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despite diagnostic and therapeutic improvements , cardiogenic shock ( cs ) is still the most common cause of death in patients with acute myocardial infarction . although percutaneous coronary intervention ( pci ) , inotropes , fluids , adjunctive medication , intra - aortic balloon pump ( iabp ) , and ventricular assist devices are widely available therefore , munsterman and colleagues , whose investigation of the microcirculation in patients with iabp was reported in the previous issue of critical care , have addressed an important topic . in the last five years , an important body of knowledge showing the pathophysiological importance of the microcirculation in the development of multiple organ failure in critically ill patients has been built up . this has been made possible because of the development of novel techniques to either directly visualize or indirectly evaluate microvascular perfusion . in cs , microvascular alterations have been observed , resulting in a decrease of vessel density , the proportion of perfused capillaries , or microvascular flow . different treatment strategies , including pharmacological interventions and mechanical assist devices , may lead to microcirculatory improvement in cs [ 5 - 7 ] . in their article , munsterman and colleagues show that in patients deemed ready for discontinuing iabp support , microcirculatory flow in small vessels increases after ceasing iabp therapy . these important findings not only highlight the need for optimal timing of weaning from iabp support but also demonstrate that global hemodynamics do not necessarily result in changes of microvascular perfusion . in theory although sufficient cardiac output and arterial pressure are prerequisites for adequate microvascular perfusion , their relationship is very complex . changes in microvascular vessel density and flow , their heterogeneity , autoregulation , and response to therapeutic interventions might be dissociated from systemic effects . furthermore , with the knowledge of the study by munsterman and colleagues , it is obviously important to realize that , depending on the stage of the disease course , an intervention has different effects on the microcirculation . modern therapy of cs consists of an adequate regime with revascularization , drug treatment , and mechanical support . although there is no question about the survival advantage of early revascularization and its beneficial consequences for the macrocirculation , there is no systematic study on its effects on microcirculation . however , revascularization reverses the spiral of progressive left ventricular dysfunction and therefore is understood to improve the microcirculation . different drugs , particularly fluids , vasopressors , inotropes , levosimendan , and vasodilators , influence the hemodynamics of patients with cs . the administration of fluids in cs is based mainly on pathophysiological considerations and has not been studied in adequate randomized clinical trials . no data regarding fluid administration and microcirculatory changes in the setting of cs are available . similar to fluid administration , the choice of vasopressor and inotropic therapy is based mainly on individual experience and institutional policy ; furthermore , this choice differs between guidelines . however , vasopressors might be able to stabilize the mean arterial pressure , but their use has negative consequences for the perfusion within microvasculature . in small observatory studies , beneficial effects on microcirculatory indices in cs have been described for levosimendan and nitroglycerin . owing to the lack of evidence for the use of iabp in cs after successful revascularisation of occluded infarct vessels , its role remains controversial . to date , there is no adequately powered randomized clinical trial available , and knowledge is based on observational trials or trials before the era of primary pci . iabp support improves microvascular flow in unstable patients ; however , different time points of the disease seem to be of importance . guiding inter - individual modern therapy of cs with in vivo visualization tools may allow a more specific and appropriate therapy regime and improve outcomes . more effort is needed to understand the microcirculation as a therapy target and not as a silent bystander . effect of treatment strategies on microcirculation : solid arrow , positive effect ; dotted arrow , negative effect . cs : cardiogenic shock ; iabp : intra - aortic balloon pump ; pci : percutaneous coronary intervention .

despite diagnostic and therapeutic improvements , mortality rates in patients with cardiogenic shock remain relatively high . several studies showed that cardiogenic shock is associated with alterations in the microvascular circulation . these alterations may be reversed by extracorporeal support devices . a study by munsterman and colleagues adds to the body of evidence showing that in patients deemed ready for discontinuing intra - aortic balloon pump ( iabp ) support , microcirculatory flow in small vessels increases after ceasing iabp therapy . this study not only highlights the need for optimal timing of weaning from iabp support but also supports recent findings that global hemodynamics do not necessarily result in changes of microvascular perfusion . all modalities of modern treatment in cardiogenic shock need to be evaluated for their effect on the microcirculation . microcirculatory evaluations should be part of randomized controlled trial protocols . more effort is needed to improve outcomes and understand the microcirculation as a therapy target and not as a silent bystander .

although pulmonary tb is the most common presentation , extrapulmonary tb is also an important clinical problem . patients present with dysuria and hematuria , which may be painless , flank pain , sterile pyuria , and recurrent urinary tract infection . in rare cases , other uncommon presentations include the following : nonhealing wounds , sinuses or fistulae , hemospermia and others . a 34-year - old woman presented with 1-month history of intermittent right flank pain and occasional fever . she did not have any history of pulmonary tb in the past . a marginally elevated erythrocyte sedimentation rate was noted . although urine culture was sterile , 10 - 12 pus cells were seen on microscopic urine examination . contrast - enhanced computed tomography ( cect ) showed a heterogeneously enhancing lesion 8 7 cm in dimension with areas of necrosis , involving the right kidney with enlarged aortocaval and paraaortic lymph nodes [ figure 1a and b ] . histopathology showed presence of acid - fast bacilli with multiple granulomas consistent with gutb [ figure 3a and b ] . patient recovered well , completed her antitubercular therapy , and after 1 year of follow - up she is free of tb . ( a ) computed tomography ( ct ) shows heterogeneous enhancing mass involving the upper and mid pole of the right kidney with aortocaval and paracaval lymphadenopathy(arrow ) and ( b ) contrast enhanced ct scan of the abdomen show presence of rim enhancement with central necrosis in lymph nodes ( arrow ) . section removed during right side nephrectomy shows normal looking kidney ( thin arrow and renal mass with pus around it ( thick arrow ) . 34-year - old woman with intermittent right flank pain diagnosed with genitourinary tuberculosis . histopathology slides ( a ) stained with hematoxylin and eosin ( 100 ) shows presence of multiple granulomas ( thick arrow ) and ( b ) stained with ziehl - neelsen stain ( 100 ) shows presence of acid - fast bacilli ( thin arrow ) . it continues to be an important diagnostic problem because of its nonspecific clinical presentation and variable radiographic appearances that often mimic many other pathologic lesions . urogenital tb is more logical because kidney tb , which is usually primary , is diagnosed more often than genital tb . only 53% of patients with kidney tb had genital lesions , but in 61.9% patients with epididymorchitis and in 79.3% patients with tb of the prostate , a renal lesion could be diagnosed . in gutb , the kidneys are the most common sites of infection and are infected through hematogenous spread of the bacilli , which then spread through the renal and genital tract . gutb is the second most common form of extrapulmonary tb in countries with severe epidemic situations and the third most common form in regions with a low incidence of tb . the diagnosis of tb on images of the urinary tract depends on the stage of the infection . tubercular granulomas in the renal pyramids coalesce to form ulcers that discharge mycobacteria and pus in the urine . untreated lesions enlarge and a tubercular abscess may form in the parenchyma . later on , perinephric abscess is formed and the kidney is replaced by caseous material ( putty kidney ) , which may become calcified ( cement kidney ) and nonfunctional leading to renal failure . ct findings include focal caliectasis , hydronephrosis , calcifications , cortical thinning , and soft tissue masses . usually an enhancing renal mass is caused by renal cell carcinoma , metastasis , lymphoma , or an abscess . gutb rarely manifests as pseudotumors , which otherwise are usually due to hypertrophied column of bertin , renal dysmorphism , or unusually shaped kidney . in rare cases , patients with this form , known as the pseudotumoral type , present with variable - sized but well - defined parenchymal nodules on cross - sectional images . pseudotumoral gutb end up undergoing a surgical removal and diagnosis is suspected intraoperatively or histopathologically . renal tb should be suspected when atypical renal masses are seen in patients from tb endemic areas . preoperative fine - needle aspiration cytology ( fnac ) can be considered in highly suspicious cases .

genitourinary tuberculosis ( gutb ) is a rare extrapulmonary manifestation of tuberculosis ( tb ) . various forms of presentation are described and in most cases the disease results in calcification , atrophy , or necrosis of the renal parenchyma . the kidney is not generally palpable except in cases of hydronephrosis due to an upper ureteric stricture . we present a case of gutb presenting as inflammatory pseudotumor . this case was initially diagnosed as renal malignancy and managed accordingly . histopathology confirmed the diagnosis of pseudotumoral renal tb .

eagle 's syndrome occurs due to elongation of the sp or calcification of the stylohyoid ligament , which may produce a pain sensation due to the pressure exerted on various structures in the vicinity . the sp is a cylindrical bony projection arising from the lower surface of the petrous portion of the temporal bone . it lies in front of the stylomastoid foramen and its tip projects anteriorly and inferiorly between internal and external carotid arteries and also laterally to the pharyngeal wall and tonsillar fossa . the sp provides the origin attachments for several muscles such as the styloglossus , stylohyoid and stylopharyngeus muscles and for ligaments such as the stylohyoid and stylomandibular ligaments . important structures surrounding the sp include facial and hypoglossal nerves , the occipital artery and the posterior belly of the digastric muscle laterally and the lingual , facial , superficial temporal , maxillary , and internal carotid arteries , internal jugular vein and the stylomandibular ligament medially . the purpose of this study was to evaluate the length of sp in the dry skulls present in the department . the elongated sp and the ossified stylohyoid ligament can compress the structure in close vicinity , leading to symptoms like sore throat , dysphasia , otalgia , the sensation of a foreign body in the throat , facial pain radiating to the ear or along the mandible , and head and neck mimicking neuralgic pain . the study has been conducted in 45 dry skulls at the department of anatomy , sree balaji dental college and hospital . it was observed in 4 skulls belonging to that , sp was elongated in 1 , bilaterally , and 3 , unilaterally . the skulls with the elongated processes were photographed . among the skulls , sp was elongated unilaterally in 3 skulls and bilaterally in 1 skull . among the skulls , sp was elongated unilaterally in 3 skulls and bilaterally in 1 skull . the sp can be elongated bilaterally or unilaterally , however unilateral elongation of the sp is more frequent . ossification of the stylohyoid ligament occurs with differing frequency and may be as low as 24% or as high as 84.4% but may be asymptomatic . in the eagle 's syndrome , elongated sp is a term used since the publication by eagle in reports concerning findings in both dentomaxillofacial and ear nose throat patients . eagle 's definition was : the normal sp measures between 2.5 cm and 3 cm . his method of measurement was not described , but his examples showed lateral radiographs of the skull . eagle described the syndrome and stated that the normal sp is approximately 2.75 cm and any sp beyond that may be considered elongated . he described the classic syndrome as persistent pain in the pharynx , aggravated by swallowing with the pain frequently referred to the ear on the side of the elongated sp . he also noticed increased salivation , hesitancy and difficulty in swallowing , gagging and a foreign body sensation . in the first group , symptoms are characterized by pain located in the areas of distribution of the fifth , seventh , eighth , ninth and tenth cranial nerves . it is associated in most cases with tonsillectomy that may have been performed many years earlier . pain following tonsillectomy is presumably created by stretching or compressing the nerve or nerve endings of cranial nerves in the tonsillar fossa either during healing or due to scar formation . the elongated sp can be palpated by inserting a finger orally along the occlusal plane posterior to the region of the tonsillar fossa . confirmation is made with radiographs showing an elongated sp or mineralization of the stylohyoid complex . the second type , the carotid artery syndrome , usually is not associated with tonsillectomy . the carotid artery syndrome is caused by mechanical irritation of the sympathetic nerve tissue in the walls of the internal and/or external carotid artery by the tip of the sp or the ossified ligament . there is no significant sex predilection in occurrence of mineralization of the sp ; however , symptoms are more common in females . the symptoms in eagle 's syndrome range from mild discomfort to acute neurologic and referred pain . these may include : pain in the throat , sensation of a foreign body in the pharynx , difficulty in swallowing , otalgia , headache , pain along the distribution of the external and internal carotid arteries , dysphasia , pain on cervical rotation , facial pain , vertigo , and syncope . the sp may develop inflammatory changes or impinge on the adjacent arteries , on sensory nerve endings leading to the symptoms . diagnosis can usually be made on physical examination : by digital palpation of the sp in the tonsillar fossa , which exacerbates the pain . relief of symptoms with injection of local anesthetic into tonsillar fossa relieving the pain can be used as a diagnostic tool . over the years , authors have given much pathogenic relevance to the length of sp , as well as to the shape and position in suggesting the etiology of painful syndromes . however , not all elongated sps are symptomatic , since some sps of normal length can also lead to the syndrome . clinicians must be aware of the anatomy of the sp , which may aid them in establishing a clinical diagnosis .

the styloid process ( sp ) on the temporal bone is a highly variable formation . the normal length of the sp ranges from 20 to 30 mm . in spite of its being normally distributed in the population , sps could be divided into two groups short sps with > 20 mm and long sps with < 20 mm in length . the sp is often denoted as elongated when it is longer than 30 mm or 33 mm . these dimensions , based on early reports , do not respect the natural variation of the sp . the aim of this study is to investigate the natural variation of the length of the sp .

systemic sclerosis is a multisystem disease with pulmonary involvement , which decreases exercise capacity and is related to survival.1,2 medication and exercise training have recently been shown to improve dyspnea , six - minute walking distance , maximum heart rate , and quality of life.3 most training studies4,5 have been performed using 8-week programs based on pulmonary rehabilitation used in the treatment of chronic obstructive pulmonary disease.6,7 this study was performed to evaluate the effects of a rehabilitation program including walking training over a 6-month period in a patient with systemic sclerosis and to determine any improvement in exercise capacity . a 43-year - old male patient with systemic sclerosis and ild was admitted with chronic ulceration of his fingers . he had been treated for 4 years with corticosteroids , and at a dose of 10 mg for the 4 months prior to presentation . his hugh - jones grade was 3 , ie , he was unable to keep up with healthy persons walking on the level , but was able to walk for one mile ( 1.6 km ) or more at a slower speed . on admission , forced vital capacity was 61.5% and carbon monoxide diffusion capacity ( dlco ) was 29.8% of predicted . right ventricular systolic pressure was 39 mmhg and mean pulmonary artery pressure was 18 mmhg . his six - minute walking distance was 521 m , with oxygen saturation ( spo2 ) declining from 96% at rest to 72% at completion , determined using a handheld pulse oximeter with a reflectance sensor on the forehead . perceived exertion increased from 0 to 4 on the borg 10 scale . walking distance without rest was 60 m when spo2 declined to 85% . after admission to hospital , the corticosteroid dose was kept the same as before , but bosentan , sildenafil , and prostacyclin derivatives were added to treat the ulcers . the prostacyclin dose was increased during the first 8 weeks of admission , and then remained unchanged until discharge . the rehabilitation program included walking training , training for leg muscle strengthening with a sand weight of 2.5 kg on the mat , and additional stretching exercise for the fingers because of sclerotic skin changes . the total time spent exercising was about one hour per day on 5 days per week . the patient gave informed consent to these rehabilitation treatments before starting the program . on the first day of walking training , 60 m walking in one minute was performed based on the first evaluation and was repeated with rest intervals of a few minutes . figure 1 shows the training walking distance starting from 60 m , increasing gradually to 300 m after 27 weeks of training . the six - minute walking distance , evaluated five times , was about 500 m , and perceived exertion in the fifth test also increased from 0 to 4 on the borg scale , while the end value of spo2 was increased . at discharge , when the finger ulcers had resolved , forced vital capacity was 59.8% and dlco was 24.2% of predicted . right ventricular systolic pressure was 36 mmhg and mean pulmonary artery pressure was 19 mmhg , suggesting little change in cardiopulmonary function . this patient showed no improvement in six - minute walking distance . in copd patients , the minimal important difference for a six - minute walking distance test is 25 m,8 and was 22 m in this patient . one of the exclusion criteria for the six - minute walking test is an initial resting spo2 < 90%.9 however , there are no clear criteria to discontinue the test in relation to low spo2 . the final spo2 in this patient was 72%80% , showing slight improvement , although these values were thought to be harmful to his circulation . because this patient had no severe dyspnea during the six - minute walking test , it was recommended that he continue most of his daily activities despite the low oxygen saturation which might have been causing his finger ulcers . during training in ild , high - intensity interval exercise training for copd is effective in inducing peripheral muscle adaptation , with less dyspnea compared with constant - load exercise.11 these studies are encouraging with regard to interval walking training ( spo2 > 90% ) for ild patients . exercise training was beneficial to our patient in reducing the risk of hypoxia during walking up to 300 m. thus , exercise training would be effective in improving safety , considering both hemodynamics and skin ulcer recurrence . bosentan is reported to have no effect on the six - minute walking distance in idiopathic pulmonary fibrosis,12 whereas prostacyclin derivatives improved six - minute walking distance test in systemic sclerosis with pulmonary arterial hypertension.12 these medications for pulmonary arterial hypertension did not improve cardiopulmonary function nor exercise capacity in our patient . generally , exercise training for lung disease is known to increase exercise capacity over 8 weeks . although the six - minute walking distance in this patient was about 500 m and did not change after exercise training , the risk of hypoxia was remarkably reduced up to 300 m of walking . this case report suggests a benefit of exercise training to ameliorate hypoxia in addition to improving exercise capacity .

pulmonary rehabilitation is effective for improving exercise capacity in patients with interstitial lung disease ( ild ) , and most programs last about 8 weeks . a 43-year - old male patient with systemic sclerosis and oxygen saturation ( spo2 ) declining because of severe ild was hospitalized for treatment of chronic skin ulcers . during admission , he completed a 27-week walking exercise program with spo2 monitoring . consequently , continuous walking distance without severe hypoxia ( spo2 > 90% ) increased from 60 m to 300 m after the program , although his six - minute walking distance remained the same . this suggests that walking exercise for several months may reduce the risk of hypoxia in patients with ild , even though exercise capacity does not improve .

