angiogenesis . in 1980 , thereafter , vascular endothelial growth factor played a major role in prompt of various blood vessels in diverse organs . our case was a 34-year - old male presented with proptosis in os for 2 years . after surgery , the specimen was meticulously examined for its small vascular pattern over that tumor 's capsule and its surrounding . tecs were important morphological structures that were documented and compared with the endothelial cells of the surface blood vessels . a pattern of endothelial podosome rosette [ fig . 4 ] was another pathological structure that was seen and adjoining to them , the tec showed intracellular gap junctions [ figs . 5 and 6 ] . sprouting of blood vessels could be seen in very high power objective of microscope and compare with stained section . ihc for cd34 showed positivity demarcating the structures of endothelial cells of the blood vessels . structure simulating podosome rosette formed by tumor endothelial cell and small blood vessels encircling the rosette comparative size of tumor endothelial cell and endothelial cells of small blood cells the gap junction of tumor endothelial cell in direct examination of the tissue under high power objective of compound microscope ( 400 ) we have seen in our case that there was a strong pathological evidence of tumor angiogenesis with sprouting of the blood vessels . tec which was mostly evident in the model conceptualized for tumor angiogenesis play a significant role in the biology of vascular tumor such as cavernous hemangioma .

cavernous hemangioma is the most common orbital tumor in adult . there is lot of literatures for clinicopathological features of this tumor . these tumors had been studied for the model of angiogenesis in many of the experimental setups . we present a case of 34-year - old male with this tumor in the left eye with computerized tomography evidence . postsurgical laboratory findings gave interesting evidence of tumor angiogenesis with tumor endothelial cells and sprouting of the small vessels endothelial cells . podosome rosette could be conceptualized from the characteristic patterns seen in the tumor .

a 74-year - old man presented with mild dyspnea and chest discomfort for 30 months . trans - thoracic echocardiographic findings showed a left atrial echogenic mass ( 21.5 cm ) ( fig . 1 ) . a provisional diagnosis of a left atrial ( la ) myxoma was made , and the patient was admitted for the surgical excision of the tumor . coronary angiography revealed a 50% stenosis on the mid - portion of the left anterior descending artery ( lad ) . we planned the concomitant operation with mass excision and coronary artery bypass . under general anesthesia with supine position , conventional cannulation was performed , and the right atrial wall and the interatrial septum were incised . further , we anastomosed the left internal thoracic artery to the distal portion of the lad . the resected mass was oval and was made of a white jelly - like material . we resected the mass including the myocardium , and the la wall was closed by a prolene suture . hemangioma of the heart presenting as a primary cardiac tumor is extremely rare ; it accounts for approximately 2.8% of all primary resected heart tumors . its histological subtypes are as follows : 1 ) cavernous hemangioma , 2 ) capillary hemangioma , and 3 ) arteriovenous hemangioma or cirsoid aneurysm . the capillary hemangioma has lobules of endothelial cells forming small , capillary - like vessels . the arteriovenous hemangioma consists of dysplastic thick - walled arterioles , venous - like vessels , and capillaries . in our case , the tumor is a capillary hemangioma that shows ill - defined aggregates of closely packed , thin - walled capillaries filled with blood cells ( fig . further , tumors may be located in any heart chamber , the pericardium , the endocardium , or the myocardium . , and the localization of cardiac hemangiomas was the right ventricle in 20 cases ( 35.7% ) , the left ventricle in 19 cases ( 33.9% ) , the right atrium in 13 cases ( 23.2% ) , the interatrial septum in 6 cases ( 10.7% ) , the interventricular septum in 6 cases ( 10.7% ) , and the left atrium in 4 cases ( 7.1% ) . very few cases of cardiac hemangiomas have been reported to be arising from the la wall , mimicking the classic presentation of a myxoma . in our patient , the tumor was located in the orifice of the right lower pulmonary vein . however , venous flow obstruction was not observed . some cardiac hemangiomas are asymptomatic and are discovered during cardiac surgery or upon autopsy . in symptomatic patients , cardiac hemangiomas cause arrhythmia , pericardial effusion , congestive heart failure , right ventricular outflow tract obstruction , coronary insufficiency , and sudden death . diagnosis can be made by echocardiography , computed tomography ( ct ) , or magnetic resonance imaging ( mri ) . coronary angiography is sometimes useful in revealing how the tumor is fed and its characteristic tumor blush . however , we can not find any feeding vessel or tumor blush in preoperative coronary angiography . in the opinion of a cardiologist , the tumor had a myxoma - like shape and exhibited echogenicity . atrial hemangiomas , particularly those attached to the la wall , may be erroneously diagnosed as myxomas . however , there are no myxoma cells or lepidic cells that can be found usually in cardiac myxomas , and cellular areas with numerous capillaries are usually present . patients with a resectable tumor usually have a good prognosis , but those with an unresectable tumor may have a poor prognosis because of ventricular tachycardia , sudden death , local progression , or systemic dissemination of the malignant tumor . therefore , we believe that if surgical resection is possible , surgery is the best way to treat cardiac hemangioma . cardiac hemangioma is a rare disease ; furthermore , a tumor arising from the la wall and misconceived as a myxoma is extremely rare . we removed the mass misdiagnosed as a myxoma and pathologically confirmed it to be a cardiac capillary hemangioma . in order to share our experience

hemangioma of the heart , presenting as a primary cardiac tumor is extremely rare ; it accounts for approximately 2% of all primary resected heart tumors . in our patient , the tumor was located in the orifice of the right lower pulmonary vein . few cases of cardiac hemangiomas have been reported to arise from the left atrial ( la ) wall . left atrial hemangiomas , especially those attached to the la wall , may be erroneously diagnosed as myxomas . cardiac hemangioma is a rare disease ; furthermore , a tumor arising from the la wall and misconceived as a myxoma is extremely rare . we removed a mass misdiagnosed as a myxoma ; it was pathologically confirmed to be a cardiac capillary hemangioma . therefore , we report a rare case of a cardiac hemangioma misconceived as a myxoma ; the tumor was removed successfully .

acyclovir and its congeners can rarely result in psychosis , mania and neurotoxicity in elderly , immunocompromised individuals.[14 ] however , there are no reports of acyclovir - associated hypomania in psychiatric population . mrs a is a 55-yr - old lady with bipolar affective disorder for the last 33 years with hypothyroidism since 2 years . her last episode was 10 months back , when she was diagnosed as mania with psychotic symptoms and subsequently was on treatment with tab . she presented to us with a 3-day history of irritability , increased talkativeness and decreased need for sleep . five days before the onset of these symptoms , patient had vesicular lesions over the body which was diagnosed as chicken pox by dermatologist ( she did not have past history of chicken pox ) . the hypomanic symptoms were reported to have started after 24 hrs of starting acyclovir . on mental status examination , she was distractible , had irritable mood , emotional liability , increased psychomotor activity and decreased attention span . she did not have any psychotic symptoms . on young mania rating scale ( ymrs ) her thyroid profile showed mild elevation of tsh-9.28 mciu / ml ( normal : 0.28 - 6.82 mciu / ml ) with normal t3 , t4 levels . she was diagnosed as having bipolar affective disorder , current episode hypomania ( icd-10 ) . she showed improvement in symptoms after 1 week ( ymrs score 7 ) and was discharged from hospital . index patient had an episode of hypomania within a week of developing chicken pox and 24 hours after starting acyclovir . previous reports have documented psychiatric manifestations due to acyclovir and its congeners in elderly individuals with immunocompromised state or physical illness.[25 ] although an earlier report reported resolution of symptoms after stopping acyclovir , we started her on olanzapine in view of her past history of severe manic episodes . on naranjo adverse drug reaction probability scale she had a score of 4 indicating a possible association . we did not find any previous report of varicella zoster infection resulting in mania or hypomania , thus making it unlikely to be associated with the index episode . however , index episode being secondary to stress associated with chicken pox though , less likely , is still possible . in conclusion , our report suggests that acyclovir is a risk factor for mood episode in vulnerable individual and one need to be cautious while using antiviral agents in patients with psychiatric disorders .

acyclovir , a commonly used antiviral drug can rarely result in neuropsychiatric complications especially in elderly . we for the first time report acyclovir associated hypomania in an elderly woman . our report suggests that acyclovir is a risk factor for mood episode in vulnerable individual and one need to be cautious while using antiviral agents in patients with psychiatric disorders .

computer - assisted surgery has been popularized in orthopedic surgery in the last 10 years . whilst a number of recent randomized control trials have shown some benefit in terms of implant position over conventional jig - based referencing,1 many navigation systems require the use of reference arrays , which are fixed to the tibia and femur with pins . a 58-year - old man with a diagnosis of varus osteoarthritis ( oa ) of the right knee underwent navigated total knee arthroplasty ( tka ) using standard technique . we use a passive reflector - based system ( brainlab , feldkirchen , germany ) with fixation of the femoral reference array using two 3-mm - diameter threaded pins . these are inserted anteriorly through stab incisions , with the knee in flexion , as proximally as the tourniquet will allow . tibial pins are inserted in the mid diaphysis into the subcutaneous surface of the tibia [ figure 1 ] . all pins are bicortical in order to maintain secure fixation for the duration of surgery . peroperative photographs ( a ) insertion of tibial and femoral reference arrays ( b ) the styloid used to map out the tibia and femur computer registration is performed with digitalization of the hip and ankle centers and specific landmarks of the knee . a size 6 generation ii cemented femoral implant and a size 6 generationii cemented tibial component were implanted with an 11-mm polyethylene insert . the patient had some pain and thigh swelling postoperatively , but this was considered to be in keeping with recent surgery . he was discharged on the third postoperative day , having satisfied physiotherapy and occupational therapy goals . he reported 3 days later with increased right thigh pain , swelling , and a limited range of movement . an ultrasound guided diagnosis of a quadriceps hematoma at the site of the femoral pins was made . this was confirmed by computerized topography ( ct ) with intravenous contrast [ figure 2 ] , which showed a large quadriceps hematoma and active bleeding into the femoral canal from a branch of the superficial femoral artery as it entered linea aspera at the site of pin insertion . two ct scan images showing active bleeding into the femoral canal on day 10 , the hematoma was evacuated and two 14-mm unicortical screws were inserted into the femur at the site of the bleed to tamponade the bleed . unicortical screws were used to reduce the risk of further arterial injury with bicortical screws and the ct scan also showed unicortical injury . at 2 weeks post presentation he then had a flexion of 090 , but also had some persistent swelling and was prescribed a short course of diazepam . he showed continued improvement since the second operation and had no further complications at the final followup 6 months later [ figure 3 ] . computer navigated tka has the potential advantage of improved implant position , which is known to reduce the rate of aseptic loosening . there have been a number of studies reporting complications of computer navigated tka among these . bhling et al.,9 chin et al.,10 and bthis et al.11 demonstrated longer tourniquet time with computer navigation . kalairajah et al.12 reported a longer tourniquet time as well as a statistically significant decrease in blood drainage . chauhan et al.13 and jenny et al.4 found that computerized navigation was associated with a longer operating time . stckl et al.14 reported one case of poor tibial tracker stability , related to osteoporotic bone , resulting in abandonment of computer navigation , from 64 patients . hernadez - vaquero15 reported four cases of failed pin fixation ( three iliac crest and one femur ) requiring abandonment of computer navigation from a total of 112 patients . our report is the only case of arterial injury in the literature related to navigation pin usage . if the patient develops an unexpected postoperative swelling with increasing pain this diagnosis needs to be taken into consideration .

the use of computer navigation has the potential to improve implant position in total knee arthroplasty ( tka ) , but pin fixation of reference arrays introduces an additional potential source of complications . we report a case of vascular injury related to the insertion of a femoral pin during navigated tka .

in this issue of critical care , yildiz and colleagues reported the first randomized , controlled trial on the efficacy and safety of physiologic doses of steroids in severe sepsis . during the past 5 years , five phase ii trials and a phase iii placebo - controlled trial on cortisol replacement , i.e. prolonged treatment with physiologic doses of steroids , have been completed in patients with vasopressor - dependent septic shock ( table 1 ) . two of them have already been published in peer - reviewed journals , three have been published in abstract form and will be published shortly in peer reviewed journals , and the results of a phase ii trial that has just been completed will be available very soon ( oppert and colleagues , personal communication ) . these trials have consistently shown beneficial effects of cortisol replacement on the amount of vasopressors , on the duration of shock , on the duration and intensity of organ dysfunction , and on the intensity of the systemic inflammatory response . the survival benefit observed with cortisol replacement in several phase ii trials was recently confirmed by the phase iii trial . in all these trials , cortisol replacement was never associated with even a trend toward serious side effects . a confirmatory phase iii , multinational , placebo - controlled trial ( the corticus study ) is under way , and results should be available within the next 3 years . in the meantime , given the consistency of the results across available trials , cortisol replacement should be considered as a standard of care for patients with vasopressor - dependent septic shock . yildiz and colleagues found that , in patients with severe sepsis , irrespective of the need for vasopressors , treatment for 10 days with prednisolone given intravenously twice daily ( 5 mg at 6 a.m. and 2.5 mg at 6 p.m. ) was associated with a 20% absolute reduction in mortality within 28 days . these findings are very challenging , because they suggest that cortisol replacement might be introduced in severe sepsis as well as in vasopressor - dependent septic shock , and that the mechanisms underlying the favorable effects of the treatment might not be limited to a reduction of the need for vasopressors . obviously , a phase iii trial must be set up to confirm the potential survival benefit of cortisol replacement in patients with severe sepsis who are not vasopressor - dependent . recently completed randomized , controlled trials of cortisol replacement in septic shock the study by yildiz and colleagues addressed another important issue , i.e. the need for an adrenocorticotropic hormone ( acth ) test to identify patients with severe sepsis or septic shock who will benefit from cortisol replacement . in this small trial , the effects of steroids were not significantly altered by the results of a short acth test . however , there were only 14 nonresponders ( 5 in the steroid group and 9 in the placebo group ) to the test , i.e. a cortisol increment after a 250-g intravenous bolus of acth of less than 9 g / dl , as previously defined . subsequently , in this subset of patients with occult adrenal insufficiency , the 15.6% absolute reduction in 28-day mortality in favor of the steroid group was not statistically significant . among the six completed trials of cortisol replacement in septic shock , only two reported separate data according to the results of a short corticotropin test , and only one trial was adequately powered to assess the survival benefit of cortisol replacement in patients with occult adrenal insufficiency . in fact , in this trial , cortisol replacement dramatically improved rates of survival for 28 days in the intensive care unit or elsewhere in the hospital in the nonresponders to the acth test but not in those having an increase in cortisol levels of more than 9 g / dl after acth . however , this trial was not adequately powered to allow definite conclusions regarding patients deemed to have normal cortisol response to acth and we therefore need to wait for the results of the corticus study . in the meantime , cortisol replacement should be considered only in vasopressor - dependent septic shock with occult adrenal insufficiency . as the results of the acth test might not be available everywhere at all times , it is recommended that cortisol replacement be started immediately after the acth test is performed , and that in the light of the results of the test , treatment could be continued for up to 7 days in nonresponders and stopped in patients with normal cortisol response to acth .

based on several recently completed randomized controlled trials , cortisol replacement is likely to become a standard of care for vasopressor dependent septic shock . further studies are needed in order to accomplish whether this treatment should be limited to patients with a blunted cortisol response to corticotrophin . similarly , in patients with severe sepsis who do not need vasopressors , the benefit / risk ratio of cortisol replacement remains to be assessed .

a 32-year - old male came to us with complaints of cystic lesions in both lids [ figs . 1 , 2a and b ] . he was diagnosed to have lipoid proteinosis elsewhere and was completely screened for systemic involvement . a buccal mucosal biopsy taken elsewhere showed deposition of pas - positive hyaline material [ fig . 3 ] . there were verrucous lesions in both upper and lower lids with cauliflower shaped lesion in the lower puncta of both eyes . . external photograph of the eye external photograph closer view ( a ) upper lid ( b ) lower lid histopathology picture depicting pas positive hyaline material uws is an autosomal recessive disorder , first described by urbach and wiethe in 1929 . the incidence of hyalinosis cutis et mucosae seems to be fairly high in south africa . it is a multi - system disease caused due to mutations in the gene encoding extracellular matrix protein 1 on chromosome 1q21 . skin lesions generally appear as nodules on the face , lips ( at earlier stages ) , and later become hyperkeratotic . schirmer 's test in both eyes was normal suggesting no involvement of lacrimal gland in our case . various ocular manifestations such as dry eyes , open angle glaucoma , drusen in the macula , retinitis pigmentosa , uveitis and subluxation of the lens has been reported along with lipoid proteinosis . however , our patient had no abnormality in his eyes . the most common radiological hallmark is the presence of bean or comma shaped intracranial calcifications in the temporal lobes in the amygdala , which is more evident in the patients who have lipoid proteinosis for a long duration . patients with neurological manifestations present with a migraine , seizures , mental retardation , anxiety , depression , and panic attacks . though rare , systemic manifestations of lipoid proteinosis include life - threatening situations like acute respiratory distress or seizures . awareness among ophthalmologists about this rare entity is crucial for appropriate management of these patients .

urbach wiethe syndrome or lipoid proteinosis is a rare autosomal recessive disorder characterized histologically by infiltration of periodic acid schiff - positive hyaline material in the skin , upper aerodigestive tract , eyelids , and internal organs . classical clinical features include scarring of the skin , beaded eyelid papules ( moniliform blepharosis ) and laryngeal infiltration leading to hoarseness of voice . lipoid proteinosis can lead to life - threatening conditions such as acute respiratory distress and seizures . awareness among ophthalmologists about this rare entity is crucial for appropriate management of these patients .

cylindroma is a benign skin adnexal neoplasm that presents in the head and neck region . the tumor may be single or multiple , and is commonly located on the scalp . histopathology is diagnostic with characteristic ' jigsaw puzzle ' architecture and features of ductular differentiation . a 58-year - old man presented to the outpatient department with the complaints of a painful swelling over the right side of the face and scalp that gradually increased in size since two years . on examination , the facial swelling appeared bosellated and fungating , with surface ulceration [ figure 1 ] . a trucut biopsy was done from the face as well as the scalp nodule [ figure 2 ] . histopathological examination from both the swellings were identical and revealed lobules of epithelial cells separated by thin acellular eosinophilic septae , which imparted a mosaic or jigsaw the lobules comprised of a peripheral layer of dark staining basaloid cells and pale staining cells in the center . the periodic acid schiff ( pas ) stain highlighted the acellular basement membrane like material surrounding the lobules as well as entrapped masses of hyaline material within the lobules [ figure 4 ] , thereby supporting a diagnosis of eccrine cylindroma . there was no significant family history to support a diagnosis of brooke spiegler syndrome or familial cylindromatosis . bosellated and ulcerated swelling on the face low - power view ( h and e 10 ) showing islands of epithelial cells giving a jigsaw puzzle appearance pas stain highlighting the eosinophilic ribbons surrounding the islands and hyaline globules ( h and e 40 ) the cell of origin is from the pluripotent stem cells in the folliculo - sebaceous - apocrine unit . the tumor continues to incite the curiosity of dermatologists and dermatopathologists , due to its syndromic association as well as due to its unique histopathological appearance . spiegler syndrome is an autosomal dominant cutaneous tumor syndrome , which presents with multiple skin adnexal neoplasms including cylindromas , trichoepitheliomas , and rarely spiradenomas . multiple scalp lesions can cover the entire scalp like a turban , earning it the name of turban tumor . histopathology is diagnostic with islands of cells separated by hyaline basement membrane material that is pas positive . pas - positive hyaline material in globules is also seen within the lobules . in conclusion , this in conjunction with a carefully elicited family history is mandatory to suggest or refute a syndromic association such as brooke spiegler syndrome .