planar thyroid scintigraphy showing increased 99mtco4 ( pertechnetate ) uptake is the hallmark of graves disease , and is used to differentiate this condition from thyroiditis . however , diffuse uptake of f-18 fluorodeoxyglucose ( fdg ) in the thyroid is usually associated with thyroiditis . a 63-year - old female patient with non - hodgkin 's lymphoma in remission for the last 2 years after chemotherapy was referred to our department for a whole body fdg - positron emission tomography ( pet)/computed tomography scan to assess for disease recurrence after recent onset of diplopia and raised 2-microglobulin levels . multiple lymph nodes in the cervical , mediastinal and right axillary regions showed increased metabolic activity , suggestive of recurrence . in addition , diffusely increased fdg uptake was seen in both lobes of the thyroid gland on the whole body pet image [ figure 1a ] , with a standardized uptake value of 12.3 . on clinical examination , she was found to have bilateral exophthalmos and the biochemical profile showed high t3 and t4 and low thyroid stimulating hormone values , suggestive of hyperthyroidism . subsequently , a 99mtco4 ( pertechnetate ) scan [ figure 1b ] , also showed diffusely increased tracer uptake in the thyroid gland ; uptake at 20 min was 6.1% . ( a ) whole body fluorodeoxyglucose ( fdg)-positron emission tomography ( maximum intensity projection image ) showing diffusely increased uptake of fdg in both lobes of the thyroid gland . ( b ) 99mtc pertechentate scan showing homogenously increased tracer uptake in both lobes of the thyroid gland the value of fdg pet for the diagnosis of several diseases affecting the thyroid gland has been demonstrated , and there is a growing evidence that this investigation may help in differentiating malignant from benign disease . with increasing use of whole body fdg - pet in clinical practice , incidental focal or diffuse fdg uptake in the thyroid is being detected more frequently . diffusely increased fdg uptake in the thyroid has been reported in 0.6 - 3.3% of the cases . although , some authors believe that this may be a normal occurrence , other studies suggest that such uptake is primarily associated with autoimmune thyroiditis or hypothyroidism . diffuse thyroidal fdg uptake is most commonly benign and is usually caused by chronic lymphocytic ( hashimoto 's ) thyroiditis . in a few other cases , diffuse thyroid fdg uptake has also been linked to graves disease . the added visualization of the thymus gland and fdg uptake in the skeletal muscles has been described as characteristic of graves disease . the present case shows that increased fdg uptake in the thyroid may also be seen in this condition without any thymic or skeletal muscle involvement . graves disease with significant infiltration and activation of t lymphocytes in the thyroid and thymus can induce upregulation of glucose transporter 1 ( glut1 ) , which is the major isoform of glucose transporter in the t lymphocytes .

increased uptake of f-18 fluorodeoxyglucose ( fdg ) has been reported in thyroiditis and hypothyroidism . the authors present a case where increased fdg uptake in the thyroid was subsequently corroborated with a pertechnetate scan and thyroid hormone levels to diagnose previously undetected graves disease in a patient of non - hodgkin 's lymphoma being followed - up with positron emission tomography for disease recurrence .

in reviewing previous research , hernandez - reif et al . contend unequivocally that mt has been shown to enhance immune functions [ of ] children and speculate that this follows from mt 's effect on the stress hormone cortisol . quantitative reviews of mt randomized control trials do not yield statistically significant effects on cortisol levels of adults ( 4 ) [ effect size ( es ) = 0.14 , 95% confidence interval ( ci ) = 0.10 , 0.38 ] or children ( 5 ) ( es = 0.28 , 95% ci = 0.27 , 0.84 ) , nor on childrens immune functions ( 5 ) ( es = 0.06 , 95% ci = 0.52 , 0.63 ) . presumably , hernandez - reif et al . have scientifically grounded reasons to disagree with the results of those quantitative reviews . in that case , those reasons should be illustrated or at least mentioned in their section asserting mt effects on cortisol and immune functions . what should not happen is for mt effects that are contentious to be presented as well established . even a brief review of the results on which a current study is based should accurately represent the consensus , or lack thereof , among researchers . 's support for cortisol and immune function effects , and my own position that these effects are unestablished and possibly nonexistent , are primarily based on the same set of studies i am convinced that the cause of this discrepancy is what i discuss next ; specifically , that randomized control trials of mt are frequently analyzed and reported as if they were uncontrolled within - group studies , which consequently leads to misinterpretation of their results . in effect , they are randomized control trials in name only , and fail to properly utilize the well - established logic of randomization and experimental control . in discussing their results , the study authors state they have completed the first randomized control trial to examine massage therapy for enhancing development and decreasing maladaptive behaviors in young dominican children infected with hiv, but this is not true , for the study is not a randomized control trial if it does not make between - groups comparisons of the dependent variables . the entire purpose of employing randomization to create treatment and control groups , as opposed to using a simpler within - group design , is so that one can make between - groups comparisons that control for the validity threats of spontaneous remission , placebo effects , and statistical regression . having performed analyses inconsistent with the study design , and that introduce rather than control these threats , the authors reach conclusions that are difficult to justify . to conclude that mt improved the behavior of the older sample of children , that it provided a marginally significant increase in iq , or that it appears to be a viable therapy for promoting greater daily functioning and communication based on within - group analyses is misleading , because any or all of those pre post effects could be observed as a result of the aforementioned threats even if mt was wholly ineffective . further , those threats can not be controlled by the authors occasional use of what could be called side - by - side within - group comparisons , in which they test each group separately for its own pre post effect , and then give the impression that mt worked if it shows a statistically significant pre - post effect and the control group does not . this approach is not at all equivalent to making the required between - groups comparison , and the result is misleading , as it is easily possible in that situation ( especially with small samples ) to have only one of the two within - group comparisons be statistically significant when there is actually no difference between the groups . possibly the authors decision to exclude between - groups analyses of dependent variables was motivated by concern that the tests would be underpowered and therefore not attain statistical significance . however , even if this was the case , the small size and exploratory nature of the study can not be used to justify the decision to use within - group analyses . if problems pertaining to the statistical power of between - groups analyses were anticipated , there are defensible alternatives . these include choosing a more liberal value for alpha ( e.g. using p < 0.10 or p < 0.20 , rather than p < 0.05 ) , placing greater emphasis on effect sizes and their confidence intervals than on probability values , and examination of clinical significance ( 6 ) . simply stated , between - groups study designs such as randomized control trials logically demand between - groups analyses . until this is reflected in mt research , our knowledge of

the most recent massage therapy ( mt ) study by hernandez - reif et al . displays flaws persistent in this area of research that are attributable to mt researchers frequent mistake of using within - group analyses of dependent variables in studies that are purported to be randomized control trials . this practise violates the logic of using randomization to create treatment and control groups , and thereby fails to control for the validity threats of spontaneous remission , placebo effects , and statistical regression . the result is that a clear understanding of what mt can and can not do is seriously hampered .

a 23-year - old woman with recently diagnosed invasive melanoma of the back presented with an asymmetric , dark brown papule measuring 7 5 mm in the right axilla ( figure 1 ) . dermoscopy revealed a homogenous globular pattern at the center with brown to gray - bluish pigmentation and slight vascular blush , while at the periphery there were regular globules ( figure 2 ) . the leading diagnosis was irritated melanocytic nevus , while the possibility of melanoma was considered , given the patient s history of melanoma as well as the lesion s variegation of color and increased vascularity . an rcm examination showed enlarged junctional nests of cells with marked differences in size and shape . within the nests , there was diminished cohesion of melanocytes ( figure 3a ) . the surface of the skin showed a papillomatous contour , and at the level of the spinous and granular layers , a regular honeycomb pattern was seen ( figure 3b ) . the presence of enlarged junctional nests with discohesive cell clusters ( figure 4 ) were consistent with the recent histopathologic descriptions of nevi in flexural sites . flexural nevi that fit criteria for special site nevi may be clinically indistinguishable from other types of melanocytic nevi . the axillary nevus in the present case exhibited regular , uniform globules , but with variegated pigmentation pattern on dermoscopy . while specific dermoscopic features of flexural nevi have only been identified in a few case reports , some authors have categorized axillary lesions with those of the breast and other locations along the milk line due to their overlapping histopathologic features and the possible contribution of embryologic and hormonal influence . a retrospective study of the dermoscopic features of 104 nevi and 13 melanomas from the breast and chest found the presence of atypical pigment network and irregular globules did not discriminate well between nevi and melanoma . site - specific , in which atypical pigment network and irregular globules were sensitive and specific for melanoma . this discrepancy indicates that the when evaluating the dermoscopic characteristics needed to differentiate nevi from melanoma , the anatomic site should be taken into consideration . thus , ancillary diagnostic methods that can assist to exclude , reliably and reproducibly , melanoma in special anatomic locations are warranted . rcm is a noninvasive tool that utilizes differences in refractivity of skin structures to visualize the epidermis , dermal - epidermal junction , and dermis at the cellular level . while there exists a considerable amount of data on rcm features of melanoma and nevi rcm features specific to flexural or other special site nevi have not yet been elucidated . the well - conserved honeycomb pattern of keratinocytes visualized at the spinous and granular levels in this case is more consistent with rcm findings of nevi . in contrast , the rcm finding of enlarged , discohesive junctional nests with variability in shape , size , and spacing may elicit concern for melanoma , but have also been described in an rcm study of nevi , denoted by the authors as dysplastic nevi , from non - special anatomic sites . absence of large , bright pagetoid cells in the epidermis and cytologic atypia at the basal layer were criteria supporting the diagnosis of a nevus . two histopathologic patterns have been observed in flexural nevi ; one with a papillomatous epidermis and mild cytologic atypia that rarely raises concern , and another with irregular nests and uniform junctional cytologic atypia that the pathologist may , at times , find to be more concerning for melanoma . a study of the histopathologic characteristics of 40 cases of nevi on flexural sites such as the axilla , umbilicus , and inguinal creases showed a primarily nested and discohesive pattern . this junctional nested pattern correlates well with the histopathology of our patient s axillary nevus , although cellular atypia was not observed in this case . in high - risk patients , such as the individual in this case , it is important to achieve a balance between careful surveillance of lesions for any clinical or dermoscopic concern and prevention of unnecessary excisions . the consistency between rcm and histopathologic features of the special site nevus described in this case report support the possibility of diagnosing such nevi less invasively in the future . larger studies are needed to define specific criteria required to distinguish special site nevi from melanoma when the clinical and dermoscopic features are indeterminate .

nevi of special sites is a term that denotes melanocytic nevi presenting in specific anatomic locations including the scalp , genital area , flexural sites , and acral sites [ 1 ] . nevi from these anatomic sites display at times histopathologic features that may lead the reading pathologist to recommend re - excision of these benign nevi . reflectance confocal microscopy ( rcm ) is a noninvasive imaging tool that allows for visualization of epidermal , dermal - epidermal junctional ( dej ) , and superficial dermal tissue structures at cellular level resolution . rcm features of special site nevi have not been previously described in the literature . defining the rcm characteristics of special site nevi may increase diagnostic accuracy and assist in ruling out melanoma.here , we report a case of a pigmented lesion appearing in the axilla of a patient with a recently diagnosed melanoma . dermoscopic and histopathologic results were consistent with the diagnosis of nevus in flexural anatomic sites . in this case , rcm showed a regular honeycomb pattern of epidermal keratinocytes and enlarged , non - homogenous , discohesive nests at the dej , a pattern that corresponded well with the histopathologic findings . larger studies are needed to establish rcm features of special site nevi in order to reliably rule out melanoma and lower the rate of unnecessary excisions of these benign nevi .

the polymodal sensory neuron must transform disparate stimuli such as heat and touch into informative neural activity that relays the physical description of the stimulus to the nervous system . like mammalian sensory neurons , polymodal md sensory neurons from drosophila express multiple channel types including members of the deg / enac , trp and piezo channel families , that are required for md neurons to respond to a broad range of noxious stimuli including chemical , mechanical , or thermal . whether the biophysical properties of the individual channels are sufficient to inform the nervous system about the nature of stimuli remains unclear . considering the data demonstrating the genetic separation of sensory modalities in invertebrates , a simple model is that the channels sensing these modalities function in parallel and that perception is the result of a unique current signature produced from the specific combination of channels responding to a distinct stimuli ( fig . trp channels play an important role in modifying and filtering the current generated by the upstream incidence receptors . ( c ) the adsr waveform as a result of the combination of ra and sa currents . interestingly , some trp channels , such as the painless or trpa1 channels , are required in the md neuron for the appropriate response to more than one sensory modality . in addition , genetic epistasis analysis of channel protein mutants in flies finds that these channels are arranged in genetic pathways . for example , in drosophila md sensory neurons the mechanosensitive piezo channel , the trp family member painless and the deg / enac family member ppk1 are all required for mechanical nociception . genetic epistasis finds that piezo and ppk1 function independently during mechanical nociception but that piezo and painless function in the same genetic pathway ( fig . combined with the observation that painless is required for multiple modalities in md neurons , these data suggest an organization where trp channels function downstream of deg and pzo channels in a sensory network ( fig . this organization could allow for the encoding of a broader range of stimuli and places trp channels as critical modifiers of incidence detection . the collection of ion channel currents found in sensory neurons can be characterized by their nonstationary response to continued stimulation : currents that rapidly adapt ( ra ) resulting in transient responses , slowly adapting ( sa ) currents resulting in a persistent response and currents that are intermediate to ra and sa in adaptation ( ia ) to stimuli . furthermore , sensory neurons can contain multiple adapting currents for the same modality . during stimulation it is predicted that a large number of channels , conducting both ra and sa currents , are recruited contributing to a cell - wide current signature that is representative of the stimuli . currently there is little evidence that the current signatures generated in md neurons during stimulation encode sensory information . we find that drosophila md neurons harbor molecularly distinct ra and sa acid - sensitive currents . specific activation of the ra current generated by the ppk1 channel is sufficient to generate a burst of action potentials that precisely reflects the kinetics of the adaptation of this ppk1-dependent current . furthermore , a gain of function mutation in ppk1 that alterschannel gating generates a sustained burst of action potentials reflective of the more sustained adaptation of the mutant channel . importantly , larvae harboring this mutant ppk1 channel have impaired nociception , providing evidence that the adaptation kinetics of the ppk1 channel is important for encoding information about the nature of the stimuli . also consider drosophila larvae that have the same behavioral response to harsh touch and high heat , even though these modalities utilize distinct collections of channel proteins . if the current signature of the md neuron encodes information about the nature of the stimuli , than we predict that the current signatures generated by harsh touch and high heat should be very similar . although data from heterologous cells support that the channels supporting this behavior have similar adaptation kinetics , it will be important to extend these analyses into sensory neurons to evaluate the bursting patterns generated during nociceptive stimuli . because our stimulation of ppk1 is heterotypic , it remains to be seen what the in vivo bursting pattern of md neurons during stimulation is . one possibility is that these currents combine to create a distinct current waveform with a shape that describes the stimulus . this waveform could resemble the attack - decay - sustain - release ( adsr ) waveform used by moog synthesizers to generate sounds as diverse as a cymbal crash to a low hum ( fig . the utility of the adsr waveform for information encoding is demonstrated by the broad range of unique waveforms that can be generated as well as the ability of this waveform to report changes in the quality of stimuli over time . thus , perception by md sensory neurons could consist of the activation of unique sets of currents ( ra and sa ) that generate a cellular current signature resulting in a unique bursting event that sufficiently describes the stimuli . further comparisons of sensory neuron bursting , channel currents and the resulting behavior will be required to determine how the biophysical properties of channels can guide behavior .

polymodal sensory neurons inform organisms about the nature of the physical world around them . the activity of these cells guide behaviors including the withdrawal from nocifensive stimuli such as intense heat or harsh force to feeling the comforting weight of a warm blanket . molecular and genetic analysis of the channel proteins required for these divers behavioral responses have revealed an elaborate and disparate collection of channel proteins within the polymodal sensory neuron . recent data supports that the biophysical traits of the channel proteins combined with the collection of channels activated during stimulation is sufficient to describe the nature of the stimulus . it is currently unclear what the functional arrangement of channel proteins are during perception . specifically , are channel proteins arranged in parallel and function independently during perception , or are these channel proteins arranged in functional sensory networks . we propose a hierarchal functional arrangement of channels within polymodal sensory neurons that incorporates aspects of both parallel and serial arrangements of channel proteins .

giant cell tumours and intraosseous lipomas of the sacrum are both rare . to our knowledge depending on the size and location , these lesions can be excised surgically , supplemented by cement or bone graft augmentation . in inoperable cases embolisation and/or radiotherapy denosumab offers a new treatment option for giant cell tumours and early results of its use are encouraging . a healthy 58 year old female presented to our department complaining of acute - on - chronic low lumbar back pain . she had a history of diffuse non - radiating low back pain for over 20 years . over a 6 month period the pain had intensified and begun to radiate to the right buttock and posterior thigh . she did not have any constitutional symptoms such as fever , sweats or weight loss . she had objective sensory loss in the s1 and s2 dermatomes in the right lower limb . blood tests including full blood count , urea & electrolytes and inflammatory markers were normal . the patient underwent plain radiographs , mri and ct scans of the lumbar spine and pelvis . 1 ) revealed a heterogeneous mass within the proximal sacrum ( high signal on t2-weighting ) , occupying the midline and extending to the sacral ala on the right side , measuring approximately 5x6 cm . within this lesion was a 3 cm area of abnormal low signal towards the midline of the sacrum . the lesion was in close proximity to the exiting right s1 and s2 nerve roots . 2 ) confirmed the presence of a lytic lesion in the sacrum containing a smaller focus of different signal intensity . a percutaneous biopsy was performed which revealed the presence of adipose cells in the periphery of the mass . the central portion showed polygonal multinuclear tumour cells with mild atypia consistent with a giant cell tumour . the thecal sac and exiting l5 , s1 and s2 nerve roots were identified and protected ( fig 3 ) . the peripheral fatty tissue was removed using an ultrasonic surgical aspirator , exposing the central gct mass . intra - operative picture the patient made an uneventful recovery with no alteration in neurological function . she was allowed to mobilise partial weight bearing on crutches , and was discharged within a few days . histological analysis of intra - operative samples confirmed the presence of a giant cell tumour within a lipoma . at follow - up she shows no sign of recurrence to date but will be kept under radiological surveillance . this 58 year old female presented with acute - on - chronic low back pain with features of neurological compromise . our patient s presentation of diffuse low back pain with radiation to the lower limb is typical of degenerate disc disease but could also be seen in a sacral gct . mri revealed a mass within the sacrum consisting of two distinct parts : a peripheral high - signal area and a central low - signal area . the high intensity signal ( on t2-weighting ) was characteristic of fatty tissue . radiographically , the central area was in keeping with a giant cell tumour ( gct ) , although typically these tend to occur eccentrically rather than in the midline . gcts are low signal intensity on t1 and t2-weighted images , relating to the haemorrhagic and fibrotic components of the tumour ( 1 ) . histology revealed multinucleated cells , characteristic of the giant cells ( resembling osteoclasts ) that are pathognomic of gct . giant cell tumours are more common in women between the ages 15 - 40 years ( 2,3 ) . they are most often found in the epiphyses of long bones , typically the distal femur and proximal tibia . in the axial spine gcts a recent study ( 4 ) found that sacral gcts represented 1.7% of all gcts treated at that unit , with a male to female ratio of 1:2 . sacral giant cell tumours have low malignant potential although local recurrence rates can be up to 50% after surgical treatment ( 4,5 ) . pre - operative embolisation can be used to down - size large lesions or those in close proximity to vital structures . surgical management can be excision by curettage or , preferably , en - bloc excision followed by bone graft or cement stabilisation ( 4,8,9 ) . for inoperable cases embolisation and/or radiotherapy where symptoms are present they usually consist of minor aching in the region of the lesion . stage 3 consists of fat necrosis , cyst formation , calcification and new bone formation . it is likely that the fairly extensive intraosseous lipoma in her sacrum was at least in part responsible for some of her symptoms hence the sacrum was grafted with allograft following removal of the fat and the giant cell tumour . it is worth noting that in future the management of giant cell tumours of the sacrum may be transformed by the use of denosumab , a rank ligand inhibitor which has shown to be effective in controlling gcts in most cases . the results of an ongoing prospective study are still awaited although early results look promising ( 10 ) .