cylindroma is a benign skin adnexal tumor of eccrine differentiation . clinically , they are disfiguring lesions that can mimic a malignancy . cylindromas can be single or multiple and commonly involve the scalp ( turban tumor ) and face . multiple cylindromas can have a syndromic association as seen in brooke spiegler syndrome and familial cylindromatosis . we present a case of non familial cylindroma of the face that clinically mimicked a basal cell carcinoma . the histopathology was confirmatory . herein we also highlight the utility of a simple and inexpensive histochemical stain periodic acid schiff in supporting the diagnosis .

subcuteneous swelling as metastases are an uncommon presenting feature for primary solid tumors like lung cancer usually in the range of 1.52.6% . it is important to distinguish such metastases from a soft - tissue mass as they may represent the first clinical sign of an occult tumor . in this report , we describe an unusual case of small - cell lung cancer metastasizing to his anterior chest , back and left arm as soft tissue nodule at the time of initial diagnosis ; an aggressive cancer which has a poor prognosis owing to its late presentation . a 64-year - old male , chronic smoker presented in the medicine outpatient department with complaints of breathlessness , loss of weight , multiple swellings on the chest , back and left arm since 2 months . there was no history of trauma , pulmonary tuberculosis , chronic obstructive pulmonary disease , bronchial asthma , ischemic heart disease , hypertension or diabetes . on examination , there were firm , variegated and no tender cystic swellings on the anterior chest , back and left arm ( figure 1 ) . the hemoglobin was 9.6 g% , total leukocyte count was 6300/cmm with a differential of 45% neutrophils , 37% lymphocytes , 17% monocytes and 1% eosinophils , in the peripheral smear . serum calcium , phosphorus and alkaline phosphatase were 13.2 mg% , 4.0 mg% and 7.2 bodansky unit , respectively . fine needle aspiration cytology of the swelling from chest showed small cell lung carcinoma seen as small round cells in rosettes and nests with high n / c and pepper salt chromatin ( 40 , pap . computerized tomography of the chest showed pleural effusion , rib fracture with multiple small hypoechoic shadow suggestive of lung cancer ( figure 3 ) . he was referred to radio - oncology department for further management but he refused due to non - affordability . figure 2small cell lung carcinoma seen as small round cells in rosettes and nests with high n / c and pepper salt chromatin ( 40 , pap . stain ) . small cell lung carcinoma seen as small round cells in rosettes and nests with high n / c and pepper salt chromatin ( 40 , pap . figure 3computerized tomography of the chest showing pleural effusion and rib fracture with multiple small hypoechoic shadow , suggestive of lung cancer . computerized tomography of the chest showing pleural effusion and rib fracture with multiple small hypoechoic shadow , suggestive of lung cancer . small cell lung cancer results from bronchial epithelial cells , which are relatives of kultchitsky cells , a type of intestinal epithelial cell . it is much lower compared to adenocarcinomas ( 2.95% ) and squamous cell carcinomas ( 1.16% ) of the lung . the disease most frequently metastasizes to the central nervous system , bone marrow and suprarenal glands . small cell lung cancer may be accompanied by paraneoplastic syndromes , superior vena cava syndromes , compressions to the spinal cord and , very rarely , skin metastases . although they can occur in any part of the skin , most common sites for cutaneous metastases are chest , back , abdomen , and scalp . diagnosis may be delayed by several months , unless the skin lesion grows rapidly or other sites such as the lung or liver are affected by the tumor 's spread . early recognition of tumor from a suspicious skin lesion may lead to initiation of treatment before widespread metastases occur . in our case , the metastasis in the form of subcutaneous swelling was found simultaneously with the primary lung tumor , facilitating diagnosis . although at the time of initial presentation he also had pleural effusion and rib fracture . moreover in this case nature of swelling was not suspicious rather it looked like lipoma and on aspiration cytology it was metastasis from small cell lung cancer . the basic metastatic course can occur in the following steps : detachment from the primary tumor followed by invasion , intravasation into a vessel , circulation , stasis within a vessel , extravasation , invasion into recipient tissue bed , and proliferation . in conclusion , as seen in this case of rare unexpected skin metastasis of small cell lung carcinoma , which lack a pathognomonic physical appearance , like rapid enlargement , ulceration , tender , physicians should be vigilant about this entity . any skin lesions in the form of swelling should be evaluated meticulously and biopsies should be done to exclude metastases in the clinical scenario of breathlessness , chest pain and loss of weight especially in old age . because in this case though both primary and metastasis were detected at the same time , earlier diagnostic anticipation about this cuteneous swelling could have different and better prognosis .

subcutaneous swelling as first clinical presentation of small cell lung carcinoma is uncommon and rarely reported in literature . this case highlights a rare presentation in which subcutaneous swelling was the first clinical manifestation of a small cell carcinoma of lung which also had metastasis to rib bone , muscle and pleural involvement as pleural effusion . we describe the case of a 64-year - old male patient who presented with dyspnea , pleuritic pain , loss of weight and nodule on his anterior chest , back and left arm suspicious of lipoma . biopsies revealed small cell carcinoma of lung . this case demonstrates the meticulous work up of subcutaneous swelling in the clinical scenario of breathlessness , chest pain and loss of weight .

nasopharyngeal angiofibromas are relatively rare tumors that represent 0.5% of all head and neck neoplasms and they predominantly occur in adolescent males ( 1 ) . this type of tumor originates from the region of the sphenopalatine foramen . in most cases , imaging studies will demonstrate a widening of the pterygopalatine fossa and anterior bowing of the posterior wall of the maxillary sinus ( 2 ) . i describe an extra - nasopharyngeal angiofibroma arising from the parapharyngeal space in a middle - aged woman without involvement of the sphenopalatine foramen or the nasopharynx . a 53-year - old woman presented with a diffuse anterior neck swelling of one - month duration . the patient had not undergone any previous surgery . ultrasonography ( us ) showed diffuse goiter with multiple thyroid nodules . a homogeneous and hypoechoic solid mass , adjacent to the upper margin of the right submandibular gland with focal flow signals on color doppler sonography within the mass was detected ( figure 1 ) . a computed tomography ( ct ) scan revealed a circumscribed mass , hypodense to the masseter muscle and hyperdense to the parotid gland in the right parapharyngeal space ( figure 2 a - c ) . after intravenous contrast administration , the mass , 1.7 1.7 1.6 cm in size , demonstrated homogeneous enhancement without infiltration to the adjacent muscle . at that time enlargement of the bilateral thyroid lobes with multiple non - enhancing hypodense and calcified thyroid nodules was also noted . under general anesthesia after surgery , the patient revealed an uneventful postoperative course . at the three - year follow - up examination , angiofibromas are histologically benign , but potentially locally destructive fibro - vascular tumors that account for less than 0.5% of all head and neck neoplasms ( 3 ) . they originate from the region of the sphenopalatine foramen and commonly spread to the sphenoid sinus , the nasal cavity , and the pterygopalatine foramen ( 1 ) . angiofibromas that do not originate from the area around the sphenopalatine region are very rare ( 1 ) . the primary site of extra - nasopharyngeal angiofibromas varies and can include the ethmoid and sphenoid sinuses , the nasal septum , the tonsils , the ears , the trachea , the larynx , and the infratemporal fossa ( 1 ) . the most common site of extra - nasopharyngeal angiofiroma is the maxillary sinus . in the recent literature , there were five more cases of extra - nasopharyngeal angiofibromas reported in the literature since then ( 5 - 9 ) . only one parapharyngeal angiofibroma was reported in a 25-year - old male in the english literature ( 10 ) . they reported homogeneous enhancement on ct and hypervascularity on conventional angiogram in the left parapharyngeal mass . i report the very rare case of an extra - nasopharyngeal angiofibroma arising from the right parapharyngeal space in a middle - aged woman . to the best of our knowledge , this represents the second demonstrated case of an angiofibroma originating in such a location . extra - nasopharyngeal angiofibromas occur more commonly in females and tend to develop at an older age ( 11 ) . the male - to - female ratio is roughly 3:1 and the mean age at presentation is 22 years . clinical manifestations of extra - nasopharyngeal angiofibromas are variable including headache , hoarseness , dysphagia , dyspnea , stridor , and pain according to their location ( 4 , 11 ) . extra - nasopharyngeal angiofibromas may have less specific and confusing clinical symptoms and diagnosis may be delayed ( 4 ) . enlargement of the sphenopalatine foramen with an intensely enhancing mass is the typical pathognomonic radiological finding , especially in young boys ( 1 ) . in the patient with characteristic radiological findings and typical clinical symptoms of nasopharyngeal angiofibromas , preoperative biopsy extra - nasopharyngeal angiofibromas are harder to diagnose radiologically due to their various locations ( 4 ) . unlike nasopharyngeal angiofibromas , lack of hypervascularity on conventional angiograms does not exclude the diagnosis of extra - nasopharyngeal angiofibromas ( 2 ) . an axial ct showed well enhancing mass in the right parapharyngeal space without perilesional infiltration . the mass was thought to be a minor salivary gland origin tumor or a paraganglioma , hemangiopericytoma , solitary fibrous tumor or neurogenic tumor , preoperatively . differential diagnoses of parapharyngeal masses may also include parapharyngeal space metastatic lymph node , lymphoma , inflammatory pseudotumor , tuberculous and fungal infections ( 12 ) . the most acceptable treatment for angiofibroma is endovascular embolization and then surgical excision ( 13 ) . nasopharyngeal angiofibroma seems to have a poorer prognosis than an extra - nasopharyngeal lesion due to inadequate surgical exposure ; consequently , it may result in a higher recurrence rate ( 3 ) . in the present case , complete surgical resection was performed without preoperative embolization . on follow - up after a period of 3 years , there was no tumor recurrence .

nasopharyngeal angiofibroma is a relatively uncommon vascular tumor affecting adolescent males and it characteristically originates in the posterior lateral wall of the nasopharynx . primary extra - nasopharyngeal angiofibroma is very rare . here , i present a case of angiofibroma of the parapharyngeal space in a 53-year - old woman with ct and sonographic findings .

a 77yearold man complained of slight shortness of breath , and was referred to our hospital due to enlarging mediastinal / hilar lymphadenopathy with calcification and right pleural effusion on computed tomography ( ct ) ( fig . chest ct on parenchymal ( a ) and mediastinal ( b ) window settings showed right pleural effusion and mediastinal / hilar lymphadenopathy with calcification . what is the appropriate procedure to approach this lesion , and what is the differential diagnosis ? endobronchial diagnosis at nagoya medical center was requested and endobronchial ultrasoundguided transbronchial needle aspiration ( ebustbna ) of lymph node station 7 was performed . pathological examination revealed amorphous eosinophilic tissue with few cellular components ( figs . 2 and 3a , b ) . ( if the plasma cell rate is more than 10% , myeloma can be diagnosed . ) as a result , monoclonal gammopathy of undetermined significance ( mgus ) associated with mediastinal amyloidosis was diagnosed . echocardiography showed an ejection fraction of 45% , and there was brightness in part of the interventricular septum . cytology of the lymph node . a lump of amorphous light green material ( papaniclaou staining , 200 ) . ( a ) section showing amorphous eosinophilic materials with hematoxylin eosin staining ( h&e , 200 ) . ( b ) these materials stained positive for direct first scarlet staining ( dfs , 200 ) , indicating amyloid deposits . we are currently administering combination therapy of bortezomib , melphalan , and prednisolone to this patient . as a result , the serum igg has decreased and there is no systemic aggravation ; however , his cardiac function has not improved with this treatment . as jenkins et al . stated , amyloidosis should be considered in the differential diagnosis of a large mediastinal mass , especially if calcification and/or plasma cell neoplasm is present 1 .

key clinical messagea 77yearold man was referred to our hospital due to enlarging mediastinal / hilar lymphadenopathy with calcification . endobronchial ultrasoundguided transbronchial needle aspiration ( ebustbna ) and bone marrow aspiration were performed . subsequently , monoclonal gammopathy of undetermined significance ( mgus ) associated with mediastinal amyloidosis was diagnosed . we hereby report a case in which ebustbna led to a successful diagnosis of amyloidosis .

they are a congenital disturbance of the position of the eyelashes , which are usually on the lateral quadrant of the upper eyelid or conjunctival surface of the eyelid . the origin of these abnormally placed cilia is not clear , but a previous theory of meibomian gland substitution has been refuted and an embryologic origin suggested.1,2 in most cases , it causes no apparent medical morbidity and there is no positive family history . here we report a case of a patient with ectopic cilia and hypochromic patches on the right arm . a 6-year - old girl was referred for evaluation of a congenital lateral upper eyelid ectopic cilia cluster ( figure 1 ) . on physical examination , she had hypochromic lesions on the right arm , diagnosed by the dermatology service as hypochromic nevi ( figure 1 ) . the specimen comprised a circular 106 mm portion of skin and contained a centrally placed tuft of strong and pigmented hairs . longitudinal sections and histologic analysis showed dermal and subcutaneous pilosebaceous follicles ( figure 1a and 1b ) , packed in a dense fibrous tissue core ( figure 1b ) extending through the eyelid from the subcutaneous area , scarcely represented in the specimen . well developed sebaceous lobules ( figure 1c ) , bulbs of pilous follicles ( figure 1d ) , and apocrine - lined epithelial ducts consistent with glands of moll ( figure 1e ) and associated with pilous follicles were observed . occasional striated orbicularis muscle fibers were present in the depths of the specimen ( figure 1f ) , with the lowest hair bulbs ( figure 1f ) superficial to them . they have been observed to protrude from the anterior surface of the eyelid skin and the posterior aspect of the tarsal plate . there are 15 cases located on the anterior surface of the eyelids.1,2 histologic examination has demonstrated the presence of apocrine and pilosebaceous glands , and there is evidence that ectopic cilia in the palpebral conjunctiva are acquired aberrant cilia , in contrast with anterior ectopic cilia , which are congenital.3 in this case , histopathologic examination of the specimen revealed the typical characteristics of ectopic cilia described in the rare cases reported in the literature . we found strong and pigmented hairs in a dense fibrous stroma associated with sebaceous and apocrine glands located in the dermis and subcutis and superficial to the orbicular muscle fibers . importantly , ectopic cilia must be differentiated from abnormally placed hairs . as in our present case , the diagnosis of ectopic cilia is confirmed histologically by identification of sweat glands of the apocrine type attached to the follicles.4 recent reports also underscore the importance of morphologic observation of ectopic cilia in association with lobules of sebaceous glands and apocrine glands.5 in the present case , the cilia arose from the anterior surface of the tarsal plate , being classified as anterior - type ectopic cilia , which are congenital , in contrast with posterior ectopic cilia that arise in the palpebral conjunctiva and are acquired aberrant cilia.3 although previous reports have not correlated ectopic cilia with other skin hypopigmentation disorders , it is important to note that congenital hypochromic patches ( hypochromic nevi ) were observed in this case .

ectopic cilia are rare in humans . we report a 6-year - old girl with typical characteristics of ectopic cilia as described in the rare cases reported in the literature , in association with cutaneous lesions that appeared to be hypochromic nevi . this framework could be a different clinical presentation of ectopic cilia .

percutaneous coronary intervention ( pci ) for chronic total occlusion ( cto ) has a lower success rate than pci for non - cto lesions . a cto lesion was defined as an obstruction of a coronary artery with thrombolysis in myocardial infarction or a flow grade of 0 , with an estimated duration of at least 3 months prior to the event . in 1990 , the first retrograde approach technique was applied for cto via a degenerated saphenous vein graft . over the next 2 decades , variable and new retrograde techniques were reported over the next few years , including the following : kissing wire technique , knuckle wire technique , the controlled antegrade and retrograde subintimal tracking ( cart ) technique , the reverse cart technique , the modified reverse cart technique , the wire trapped technique , and the reverse wire trapped technique . despite the development of these various approaches , cto lesion still remains a challenge . in this situation , information about the cto lesion from intravascular ultrasound study ( ivus ) , cardiac ct angiography is a very useful approach , and is required for greater success in pci . in this case , we report our experience using the reverse cart technique under the aid of ivus , cardiac ct angiography for an ambiguous cto of proximal right coronary artery ( p - rca ) ( c , 100% , 0 ) with grade iii collateral flow . a 68-year - old man with a history of hypertension presented with worsening exertional dyspnea . fifteen months prior , angiography performed at a different hospital showed total occlusion of the p - rca ( 100% , c , 0 ) and distal left circumflex artery ( lcx ) ( 100% , c , 0 ) with significant stenosis of the proximal left anterior descending artery ( lad ) ( 95% , b2 , ii ) . at that time , pci using drug - eluting stent was performed in the proximal lad and distal lcx , only because multiple trials through the anterograde approach of cto of p - rca failed . bilateral coronary angiography demonstrated total occlusion of the p - rca and rentrop grade 3 collateral flow from lad , filling in a retrograde manner , the distal right coronary artery ( rca ) . a small vessel of rca proximal portion was looked as conus branch in coronary angiography ( fig . 1 ) . but , ivus study via anterograde approach in p - rca revealed tapered - type cto lesions , which was looked as conus branch . and , this distinction was detected in previous cardiac ct angiography , too ( fig . multiple guide wires were used to bypass the lesion through use of the collaterals , retrospectively . finally , the guide wire ( fielder fc 300 cm asahi intecc , osaka , japan ) passed the lesion via the septal branch to mid rca . then , a 2.515 mm size percutaneous transluminal coronary angioplasty balloon was inserted through the septal branch via retrograde guide wire and inflated to 12 atm . two cypher stents , 3.528 mm and 3.533 mm , were implanted in the mid- and proximal - rca . several studies show that successful recanalization of the cto improved angina pectoris , survival , and left ventricular systolic function.1 - 5 ) despite this necessity , the success rate of recanalization was still unsatisfied . the most common reason for pci failure in cto is passage failure of guidewire.6 ) ivus can give adjunctive information to detect the area of occlusion in selective cases from adjacent side branches or from the false lumen and the anatomical information about the distal segment of the totally occluded coronary artery , when dye could not penetrate.7 ) in addition , cardiac ct angiography can help identify features that most influence the current success rates of pci , such as marked calcifications at the stump , severe tortuosity of the proximal vessel , long length of the occluded segment , as well location of the vessel distal to the occlusion , which often can not be well visualized using conventional angiography.8 ) in this case , cardiac ct angiography and ivus in addition to angiography were performed to evaluate cto lesions because of the previous failure of intervention for p - rca . segmental calcified and soft plaques were detected in p - rca with cto by cardiac ct angiography . and , the conus branch was made out at the proximal portion of the plaques . thus , we identified the lesion that firstly considered as tapered stump was conus branch . and it looked as tapered stump . retrograde approach through the collateral channels has been proposed recently and has the potential to improve the success rate of pci towards the treatment of cto lesions.9 ) in addition , rathore et al.10 ) demonstrated a 100% success rate of cto recanalization using reverse cart . in general , this technique is performed after previous techniques have failed via the anterograde approach , with the presumption that the distal cap of the cto lesion may be softer than the proximal cap . several strategies using the retrograde approach may be proposed to cross the occlusion , according to the cto lesion characteristics , and sometimes , a very complex cto lesion may require a combination of several techniques . the reverse cart technique has been shown to be safe and feasible , with a high success rate when performed by highly experienced operators . in conclusion , if previous attempts to cross the totally occluded lesion from anterograde approach fail , the retrograde approach from collateral should be considered first , as in our case . with the help of diagnostic imaging , such as ivus and cardiac ct angiography , , the development of diagnostic methods will be reduced to reduce the failure to passage the cto lesion .