we report the case of a 58-year old female who presented with insidious low back pain radiating to the buttock and thigh . magnetic resonance imaging revealed a heterogenous high - signal ( on t2-weighting ) in the midline of the sacrum . within this mass was a distinct area of low - signal intensity . computed tomography revealed a lytic lesion within the sacrum . biopsy confirmed the presence of a lipoma that contained within it a giant cell tumour . the patient proceeded to have surgical excision and bone graft augmentation .

a central database was created in august 2002 for two cohorts of participants in the maestro project : 1 ) a younger group ( aged 18 years , n = 84 ) who had the assistance of the navigator as they graduated from pediatric care and 2 ) an older group ( aged 1925 years , n = 64 ) who were transferred to adult care without this initial support . they were later enrolled in the program , 17 years after graduation from pediatric care . the maestro collected information from the participants by telephone every 6 months regarding medical or diabetes education visits , the presence of chronic complications , diabetes - related hospitalizations for diabetic ketoacidosis ( dka ) or severe hypoglycemia , and barriers to accessing care in the adult diabetes care system . evaluation was completed from september to december 2004 for the year before the maestro project was created and for the year after the maestro project was in place . sources of data included database review , audit of medical records , and a qualitative participant survey . the number of medical and diabetes educator visits was available for the year before and year after referral to the maestro project for 101 of 164 patients ( 62% ) in the older group and 64 of 84 patients ( 76% ) in the younger group . as seen in table 1 , the systems navigator model helped the older group reconnect with adult medical services and helped the younger group reduce their first year fall - out rate after transfer from pediatric to adult care . prior to intervention from the navigator , over 40% of this fall - out rate was lower in the younger group , who had access to the navigator at the time of transfer from pediatric care ; only 11% of this younger group dropped out of adult medical care completely after transfer . the older group reported pregnancy loss of 38% ; 1 case each of heart failure , legal blindness , and amputation ; 4 cases of proliferative diabetic retinopathy ; 4 deaths ( 2 from dka and 2 unrelated to diabetes ) . both groups reported acute complications requiring visits to the emergency room or admission to a hospital . for dka , there were 3.0 cases per 100 patient - years in the older group versus 7.9 cases per 100 patient - years in the younger group ( ns ) . for severe hypoglycemia , there were 2.4 cases per 100 patient - years in the older group versus 4.7 cases per 100 patient - years in the younger group ( ns ) . of the participants , 33% of the younger group and 42% of the older group experienced difficulties or frustrations with establishing regular follow - up with their adult health care team after transfer from pediatric care . reasons for dropping out of care included difficulty scheduling appointments and knowing who to see , difficulty establishing relationships with the new team , feeling overwhelmed and lost in the system , and a lack of perceived value of adult care . of the participants , 100% of the older group and 78% of the younger group felt that there was a need for the maestro project . the maestro project had facilitated 374 referrals for 168 participants to endocrinologists , diabetes educators , mental health professionals , and eye specialists , and 198 individual participants had contacted the maestro project 515 times for information . at the time of transfer from pediatric to adult care , many young adults are unable to independently navigate the adult diabetes care system . the young adults who are enrolled in a systems navigator and support program before age 18 years are better connected to the adult health care system than those who graduated before the program existed . in the first 2 years of the maestro project , there was improved medical surveillance but no evidence of improved short - term medical outcomes . this may be due to specific characteristics of this young adult cohort , specific characteristics of service delivery in the adult care system , or inadequate development or time for optimum evaluation of this model .

objectives to determine whether a systems navigator service , the maestro project , could increase medical surveillance for young adults with type 1 diabetes who transfer from pediatric to adult care.research design and methods there were two cohorts of participants : 1 ) a younger group ( aged 18 years , n = 82 ) who had the assistance of the navigator as they graduated from pediatric care and 2 ) an older group ( aged 1925 years ) who were transferred to adult care without this initial support but later enrolled in the program.results of the older group ( who did not have initial access to the navigator ) , 40% dropped out of adult medical care , compared with a dropout rate of 11% for the younger group , who had access to the navigator at the time of transfer from pediatric care.conclusions the systems navigator helped improve medical surveillance for both groups , although there was no evidence of improved short - term medical outcomes .

after reading the paper by cristian tomasetti and bert vogelstein ( 1 ) and the following comments , including those from the world health organization international agency for cancer research ( lyon , france ) and the collegium ramazzini in italy ( 210 ) , we herein present a molecular biology , epidemiological and mathematical modeling reanalysis that strongly disagrees with their conclusion , stating that several cancer types may be caused by random somatic mutations arising during dna replication of normal stem cells . instead of the author 's two - group individualized model , a three - group model is proposed , considerably reducing the fraction of cancer hypothetically attributable to random mutations . the hypothesis that the lifetime risk of cancer differs according to tissue type due to the different total number of divisions of stem cells in normal tissues , is coherent with our knowledge on carcinogenesis , since , according to the somatic mutation theory , cancer is associated with mutations ( 11,12 ) and cell divisions are required for mutations to occur ( 13 ) . however , carcinogenesis is a multistep , multifactorial process , with etiological factors other than the natural proliferative rate of normal tissue ( 14 ) . while random mutations , which may occur in addition to deterministic events during the whole process of carcinogenesis , are well known , this is more problematic when applied to cancer initiation . cancer may result from gene - environment interactions mediated by epigenetic mechanisms ( 15 ) ; thus , in addition to innate or acquired hereditary susceptibility factors , clearly exogenous factors such as chemicals , radiation and/or microorganisms , play a key role in carcinogenesis directly , by interfering with dna , and/or indirectly , through epigenetic pathways ( 1618 ) . moreover , it has been estimated that stochastic mutations , referred to as spontaneous somatic point mutations , may be in the order of 10 to 10 per sexual generation for the entire genome of eukaryotic cells ( 19 ) , and these mutations are not randomly distributed within the eukaryotic genome , but mainly in its non - coding nucleosome - depleted part ( 20 ) . it is unlikely that random mutations at this rate may cause cancer initiation and account for cancer occurrence that is at present significantly more frequent than 1 case out of 1,000 . in fact , as random mutations mainly encompass somatic point mutations rather than cancer - causing ( clonogenic ) driver mutations , and cancer results from several driver mutations ( 15 ) , random mutation - related cancer should be much less frequent yet . we therefore analyzed from the standpoint of epidemiology the authors ' different cancer types in the so called replicative ( r ) stochastic group . 1 , apart from pancreatic cancer , all r group cancers have been shown to be associated with an increased incidence over the last 3 or 4 decades in the usa ( 21 ) , as well as in europe ( 22 ) . we disagree with tomasetti 's response to our question , that the fact that cancer incidence has increased over the last 34 decades may be explained in part as a consequence of random replicative mutations , given the longer lifespan of the population and that an increase in screening and awareness certainly played a role in the increase in the observed incidence of melanoma , as well as that of many other cancers. these arguments are not convincing , since cancer may be initiated at the fetal stage ( 23 ) , increased cancer incidence concerns all age categories , and screening by itself can not account for the continuous increased incidence of several cancer types , including those which can not be screened ( 24,25 ) . we therefore concluded that the stochastic interpretation attributed to the author 's r group is not consistent with current epidemiological and biological data . taking into account the supplementary material of the article , we investigated the mathematical method that tomasetti and vogelstein used to define their two groups , r and deterministic ( d ) , the basis of their claim . considering the association between the lifetime cancer risk and the total number of stem cell divisions ( fig . 1a ) , a strong correlation at 0.804 was demonstrated statistically by using the pearson 's chi - square test . however , applying a linear regression test , we obtained a coefficient of determination , denoted r , of only 0.6463 , indicating that a soundly established linear relation is unlikely . moreover , we combined figs . 1 and 2 of the authors article in a single figure for the purpose of simplification and better understanding , and estimated r for each of the arbitrarily individualized r and d groups . we therefore tentatively individualized a third group from the r and d initial groups . as indicated in fig . 2b , we observed a significantly improved linear regression , with r of 0.88 , 0.89 and 0.98 for the newly individualized d , intermediate and r groups , respectively . this suggests that , when restricting the r group to a significantly smaller number of cancer types , the intermediate group may in fact include both stochastic and deterministic events , a hypothesis which appears to be more coherent with what we previously discussed . although a very small proportion of cancers may be caused by spontaneous random mutations , we strongly suggest that the scientific message of tomasetti and vogelstein does not agree with the currently available biological , epidemiological and toxicological data . the process of carcinogenesis has not been sufficiently taken into consideration , so the interpretation of tomasetti 's and vogelstein 's results may be hazardous , as it de - emphasizes highly needed primary prevention and limits it to for a small proportion of cancer types .

a careful molecular biology , epidemiological and mathematical modelling reanalysis of the recently published study titled cancer etiology . variation in cancer risk among tissues can be explained by the number of stem cell divisions by cristian tomasetti and bert vogelstein , which was published on january 2 , 2015 in the distinguished journal science , led to the conclusion that , contrary to the authors ' claim , many cancer types are not caused by replicative random mutations . rather than the authors ' two arbitrarily individualized groups of cancer , a three - group model is herein proposed in the framework of this technical comment , considerably reducing the fraction of cancer cases hypothetically attributable to random mutations .

takayasu 's arteritis is a chronic inflammatory disease that afflicts the aorta and its principal branches as well as the pulmonary artery , resulting in the formation of aneurisms and arterial stenosis . in general pre - pulseless phase , characterized by constitutional symptoms such as fever , weight loss , arthralgia , myalgia , lethargy and mild anemia , and a later or neurological symptoms occur in 50% of cases and most commonly include headache , dizziness , visual disturbances , convulsive crisis , transient ischemic attack , stroke and posterior reversible encephalopathy syndrome . a 19-year - old caucasian female from brazil was admitted with focal neurological deficit 3 days after symptom onset . she presented asymmetry of brachial and radial pulses , aphasia , dysarthria and right hemiplegia . 1 ) . cerebral angiography displayed occlusion of the right subclavian and left common carotid arteries , stenosis of the brachiocephalic trunk and flow inversion of the right vertebral artery and left posterior communicating artery , irrigating the territory of the left common carotid artery ( fig . only nonspecific inflammatory markers such as velocity of hemosedimentation and c - reactive protein were elevated . during hospitalization , clinical treatment was performed using pulse therapy with methylprednisolone 1 g / day for 3 days as well as methotrexate 15 mg / day , acetylsalicylic acid 200 mg / day and simvastatin 20 mg / day . after pulse therapy , prednisone 60 mg / day was initiated , showing progressive neurological recuperation on the subsequent days . after 4 months , the patient was submitted to medicated angioplasty of the brachiocephalic trunk with paclitaxel , with significant improvement of the stenosis . at the 6-month follow - up , the neurological exam presented mild dysarthria , faciobrachial predominant disproportionate hemiparesis , an nihss score of 4 and a modified rankin scale score of 3 ( moderate incapacity ) . stroke incidence in this disease is 1020% , but stroke as a first manifestation of takayasu 's arteritis in young patients is rarely found in the literature . the patient in this study did not show any systemic manifestations at any moment during the clinical follow - up , which also leads to an uncommon form of presentation of the disease . the stroke mechanisms in takayasu 's arteritis are described as embolism of stenotic or occlusive lesions of the aortic arch and its branches , hypertension , cardioembolism and cerebral hypoflow . the principal objective of the clinical treatment of takayasu 's arteritis is to control the activity of the disease , thus achieving radiological and clinical improvement . invasive treatments including angioplasty and vascular surgery ( bypass ) must be considered only for stenoses or occlusions of critical arteries such as renal arteries , common carotid and internal carotid arteries . in our case , there was a delay in the diagnosis because the symptoms were associated with a psychiatric condition . in conclusion , takayasu 's arteritis must be recognized as a potential cause of ischemic stroke in young females .

takayasu 's arteritis is a chronic inflammatory disease , and neurological symptoms occur in 50% of cases , most commonly including headache , dizziness , visual disturbances , convulsive crisis , transient ischemic attack , stroke and posterior reversible encephalopathy syndrome . the aim of this study was to report the case of a young brazilian female with a focal neurological deficit . she presented with asymmetry of brachial and radial pulses , aphasia , dysarthria and right hemiplegia . stroke was investigated extensively in this young patient . only nonspecific inflammatory markers such as velocity of hemosedimentation and c - reactive protein were elevated . during hospitalization , clinical treatment was performed with pulse therapy showing improvement in neurological recuperation on subsequent days . in the chronic phase , the patient was submitted to medicated angioplasty of the brachiocephalic trunk with paclitaxel , with significant improvement of the stenosis . at the 6-month follow - up , the neurological exam presented mild dysarthria , faciobrachial predominant disproportionate hemiparesis , an nihss score of 4 and a modified rankin scale score of 3 ( moderate incapacity ) . in conclusion , takayasu 's arteritis must be recognized as a potential cause of ischemic stroke in young females .

in this issue of critical care , triltsch and colleagues report on the use of the bispectral index ( bis ) as a monitor of sedation in the paediatric intensive care unit ( picu ) . they attempted to correlate bis scores with the comfort score a commonly used clinical sedation scoring system . the authors were able to demonstrate good correlation between bis scores and comfort scores during deep sedation and in cases where the electrical impedance of the bis electrodes was lowest . the stated aim was to determine whether bis is a useful tool for assessing the level of sedation in critically ill children . in their study , analysis of the bis score enabled correct prediction of the comfort score in 80% of cases overall , but in only 55% of lightly sedated children . the study population was quite selected in that 85% of patients had undergone cardiac surgery , and children were assessed only in the first few hours of admission to the picu . this makes the study findings less applicable to a general picu population , where children are admitted with a much broader range of diagnoses , particularly with neurological dysfunction and altered levels of consciousness , which would have an impact on the use of bis scores . the median duration of endotracheal intubation in a noncardiac picu would typically be in region of 34 days , and the utility of bis as a measure of sedation in critically ill children would therefore have to be assessed during the entire period of sedation rather than just focusing on the first few hours . this is particularly important , given the finding of the authors that analysis of the bis score would enable correct prediction of the comfort score in only 55% of lightly sedated children . during the course of a period of critical illness , children require different depths of sedation according to their clinical status and the interventions to which they are subjected . frequently , at the outset of a picu admission a relatively deep level of sedation is required to allow for the instigation of certain invasive procedures and therapies , particularly in certain specific disease states such as raised intracranial pressure or pulmonary hypertension . as a picu admission progresses there is usually a requirement for a lighter degree of sedation , and the utility of bis scores in guiding the titration of sedative agents longitudinally during a picu admission that includes such periods of lighter sedation remains questionable . crain and colleagues studied 31 mechanically ventilated picu patients using the bis score and the comfort scale twice daily for up to 5 days and found that individual measurements of bis score and comfort scale were only moderately correlated . the authors concluded that bis scores may be best used to identify and prevent over - sedation in the picu . berkenbosch and colleagues compared bis scores with simultaneously obtained clinical sedation scores in 24 mechanically ventilated picu patients . in differentiating adequate from inadequate sedation , bis values below 70 had a sensitivity of 0.870.89 and a positive predictive value of 0.680.84 . in differentiating adequate from excessive sedation , bis values below 50 had a sensitivity of 0.670.75 and a positive predictive value of 0.070.52 . the bis reliably differentiated between inadequate and adequate sedation , but it was relatively insensitive for differentiating between adequate and over - sedation . the data suggested that 80% of patients were adequately sedated when bis scores were maintained at less than 70 . at bis scores below 40 , fewer than half of the clinical sedation scores were found to indicate excessive sedation , whereas almost half of those determined to be excessively sedated patients on clinical sedation scales had bis scores in excess of 40 . a group of patients we are particularly anxious to sedate adequately are those receiving neuromuscular blocking agents . these patients are at risk of inadequate sedation and of being able to recall periods of neuromuscular blockade . aneja and colleagues compared the bis score with clinical assessment of sedation using the ramsay score in 24 mechanically ventilated picu patients . they compared picu nurses ' clinical assessments of depth of sedation with bis scores of children receiving neuromuscular blocking agents . nurse assessments detected only 8% of those patients with a bis score of 80 or greater , and who were therefore at risk for awareness and recall . nurses clinical assessment for oversedation ( bis < 40 ) had a reasonable sensitivity of 89.7% but a low specificity of 38.6% . that study served to highlight the inadequacy of clinical scoring systems in the assessment of sedation in those receiving neuromuscular blocking agents . triltsch and colleagues have demonstrated that the bis has potential for monitoring sedation in critically ill children , but that this role has yet to be clearly defined . it must be remembered that the optimal range of bis scores for varying depths of sedation remain poorly defined and are subject to great variability between patients . many factors encountered during critical illness , including body temperature variation , hypotension and even critical illness itself , may alter the bis score , as may drugs such as opioid analgesics , ketamine and nitrous oxide . electrical interference from picu equipment and muscle activity at lighter levels of sedation may both confound bis scores . there is currently insufficient evidence to recommend the routine use of bis monitors in the picu , even in those patients who are receiving neuromuscular blocking agents .

the bispectral index ( bis ) is a processed neurophysiological electroencephalographic parameter that may be used to evaluate the depth of sedation in critically ill children . triltsch and colleagues attempted to correlate bis scores with a commonly used clinical sedation scoring system . they were able to demonstrate good correlation during deep sedation and in cases where the electrical impedance of the bis electrodes was lowest . studies have shown only moderate degrees of correlation between bis scores and clinical sedation scoring systems . there is currently insufficient evidence to recommend routine monitoring of bis scores in critically ill children .

congenital erythropoietic porphyria is usually associated with hemolytic anemia . congenital erythropoietic porphyria ( cep ) or cep was the first human porphyria to be described and first to be related to specific enzymatic defect . major clinical manifestations are severe cutaneous photosensitivity and blistering that exacerbates on exposure to sunlight along with features of chronic hemolysis and massive porphyrinuria ( characterized by red colored urine ) . these are due to accumulation of predominantly type 1 porphyrin in erythrocytes , bone marrow , skin , teeth ( characterized by erythrodontia ) , bones and other organs . we report a case of cep with classical clinical presentation but without any feature of hemolysis . an eleven month old female child , born of a primigravida mother of non - consanguinous marriage came to us with history of recurrent blisters face and upper limbs since two months of age . blisters in different stages of healing over the arm and forearm her pulse rate was 102/min , blood pressure was 84/58 mm of hg . her weight was 7.9 kg , length was 70 cm and head circumference was 45 cm . blisters were present on scalp , face , upper and lower limbs with atrophic scars on scalp and upper limbs along with alopecia . copper - red discoloration of the two erupted teeth was noted [ figure 2 ] . neurological examination was normal . on the basis of infancy - onset blistering over sun - exposed areas , atrophic scars , red colored urine and teeth without neurological involvement and evidence of arthritis copper red discoloration of the erupted teeth complete blood count showed mild anemia ; hb-9.2 mg / dl , total leucocyte count-8,200 and platelet count of 1.4 lac / cumm . on peripheral smear anemia was microcytic , hypochromic in type . but , on screening test with a spectrophotometer urinary total porphyrin level was 1023 nmol / mmol of creatinine ( normal < 35 nmol / mmol ) . twenty four hours urinary and faecal level of uroporphyrin and coproporphyrin were also significantly elevated . the erythrocyte porphyrin level was 115.3 mcg/100 ml using the haematofluorometric method ( normal value < 40 mcg/100 ml ) . bright red fluorescence was also noted in the urine , teeth and blood under wood 's lamp . demonstration of deficiency of uros activity and genetic study could not be performed due to lack of laboratory facilities . the inheritance of two mutant alleles for the gene encoding the enzyme uroporphyrinogen iii synthase leads to accumulation of porphyrins thatcause cutaneous photosensitivity characterized by blisters , erosions , and scarring of light - exposed skin . the disease can be detected in utero by measuring porphyrins in amniotic fluid and uros activity in cultured amniotic cells or chorionic villi . clinical manifestations can vary from mild to severe grade , starting from non - immune hydropsfoetalis as a result of severe hemolytic anemia in - utero to late onset clinical cases where the only symptom is cutaneous photosensitivity in adulthood . an indian adult with cep was reported with photosensitivity , severe acral mutilation and blindness . erythrodontia ( red fluorescence under ultraviolet light ) when present is virtually pathognomonic of cep . photoactivity of porphyrins causes bright pink fluorescence of this pigments in urine . in our case there was cutaneous photosensitivity , infancy - onset blistering , red - colored urine and teeth along with cutaneous scarring . bhutani , et al . reported the autopsy findings of a case of cep and all the viscera showed orange - red fluorescence under wood light . pseudoporphyria , a drug induced bullous disorder with photosensitivity , is closely similar to cep . however , in both of them the porphyrin levels in urine , plasma and faeces are not raised . in most other photodermatoses inflammation is not severe enough to that extent to produce cutaneous blisters . hep is characterised by childhood onset and elevated levels of faecal or urinary isocoproporphyrin and erythrocyte zn - protoporphyrin . but in our case of cep the blister and photosensitivity were of infancy onset and there was increased level of faecal and urinary copro and uroporphyrin along with elevated erythrocyte porphyrin . topical sunscreen lotion , oral beta - carotene and sometimes splenectomy are the treatment options . stem cell transplantation is the only permanent curative option . in our case , we advised strict avoidance of sunlight and prescribed topical sunscreen lotion of high sun protection factor with oral beta - carotene . recently some indian authors have reported cases with mild anemia and hypertrichosis on face . in our case high index of suspicion is needed in all cases ofcutaneous photosensitivity , red colored urine and blistering over sun - exposed areas to rule out cep .

porphyrias are group of disorders caused by deficiency of the enzymes in heme synthetic pathway . congenital erythropoietic porphyria ( cep ) is an extremely rare disease with mutation in the gene that codes for uroporphyrinogen iii synthase leading to accumulation of porphyrin in different tissues and marked cutaneous photosensitivity . here , we describe a case of cep with infancy onset blistering , photosensitivity , red colored urine and teeth along with scarring but without any feature of hemolysis .

wells syndrome is a rare condition of unknown etiology and pathogenesis . in 1971 , george wells first described this syndrome as a recurrent granulomatous dermatitis with eosinophilia . the term eosinophilic cellulitis was introduced by wells and smith in 1979 . wells syndrome is characterized by clinical features of cellulitis and a histopathologic picture of eosinophilic infiltrate of the dermis along with the presence of flame figures . the typical clinical presentation of the eosinophilic cellulitis is mildly pruritic , recurrent , cellulite like plaque , although several clinical presentations like urticarial , papulonodular , and vesicobullous lesions have been reported , depending upon the location of the infiltrate . wells syndrome is associated with a range of disorders like arthropod bite , myeloproliferative disease , colon cancer , reaction to thiomersal - containing vaccination , churg strauss syndrome , hypereosinophilic syndromes , dermographism , onchocerciasis , herpes - simplex infection , immunobullous disease , and drug reaction . while some authors consider wells syndrome to be a histological reaction pattern,[35 ] others consider it to be a distinctive disease entity . a 32-year - old female presented with an erythematous , edematous plaque on the flexor aspect of left forearm of 10 days duration , associated with a prodrome of malaise followed by itching and burning sensation at the site [ figure 1 ] . the lesion was small initially , but later on increased to size of about 5 cm 4 cm . the plaque was pink - red in color at onset that evolved into violaceous color over a period of 10 days and subsided within 3 weeks , leaving mild hyperpigmentation . the severity of the episodes varied each time at some times , the patient would require antihistamines and oral steroids for relief . absolute eosinophil count was 440 cells / mm ( normal : 40440 cells / mm ) . random blood sugar , liver and renal function tests , urinalysis , chest x - ray , and antinuclear antibodies were normal . histopathologic examination from a biopsy taken from the plaque showed moderately dense superficial and deep perivascular and periappendageal infiltrate of eosinophils and lymphocytes [ figure 2 ] . several eosinophils were scattered in the interstitium of reticular dermis and around the deep vascular plexus [ figure 3 ] . based on the clinical presentation and the histopathology , a diagnosis of wells syndrome was made . the patient was given oral prednisolone 40 mg/ day in tapering dose over 4 weeks . clinical photograph showing erythematous and indurated plaque on the flexor aspect of left forearm below elbow ( encircled ) photomicrograph showing moderately dense superficial and deep perivascular and periappendageal infiltrate of eosinophils and lymphocytes ( arrows ) ( h and e , 100 ) photomicrograph showing eosinophils scattered in the interstitium of reticular dermis and around the deep vascular plexus ( arrow ) ( h and e , 400 ) wells syndrome is a rare , idiopathic dermatosis with recurrent , erythematous , urticarial plaques that become more indurated and subsequently heal with mild pigmentation . the course of the disease is mild despite occasional constitutional symptoms . although wells syndrome is usually sporadic , familial , neonatal , and childhood cases have been reported . there is wide polymorphism in the clinical and histological presentation of the disease , depending upon the nature and location of the infiltrate . the diagnosis of the wells syndrome is based on the clinical features and the course of the disease , especially its recurrences and the histopathologic features of eosinophilic infiltration of the dermis . histopathologically , a dermal infiltrate of histiocytes , eosinophils , and eosinophilic granules occurs between collagen bundles , which form the classic flame figures . classical flame figures were not documented in the histopathology of our case as the patient presented in the resolving phase . flame figures are not unique to the wells syndrome and can be found in any disorder with a eosinophil - rich infiltrate such as insect bites , pemphigoid and churg strauss syndrome . the flame figures may disappear after the acute stage with the granulomatous infiltrate becoming more obvious . peripheral t - cell immunophenotyping studies have shown an increased proportion of cd3 and cd4 t cells . these lymphocytes spontaneously release significant amounts of interleukin 5 ( il- 5 ) which is involved in the pathogenesis of blood and tissue eosinophilia . the eosinophils then degranulate in the dermis , causing edema and inflammation . with immunofluorescent stains , dapsone , interferon - alpha , cyclosporine , antihistamines , or minocycline have also proved effective . history and clinical presentation should prompt the clinician to consider the diagnosis of the wells syndrome , and histopathologic examination should be done for confirmation .

wells syndrome or eosinophilic cellulitis is characterized clinically by an acute dermatitis resembling cellulitis and histopathologically by dermal eosinophilic infiltration . various morphological presentations have been described . we report a 32-year - old female with recurrent , erythematous plaques on left forearm of 8 months duration , associated with mild itching that resolved leaving mild hyperpigmentation .

a 75-year - old - male with a history of a right middle cerebral artery infarction 5 years previously was admitted for the management of bilateral proximal internal carotid artery ( ica ) stenoses diagnosed by magnetic resonance angiography . an acute infarct lesion was not observed , but gre - sequence mri revealed several smbs exclusively in the bilateral cerebral cortex ( fig . smbs were not found in the basal ganglia or thalamus . because severe stenoses of bilateral proximal icas ( > 70% , nascet criteria ) were confirmed by cerebral angiography , balloon angioplasty and stenting was performed on the left proximal ica immediately and on the right proximal ica 1 month later . there were no initial complications after stenting , such as hyperperfusion syndrome or embolic infarction . twenty - five days after the last stenting , the patient became slightly obtunded and was unable to lift his left arm . brain diffusion - weighted and gre - sequence mri was performed at 2 days after ictus . two acute ischemic stroke lesions were identified in the striatum and the cortex by diffusion - weighted imaging ( dwi ) ( fig . interestingly , multiple embolic strokes had resulted in an embolus flowing to the right parietal lobe where an smb had been present on the previous gre - sequence mri investigation , which caused a hemorrhagic infarction , whereas no hemorrhage was found around the striatal lesion ( fig . smbs are usually caused by chronic hypertension,4 and an increased burden therefrom is also correlated with increased hypertension.5 the close relationship with chronic hypertension is also supported by pathological data indicating that smbs are hemosiderin - containing macrophages that appear around advanced hypertensive microangiopathic lesions such as lipohyalinosis.6 furthermore , these lesions are strongly associated with the presence of intracerebral hemorrhage in patients with hypertension , with their cerebral locations coinciding with the locations of the intracerebral hemorrhage.1,7 because smbs and silent lacunar infarctions exhibit different topographical distributions,8 smbs may be considered indicative of bleeding - prone microangiopathy . this hypothesis is further supported by the association with cerebral amyloid angiopathy ( which is another causal disease for lobar hemorrhage ) that is possibly of even greater importance : most amyloid angiopathy - related smbs are found in the lobar area . the integrity of the cerebral microvasculature is maintained by the blood.brain barrier and subtending basal lamina . microvascular damage can result in extravasation of plasma and blood cells into brain parenchyma , and in overt hemorrhagic transformation . considering that smbs result from tiny extravasations of blood,6 it can be speculated that smbs are associated with the formation of hemorrhagic transformation . although microvascular structural disruption has not been directly associated with the development of smbs , we believe that smbs reflect the degree of bleeding tendency in the brain , and are predictive of subsequent bleeding episodes . thus , the cerebral cortex of our patient might have been in a bleeding - prone state , as indicated by the presence of smbs exclusively in the cortex . the subsequent embolic infarctions involved the deep gray matter and the cerebral cortex , but hemorrhagic conversion therefore , this case report indicates that the bleeding tendency may differ even within the same brain , and that this variation may be detected by analyzing the locations of smbs . it is possible that the cortical lesion in our patient was not a hemorrhagic conversion of embolic infarction but a pure hemorrhage . in dwi the concept of perihematomal ischemia or penumbra is not generally accepted,9 and high signal intensities are not usually observed in patients with intracerebral hemorrhage.10 a surrounding high signal on dwi may simply represent a paramagnetic artifact caused by a hematoma . however , the wide extents of high signals on dwi in our patient suggest that they were due to cytoxic edema associated with acute infarction , and did not originate from signal distortion due to extravasation of heme . to our knowledge this is the first case report of a direct association between smbs and the hemorrhagic conversion of a subsequent embolic infarction .

we report a patient with multiple simultaneous embolic infarctions with localized hemorrhagic conversion . a 75-year - old male patient had several silent microbleeds ( smbs ) exclusively in the cerebral cortex , and underwent angioplasty and stenting for bilateral carotid stenosis . he subsequently experienced embolic infarctions in the cortex and the striatum : the cortical infarction , where an smb had been present , showed hemorrhagic conversion , whereas the striatal infarction did not . this case suggests that smbs are indicators of an underlying hemorrhage - prone state .

an intramural duodenal hematoma ( idh ) with duodenal obstruction is usually a complication of blunt abdominal trauma , endoscopic biopsy , or peptic ulcer disease.1 in particular , non - traumatic idh is associated with coagulation abnormalities . however , few cases of idh caused by acute pancreatitis have been reported.2 the presentation of spontaneous idh can vary from mild abdominal pain to intestinal tract obstruction and acute abdomen . most patients with non - extensive hematoma will show improvement with non - operative treatments such as nasogastric decompression and correction of abnormal coagulation . percutaneous drainage or surgery may be necessary in cases with suspected malignancy , perforation , or intestinal tract obstruction . here , we present a case of idh in which duodenal obstruction was caused by acute pancreatitis and an experience of successful endoscopic decompression of the hematoma . a 55-year - old man who had been experiencing right upper abdominal pain and vomiting for 2 days was admitted to the hospital . he had been treated previously for alcoholic pancreatitis caused by heavy drinking and had no history of antiplatelet , anticoagulants , or non - steroidal anti - inflammatory drug use . laboratory analysis showed mild leukocytosis ( 13,850 cells/l ) and marked elevation of serum pancreatic enzyme levels ( amylase , 1,001 u / l ; lipase , 1,809 u / l ) . activated partial thromboplastin time and prothrombin time were measured at 30.4 seconds and 10.1 seconds , respectively , which were within their normal ranges . computed tomography ( ct ) revealed a highly attenuated mass along the duodenum and acute pancreatitis ; the mass narrowed the lumen , causing significant distension of the stomach and mild pancreatic swelling with peripancreatic infiltration ( fig . upper endoscopy revealed a submucosal mass with a hyperemic mucosa in the duodenal bulb and complete obstruction of the second duodenal portion caused by external compression . a tiny erosion was found on the surface of the duodenal hematoma , suggesting the presence of fistula between duodenal lumen and hematoma . we decided to perform rapid decompression of this hematoma in order to resolve the gastric outlet obstructive symptoms and the nothing per oral ( npo ) period . we removed the mucosa at the erosive surface of the mass using biopsy forceps and made a small fistula . after the blood had flowed out , we carefully advanced an endoscope through the fistula and observed the presence of blood clots with oozing . therefore , we removed some of the clots using a basket and suctioned them to decompress the luminal obstruction ( fig . conservative therapies such as fluid therapy and npo were continued , and the patient 's symptoms and abnormal laboratory findings improved after 1 week . in a follow - up ct scan of the abdomen conducted after 2 weeks , the previously large mass was found to be smaller ( fig . 3 ) . only a small duodenal ulcer was found after 18 days ( fig . idh with duodenal obstruction is usually a complication of trauma.1 non - traumatic idh is generally associated with coagulation abnormalities.3 however , few cases of idh caused by acute pancreatitis have been reported.2 non - traumatic idh can cause intestinal stenosis , often initially presenting as abdominal pain and vomiting.4 obstructive symptoms from duodenal hematomas generally resolve in 10 to 15 days ; however , some patients experience a prolonged course with persistent duodenal obstruction that requires operative exploration.5 intensive medical therapy is now gaining wide acceptance with recent advances in diagnostic imaging techniques.6 in the current case , the large hematoma was treated adequately with endoscopic evacuation of the hematoma through a fistula that was created at the erosive surface using biopsy forceps , and after this treatment , the symptoms of gastric outlet obstruction improved rapidly . in our patient , it is not clear if the acute pancreatitis occurred because of the hematoma , probably due to obstruction of the duodenal papilla , or if the compression of the pancreas was caused by the hematoma ; however , the patient did not experience any traumatic event or have a suspect medication history , although he did drink a significant amount of alcohol before being admitted to the hospital for abdominal pain . therefore , we believe that acute pancreatitis was the likely cause of duodenal hematoma with gastric obstruction . to the best of our knowledge , this is the first case of successful endoscopic decompression for idh with gastric outlet obstruction caused by acute pancreatitis . although the effectiveness of endoscopic decompression for idh has not been proved because idh is rare , we hope our experience will allow patients to avoid more invasive procedures in the future .

non - traumatic intramural duodenal hematoma ( idh ) with duodenal obstruction caused by acute pancreatitis is rare . most patients with non - extensive hematoma show improvement with non - operative treatments . percutaneous drainage or surgery may be necessary in cases with suspected malignancy , perforation , or intestinal tract obstruction . we present a case of idh caused by acute pancreatitis that led to obstruction of the duodenum and an experience of successful endoscopic decompression of the hematoma .