passage failure of guidewire is still remained most common reason for percutaneous coronary intervention ( pci ) failure in chronic total occlusion ( cto ) . intravascular ultrasound study ( ivus ) and cardiac ct angiography can help identify features that most influence current success rates of pci . we report our experience using the reverse controlled antegrade and retrograde subintimal tracking technique under the aid of ivus , cardiac ct angiography for an ambiguous cto of proximal right coronary artery .

nevus depigmentosus is a hypomelanotic condition which is usually refractory to medical modalities of treatment.a few cases of surgical repigmentation have been reported.one case report from south korea described the recurrence of hypomelanosis at the surgically treated site after eight years . nevus depigmentosus is a hypomelanotic condition which is usually refractory to medical modalities of treatment . one case report from south korea described the recurrence of hypomelanosis at the surgically treated site after eight years . nevus depigmentosus ( nd ) is a rare , congenital , stable hypomelanosis first described by lesser in 1884 . the lesions usually present as dermatomal or quasidermatomal macules commonly on the trunk , lower abdomen , or proximal extremities . they are off - white in colour and have irregular , serrated , feathered , or geographic margins . the face , when involved , is a cause of social embarrassment for the patient . unfortunately , there is no effective treatment for this condition . here we report a patient of nd treated successfully with suction blister grafting , in whom the pigment has been well maintained even after 10 years . a 15-year - old female student presented with a hypopigmented asymptomatic macule on the left half of the upper lip [ figure 1 ] slightly extending to the left cheek , since birth . examination of other areas of the skin did not reveal any similar lesions or any other type of skin lesions and the other systems particularly the skeletal and nervous system were within normal limits . her investigation revealed normal blood counts ; liver function test ( lft ) , renal function test ( rft ) , clotting profile , and test for hiv were negative . nevus depigmentosus distributed on the left half of the upper lip with extension to the chin in march 2002 , suction blister grafting was performed on her after taking informed consent . multiple blisters were raised on the left thigh using a suction blister technique described by gupta et al . then , the blister roof from the thigh was removed with the help of iris scissors , transferred on to a glass slide ; the edges were trimmed to fit the shape of the recipient area and then applied on to the recipient nd site [ figure 2 ] . when the dressing was removed after 48 hours the patient was put on topical puvasol ( psoralen plus ultraviolet - a of solar origin ) after the grafts fell off and the resultant pigmentation was satisfactory at a follow - up after 1 month . application of suction blister grafts at the recipient site the patient followed up in the clinic after a gap of 10 years in may 2012 , and on examination , it was found that the pigmentation achieved with suction blister grafting was well maintained [ figure 3 ] , though there were a few areas of patchy hyperpigmentation toward the angle of the lip on the left side . the disease is primarily limited to the skin though there are reports of association of neurological abnormalities and limb hypertrophy the commonly used clinical diagnostic criteria for nd are as follows : leukoderma present at birth or of an early onsetno alteration in the distribution of leukoderma throughout lifeno alteration in texture or change in sensation in the affected areaabsence of hyperpigmented border leukoderma present at birth or of an early onset no alteration in the distribution of leukoderma throughout life no alteration in texture or change in sensation in the affected area absence of hyperpigmented border lee et al . found that the majority ( 92.5% ) of nd present before the age of three years and have serrated irregular borders ( 77.4% ) . wood 's lamp examination shows an off - white accentuation in nd as compared to the chalky white accentuation in the case of vitiligo . described the procedure of suction blister grafting as helpful in nd but the follow - up details in that case were not known . kim et al . reported a case of recurrence of nd eight years after autologous epidermal grafting where he considered the newly developed hypopigmented macules to be a functional impairment of melanocytes in nd . in the present case , the follow - up was after 10 years and the pigment gained after suction blister grafting was stable . the epidermal sheets used for grafting in nd should completely cover the area of nd for a uniform repigmentation . in contrast , there have been reports of poor quality of repigmentation with cell suspension or melanocyte keratinocyte transplantation . as the resultant cosmetic discomfort for facial lesions of nd can be embarrassing to the patient and no effective therapeutic options are available , surgical repigmentation with blister grafting should be offered to all interested patients . pigmentation was well maintained at the site of suction blister grafting after 10 years , and hence , suction blister grafting should be offered to all willing patients .

nevus depigmentosus is a congenital hypomelanotic condition for which no effective treatments are available . the hypopigmentation is permanent and enlarges in proportion with growth in the person . here , i report a patient of nevus depigmentosus on whom we performed suction blister grafting and the resultant pigmentation was satisfactory even at a follow - up after 10 years .

we obtained data on persons with hiv / aids and tb from the national databank at the centers for disease control ( cdc taiwan ) of the department of health , taiwan . coinfection with hiv and tb was defined as hiv infection in persons in whom tb was later diagnosed . a total of 660 persons with both hiv and tb were reported during 19932006 . we used microsoft excel xp spreadsheet ( microsoft , redmond , wa , usa ) and sas version 9.1 ( sas institute inc . , the goodness - of - fit test with type i error = 0.05 was used to examine differences in demographic , clinical , and behavioral characteristics of persons with hiv and tb coinfection during 19932006 . multivariates for analysis were sex and age , results of sputum smear and sputum culture , pulmonary radiographic diagnosis , tb types ( extrapulmonary and nonextrapulmonary ) , mode of hiv transmission , sexual behavior , compliance with haart , and use of the surveillance system ( table 1 ) . we used the kaplan - meier method ( 4 ) from sas to evaluate and compare the effect on survival rates of different factors in persons coinfected with hiv and tb 1 year after reported tb diagnosis . * goodness - of - fit test with type i error = 0.05 used to examine differences in demographic , clinical , and behavioral characteristics . kaplan - meier analysis yielded the following results : 63% of persons coinfected with hiv and tb survived during 19931996 ; 78% survived during 19982000 ; and 93% survived during 20022006 ( p<0.0001 ) ( figure ) . we then applied cox proportional hazards modeling ( 5 ) to each variable to assess the effect on survival rates after implementation of haart and the surveillance system . age < 45 years , negative sputum smear , availability of free haart , and implementation of the national surveillance system substantially increased survival rates of persons coinfected with hiv and tb ( table 2 ) . kaplan - meier analysis of survival of hiv - infected patients with tuberculosis in taiwan during 3 different periods : before free highly active antiretroviral therapy ( haart ) was available ( 19931996 , black line ) ; b ) after free haart was available but before the national web - based reporting and management surveillance system was implemented ( 19982000 , red line ) ; and c ) after free haart and the surveillance system were available ( 20022006 , blue line ) . many factors can increase survival rates of hiv - infected persons , such as haart ( 69 ) , prevention of opportunistic infections , patient attitude , healthcare worker knowledge , and promotion of health education . our data indicate that national web - based surveillance reporting and management , coupled with the availability of free haart , increase survival rates of persons coinfected with hiv and tb ( p<0.0001 ) . taiwan s national web - based surveillance system enables healthcare workers to follow , record , and understand the conditions of patients without geographic limitations . physicians , public health nurses , health administrators , and other healthcare professionals in local through federal government agencies can use the system to follow up and manage the condition of persons coinfected with hiv and tb . for example , public health nurses from national healthcare centers visit such patients regularly , record treatments , and assess their conditions and compliance with therapy ; staff from central health department monitor and supervise the condition of each patient through the system . in this way , the system may increase patients compliance and thus their survival rates ( 1014 ) .

in 1997 , taiwan made highly active antiretroviral therapy ( haart ) available without cost to hiv - infected persons ; in 2001 , a national web - based surveillance system was implemented . healthcare workers use the system to monitor patients ' conditions and can intervene when necessary . free haart , coupled with the surveillance system , appears to have increased survival rates of hiv - infected persons with tuberculosis in taiwan .

a retrocaval ureter or pre - ureteric venacava is a rare anomaly which occurs in 1 per 1000 live births . it is seen three times more often in males and is usually on the right side . a left retrocaval ureter as such is very rare and is usually associated with situs inversus or ivc duplication . these patients usually present in the third or fourth decades and symptoms depend on the degree of obstruction . an 84-year - old male patient presented to us with dull , aching left flank pain of 6 months duration . ct scan of the abdomen revealed transposed ivc to the left side and classic retrocaval ureter with proximal hydro - ureteronephrosis [ figures 13 ] . intravenous urogram showing a sea - horse sign coronal ct image showing left retrocaval ureter with pre - caval ( arrowhead ) and post - caval ( arrow ) segments axial ct images with arrows showing ( a ) pre - caval ureter ( b ) post - caval ureter and ( c ) left renal vein the embryogenesis of the ivc is a complex process of development involving the posterior cardinal , the subcardinal , and the supracardinal venous systems . aberrant complexation of these veins can result into four anomalies : duplicated ivc , transposition of ivc to left , retroaortic left renal vein , and circum - aortic left renal vein . left retrocaval ureter is rare , and only eight cases have been reported in the literature so far . left retrocaval ureter without situs and without ivc duplication is rarer with only four cases being reported in the literature . pierro et al . reported a 0.2 to 0.5% prevalence of transposition of ivc to the left and a 0.1% prevalence of left retrocaval ureter .

retrocaval ureter ( pre - ureteral vena cava ) is an uncommon congenital anomaly that causes ureteral obstruction by external compression . although right retrocaval ureter is a common entity , left retrocaval ureter is extremely rare . a left retrocaval ureter is usually associated with situs inversus or duplicated inferior venacava ( ivc ) . an isolated left retrocaval ureter with single left - sided ivc is even rarer and only four cases have been reported in the literature . we present images of a case with isolated left retrocaval ureter with a single left - sided ivc without situs inversus .