chronic infections with s. stercoralis can be clinically unapparent or can lead to cutaneous , gastrointestinal or pulmonary symptoms . we report the first case of capd - related peritonitis as an unusual presentation of s. stercoralis infection . a 67-year - old male patient who had been on capd therapy for end - stage renal disease secondary to type 2 diabetes mellitus . he experienced two episodes of capd peritonitis secondary to enterococcus spp and metycilline - sensitive staphylococcus aureus in december 2007 and june 2008 , respectively . the patient presented to our hospital due to abdominal pain , tenderness , cloudy effluent and pruritus . the remaining physical examination was normal . on admission , haemogram showed white blood cell count 10.700/mm with 76% neutrophils and 6% eosinophils and haemoglobin 11.6 g / dl . blood urea nitrogen was 72 mg / dl , and serum creatinine was 6.6 mg / dl . s. stercoralis larvae were seen on centrifuged dialysate sediment with microscopic examination ( figure 1 ) . the patients ' complaints disappeared and dialysate white blood cell count decreased to 100/mm 4 days later without a need for catheter removal . we did not detect larvae in three stool samples and treatment finished at the end of the first month . some rhabdoid larvae may transform back into filariform larvae and penetrate either the colonic mucosa ( internal autoinfection ) or the perianal skin ( external autoinfection ) , allowing the internal life cycle leading to small intestinal infection to continue . transient and pruritic dermatitis is caused by the intradermal migration of the larvae in the skin . the other symptoms are abdominal pain , diarrhoea , cough and anorexia [ 68 ] . strongyloides infections can be detected by the examination of host faeces for strongyloides larvae or by the examination of the small intestine of a host for parasitic females . elisa tests for detecting serum igg against antigens of s. stercoralis may also use for strongyloidosis . response to anthelmintic therapy was defined as the disappearance of parasites in three stool samples performed at least 6 weeks after therapy . in our patient , strongyloides peritonitis may have occurred due to transmigration of parasite across the bowel wall . alternatively , the entrance of parasite into the peritoneal cavity is also possible via touch contamination of the catheter during an exchange . our findings suggest that s. stercoralis may cause the development of capd peritonitis and pruritus might be the sign of this infection .

a 67-year - old male continuous ambulatory peritoneal dialysis ( capd ) patient presented with abdominal pain and pruritus . strongyloides stercoralis larvae were seen on dialysate sediment and stool microscopic examination . albendazole was given and improved the symptoms in 4 days . there was no episode of relapsing peritonitis after the therapy . this is the first report of s. stercoralis peritonitis in patients on capd . strongyloides should be considered as a probable peritoneal pathogen in capd patients .

nevus spilus ( ns ) is a potential precursor of melanoma ; the vast majority of cases reported in the literature were histologically classified as superficial spreading melanoma . to demonstrate the diagnostic value of reflectance confocal microscopy ( rcm ) in this subtype of congenital nevi . we report a case of a large congenital ns with equivocal clinical and dermoscopic findings in which rcm was applied for diagnosis and follow - up . there was a good correlation of rcm with histopathology and a lack of dynamic changes during follow - up . our observations indicate that rcm , as a non - invasive tool , can be useful for diagnosis and follow - up of clinically and dermoscopically equivocal ns . nevus spilus ( ns ) is a relatively common cutaneous lesion that is seen in 23% of the population . it is characterized by numerous small , darkly pigmented macules or papules on a tan background pigmentation and is also referred to as speckled lentiginous nevus , the background tan patch is usually present at birth and ns is therefore considered a subtype of congenital melanocytic nevus . the typical dimension of ns ranges from 2 to 10 cm , but some ns may cover extensive skin areas with regional or zosteriform distribution . histologically , the background hyperpigmentation has been described as having the features of a lentigo simplex or a caf - au - lait macule . the darker speckles of ns are classically reported as superimposed junctional or compound nevi , but intradermal , spitz , and blue nevi may occasionally occur . ns are potential precursors of melanoma , which underlines the need for a precise examination and a close lifelong follow - up to exclude malignancy . the risk that melanoma develops within a ns is thought to be proportional to the size of the lesion and has been reported to be higher for macular than for papular ns . more than 20 cases of melanoma arising within a ns have been reported in the literature ; over 90% of these cases were histologically classified as superficial spreading melanoma . with the following case report , we will show for the first time that in vivo reflectance confocal microscopy ( rcm ) , as a convenient non - invasive method for skin investigation , is useful in diagnosis and follow - up of ns . a 15-year - old girl was referred to our outpatient department because of a giant congenital ns covering her right scapular region and upper aspect of her right arm . recently , the patient had noticed the development of multiple darkly pigmented spots within the nevus . skin examination revealed multiple light to dark brown macules and papules within the ns , measuring 0.2 to 3 cm in diameter ( figure 1 ) . dermoscopy of the newly developed lesions showed a brown to black homogeneous or homogenous - reticular pigment pattern with focal gray - blue areas , suggestive of regression ( figures 2a and 3a , c ) . in addition , many of the lesions displayed irregularity of the pigment network and irregular dots , altogether raising the suspicion of malignancy . in vivo rcm ( vivascope 1500 , mavig gmbh , munich , germany ) of a representative lesion showed a typical honeycomb pattern at epidermal layers and a regular ringed pattern at the dermoepidermal junction ; uniformly distributed dermal papillae surrounded by a rim of bright monomorphous cells , correlating to pigmented keratinocytes and melanocytes , were seen ( figure 2b , c ) . additionally , small junctional aggregates of melanocytes protruding into the dermal papillae were found . at upper dermis , there were focal aggregates of non - nucleated plump bright cells compatible with melanophages . these results correlated well with the histopathologic findings , which were consistent with the diagnosis of junctional melanocytic nevus without atypia ( figure 2d ) . the remaining newly developed lesions within the ns showed similar confocal findings suggestive of benign nevi . these lesions were monitored with digital dermoscopy and rcm and did not show any changes at a three - month follow - up visit ( figure 3 ) . the progressive appearance of macules and papules within a ns , as observed in our case , is not unusual . although the majority of these newly arrived lesions are benign , a risk for melanoma exists ; therefore , a close follow - up of large ns is essential since their dimensions rarely permit a complete surgical excision . rcm , as a new method capable of producing real - time in vivo sections of the skin at a nearly histologic resolution , permits cytological analysis to complement dermoscopy and histopathology for melanoma detection . multiple studies have already demonstrated excellent correlation between confocal microscopy and conventional histology for melanocytic lesions . despite its maximum in vivo imaging depth of approximately 250 m therefore , rcm should be adequate for the detection of melanoma within ns , since most cases reported were superficial spreading melanomas . in addition , this technique allows completely safe and painless repetitive application and observation of dynamic changes in situ over time and consequently may reduce unnecessary excisions . the good correlation of rcm with histopathology in our case indicates that rcm , as a non - invasive tool , can be used as an auxiliary for differentiation of nevi from melanoma in clinically and dermoscopically equivocal ns .

background : nevus spilus ( ns ) is a potential precursor of melanoma ; the vast majority of cases reported in the literature were histologically classified as superficial spreading melanoma.objective:to demonstrate the diagnostic value of reflectance confocal microscopy ( rcm ) in this subtype of congenital nevi.methods:we report a case of a large congenital ns with equivocal clinical and dermoscopic findings in which rcm was applied for diagnosis and follow-up.results:there was a good correlation of rcm with histopathology and a lack of dynamic changes during follow-up.conclusion:our observations indicate that rcm , as a non - invasive tool , can be useful for diagnosis and follow - up of clinically and dermoscopically equivocal ns .

a 35-year , 10 month - old male patient presented to department of oral surgery with a chief complaint of swelling in the left side of the face with visual disturbances [ figure 1 ] . further , he complaints of a huge mass in the upper left dental arch region for past 1 year , which gradually increasing in size with difficulty in mastication and bleeding on touch without any difficulty in pain and swallowing . past medical history extra oral examination showed along with swelling in the left region off the face an altered infra orbital bony contour and proptosis . on intra oral examination , a large circumscribed mass involving the left posterior region of hard palate from midline and extended bilaterally displacing the left upper molars and premolars [ figure 2 ] . swelling was firm and well - demarcated margin . 2 and 3 molar teeth was having grade 3 mobility , displaced , extruded severely below the occlusal plane , bleeding on probing without pain and tenderness . extra oral photograph- frontal view intraoral photograph showing displaced teeth orthopantomogram and contrast enhanced computed tomography scan showed expansible lytic lesion with osseous fragments involving the posterior 1/3 of the hard palate and alveolar ridge corresponding to premolar and molar regions [ figures 3 and 4 ] . further , it invades the left maxillary sinus involving the floor of the orbit and part of ethmoid . anteriorly , it involves the right nasal passage abutting the inferior turbinate and blocking the airway . orthopantomogram showing the lesion computed tomography image showing the extension of the lesion weber - fergusson approach was carried out with en - bloc resection of the tumor [ figures 5 and 6 ] . following resection closure of palatal defect was carried out using ipsilateral buccal pad of fat by careful , gentle dissection and reconstruction [ figure 7 ] . remaining portion was packed with bismuth iodoform paraffin paste pack and secured with an acrylic stent . post - operative period was uneventful and healing was favorable and good [ figure 8 ] . intraoperative view after excision of mass specimen of the lesion intra operative buccal fat of pad harvesting post - operative surgical site after 6 months of healing weber - fergusson approach was carried out with en - bloc resection of the tumor [ figures 5 and 6 ] . following resection closure of palatal defect was carried out using ipsilateral buccal pad of fat by careful , gentle dissection and reconstruction [ figure 7 ] . remaining portion was packed with bismuth iodoform paraffin paste pack and secured with an acrylic stent . post - operative period was uneventful and healing was favorable and good [ figure 8 ] . intraoperative view after excision of mass specimen of the lesion intra operative buccal fat of pad harvesting post - operative surgical site after 6 months of healing cof was a well - circumscribed expansible lesion with calcified matrices involving both maxilla and mandible and it was considered as an aggressive lesion when it involves the maxillary antrum . however , surgical resection was done when lesion was very wide with involvement of adjacent structures . recurrence following complete excision is generally considered to be uncommon . in case of bone erosion reconstruction of the defect also is simple with primary closure , split thickness skin grafting , regional flap , skin graft , tongue flap and buccal pad of fat . studies suggested that the buccal fat of pad with its high vascularity and easy harvesting technique has a very high success rate in the reconstruction of oral defects . cof a rare kind of lesion in maxilla even in aggressive extensive form can be managed surgically with least recurrence . reconstruction of the defect with buccal fat pad helps the surgeon to reduce the size of the defect with favorable prognosis thereby avoiding the need to opt for extensive flaps or other reconstructive options .

a cemento - ossifying fibroma ( cof ) is a rare benign neoplasm of maxilla when compared with mandible ( world health organization , 1992 ) . cof of maxilla may be quite large and locally very aggressive lesion . these tumor mass was peeled out by en - bloc excision using gentle blunt dissection . this paper presents 35-year - old male patient who had a gradually expanding lobular mass in the left maxillary posterior region for past 1 year . he has been treated successfully by surgical en - bloc resection . various techniques were used to reconstruction the defect . buccal pad of fat is a simple technique having advantages like good vascularity , adaptability , good closure of the defect with favorable prognosis .

the rapid increase in the number of bariatric surgeries such as sleeve gastrectomy ( sg ) or roux - en - y gastric bypass has driven a parallel increase in revisional bariatric surgeries which is needed in 550% of patients [ 1 , 2 ] . leaks remain a major complication after primary sg , due to its associated high morbidity and mortality [ 3 , 4 ] . according to a recent review comparing primary and revisional sg , management of leaks after sg is challenging and more complex , including surgical revision , percutaneous drainage of abcess , enteral hyper - alimentation and antibiotics therapy [ 69 ] . endoscopic approach developed recently using deployment of stents or pigtail drain [ 8 , 9 ] . however , pigtail drain acts as a foreigner body , which can migrate through fluid collection . we reported the first case of esophagopericardial fistula ( epf ) secondary to migration of a double pigtail drain , set up in order to resolve a gastric leak after revisional sg . a 31-year - old woman , who underwent revisional sleeve gastrectomy ( rsg ) 12 days ago in another hospital , was admitted in our multidisciplinary care team dedicated to the management of bariatric complications , with severe sepsis . emergent chest and abdominal computed tomography ( ct ) scan showed a deep - seated abscess in link with a fistula on the upper third of the staple line . surgical revision was performed to treat peritonitis and included abdominal washout , abdominal drainage close to the staple line and a feeding jejunostomy , respectively . medications included proton pump inhibitors , appropriate antibiotics , somatostatin analogs and exclusively parenteral nutrition followed by enteral nutrition via the feeding jejunostomy . after the initial re - operation , percutaneous drainage ( using 14fr and 10fr external pigtail drains , respectively ) was required on postoperative day ( pod ) 8 due to persistent intra - abdominal abscess on ct scan . during follow - up , a plastic 4 cm x 10 french double pigtail drains was placed on pod 21 through the staple line orifice by endoscopy ( figs 1 and 2 ) . external drainage ( inserted during radiological procedure on pod 8) was removed 3 days later not only because of clinical and biochemical patient 's improvement but also to avoid the development of an external fistula . figure 1:fibroscopy : a 5-mm fistulous hole on the high part of the stomach . control x - ray after the double pigtailed drain has been put up . on pod 13 , the patient experienced retrosternal pain , breathlessness , tachycardia ( 110 beats per minute ) and pyrexia ( 38.5c ) . chest ct scan performed emergently confirming a fistula between the pericardium and the esophagus related to the proximal end of the double pigtail drain ( figs . stabilization was achieved with catecholamines and fluids and the multidisciplinary team decide to operate urgently . therefore , a right - sided thoracotomy was used to enter the pleural cavity through the seventh intercostal space . the intraoperative situs showed a 15-mm defect of anterior side of the esophagus with penetration to the pericardium . a pericardial incision was performed in order to evacuate turbid fluid followed by a pericardial window for continuous drainage . because of severe sepsis , the esophagus was defunctioned with a cervical esophagostomy , a gastrostomy and a previous feeding jejunostomy . an elective reconstruction of his esophagus with the colon will occur 6 months later . figure 3:circumferential pericardial effusion ( arrow ) . figure 4:proximal end of the double pigtail drain externalizes in the pericardium ( arrow ) . figure 5:coronal view of opacification on ct showing the externalization of the drain in the pericardium ( arrow ) . figure 6:axial view of opacification on ct showing the externalization of the drain in the pericardium ( arrow ) . coronal view of opacification on ct showing the externalization of the drain in the pericardium ( arrow ) . axial view of opacification on ct showing the externalization of the drain in the pericardium ( arrow ) .

abstractesophagopericardial fistula ( epf ) is an uncommon but life - threatening complication of upper gastrointestinal tract surgery or endoscopy , which is related to anastomotic breakdown , chronic infection or esophageal traumatism . we first describe the first case of an epf secondary to double pigtail drain migration : an endoscopic internal approach for the treatment of leak following revisional sleeve gastrectomy .

nevus sebaceus ( ns ) is a common congenital birthmark that occurs most frequently on the head and face . removal is preferable because various tumors have been reported to develop in ns [ 1 , 2 ] . basal cell carcinoma ( bcc ) seldom occurs in ns , and it is very important to be able to clinicopathologically distinguish bcc from trichoblastoma . herein , we describe a case of bcc and trichoblastoma occurring simultaneously in the same ns , including the differential dermoscopic features . a 77-year - old woman had been diagnosed at the age of 15 years with ns which had started from the left side of her ear and extended to her chest . she was referred to our hospital with a 3-year history of black macules on the left ear . a physical examination showed yellowish plaques around the left side of the neck and small , numerous yellow papules in the ns . a black macule of 2 mm in diameter was observed on the left auricle ( fig . a dermoscopic examination revealed multiple blue - gray ovoid nests and whitish veils , but arborizing vessels were not found ( fig . a surgical specimen showed that tumor cells were proliferating from the epidermis to the upper dermis and were arranged in a palisading pattern at the periphery with basal melanosis . deposits of mucin and clefts were observed in the surrounding area with dilated vessels in the papillary dermis ( fig . three months after the surgery , a small black macule appeared on the left earlobe which slowly enlarged . a physical examination indicated the presence of a small black macule with a diameter of 1 mm on the left earlobe ( fig . a dermoscopic examination revealed a round , homogeneous , brownish structure without arborizing vessels ( fig histopathologically , the surgical specimen showed that the tumor cells were proliferating in the dermis , presented as multiple different shapes , were either clear or basophilic , and were arranged in a partial palisading pattern . the tumor cells also resembled follicular germinative cells without keratinizing cysts , and islands of tumor cells were present as hair bulbs surrounding fibrous stroma ( fig . a study on tumors occurring in ns found that trichoblastoma was observed in 4.7% of cases ( 28 of 596 cases ) and bcc in 0.8% of cases ( 5 of 596 cases ) . in a dermoscopic examination of bcc , arborizing vessels were observed in 84.1% of cases and multiple blue - gray ovoid nests in 36% of cases . multiple black structures , and the trichoblastoma showed a single black structure without arborizing vessels . we theorize that this difference is a specific clue when distinguishing between bcc and trichoblastoma in ns . in a dermoscopic examination of ns , it is difficult to precisely evaluate a macule with vessels directly under the epidermis due to histopathological modifications of the background , particularly under the influence of epidermal proliferation . this is why our bcc did not reveal arborizing vessels . in conclusion , most ns are removed to avoid secondary tumors , including bcc ; thus , there have been no reports on their dermoscopic findings .

nevus sebaceus ( ns ) is a common congenital birthmark , and various tumors have been reported to develop in ns . basal cell carcinoma ( bcc ) seldom occurs in ns , and it is very important to be able to clinicopathologically distinguish bcc from trichoblastoma . herein , we describe a case of bcc and trichoblastoma occurring simultaneously in the same ns , including the differential dermoscopic features . bcc is clinically difficult to distinguish from trichoblastoma because the clinical manifestations are similar . in a dermoscopic examination of bcc , arborizing vessels are one of the diagnostically significant features . in our case , the bcc showed multiple black structures , and the trichoblastoma showed a single black structure without arborizing vessels . to the best of our knowledge , there have been no reports on the dermoscopic findings of secondary tumors on ns .