acute flaccid paralysis ( afp ) is a clinical entity characterized by areflexia and/or hyporeflexia and weakness which reaches a maximum within days or weeks . polioviruses , enterovirus 71 , flavivirus , herpes virus , and rabies virus are well - known as viral etiologic agents . in this article , who presented with lower respiratory tract infection and afp , and was detected to have co - infection of human coronavirus ( hcov ) 229e and oc43 is reported . afp associated with hcov infections has not been reported previously in the literature , and has been reported for the first time in this article . a 3-year - old girl hospitalized due to the development of shortness of breath and inability to walk 1-day after the beginning of fever , rhinorrhea , cough , and weakness . on the same day , respiratory distress increased , she was intubated , and mechanical ventilation started . on physical examination , she was conscious but swallowing , chewing and speech functions damaged , muscle strength was 0/5 and deep tendon reflexes ( dtrs ) were absent , the plantar response was flexor . complete blood count , electrolytes and blood biochemistry and urinalysis were normal , c - reactive protein was negative and erythrocyte sedimentation rate was 20 mm / h . no abnormalities in the brain and spinal cord magnetic resonance imaging were detected - so intracranial and spinal pathologies were excluded . after 48 h of hospitalization , a total of 2 g / kg intravenous immunoglobulin ( ivig ) in 3 days was given . muscle strength improved to 23/5 , dtr became norm active , bulbar paralysis and respiratory distress had regressed . at the end of the 2 week , she could mobilize and walk with a guide . lumbar puncture and enmg repeated in the 3 week did not reveal any pathological findings and gullian barre syndrome ( gbs ) was completely excluded . real - time polymerase chain reaction ( pcr ) analysis of nasal swab samples was reported to be positive for hcov 229e and oc43 and hcov co - infection was diagnosed . flaccid paralysis occurs by the damage of lower motor neurons in the anterior horn of the spinal cord or peripheral nerves either by direct invasion or parainfectious and/or postinfectious immune - mediated mechanisms . besides gbs , differential diagnosis of afp includes : compressive and inflammatory diseases of spinal cord , the anterior horn motor neurons involvement by infectious ( poliomyelitis vaccine - associated poliomyelitis , other enteroviral myelitis , a japanese encephalitis , and west nile virus as agents ) and vascular pathology , myasthenia gravis , drug and toxins affecting neuromuscular junction ( aminoglycosides , organophosphates , snake venom and botulism , etc . ) , muscle disease such as viral myositis or inflammatory myopathy , hypokalemic periodic paralysis and electrolyte disorders ( hypermagnesemia and hypokalemia ) . preliminary diagnosis was gbs for this case ; however , csf and enmg findings in the 1 week of paralysis did not support this diagnosis . during the period of mechanical ventilation muscle strength increased and in this short time dtr normalized , as well as after 3 weeks paralysis started no pathologic findings observed by repeating lumbar puncture and enmg so gbs was excluded . history , clinical presentation , physical examination , and laboratory tests were totally normal that ruled out toxicological etiology , polio , and botulismus . members of coronaviridae can cause respiratory , intestinal , hepatic and neurological diseases of various severities in humans and animals . hcovs can cause neurological symptoms such as seizures and meningoencephalitis in children but afp has not been reported until now . hcovs may cause more serious respiratory disease in case of immune suppression and with various respiratory agents rather than single infection . in addition hcov , 229 and oc43 co - infection causing more severe respiratory disease has been demonstrated by a study . we have reported case of co - infection with hcov 229e and oc43 detected by real - time pcr analysis of nasal swab samples , and additional different respiratory pathogen has not been demonstrated , it suggests that co - infection caused lower respiratory tract infection and afp . we believe that hcov 229e and oc43 co - infection may cause respiratory failure and afp . whether ivig have a role in the treatment needs to be supported by more data from the literature .

acute flaccid paralysis ( afp ) is a life - threatening clinical entity characterized by weakness in the whole body muscles often accompanied by respiratory and bulbar paralysis . the most common cause is gullian barre syndrome , but infections , spinal cord diseases , neuromuscular diseases such as myasthenia gravis , drugs and toxins , periodic hypokalemic paralysis , electrolyte disturbances , and botulism should be considered as in the differential diagnosis . human coronaviruses ( hcovs ) cause common cold , upper and lower respiratory tract disease , but in the literature presentation with the lower respiratory tract infection and afp has not been reported previously . in this study , pediatric case admitted with lower respiratory tract infection and afp , who detected for hcov 229e and oc43 co - infection by the real - time polymerase chain reaction , has been reported for the first time .

a 2.5 kb vec promoter sequence was cloned between insulators from the chicken -globin gene 29 and used to drive cre expression . r26r - lacz/+;vec - cre or r26r - yfp/+;vec - cre conceptuses were generated by crossing vec - cre/+ males with r26r - lacz/+ or r26r - yfp/+ females . runx1;vec - cre and runx1;vec - cre conceptuses were generated by crossing runx1 ; vec - cre/+ males with runx1 females . runx1;r26r - yfp/+;vec - cre or runx1;r26r - yfp/+;vec - cre conceptuses were generated from crossing runx1;r26r - yfp/+ ; vec - cre/+ males with runx1 females . conceptuses were suspended in phosphate - buffered saline or in a 1:2 mixture of benzyl alcohol / benzyl benzoate and visualized with a stereomicroscope . x - gal ( sigma ) staining was performed as described previously 4 . in some cases the conceptuses were also incubated with rat anti - mouse pecam1 and abc reagent at 4c 30 , then treated with dab peroxidase substrate . conceptuses were embedded in paraffin , sectioned , and counterstained with nuclear fast red . to analyze intra - aortic clusters , embryos were fixed and stained with anti - c - kit and anti - pecam1-antibodies . a 1:2 mix of benzyl alcohol / benzyl benzoate was used to increase the transparency of tissues . three - dimensional reconstructions were generated from z - stacks ( 6287 serial sections ) . methylcellulose colony forming assays were performed as described previously 4 and colonies counted after 7 days . immuno - staining was performed with phycoerytherin , allophycocyanin , or alexa fluor 647 conjugated antibodies stained cells were analyzed on a becton dickinson facscalibur flow cytometer . a 2.5 kb vec promoter sequence was cloned between insulators from the chicken -globin gene 29 and used to drive cre expression . r26r - lacz/+;vec - cre or r26r - yfp/+;vec - cre conceptuses were generated by crossing vec - cre/+ males with r26r - lacz/+ or r26r - yfp/+ females . runx1;vec - cre and runx1;vec - cre conceptuses were generated by crossing runx1 ; vec - cre/+ males with runx1 females . runx1;r26r - yfp/+;vec - cre or runx1;r26r - yfp/+;vec - cre conceptuses were generated from crossing runx1;r26r - yfp/+ ; vec - cre/+ males with runx1 females . conceptuses were suspended in phosphate - buffered saline or in a 1:2 mixture of benzyl alcohol / benzyl benzoate and visualized with a stereomicroscope . x - gal ( sigma ) staining was performed as described previously 4 . in some cases the conceptuses were also incubated with rat anti - mouse pecam1 and abc reagent at 4c 30 , then treated with dab peroxidase substrate . conceptuses were embedded in paraffin , sectioned , and counterstained with nuclear fast red . to analyze intra - aortic clusters , embryos were fixed and stained with anti - c - kit and anti - pecam1-antibodies . a 1:2 mix of benzyl alcohol / benzyl benzoate was used to increase the transparency of tissues . three - dimensional reconstructions were generated from z - stacks ( 6287 serial sections ) . methylcellulose colony forming assays were performed as described previously 4 and colonies counted after 7 days . immuno - staining was performed with phycoerytherin , allophycocyanin , or alexa fluor 647 conjugated antibodies stained cells were analyzed on a becton dickinson facscalibur flow cytometer .

hscs are the founder cells of the adult hematopoietic system , and thus knowledge of the molecular program directing their generation during development is important for regenerative hematopoietic strategies . runx1 is a pivotal transcription factor required for hsc generation in the vascular regions of the mouse conceptus - the aorta , vitelline and umbilical arteries , yolk sac and placenta 1 , 2 . it is thought that hscs emerge from vascular endothelial cells through the formation of intra - arterial clusters 3 and that runx1 functions during the transition from hemogenic endothelium to hscs 4 , 5 . here we show by conditional deletion that runx1 activity in vascular endothelial cadherin ( vec ) positive endothelial cells is indeed essential for intra - arterial cluster , hematopoietic progenitor , and hsc formation . in contrast , runx1 is not required in cells expressing vav , one of the first pan - hematopoietic genes expressed in hscs . collectively these data show that runx1 function is essential in endothelial cells for hematopoietic progenitor and hsc formation from the vasculature , but its requirement ends once or before vav is expressed .