humans deploy deictic gestures , such as pointing , to direct a recipient 's attention to a particular object or location , while iconic gestures are deployed to recreate an aspect of the shape or movement of an object or event . both types of signals are referential , in that they either direct attention to a present referent or generate a mental representation of an absent referent . so far , there has been very little evidence for referential signals of these kinds in great apes . this is surprising because language - trained apes have no difficulties communicating referentially with humans . reported that kanzi and mulika made hitting motions toward nuts they wanted a human observer to crack open for them . surprisingly , however , these individuals do not spontaneously use their acquired communication skills to interact with each other . nevertheless , our study suggests that great apes are capable , in principle , of producing iconic and deictic gestures even when interacting with each other , and a main conundrum is why do not take regular advantage of this capacity . ( 1 ) motor constraints iconic gesturing may be rare because it is mechanically easier for an ape to depict a movement in space ( e.g. direction of approach , location of desired grooming ) , than to pantomime other types of activities . however , a few anecdotes suggest that apes sometimes pantomime actions , although typically when interacting with humans . for example , gruber et al . reported on a bonobo apparently pantomiming drinking from a cup to communicate to her caretaker , indicating that great apes are not fundamentally incapable of pantomiming . also , byrne and byrne have shown that gorillas can produce complex , fine - tuned finger movements to process food , suggesting that apes are not fundamentally constrained in terms of their motor control . ( 2 ) conceptual constraints another hypothesis is that great apes may only have limited capacities to mentally represent the world around them . for example , they may be able to mentally represent the notion of movement but they may have a concept of fruit tree or tool. although there is little doubt that primates and other animals can represent their worlds in terms of mental concepts , these concepts may be less clearly delineated compared to what is present in humans . although this is a difficult topic , we interpret the current evidence as consistent with the hypothesis that primates can form mental representations of social categories ( such as genetic relatives ) , or physical objects and their functional properties , such as tools ( gruber et al . submitted ) , suggesting that apes are not fundamentally constrained in terms of cognitive capacities to mentally represent their world in in conceptual categories . ( 3 ) comprehension constraints human children use deictic gestures from about 10 months when communicate to their caretakers , long before they produce their first words . iconic gestures emerge somewhat later , around 12 months , an important step toward the ability to use symbols . interestingly , however , the comprehension of iconic symbols appears much later , around 26 months , following the acquisition of basic symbolic speech . the comprehension of iconic gestures , in other words , appears to be cognitively more demanding for children than its production or the comprehension of deictic signals , including pointing . in our study , however , subjects appeared to understand the intention behind beckoning , but it was unclear whether this was due to general capacity to comprehend iconicity or some simpler process . here , it would be necessary to explore whether apes can comprehend iconic signals that are novel to them , but depict some natural behavior ( e.g. , climbing , grooming ) or a relevant object ( e.g. tool , fruit tree ) ? ( 4 ) cooperative constraints apes experience personal intentions , and use communication signals to communicate intentions to others , but they appear to be unable to share their intentions with others i.e. they lack a we - intentionality as it is typical for humans . because of this , the argument goes , great apes will only communicate what is beneficial for them and not what is useful for others . although the hypothesis has intuitive appeal , there are also some contradictory findings , suggesting that , in some conditions , primates communicate intentionally to direct the attention of others to external objects or events relevant to them . this has been found in the contexts of danger , foraging , and during fights . however , although great apes are not fundamentally incapable of sharing information with others they may only show this behavior in very specific situations where their own reproductive success is directly at stake . our findings have shown that great apes can naturally use spatial reference as part of a communicative intention with signallers producing gestures that depict the spatial features of a desired action and recipients responding to such signals appropriately . although this suggests that iconic signaling is part of natural communication in great apes , and as such present in the common ancestor of humans and apes , it is equally puzzling how rare such behavior is in great apes , despite its obvious advantages . we address 4 possible hypotheses on potential shortcomings underlying this human - ape difference : motor control , conceptual organization , comprehension abilities and shared intentional capacities , and find some support for the last one . however , it is also clear that more research is needed to decide what cognitive or psychological shortcomings really are responsible for the apparent underuse of a truly human capacity , the ability to use communication to iconically refer to an absent entity . we thank claudine andr and brian hare for permission to work at the lola ya bonobo sanctuary and the ministry of research and the ministry of the environment of the democratic republic of congo for supporting our research . we are grateful to all of the lola ya bonobo staff for their invaluable assistance , to richard w. byrne and catherine hobaiter for discussions .

we comment on a recent behavioral study in which we describe a human - like beckoning gesture in 2 groups of bonobos , used in combination with sexual solicitation postures . the beckoning gesture fulfils key criteria of deixis and iconicity , in that it communicates to a distant recipient the desired travel path in relation to a specific social intention , i.e. , to have sex at another location . we discuss this finding in light of the fact that , despite the documented great ape capacity and obvious communicative advantage , referential gestures are still surprisingly rare in their natural communication . we address several possibilities for this peculiar underuse and are most compelled by the notion that non - human primates are generally not very motivated to share their experiences of external objects or events with others , which removes most reasons for referential signaling .

in the last decades , in the health sector but especially in the clinical laboratories , the implementation of management systems under requirements of international standards has increased and improved the knowledge and functioning of processes with increasing the results , information and data which provide to the health care process and help to enhance the quality of life and generate a positive impact in health facility in terms of costs ( decrease the need of unnecessary diagnostic procedures ) . likewise , the management system has been a tool , which has improved its operative and technical processes and adopted systemic methodologies for resolving problems on a day to day basis and give answers to questions in the actual context , where the quality and security of the results is increasingly under scrutiny . in the past 2 decades , latin - american professionals of clinical laboratory have focused their efforts to meet demands of patients , the requirements from the clinicians and regulatory organisms , and have focused on implementing international certified standards , for example the iso 9001:2008 ( 1 , 2 ) . despite limited resources , professionals of clinical laboratory have worked relentlessly to implement management systems for the achievement of organizational goals . today , in the xxi century , in the year 2015 , we understand that the management system helps answer the needs of a process and have been flexible , dynamic , and simple with contribution to the organization in order to achieve an internal balance that guarantees sustainability . it has been realized that implementation of quality management benefits patient care , and it may not be promptly evident , but such an investment results in long - term sustainability . the management of quality can be defined as a set of activities that is developed with which an organization can operate and promotes fulfillment of its mission and reach its vision , through a systemic methodology that permits continual improvement under excellent planning of all its processes , including execution and verification . the implementation of corrective and preventive actions is a must ; the subsequent improvement is evidence of organizational learning . it is the authors personal experience of 20 years in implementing quality managements systems that the eventual end benefactor is the patient . in latin - america , for many years , the clinical laboratories implemented the iso 9001:2008(1 ) standard for their management system , this constituted a true challenge because this standard is not specific for clinical laboratory processes and in some requirements was short in the must for the particularities of laboratory . however , the model was implemented and with the iso 9001:2008(1 ) our laboratories gained experience with registry , methodology for documenting their procedures , control mechanism and follow - up . they implement very important components like program of internal audits that result in management indicators ; these are elements that were not materialized in the iso standards . additionally , with the follow - up of measuring instruments , for first time , the phrase metrology is real in the clinical laboratories and inside the language of our professionals , the traceability , calibration , reference materials are part of the day to day procedures of all laboratories ( 3 ) . the iso 15189:2012(2 ) specific standard for quality requirements and competence for clinical laboratories is widely delineated . the accreditation for our quality management system in clinical laboratories with conformity to quality requirements and competence of iso 15189:2012(2 ) standards is a real context and the correct way for us that we have been committed with the quality of results and security of the process in clinical laboratory . this standard iso 15189:2012:2012(2 ) implies a system of management of quality with risk approach ; this guarantees migration from a reactive approach to a preventive and proactive model . with the exhaustive incorporation of musts toward patient security , identification of technology risks and reactivity , we have succeeded in confirming to the global guidelines of the world health organization ( who ) as regards to patient security , techno vigilance , and reactive vigilance and hemovigilance as applicable . in terms of clinical effectiveness , it streamlines the responsibility of clinical laboratory in the notification of critical results , definition , communication and impact measurement , as well as tied all the aspects related with the information system and the mechanisms of verification , control and security of auto verification process or auto validation through mild ware ; this was beyond contention in previous versions . additionally , the requirement of validation / verification/ evaluation of methods , insurance of quality , the obligation to participate in programs with other laboratories accredited with iso 17043(4 ) the need of measure the uncertainty e.g. , parameter of exactness in the result , have been the challenge in the academy for our analysts and has generated an improvement of competences . as such , today we have the professionals of best domain and empowerment , not only in statistical tools but also in knowledge of assay tools and control of variables . the management systems have contributed significantly to decrease the variability of procedures through the standardization and the possible use of means available with eventual benefit to patient care . added to this , the goal that is possible , visible and quantifiable in the transformation towards the culture of improved quality and security of patient care . the actions towards continued improvement , the search of excellence and zero mistakes is invaluable for attainment of precise information to professionals in this discipline .

the implementation of management systems in accordance with standards like iso 9001:2008 ( 1,2 ) in the clinical laboratories has conferred and added value of reliability and therefore a very significant input to patient safety . as we know the iso 9001:2008 ( 1 ) a certification standard , and iso 15189:2012 ( 2 ) an accreditation standard , both , at the time have generated institutional memory where they have been implemented , the transformation of culture focused on correct execution , control and following , evidence needed and the importance of register .

a 56-year - old fit and healthy gentleman was admitted with symptoms of belching , mild abdominal pain and weight loss of 2 weeks duration . ct also demonstrated filling defects in the portal vein and its intrahepatic main branches consistent with thrombosis and hepatosplenic infarcts ( fig . 1 , fig . 2 , fig . 3 , fig . additional evaluation by magnetic resonance imaging ( mri ) did not reveal any lesion in the porta hepatis . the patient had upper gastrointestinal endoscopy to rule out varices and colonoscopy which did not reveal any lesion . contrast ct and mri demonstrated revascularisation of the previously thrombosed portal vein and resolution of infarcts in the liver and spleen ( fig . portal vein thrombosis ( pvt ) is rare but can occur with any condition predisposing to thrombosis . the population prevalence of pvt is around 1% and mostly secondary to hepatic cirrhosis ( 28% ) . 10% have been implicated with major abdominal infections or inflammatory disease and 3% with myeloproliferative disorder . the signs and symptoms of pvt can be subtle or nonspecific as in our case or they can be overshadowed by those of the underlying illness . abdominal pain , gastrointestinal haemorrhage due to esophageal varices , hepatosplenomegaly , ascites and portal systemic encephalopathy are recognised clinical features . the preferred investigations include duplex ultrasonography and/or colour doppler ultrasonography , ct and magnetic resonance angiography ( mra ) . plain abdominal ultrasound may not be helpful in diagnosing pvt , sometimes clot with variable echogenicity may be depicted in the portal vein . although in most patients ultrasound is the initial investigation , our patient had ct scan of the abdomen first and ultrasound scan of the abdomen later as the sensitivity of thrombus characterisation is reportedly low in ct although if seen it complements the diagnosis . hepatic infarcts usually appear as well - circumscribed , peripheral , wedge - shaped areas of decreased attenuation at ct as in this patient . treatment options include mechanical recanalisation of the portal vein , systemic anticoagulation , local fibrinolysis with or without placement of a transjugular intrahepatic portosystemic stent shunt , combination of mechanical recanalisation and local fibrinolysis and surgical thrombectomy . sheen et al . suggest that if acute pvt is found , patients have to be treated with anticoagulant therapy .

a 56-year - old male was admitted with symptoms of belching , abdominal pain and weight loss of 2 weeks duration . examination revealed hepatosplenomegaly which was confirmed by computed tomography ( ct ) . ct images also revealed filling defects in the portal vein and intrahepatic branches consistent with thrombosis and hepatosplenic infarcts . alkaline phosphatase was elevated at 688 units , all other investigations , including full blood count , coagulation screen and tumour markers , were normal . magnetic resonance cholangiopancreatography did not reveal any mass in the porta hepatis . upper gastrointestinal endoscopy and colonoscopy were normal . liver biopsy was normal and did not reveal any evidence of lymphoma . the raised alkaline phosphatase settled to reference range over a period of 3 weeks . thrombophilia screen was negative . contrast ct of the abdomen performed after 4 weeks displayed revascularisation of the previously thrombosed portal vein and intrahepatic branches . the patient has remained asymptomatic since and we note spontaneous recanalisation of the previously occluded portal vein .

in 1983 , rosen first described syringomatous adenoma of the nipple ( san ) , a benign tumor of the breast that shows locally infiltrative proliferation and is histologically similar to syringomas . we describe a case of san that is the fourth in japan and the first case reported here within the field of dermatology . the patient was a 51-year - old male office worker who visited the dermatology and allergology clinic of our hospital in july 2009 for evaluation of a subcutaneous nodule in the right breast . he had first noticed the lump 5 years earlier and had become concerned as the lump gradually increased in size . the lesion was a relatively well - circumscribed , elastic , hard , 17-mm subcutaneous nodule adjacent to the areola of the right breast . 1 ) . we considered the lesion likely to be a mammary gland tumor , and the patient was referred to the department of breast surgery for further evaluation . mammography showed a well - circumscribed nodule with a smooth margin on the outside of the upper right breast . these results indicated that the lesion was not a malignant tumor ; furthermore , it was determined that the lesion had not derived from the mammary gland . histopathological analysis revealed several relatively well - circumscribed nodular lesions occurring from within the dermis to the subcutaneous tissue . cells within the nodules showed two phases : ( i ) proliferating tumor cells with compressed duct - like structures surrounded by fibrotic stromal cells and ( ii ) other scattered tumor cells filled with abundant mucus and with no apparent duct - like structures . the highly magnified image of the duct - like structures showed proliferation of multilayered epithelial cell nests forming comma - shaped partial ducts . the duct - like structures were composed of an external layer of relatively pale - stained tumor cells and an internal layer of tumor cells with eosinophilic cytoplasm ( fig . the stromal cells tested positive for alcian blue staining and showed deposition of mucus and hyalinization of collagen fibers . images of dyskaryosis or karyokinesis in the tumor cells were unremarkable . in immunohistochemical staining , the cells within the lesions all tested positive for antibodies to ae1/ae3 , ck7 , cam5.2 , p63 , sma and s-100 protein . the myoepithelial cells were positive for anti - p63 antibody , and the epithelial cells were negative ; thus , the epithelial cell nests showed a biphasic staining pattern , confirming their benign nature . based on the morphological features and the findings of the immunohistochemical staining , these tumors were diagnosed as san . there have been english - language reports on 34 cases of san since rosen initially reported 5 cases in 1983 ( table 1 ) . san is a locally infiltrative tumor that does not cause distant metastasis ; however , recurrence has been reported in cases of incomplete excision [ 2 , 3 , 4 , 5 , 6 , 7 ] . based on histological classification of mammary gland tumors , differential diagnoses include nipple adenomas and low - grade adenosquamous carcinomas . nipple adenomas are papillary or solid adenomas developing within the nipple where proliferation of papillary epithelium is remarkable [ 1 , 2 ] . low - grade adenosquamous carcinomas that derive from the salivary gland duct show an adenoma - like structure . because they frequently develop in the large and small salivary glands , these carcinomas can be differentiated from their sites of origin . based on histological classification of apocrine and eccrine sweat gland tumors , differential diagnoses include malignant mixed tumors and microcystic adnexal carcinomas ( macs ) [ 9 , 10 ] . malignant mixed tumors are composed of both epithelial and stromal components and have a cartilage - like appearance . macs derive from the eccrine sweat ducts and have an upper layer composed of funicular , keratinous cyst - like and syringoma - like structures , and a lower layer composed of duct - like structures and funicular structures . macs differ from san in that they have a high recurrence rate , compared to a low recurrence rate for san even after conservative excision . another difference is that metastasis of macs has been reported , but there have been no reports of san metastasis . san forms comma - shaped cell nests or small glandular cavities with single or multiple layers of small homogeneous epithelial cells in a background of dense stromal cells . it proliferates and can infiltrate tissue from the nipple to as far as the subareolar stroma . some san differentiate to squamous epithelium . based on morphological features the tumors are likely to have originated from the eccrine sweat ducts remaining in the breast . to our knowledge , only 4 cases of san , including our case , have been reported in japan since 1983 . the cases include 3 women and 1 man , ranging in age from 36 to 87 years ( mean age 63 ) . the sites of origin were the nipple in 3 cases and the areola in 1 case . careful excision is necessary for the treatment of san in order to avoid recurrence of the tumor .

syringomatous adenoma of the nipple ( san ) is an extremely rare disease originating in the adnexal gland ; it was first reported by rosen in 1983 [ am j surg pathol 1983;7:739745 ] . since then , 34 cases have been reported worldwide . we present the case of a 51-year - old man with san , in whom local excision of the tumor was performed . histologically , the tumor consisted of tubules , ductules and epithelial cell strands , and most of the proliferating ducts presented with a characteristic teardrop or comma - shaped appearance .

despite recent advancement in radiotherapy and molecular - related therapies , radical cystectomy remains the mainstay of treatment for muscle - invasive bladder cancer . although technically easier to perform compared with continent reservoirs , ileal conduit has not been associated with lower complications . we report a case of a male patient with a recent 4-month history of cystectomy and ileal conduit , presented to the accident and emergency department with an ileal conduit stricture . an 80-year - old gentleman presented to a&e department for general weakness and paralysis of all four limbs . his past medical history includes type 2 diabetes mellitus , spinal stenosis at the level of l2/l3 , l3/l4 and l5/s1 . he said that he had become unwell since his cystectomy operation 4 months prior to his attendance at a&e . he also denied any loin pain . on examination , his abdomen was soft , a draining ileal conduit stoma was observed , sensation and reflex at all limbs were intact , but motor power of all limbs was diminished . his initial blood test shows the potassium level of 9.1 meq / l , serum urea of 20.1 mm / l , creatinine of 521 m / l . he was immediately treated with calcium gluconate 10% , insulin - sliding scale and salbutamol nebulisers . an ultrasound scan of the renal tracts was carried out and subsequently shows bilateral hydronephrosis . computed topography of the head revealed no intracranial bleed or infarct for the cause of paralysis . due to his worsened renal function , a loopogram was performed and showed a stricture 4 cm proximal to the skin opening of the ileal conduit ( see fig . 1 ) . figure 1:loopogram revealed the stricture at 4 cm proximal to the skin opening of the conduit . loopogram revealed the stricture at 4 cm proximal to the skin opening of the conduit . the patient was treated conservatively with 2 weeks of intravenous ciprofloxacin antibiotics and nephrostomy tubes were inserted as a diversion . the surgical exploration revealed a small fibrous tissue band of mesenteric origin 4 cm proximal to the skin opening of the ileal conduit . the patient recovered uneventfully , his renal function improved remarkably and he was discharged back to community care after a stormy hospital stay . ileal conduit stricture has been described in a 2.58.5% at a median of 10 years after surgery . in relation to our case prior authors have suggested the occurrence of ileal conduit stricture is secondary to ischaemia which has resulted in severe transmural inflammation with submucosal fibrosis . magnusson et al . used transmission electron microscopy to demonstrate a reduced height of microvilli , presence of glycocalyceal bodies and an increased number of lysosomes . other hypotheses such as reaction to noxious agent in the urine , immune causation were also proposed . ileal conduit strictures can be investigated through three means : computed topography urogram , loopogram and looposcopy . due to our patient 's nature of renal failure , a series of x - ray was initiated after contrast liquid was injected through the stoma . in our case , it showed a stricture 4 cm proximally to the skin opening of the ileal conduit . stenosis at the skin level can be managed by dilating the stoma opening , usually by inserting a lubricated digit down to the fascial layer for several minutes . the downside is patients may need frequent and repeated technique , and it also carries the small risk of forming false passage or opening . in our case , although ileal conduit stricture is rare , this potentially serious and life - threatening complication can be prevented with cautious surgical closure of abdomen . stringent follow - up in stoma centre is also an essence to continuity of patient care . in the case described , the patient experienced significant morbidity in terms of re - admission to hospital , further surgical procedures and prolonged hospital stay . consequently , surgeons should always be mindful of checking that the mesenteric pedicle is not twisted to avoid further perils during the postoperative period .

ileal conduit remains a widely used urinary diversion performed after radical cystectomy . however , complications of ileal conduits remain an important concern in urological surgery . we report a rare case of an ileal conduit stricture , which can have grim complications if unobserved during the operation . following an initial operation of radical cystectomy and ileal conduit formation in france in 2011 , an 80-year - old male travelled back to the uk after 4 months of general weakness and limb paralysis . initial blood test shows life - threatening hyperkalemia and worsened renal function . subsequent ultrasound kub scan and loopogram revealed obstructive uropathy . the initial management includes intravenous antibiotics and bilateral nephrostomies were inserted to aid diversion of urine . a thorough surgical exploration revealed a twisted , fibrous mesenteric band adhered to the proximal part of the ileal conduit . only one case report of ileal conduit stenosis was described many years after the procedure .

the field of cell biology emerged in the 1950s with the ability to observe at nanometer resolution cellular structures and their interconnections through the electron microscope . however , a limitation of this technology is the small field of view captured in a single image only on the scale of a few microns square . although these high - magnification images provide impressive resolution of the selected area of the cell , they are often difficult to put into the broader biological context of a cell or tissue . on the other hand , overview images taken at a lower magnification help to present the big picture but lack cellular detail . recent technological developments have enabled the integration of imaging and computational tools to allow virtual nanoscopy , the visualization of specimens at nanometer resolution but millimeter scale , a scale unheard of just a few years ago . these approaches allow the seamless zooming in and out from subcellular- to tissue- or even organism - level views without loss of resolution ( fig . 2012 ) describe automated image acquisition and stitching technology using a standard laboratory transmission electron microscopy platform to generate large - scale electron microscopy datasets . by accurately stitching together more than 26,000 individual images at nanometer resolution , they generated virtual slides up to 1.5 mm ( 921,600 pixels ) 0.6 mm ( 380,928 pixels ) for a total of 281 gigapixels ( http://jcb-dataviewer.rupress.org/jcb/browse/5553 ) . as a proof of principle , they applied this method to generate a map of the vast majority of a 5-day post - fertilization zebrafish embryo at 1.6-nm resolution per pixel ( the equivalent of 16 million dpi ) . ( 2012 ) does not require a customized imaging platform , and it is applicable to a broad range of transmission electron microscopy samples , including samples that have been embedded in resin or cryo - vitrified and that are either unstained or have been immunolabeled using chemical or immunogold techniques . the resulting large - scale images allow the interrogation of morphological features over scales ranging from subcellular organelles and single cells to whole tissues to nearly an entire embryo . the ability to integrate information across cells and tissues in an unbiased manner provides an exceptional opportunity for discovery from the cell biological to the organismal level . overlapping images at progressively higher magnification from a 281-gigapixel composite image of a 5-day post - fertilization zebrafish embryo reveal subcellular features within single - cell , tissue , and organismal contexts ( image data faas et al . , 2012 ) . red boxes indicate the region selected for each successive magnification step ( indicated as percent magnification ) . conventional venues such as supplemental materials sections are not sufficient for publishing these large - scale image maps , however . to make publication of these data possible , jcb announces a major enhancement to the jcb dataviewer to host virtual nanoscopy data at the gigapixel scale . the jcb dataviewer was launched in 2008 to promote sharing of original data associated with jcb publications ( hill , 2008 ) . since then we have expanded the dataviewer to promote data analysis ( decathelineau et al . , 2010 ) and hosting of entire high - content , image - based screens ( williams and misteli , 2011 ) . now , if you are ready to go big with your imaging , the jcb dataviewer is ready to help you share your data with the cell biology community . despite ever - changing cell biological methods , imaging remains one of the key tools in our field . jcb remains committed to developing cutting - edge tools for the presentation of the data that drive progress in the field of cell biology . wherever the field of cell biology goes , jcb will continue to lead the way .

one of the major forces driving the birth of the field of cell biology was the application of electron microscopy to cells . today , virtual nanoscopy has brought electron microscopy and the cell biology community to a new frontier in biological imaging and cell biological inquiry . the journal of cell biology is pleased to announce that the jcb dataviewer is going big to host electron microscopy data at a whole new scale .

despite medicare approving the use of positron emission tomography / computed tomography ( pet / ct ) in staging primary breast cancer , little evidence is available to support the use of f - fdg - pet / ct for the detection of distant metastases in the initial staging of breast cancer . the national comprehensive cancer network recommends the following types of imaging for staging locally advanced breast cancer at the time of clinical diagnosis : bilateral mammography , breast ultrasonography as necessary , and chest imaging if patients had no symptoms or other abnormal staging studies , and breast magnetic resonance imaging ( mri ) , skeletal scintigraphy ( ss ) , and abdominal and/or pelvic computed tomography ( ct ) , ultrasonography , or mri if patients had symptoms or other abnormal staging studies.1 breast cancer patients with large tumors ( stage t3 or greater ) have an 8.3% to 15.1% risk of distant metastases.2 - 4 because locally advanced breast cancer has a very high rate of relapse,5 it is possible that the conventional imaging modalities noted above may fail to detect a substantial number of metastases.6 in this review , we examine whether f - fdg - pet / ct may play a role in the initial staging of breast cancer . many practicing investigators speculate that pet / ct might be more accurate than conventional imaging techniques for detecting distant metastases ; table 1 summarizes studies that have addressed this issue . fuster et al . , in a study of 60 primary breast cancer patients with large tumors , reported that 5 of the 8 cases of distant metastatic lesions were unsuspected before pet / ct was performed.7 carkaci et al . reported that among 41 patients with inflammatory breast cancer , 7 of the 20 cases of distant metastases were unsuspected before pet / ct examination.8 alberini et al . reported that among 62 patients with inflammatory breast cancer , 6 of 18 cases of distant metastases were unsuspected before pet / ct was performed.9 heusner et al . reported that among 40 patients with breast cancer , 3 of 10 cases of distant metastases were unsuspected before pet / ct was performed.10 groheux et al . reported that among 39 patients with clinical stage ii and iii breast cancer , all 4 cases of distant metastases were unsuspected before pet / ct was performed.11 on the basis of their results , both carkaci et al . and alberini et al . recommended the use of pet / ct in the initial staging of inflammatory breast cancer.8,9 in summary , although pet / ct has an estimated specificity and sensitivity of 95% and 99% , not enough data are available to recommend the routine use of pet / ct in breast cancer staging because the studies mentioned above all had small numbers of patients . further , the ability of pet / ct to detect distant metastases has never been tested prospectively in a large group of patients . another possible role of pet / ct may be its use in detecting local lymph node metastases from breast cancer . pet / ct provides more detailed anatomical information than pet alone about axillary and extra - axillary lymph nodes.78 fuster et al . reported that pet / ct was able to reveal previously unsuspected infiltration of axillary lymph nodes in 10 of 60 patients and infiltration of extra - axillary lymph nodes in 3 of 60 patients.7 carkaci et al . reported that among 41 inflammatory breast cancer patients , pet / ct detected metastases in the axillary lymph nodes of 37 ( 90% ) , subpectoral lymph nodes of 19 ( 46% ) , supraclavicular lymph nodes of 10 ( 24% ) , and internal mammary lymph nodes of 9 ( 22%).8 in the same study , 6 false - negative findings did not show hypermetabolism on pet / ct but showed malignancy on sonography - guided fine - needle aspiration biopsy . ueda et al . reported that the diagnostic sensitivity and specificity of f - fdg - pet / ct were nearly equal to those of ultrasonography , 58% and 95% , respectively , compared with 54% and 99% in ultrasonography.12 although the studies listed above reported some false - positive findings in both the lymph nodes and distant sites,7,8 pet / ct resulted in fewer false - positive findings than did pet alone.7,8 however , not every distant metastatic site detected by pet / ct was confirmed by histopathological analysis in these studies . diagnostic biopsy of the metastatic site is the gold standard for diagnosing metastatic lesions , and if pet / ct reveals suspected distant metastases , a biopsy must be performed to confirm those findings . in summary , the use of pet / ct in the initial staging of primary breast cancer is not yet well defined and not recommended at present because there is limited evidence to support its use . however , because studies have shown that pet / ct may enable accurate detection of local lymph node metastases and distant metastases , pet / ct offers another option for use in primary breast cancer staging . for cases in which conventional imaging techniques ( i.e. ultrasonography , ct , mri , ss ) do not provide adequate information , pet / ct could be used to obtain more detailed anatomical information .

despite medicare approving the use of positron emission tomography / computed tomography ( pet / ct ) in staging primary breast cancer , little evidence is available to support the use of 18f - fdg - pet / ct for the detection of distant metastases in the initial staging of breast cancer . in this review of the literature listed in medline , we examine whether 18f - fdg - pet / ct may play a role in the initial staging of breast cancer . we discuss studies comparing pet / ct with conventional imaging for diagnosing distant metastases and axillary and extra - axillary lymph node metastases .

a 50-year - old male patient presented with a history of moderate periodontitis with grade 2 mobility of most of the mandibular [ figure 1 ] teeth and his profession dictated for an immediate solution . atraumatic extraction of 41 42 43 44 45 51 52 53 54 55 56 57 58 was carried out under local anesthesia [ figure 2 ] using lignocaine with adrenalin . atraumatic extraction using periotomes without excessive enlargement of the socket was done in order to preserve the alveolar bone which is very important to the success of immediate implant placement . the implant size is determined by the help of the root length and diameter also with conventional methods [ figures 3 and 4 ] . the sockets were debrided and 3i biomet implants 4 mm 11.5 mm were placed in the extracted sockets of 45 55 12 22 [ figures 5 and 6 ] . a pre - fabricated mandibular provisional denture with a soft reline was placed [ figure 7 ] . pre - operative view showing the mandibular teeth extracted teeth ( above ) measuring the root length to synchronize with the implant placement of implants ( above ) osstell to check the stability of the implant post - operative orthopantamogram with implants insertion of provisional denture success in dental implants is a result of certain level of competence of the dentist along with use of products that ensure predictable functional balance between technology and biology , which predicts a lifelong functional and esthetic solution for the patient . the advent of calcium oxide anodized titanium surface treated implants has shown to accelerate and enhance the osseointegration of the implant in the living bone .

this case describes extraction of teeth in the mandibular arch , i.e. , 41 42 43 44 45 51 52 53 54 55 56 57 58 ( grade two mobility ) , followed by immediate placement of four dental implants ( 3i biomet ) , two in the 45 55 region and two dental implants in 12 21 region . a prefabricated provisional mandibular denture was immediately placed . the purpose of immediate placement was to aid the patient resume his professional duties the next day itself along with esthetic and functional comfort , psychological well - being and most importantly preserving the remaining tissue in a healthy condition .

case 1 a 52-year - old male was examined in the clinic on first generalized tonic clonic seizure . blood tests were normal , except decreased levels of parathormone ( 6.46 pg / ml [ range : 15 - 65 pg / ml ] and calcium ( 5.7 mg / dl [ range : 8.6 - 10.2 mg / dl ] ) . he was not taking any medication , and there was no family history of dementia , movement disorder or other neurological illness . his brain computerized tomography ( ct ) scans demonstrated extensive , bilateral calcification of basal ganglia ( figure 1 ) . case 2 a 56-year - old male who had his first epileptic seizure , a generalized tonic clonic motor seizure , was referred to the hospital . blood tests were in normal range , except decreased vitamin d level ( 12 ug / l [ range : 20 - 120 ug / l ] ) . his ct scans demonstrated bilateral calcification of basal ganglia and cerebellum ( figure 2 ) . though it was patient s first seizure , sodium valproat was prescribed for 6 months in addition to vitamin d replacement treatment because of the eeg abnormality and no further seizure was seen after treatment . in the literature , varying manifestations of fahr s syndrome are described as memory disturbance , hallucination , delusions , personality change , and depression ; motor and phonic tics , stereotyped behaviors ; and extrapyramidal signs , such as parkinsonism and paroxysmal nonkinesigenic dyskinesia . hoque et al . described a case of fahr s disease that presented with complex partial seizure and behavioral abnormalities . several families with basal ganglia calcification , representing a heterogeneous group of disorders with variable inheritance , have been described . , the cause of the intracranial calcification is abnormal calcium metabolism due to iatrogenic hypoparathyroidism . however , no phosphorus or calcium metabolism disorder , with the exception of decreased vitamin d level , was found in case 2 . since just decreased vitamin d level could not be the cause of intracerebral calcification , case 2 was diagnosed as primary fahr s syndrome . it was notable that no family history of neurological disease or psychiatric , demential or extrapiramidal signs were found in neurological examination of case 2 . it is possible that others with fahr s syndrome in this patient s family are asymptomatic . the cause of seizure in case 1 seems to be hypocalcaemia due to iatrogenic hypoparathyroidism . in addition , another theory of pathogenesis in these patients may be a dysfunction of cortico - basal connections and their interhemispheric relationship . in case 2 , fahr s disease has been used to describe a characteristic pathological pattern of nonarteriosclerotic vascular calcification of the striopallidodentate system bilaterally , with variable deposition of ferro - calcareous concretions in cortical sulci , thalamus , cerebral white matter , and cerebellum . it is a misnomer , as fahr s original case was a rare example of hypoparathyroidism associated with calcification in the media of larger vessels in the cerebral white matter , without basal ganglia calcification . basal ganglia calcification may be categorized as idiopathic versus symptomatic ( especially of parathyroid insufficiency ) , or sporadic versus familial . prevalence of certain common neurological disorders , including dementia , stroke , and epilepsy , is similar in patients with incidentally discovered basal ganglia calcification and in age - matched controls . forty - two patients with incidentally discovered radiological basal ganglia calcification in the series of harrington et al . , and 33 cases reported by vles et al . murphy found basal ganglia calcification in 53 of 7081 consecutive ct scans . in patients over 50 years of age , it was associated with clinical signs of basal ganglia dysfunction ( parkinsonism ) in only 3 patients . in a series of 42 cases of basal ganglia calcification revealed on ct ( performed for various reasons ) , puvanendran et al . found a single patient with parkinsonism ( right - sided tremor and rigidity ) associated with dementia . most of reported families with basal ganglia calcification do not display clinical evidence of basal ganglia disease . the clinical feature of epileptic seizure in present cases was not typical for basal ganglia calcifications , whereas radiological appearances were those of fahr s syndrome . in conclusion , the present cases are important because it would appear that there is no case in the literature of fahr s disease presenting with generalized tonic clonic seizure . the seizures in such patients may be due to calcium metabolism abnormities and/or dysfunction of cortico - basal connections and their interhemispheric relationship .

fahr s syndrome is a neuropsychiatric syndrome characterized by symmetrical and bilateral intracerebral calcifications located in the basal ganglia and usually associated with a phosphorus and calcium metabolism disorder . clinical manifestations of fahr s syndrome vary ; it may start at different ages and have a variety of presentations . this article discusses rare presentation of fahr s syndrome with epileptic seizure . these cases are important because they appear to be the first cases in the literature of fahr s syndrome presenting with generalized tonic clonic seizure .