a 20-year - old incarcerated indigenous australian male , with a history of hepatitis c and intravenous drug abuse , was admitted to the intensive care unit with fulminant hepatic failure following a 5-day history of jaundice , nausea , and vomiting . the patient was opioid dependent but had been previously well with no relevant medical history . investigations at the time of presentation revealed a severe acute hepatitis with marked synthetic dysfunction . his arterial lactate was 5.6 mmol / l , ph was 7.5 and serum ammonia was 132 viral serology revealed positive hepatitis c virus ( hcv ) antibodies and evidence of immunity to hepatitis b virus . corroborative history from prison medical staff revealed that the patient had thrice injected buprenorphine 1 day prior to the onset of his symptoms . the patient developed life - threatening multiorgan failure as a consequence of the fulminant hepatic failure and met listing criteria for liver transplantation . the patient was managed as per the american association for the study of liver diseases acute liver failure guidelines 1 . he was commenced on broad - spectrum antibiotics , antifungal prophylaxis , an n - acetyl - cysteine infusion and continuous veno - venous hemofiltration . the patient survived with supportive intensive care management and was discharged from hospital after 42 days . upon discharge , his liver function was improving with an alt of 278 u / l , inr of 1.2 , albumin of 24 g / l and serum bilirubin of 367 mol / l , having peaked at 450 mol / l . buprenorphine is a potent semisynthetic opioid derivative that is prescribed for the treatment of opioid dependence or for analgesic purposes . it undergoes extensive first pass hepatic metabolism utilizing the p450 ( cyp 3a4 ) system 2 . acute liver injury from the misuse of sublingual buprenorphine has been described in several case reports and case series . almost all cases of significant hepatocellular injury have been associated with hepatitis c viremia 37 . it has been postulated that hcv induces mitochondrial toxicity , leading to more significant liver damage . the spectrum of hepatotoxicity following therapeutic administration , misuse or overdose of buprenorphine ranges from a mild - to - severe hepatitis . the majority of reported cases of intravenous buprenorphine - associated liver damage have been in the context of known or recently detected hepatitis c infection . although intravenous buprenorphine - induced hepatitis is now well recognized , life - threatening fulminant hepatic failure due to this drug has not previously been reported . acute liver injury from intravenous buprenorphine use has been primarily attributed due to the high parenteral doses obtained from crushed sublingual tablets . the mechanism of toxicity is due to inhibition of mitochondrial respiration and fatty acid - b oxidation , leading to atp depletion and hepatocyte necrosis , in rat models 2 . most patients who have restarted conventional sublingual doses following an episode of toxicity have not had recurrent liver injury 3,5 . the prevalence of hepatitis c virus ( hcv ) infections is high among opioid - dependent individuals . care needs to be undertaken when prescribing the newer classes of protease inhibitors ; simeprevir , telaprevir , and boceprevir that are metabolized via the p450 system . in addition , the effect of alcohol on the liver contributes to the altered metabolism of buprenorphine via the cyp3a4 enzyme 8 . the additive cns respiratory depressant effects of this combination have been fatal in overdose 9 . the possibility of intravenous misuse and drug interactions should not prevent clinicians from considering sublingual buprenorphine as a maintenance treatment for heroin addiction . however , caution should be applied in patients with chronic hcv infection and who are at risk of intravenous misuse .

key clinical messagea 20-year - old indigenous australian male was admitted to the intensive care unit with fulminant hepatic failure secondary to intravenous use of buprenorphine , which had been prescribed sublingually for opioid dependence . intravenous buprenorphine - induced hepatitis is well recognized , however , life - threatening fulminant hepatic failure has not previously been reported .

in the previous issue of critical care , williams and colleagues provide an overview of the predominant causes of death in burned pediatric patients in order to develop new treatment avenues and future trajectories . over the past decades there has been a significant decrease in mortality and morbidity in severe burns due to improved burn wound management and approaches in critical care [ 2 - 4 ] . many advances have been made , not only concerning the pathophysiology of burns but also concerning burn management . survival from severe burns is no longer the exception , but unfortunately death still occurs . owing to the fact that the burn injury is multifaceted , the advances cross many injury processes . these issues range from the management of the catabolic state to modern wound care . one important aspect is that burn treatment has become more proactive , by searching out new technologies to solve old problems . now the treatment approach is altering its focus on manipulating the course of a burn and its final outcome . the survival rate is still of course the most important issue , but not the only issue . the question of whether and to what degree the patient is able to enjoy a normal quality of life becomes more and more essential in how the outcome of the burn treatment is evaluated . restoring function and esthetics are crucial in the difficult process of social reintegration and the return to a normal life . great efforts were made in the past to develop epidermal and dermal replacements to overcome the problem of poor skin quality and scar contraction . in large and deep burns , the approach has changed to rapid excision and lesion - specific coverage of the burn wound , eliminating the burn as a source of complications . rapid and effective wound coverage and closure are of utmost importance , but infection control and the preservation of active and passive motion are also essential for optimal recovery . nonviable burn tissue is well recognized to be the driving force behind wound infection and burn wound sepsis . williams and colleagues , who determined the predominant causes of death of burned children admitted between 1989 and 2009 , found that the dominant cause of death is sepsis ( 47% of all deaths ) . moreover , they found an increase of deaths due to multidrug - resistant organisms from 42% to 86% over the past 20 years . the aggressive use of antimicrobials has significantly improved survival , but has also led to an increased colonization of pathogens that have resistance to current therapies . in general , early removal and excision of the necrotic tissue with a consecutive rapid and effective closure of the burn wound has become the standard in the management of severe burns . research has proven that application of antimicrobial dressings or early excision and grafting is the key to avoid burn wound infection and its extension to systemic infection [ 8 - 10 ] . the timing and extent of surgery may vary , as well as the method of closing , between different burn centers , but the principal concept is almost the same . based on the findings of williams and colleagues , respiratory failure accounted for 29% of all deaths - 83% of these although the methods used for the management of acute respiratory distress syndrome have changed dramatically over the past 20 years , mortality has remained almost the same . moreover , it seems that there is a need for further studies or for a revisit to the manner in which studies are conducted and their results are implemented in the real world . resuscitation is the major component of initial burn care and must be managed to restore and preserve organ function . prevention of inadequate perfusion , due to burn fluid loss , remains the top priority for initial management . advances in fluid management have led to a marked decrease in fatal burn shock and its related complications . the obvious challenge concerning resuscitation is to provide enough fluid to maintain perfusion without causing overload . without effective and rapid intervention , hypovolemia will develop . a delay in fluid resuscitation beyond 2 hours of the burn injury complicates resuscitation and increases mortality . the consequences of excessive resuscitation and fluid overload are as deleterious as those of under - resuscitation : pulmonary edema , myocardial edema , conversion of superficial into deep burns , the need for fasciotomies and abdominal compartment syndrome . a recent approach has led to conversion of a formula - driven process to a more critical care approach using more physiologic endpoints such as urinary output and other measurements , so the trend in burn resuscitation is shifting the focus from fluid formulas to adequate endpoint monitoring , edema control and adjuvant therapies . on some level , a lot of burn deaths may be preventable with better airway management and more precise and adequate volume management . sepsis due to multidrug - resistant organisms , however , will continue to impede efforts to increase survival . we have to develop strategies to fight these organisms that go beyond the surgical and clinical techniques that are already implemented . moreover there will be a need for further studies that are facing the problems concerning respiratory and multiorgan failure .

many advances have been made in the understanding and treatment of burns . advances in burn surgery and critical care have decreased mortality and morbidity . survival from severe burns is no longer the exception , but unfortunately death still occurs . williams and colleagues have determined in their recent paper the predominant causes of death in order to develop new treatment avenues and future trajectories suitable to increase survival and overall outcome . a lot of burn deaths may be preventable with better airway management and a more precise and adequate volume management , but the leading cause of death in patients suffering from severe burns , which has to be faced , is sepsis . sepsis due to multidrug - resistant organisms will continue to impede efforts to increase survival , and new strategies that go beyond the surgical and clinical techniques , which are already implemented , have to be developed in order to fight these organisms and their related complications .

for patients with newly diagnosed breast carcinoma , evaluation of the extent of the disease in the breast is of paramount importance in planning appropriate surgical therapy . magnetic resonance imaging ( mri ) plays an ever increasing role in the evaluation of additional areas in the affected breast deemed suspicious but indeterminate by other radiologic modalities . technical developments such as mri with high spatial resolution , special breast coils , dynamic kinetic imaging techniques , and intravenous contrast agents contribute to enhanced diagnosis of breast abnormalities . while excitement about the role of this modality in improving the planning of surgical treatment of breast cancer patients is increasing [ 16 ] , many areas of uncertainty remain , especially related to the clinical importance of additional lesions that are detected by the use of mri [ 79 ] . in this study we evaluated the pathologic findings in mri - guided needle core biopsies of the breast obtained from other suspicious areas in the affected breast of patients with a new diagnosis of breast carcinoma . our study population consisted of 44 mri - guided needle core breast biopsies performed on 40 patients with newly diagnosed breast carcinoma at rush university medical center , chicago , il , usa between may 2007 and july 2008 . overall , 9/44 ( 20.4% ) of our mri - guided breast biopsies were malignant , 29/44 ( 66% ) were benign , and 6/44 ( 13.6% ) showed atypia ( table 1 ) . of the 9 malignant cases , 4 were infiltrating ductal carcinomas with tubular features , 2 infiltrating lobular carcinomas , and 3 ductal carcinoma in situ lesions ( table 2 ) . of the 6 atypical cases , 2 were atypical ductal hyperplasia ( adh ) , 2 were atypical lobular hyperplasia ( alh ) , and 2 showed areas of columnar cell hyperplasia with atypia ( table 3 ) . of interest , more than one third of our benign cases ( 11/29 , 38% ) consisted of a specific complex multicystic lesion lined by apocrine metaplastic epithelium , a lesion we called during the last few years there has been a heightened interest in the application of magnetic resonance imaging ( mri ) in the management of breast cancer . currently , mri is used as a supplemental tool to complement conventional methods of radiologic and ultrasonographic breast evaluation . a number of appropriate indications for the clinical use of mri in breast cancer diagnosis and management include clarification of questionable findings on mammography , evaluation and accurate staging of breast tumors in dense breasts , accurate evaluation of specific subtypes of breast carcinomas such as infiltrating lobular carcinoma , assessment of response to preoperative chemotherapy , diagnosis of occult primary breast tumors presenting with axillary nodal involvement , and surveillance programs assessing high - risk patients such as breast cancer gene carriers or patients with a history of chest irradiation [ 16 ] . however , as the use of mri at the time of new diagnosis of early stage breast cancer is quickly becoming a new standard of care , there is heightened concern that routine use of mri for preoperative staging may lead to more extensive surgery , while solid evidence for improvement of surgical management , improved rates of local control , or improved overall prognosis is lacking [ 812 ] . in addition , while in a number of studies the detection of additional foci of breast cancer by mri in the affected breast is reported to be around 16% ( ranging from 6 to 34% ) [ 12 , 13 ] , only limited information exists on the histology of the additional lesions that mri testing falsely identifies as worrisome . in this paper , we report that mri - guided needle core biopsies of separate lesions in the affected breast of patients with newly diagnosed breast carcinoma show additional foci of malignancy in 20% of cases . a high percentage ( 66% ) of these additional suspicious areas by mri are benign by histologic examination . more specifically , mri - guided needle core biopsies seem to target a characteristic complex multicystic lesion lined by apocrine metaplastic epithelium , in over one third of the cases , a lesion we called our findings suggest that mri - guided core biopsies result in an important change of detection of additional foci of malignancy in a significant number of cases . in addition , mri - directed needle core biopsies often target benign lesions with specific histopathologic characteristics , namely , a characteristic complex multicystic lesion lined by apocrine epithelium , the so - called cystic apocrine metaplasia . we suggest that awareness of the correlation of this benign lesion with abnormal mri findings by radiologists will be helpful as they evaluate breast mri studies of patients with newly diagnosed early stage breast carcinoma . ongoing carefully controlled studies comparing the strengths and weaknesses of breast mri to those of conventional breast imaging in different clinical scenarios , as well as detailed correlation of mri findings to underlying histopathology of breast lesions , are urgently needed in order to clearly define diagnostic criteria for widespread mri use .

the role of mri in the management of breast carcinoma is rapidly evolving from its initial use for specific indications only to a more widespread use on all women with newly diagnosed early stage breast cancer . however , there are many concerns that such widespread use is premature since detailed correlation of mri findings with the underlying histopathology of the breast lesions is still evolving and clear evidence for improvements in management and overall prognosis of breast cancer patients evaluated by breast mri after their initial cancer diagnosis is lacking . in this paper , we would like to bring attention to a benign lesion that is frequently present on mri - guided breast biopsies performed on suspicious mri findings in the affected breast of patients with a new diagnosis of breast carcinoma .

the clinical evaluation of left ventricular ( lv ) diastolic function has been a difficult challenge . lv filling and pulmonary venous doppler patterns have been utilized to estimate lv diastolic function , comprising variables as such stiffness , relaxation and even lv filling pressures . doppler echocardiography has been utilized not only as a diagnostic tool but also as a monitoring tool , permitting follow - up of the effects of therapeutic interventions . in the previous issue of critical care , vignon and colleagues demonstrated the value of tissue doppler imaging ( tdi ) to estimate lv diastolic function in a setting where acute alterations of preloading conditions may interfere . they also clearly show some weak points with respect to the correct use of these function variables . a typical transmitral doppler pattern consists of a larger early filling velocity wave ( e wave ) followed by an atrial contraction flow velocity wave . reduced lv relaxation ( present in patients with advanced age , ischaemic heart disease or arterial hypertension ) will induce a reduction of the e wave in comparison with the atrial contraction flow velocity wave . increasing filling pressures will increase the e wave velocity and will shorten the deceleration time of the e wave , with a transition from pseudonormalization to a restrictive pattern . the phase of diastolic dysfunction for an individual patient remains difficult because of the interplay between relaxation and preload , which makes the routine pulsed wave doppler indices useless particularly in a setting where preloading conditions may change constantly and abruptly , as in many critically ill patients . this doppler mode facilitates the assessment of the movement of the myocardial tissue , which typically reflects low velocity with very high amplitude doppler signals . tdi can therefore be utilized to estimate myocardial velocities at the mitral annulus to obtain an impression of both systolic and diastolic myocardial motion . the spectral doppler pattern is characterized by a systolic wave , an early diastolic wave ( e ' wave ) and an atrial velocity wave . the technique is hampered by shortcomings related to the doppler technology ( angle misalignment , translation and rotation of the myocardial tissue ) and by intrinsic characteristics of myocardial function ( for example , the presence of regional wall motion abnormalities ) . nevertheless , regional lv systolic function and lv diastolic function assessment is possible provided the sample volume is placed at the level of the mitral annulus and no ischaemia / infarction in the annulus region is present . whereas the systolic component of this doppler pattern has been shown to be clearly preload dependent , less transparency exists on the load dependency of the diastolic myocardial velocities . with the initial description of this variable , the index appeared to be load independent in settings of rapid infusion or preload alteration . jacques and colleagues , however , reported both afterload independency and preload dependency of the e ' wave in situations where a normal lv function was present . in contrast to the present study of vignon and colleagues , jacques and colleagues did not report the sample volume location . comparison between the septal and lateral mitral annulus signals suggests that the septal signals are apparently more sensitive to preload alterations . the reader , however , should bear in mind that the stability of the signals obtained at the septal side can be questioned , particularly in mechanically ventilated patients with ventilation - induced , right - sided , afterload shifts . nevertheless , several authors have already reported differences in e ' wave velocities between the septal and lateral walls , without the ability to indicate a clear cause for this difference . vignon and colleagues show no changes of the e ' wave in a rather small subset of intensive care unit patients , and again several issues have to be kept in mind . the effects of drugs such as epinephrine , however , have not been described ; one should expect an increase of the e ' wave , at least when considering a similar effect to that with dobutamine . it can thus be questioned whether an ultrafiltration ( and thus load diminishing ) effect is not concurring , keeping the e ' wave constant . second , the influence of ultrafiltration itself on lv systolic function and lv diastolic function during septic shock is largely unknown . the combination of lower preload ( by ultrafiltration ) and decreased lv function would render a less preload - dependent e ' wave , as suggested by jacques and colleagues the number of intensive care unit patients included in this subset is again far too small to conclude in a proper manner . from all these studies , it is unclear whether the discussed concepts apply to all haemodynamic states . the fact that the e wave / e ' wave relates to pulmonary capillary wedge pressure suggests that increased intrathoracic pressures could impede this relationship strongly . apart from the fact that the e ' wave ( in conjunction with traditional doppler parameters ) is useful in determining lv diastolic function more accurately , tdi in the critically ill patient keeps more questions open than are answered . e wave = early filling velocity wave ; e ' = early diastolic wave ; lv = left ventricular ; tdi = tissue doppler imaging . this work was supported by an unrestricted grant from the international research centre of ghent university .

assessment of left ventricular diastolic function in the critically ill patient remains a difficult issue in clinical practice . combined use of routine transmitral and pulmonary venous doppler patterns in conjunction with tissue doppler imaging have been claimed to allow bedside diagnosis of diastolic dysfunction . although in the previous issue of critical care it was clearly demonstrated there might be a difference in load dependency of the early myocardial tissue doppler velocity between lateral and septal placed sample volume , there remain still several unanswered questions , particularly with respect to the preload dependency of these indices .

decubital ischemic fasciitis is a rare entity occurring mostly in the elderly and in debilitated patients , in the deep subcutaneous tissue , at pressure points or bony prominences.[14 ] it can simulate a soft - tissue sarcoma clinically and histopathologically.[14 ] imaging helps to rule out malignancies and therefore to prevent unnecessary interventions . a 72-year - old woman presented with a palpable mass over the right hip region . physical examination revealed a 4- to 5-cm , hard , and fixated mass in the right proximal thigh , located posterolateral to the greater trochanter . mri revealed diffuse hyperintense signals on the t2w images [ figures 1a and 1b ] consistent with edema and inflammation , in the muscles and subcutaneous tissues , with prominent , peripheral , and ill - defined enhancement [ figure 2 ] , over an area measuring approximately 4 - 7 cm , at the level of the greater trochanter . a ct - guided needle biopsy showed coagulative necrosis , hemorrhage , and fibrosis involving the adipose tissue . the capillary and muscular vessels within the lesion also showed fibrinoid necrosis in their walls , without evidence of primary vasculitis [ figure 3 ] . these findings , along with the clinical features , were considered compatible with the diagnosis of ischemic fasciitis ( atypical decubital fibroplasia ) . axial ( a ) and coronal ( b ) fat - suppressed t2w images show diffuse hyperintense signals ( arrows ) in the muscles and subcutaneous tissues , adjacent to the right greater trochanter axial contrast - enhanced t1w , fat - suppressed mri shows subtle , peripheral enhancement ( arrow ) in an area measuring approximately 47 cm , at the level of the greater trochanter histopathologic slide ( h and e stain ) shows coagulative necrosis and hemorrhage with capillary and muscular vessels showing fibrinoid necrosis in their walls ( arrows ) decubital ischemic fasciitis , also called atypical decubital fibroplasia , is a distinctive fibroplasia occurring predominantly in the elderly and debilitated patients , confined to bed or wheelchair - bound.[13 ] the lesions occur in the deep subcutaneous tissue at pressure points or bony prominences . it is a rare condition , and 40 cases have been reported in the literature until 2009 . ilaslan et al . have reported the mri features of decubital ischemic fasciitis in three patients . on mri , the mass - like area in our patient was isointense compared to muscle on the t1w images , and hyperintense on the t2w images . after administration of gadolinium , subtle and peripheral enhancement was seen in the subcutaneous and muscular tissues . the bone adjacent to the affected soft tissue ( greater trochanter ) was not involved . lesions occurring in the shoulder , sacral area , posterior chest wall , and vulvovagina have been reported . the diagnosis of decubital ischemic fasciitis with typical findings on mri prevents the already debilitated patient from undergoing further and unnecessary interventions . consideration of this entity by the clinician and the radiologist helps the pathologist rule out malignancy . we want to point out that since mri is a common and appropriate imaging method used to examine soft - tissue masses , all radiologists , especially those evaluating musculoskeletal mri examinations , should be aware of this entity and be familiar with the clinical features , common locations , and mri findings .

the mri findings in a case of decubital ischemic fasciitis located posterolateral to the right greater trochanter , in a 72-year - old woman , are presented . decubital ischemic fasciitis is an uncommon entity encountered mostly in debilitated , elderly patients , in the deep subcutaneous tissue , at pressure points or bony prominences . it can simulate soft - tissue sarcomas . recognition of this lesion radiologically is important to prevent unnecessary interventions .