tennis elbow is a diagnostic term that describes a pattern of pain and localized tenderness at the lateral epicondyle of the distal humerus . the anatomic basis of the injury to the extensor carpi radialis brevis ( ecrb ) origin appears to be multifaceted , involving hypovascular zones , eccentric tendon stresses , and a macroscopic degenerative response . although many treatments have been advocated , this article discusses the treatment of steroid injection for lateral epicondylitis and documents a review of the medical literature . tennis elbow was first described in 1883 by major as a condition causing lateral elbow pain in tennis players . over the years , this term has become synonymous with all lateral elbow pain , despite the fact that the condition is most often work - related and many patients who have this condition do not play tennis . it has been estimated , however , that 1050% of people who regularly play tennis will develop the condition at some time during their careers . a recent study on biomechanics demonstrated that the eccentric contractions of the ecrb muscle during backhand tennis swings , especially in novice players , are the likely cause of repetitive microtrauma that causes tears in the tendon and lateral epicondylitis . some others suggested causes of tennis elbow , or lateral epicondylitis , are trauma to the lateral region of the elbow , relative hypovascularity of the region , and fluoroquinolone antibiotics . lateral epicondylitis occurs much more frequently than medial - sided elbow pain , with ratios reportedly ranging from 4:1 to 7:1 [ 7 , 8 ] . in the general population , the incidence is equal among men and women , and in tennis players , male players are more often affected than female players . the average age of the patient who has lateral epicondylitis is 42 years old , with a bimodal distribution among the general population . an acute onset of symptoms occurs more often in young athletes , and chronic , recalcitrant symptoms typically occur in older patients . although the term epicondylitis implied that inflammation is present , it is in fact only present in the very early stages of the disease . this intervention must be compared to the efficacy of a wait - and - see policy because the disorder is most often self - limited . reviewed 13 randomized , controlled trials that evaluated the effects of corticosteroid injections compared to placebo injection , injection with local anesthetic and injection with dexamethasone and triamcinolone . although the evaluated evidence showed superior short - term effects of corticosteroid injections for lateral epicondylitis in terms of pain relief and grip strength , no beneficial effects were found for intermediate- or long - term follow - up . among prospective , randomized trials controlled with a placebo injection , altay et al . compared 60 patients treated with 2 ml lidocaine to 60 patients treated with 1 ml lidocaine combined with 1 ml triamcinolone , with all injections performed with a peppering technique of 4050 injections . another trial compared disabilities of the arm , shoulder , and hand score , grip , and pain in 31 patients injected with lidocaine and dexamethasone and 33 patients injected with lidocaine only . a third trial randomized 19 subjects to receive rehabilitation and a sham injection , and 20 to receive rehabilitation and a corticosteroid injection . there was no significant difference between the two groups on a pain questionnaire , a visual analog pain scale , and a grip measurement at 4 , 8 , and 24 weeks ( p < 0.05 ) . both groups improved significantly over time , with more than 80% of subjects reporting improvements from baseline to 6 months ( p < 0.5 ) . bisset et al . in australia and smidt et al . in the netherlands randomized patients with tennis elbow to physiotherapy , corticosteroid injection , or a wait - and - see approach . in both studies , corticosteroid injection showed significantly better effects at 6 weeks ( p < 0.01 ) but paradoxically high recurrence rates and significantly poorer outcomes at 1 year ( p = 0.0001 ) . in a randomized trial comparing steroid injection to naproxen and placebo tablets , injections were better at 4 weeks , but over 80% of patients were better by 52 weeks in all groups with no significant differences ( p < 0.05 ) . in another double - blinded study comparing different kinds of steroid injections . found that the early response to steroid preparations was significantly better than for lidocaine ( p < 0.5 ) , but at 24 weeks , the degrees of improvement were similar . of interest was the discovery that post - injection worsening of pain occurred in approximately half of all steroid - treated patients . the objective of such conservative care is to relieve pain and reduce inflammation , allowing sufficient rehabilitation and return to activities . although this treatment has been described as highly successful , there remains a lack of information concerning the long - term outcome of steroid treatment . in conclusion , i believe that a corticosteroid injection runs the risk of delaying resolution of symptoms in the long run .

lateral epicondylitis or tennis elbow is a painful and functionally limiting entity affecting the upperextremity and is frequently treated by hand surgeons . corticosteroid injection is one of the most common interventions for lateral epicondylitis or tennis elbow . here , a review of the medical literature on this treatment is presented .

risk factors contain unhygienic conditions such as phimosis and chronic inflammatory disease , sexual history , condylomata history and smoking . penile cancer drains principally to the inguinal nodes and then spreads to the pelvic lymph nodes . if tumor - positive inguinal nodes are demonstrated , scanning methods must be used to search pelvic metastases and distant metastases for the increasing risk of further lymphatic spread . positron emission tomography / computerized tomography ( pet / ct ) scanning is a reliable method to determine pelvic and more distant metastases . if pet / ct is not available abdominal ct scan and chest x - ray are advisable and in symptomatic m1 patients a bone scan is also advisable . the aim of this case report is to represent the significance of fluoro-18 fluorodeoxyglucose ( f - fdg ) pet / ct detected by the metastases in a patient with penile carcinoma [ figures 1 and 2 ] . fluorodeoxyglucose ( fdg ) pet mip image showed that intense accumulation of fdg on inguinal lymph nodes and increased fdg uptake was detected on multiple lymphadenomegalies in abdomen - pelvis and the left - inferior jugular region , the left supraclavicular fossa and the mediastinal lymph nodes pelvis axial pet , computed tomography , fusion and coronal fusion images showed multiple lymphadenomegalies in the iliac region we report a case of a 57-year - old male demonstrated inguinal metastases with biopsy then underwent amputation and recognized histopathological grade 2 ( moderately differentiated ) penile scc . the patient was referred to our pet / ct department to search for possible further metastatic disease . following 10 h fasting ( serum glucose level 126 mg / dl ) , after 1 h waiting period , whole - body images were obtained on the siemens hi - rez pet / ct system . fused images of metabolic ( pet ) and anatomic ( ct ) information pet / ct study showed that intense accumulation of fdg on inguinal lymph nodes . additionally , increased fdg uptake was detected on multiple lymphadenomegalies in abdomen - pelvis and the left - inferior jugular region , the left supraclavicular fossa and the mediastinal lymph nodes [ figures 1 and 2 ] . also , pet images demonstrated a few uptakes in the left axilla and left parasternal lymph nodes . the lung parenchyma , liver and skeletal system demonstrated a physiological distribution of the tracer . histopathological results showed primary penile scc carcinoma [ figure 3a ] and metastatic inguinal lymph nodes [ figure 3b ] . histopathological examination showed well differentiated squamous cells with keratinization and transition zone which is concordant with primary penile squamous cancer and squamous cells with central keratinization in inguinal metastatic lymph node ( h and e , 100 ) penile carcinoma has a lymphogenic pattern of metastases and the firstly drain inguinal lymph nodes and subsequently pelvic nodes . the detection of pelvic metastases and more distant metastases has a considerable impact on therapy and prognosis . initial f-18 fdg - pet scanning is a promising method on detecting loco regional lymph node metastases and distant metastases in the stage of penile cancer . however , conventional imaging techniques such as ct scans are insufficient to detect pelvic nodal involvement in penile cancer patients . fdg - pet with low - dose ct scanning provide to scan whole body and also give functional , anatomic information on one image . correct staging is crucial in the selection of appropriate treatments and the follow - up the patients . the use of pet / ct provides considerable much knowledge of tnm clinical classification of penile cancer .

penile cancer is an uncommon malignancy which of the management depends on the clinical stage and location of the lesion . positron emission tomography / computerized tomography ( pet / ct ) is a promising method for detection of distant metastatic lesions and therapeutic strategy planning . here , we report a case of penile squamous cell carcinoma of 57-year - old male patient , was referred to pet / ct department for investigation of metastases . there were significantly increased fluoro-18 fluorodeoxyglucose activities in supradiaphragmatic and infradiaphragmatic lymphatic stations .

staff and students working at a library information desk should start to refer patrons to librarians for in - depth assistance . mui libraries should have a help desk at which staff and students may refer in - depth questions to librarians . the data from the research provided an opportunity to identify patterns and to explore how patrons are seeking reference services , and in 2011 were analyzed to answer these questions . the subject areas of the questions were also of interest because they might reflect success in outreach or areas that might be candidates for additional promotion of services . in this study the researchers extracted data by contact type , number of patrons helped , time spent , patron status , and whether or not the question was a referral from the help desk for the years 2008 - 2011 . table 1 show that both the number of consultations and the numbers of librarians reporting have decreased between 2008 and 2011 . table 2 shows that drop - in was by far the most popular way that patrons received assistance , accounting for 50% ( 3 , 141 questions ) of all transactions . the office hours refers to librarians providing dedicated office hours to answer questions from drop - in patrons , similar to traditional office hours that faculty provide . referrals from the information desk were so rare that the concept was abandoned after a short run . other could mean helping someone in the library except of those the status of patrons who directly contacted librarians ( table 3 ) shows that graduate students are the heaviest users with faculty members in a solid third place . these figures show that graduate students visit their librarians in greater numbers than any other category . table 4 shows that consultations with librarians are for the most part between 20 minutes and 1 hour 25 minutes . researchers who contact a librarian are more likely to have questions that require some research to answer , and talking with a student or faculty member in an office usually take longer than an interaction at a reference desk . of course , there are questions that need only a brief answer ; the 1 to 4 minute category includes any number of interactions that took no more than 20 seconds , but were recorded as one minute ( see table 5 ) . the number of referrals to librarians from the information or help desks is much lower than expected . some librarians offer reference assistance and this has increased the visibility of librarian services to all in these areas , and possibly resulted in direct contacts rather than referral from the reference desk . as an offer the actual referrals from the service desk may be an even lower percentage than those recorded here . mui libraries office statistics consist of office research consultations , reference assistance during office hours held in the mui schools , and assistance via instant messaging , email , phone , and referrals from the libraries ask - a - librarian email service . total contacts in 2008 were 456 , in 2009 were 570 , in 2010 were 298 , and in 2011 were 550 . students contact the librarian primarily by drop - in ( 42% , 2008 through june 2011 ) . , a general help desk is used , among other methods , to refer patrons to subject - specific librarians for in- depth assistance . data were examined to determine if patrons continue to seek librarian assistance without their presence at the reference desk . the data examined how much time librarians spend with patrons , and how patrons contact librarians . these data show that from 2008 to 2011 the majority of patrons who contacted mui librarians were graduate and undergraduate students and their primary mode of contact was drop - in . further examination shows a decline over time in the number of referrals that librarians received from the help desks . over the same time period librarians at mui are making efforts to promote their services on campus cause many advantages . it must be noted that relying simply on statistical data may not provide a complete picture of how and why trends are occurring . data gathering is useful for administrators and librarians as a means of quantifying their work . librarians may use the data to show their impact , see trends , and develop relevant online guides and tutorials .

the purpose of this study is to understand reference libraries of isfahan university of medical sciences . the reference part of libraries was examined from 2008 to 2011 . we found that the number of reference librarians should be increased . we found graduate students are the main patrons . we understand interaction with patrons is very important . this study will be helpful for specialist , librarian , and administrators .

black esophagus , is a rare multifactorial condition , characterized by endoscopic images of diffuse , circumferential black mucosal discoloration in the distal esophagus that stops abruptly at the gastroesophageal junction . the most common clinical presentation ( 90% ) is acute upper gi bleeding and this represents a diagnostic challenge . the authors report a case of a patient with acute esophageal necrosis ( aen ) developed after pancreatic resection surgery . laboratory investigation and radiological imaging revealed a neoplasia of the ampulla of vater not amenable to removal by endoscopic techniques . laboratory investigations detected anemia and an esophagogastroduodenoscopy ( egd ) showed a circumferentially black - appearing mucosa at the inferior third of the esophagus ( fig . the gastro - jejunal anastomosis was pervious to the passage of the instrument and no biopsies were performed . subsequent computed tomography ( ct)-scan revealed thickness of the wall of middle and inferior esophagus with a reduction of vascularization . the patient was treated with hemotransfusion , total parenteral nutrition and high - dose proton pump inhibitor ( ppi ) . another egd was performed a week later and revealed a complete esophageal re - epithelization ( fig . however , the disease may be underestimated due to the subtle clinical presentation and the healing properties of esophageal mucosa . men are four times more commonly affected than women and the peak incidence occurs at the sixth decade of life . the most important are tissue hypoperfusion , altered gastric motility with acid reflux , impaired local barrier defenses associated with decrease of metabolic reserves [ 2 , 3 ] . aen may arise in the setting of hemodynamic shock , diabetes , vascular disease , thromboembolic phenomena , sepsis , immunosoppression , chronic diseases , alcohol abuse , malnutrition , multiple organ failure , recent surgery , tumors , gastric volvulus and ketoacidosis . the most frequent clinical presentation ( 90% ) is upper gastrointestinal bleeding with hematemesis and melena . other symptoms include abdominal pain , dysphagia , nausea , fever and syncope [ 2 , 4 ] . laboratory tests may show anemia and leukocytosis and ct scan can reveal thickening of distal esophagus , stomach distension and a possible obstruction to gastric emptying . egd is essential to diagnose the disease documenting diffuse , circumferential black mucosa which abruptly stops in the z - line . it has been proposed an endoscopic staging of the disease : pre - necrotic esophagus ( stage 0 ) , black esophagus ( stage 1 ) , chess - board esophagus ( stage 2 ) and re - epithelized esophagus ( stage 3 ) . differential diagnosis includes malignant melanoma , acanthosis nigricans , corrosive agents ingestion and infectious diseases . possible complications are perforation , esophageal stenosis and stricture formation , microbial superinfection which can lead to mediastinitis and abscess formation . therapeutic approaches consist of treating underlying conditions with fluid resuscitation , nil - per - os , total parenteral nutrition and intravenous ppis or histamine receptor blocker . the use of naso - gastric tube is not recommended due to the risk of perforation . antimicrobial therapy should be reserved to the patients with suspected esophageal perforation , sepsis or impaired immune function . surgical treatment is to perform only with a perforated esophagus with mediastinitis or abscess formation and for the treatment of the late esophageal stricture . prognosis of black esophagus is poor with a mortality rate of 32% and it depends on underlying illnesses even if deaths secondary to esophageal necrosis occur in < 6% of cases . marta bonaldi and corrado sala were involved in the clinical management of the patients and drafted the manuscript . giorgio fratus , pierpaolo mariani and lorenzo novellino were involved in the surgical and clinical management of the patients and reviewed the manuscript .

abstractblack esophagus is a rare , multifactorial disease . a case of acute black esophagus following pancreatic resection is presented . the patient referred us with a specific gastrointestinal bleeding . an esophagogastroduodenoscopy confirmed the diagnosis . we performed conservative treatment with complete esophageal re - epithelization and negative follow - up for stenosis or necrosis relapse .

the term myiasis is derived from greek words muia and iasis , which means fly and disease , german entomologist fritz zumpt defined myiasis as the infestation of live human and vertebrate animals with dipterous larvae , which at least for a period , feed on the host 's dead or living tissue , liquid body substances , or ingested food . human or animal tissue acts as an intermediate host for the larvae in its life cycle . myiasis can be seen worldwide , with a higher incidence being observed in tropical and subtropical regions of africa and america due to the favorable climatic conditions of heat and humidity . in humans , the sites most commonly affected are skin , nose , ears , eyes , anus , vagina , and oral cavity . oral myiasis is associated with nosocomial infections , dental extractions , visits to tropical countries , alcoholism , and mouth breathing , and is commonly seen in mentally disabled individuals and people from low socioeconomic status . a 40-year - old male patient reported to our hospital with a chief complaint of facial wound on the left cheek region for past one month , which was initially smaller and increased progressively to the present large size , with appearance of worms in the wound . on extraoral examination , the ulcer was 5 cm 4 cm in size on the left chin region , including lower lip and infiltrating the underlying tissues with an everted and erythematous border . the affected region was swollen , and the swelling extended to the middle of the upper lip . on the left side of the neck , maggots seen buried deep in the wound in the left cheek region ( preoperative ) on intraoral examination , hard tissue revealed partially edentulous space and poor oral hygiene with severe deposits of calculus and stains . on soft tissue examination , a small fistula was seen in the left lower vestibule at the corner of the mouth . considering the patient 's mental status , history of epilepsy , and poor oral hygiene , it was provisionally diagnosed as an ulcer infested with maggots ( oral myiasis ) . about 1520 maggots were removed with a tweezer following the application of turpentine oil [ figures 2 and 3 ] . the removed maggots were placed in a container , sealed tightly , and disposed off . surgical debridement of the wound was carried out under local anesthesia [ figure 4 ] . the patient was prescribed antibiotic ( cefotaxime 200 mg bd ) , and analgesic ( ibuprofen ) to prevent further infection and to control pain . when the patient was reviewed after a week , the swelling had subsided and wound healing was observed to be satisfactory [ figure 5 ] . removal of maggots using tweezers following turpentine oil application immediate post - operative wound healing satisfactory after a week clinically , myiasis is classified as primary and secondary . in the primary type , larvae feed on living tissue , and in the secondary type , larvae feed on dead tissue . depending upon the condition of involved tissue , myiasis is again classified as accidental myiasis ( larvae ingested along with food ) , semi - specific ( larvae laid on necrotic tissue in wounds ) , and obligatory myiasis ( larvae affects the undamaged skin ) . based on the tissue involved , cutaneous myiasis is subdivided into creeping and furuncle . in creeping type , larvae burrow through or under the skin , and in furuncle type , larvae of the common housefly musca domestica ( indian housefly ) have also been identified in neglected wounds . the adult female flies lay eggs or larvae on food , necrotic tissue , or open wounds . warm humid climate and non - healing wound with halitosis attract the flies to lay eggs . eggs hatch within 24 hours , and the larvae formed release toxins to destroy the host tissue . larvae complete their development in 5 - 7 days , and they then wriggle out of the wound and fall to the ground to pupate . the treatment is primarily manual removal of larvae after the topical application of turpentine oil , mineral oil , chloroform , ethyl chloride , or mercuric chloride . these substances called asphyxiation drugs creates anaerobic atmosphere within the wound causing aerobic parasitic larvae to come to the surface making its removal easier . following the removal of the maggots , surgical wound debridement should be performed . a systemic treatment with ivermectin a semi - synthetic macrolide antibiotic isolated from streptomyces avermitlis is another choice , which is given orally in one dose of 150 - 200 mg / kg of body weight . it activates the release of gamma amino butyric acid , which induces the death of the larvae and their spontaneous elimination . prevention of oral myiasis can be achieved by health awareness , enhancing oral and personal hygiene , and providing proper care to individuals with neurological deficit .

myiasis is a pathologic condition in humans occurring because of parasitic infestation . parasites causing myiasis belong to the order diptera . oral myiasis is seen secondary to oral wounds , suppurative lesions , and extraction wounds , especially in individuals with neurological deficit . in such cases , neglected oral hygiene and halitosis attracts the flies to lay eggs in oral wounds resulting in oral myiasis . we present a case of oral myiasis in 40-year - old male patient with mental disability and history of epilepsy .

bariatric and metabolic surgery is the most effective treatment for longterm weight loss and for resolution of associated comorbidities . it reduces the gastric volume successfully by plication of the greater curvature and has the advantage of a reversible restrictive procedure without the use of foreign materials , gastrectomy , or intestinal bypass . gastric plication was born to overcome the previously described drawbacks of the sleeve gastrectomy 2 . however , gastric plication is not a complicationfree procedure with a complication rate reaching 8.8% 4 . among the reported complications are leaks , acute gastric perforation , acute gastric obstruction , and persistent vomiting , sialorrhea , and esophagitis . herein , we present a case of gastric plication complicated by herniation of the gastric fundus into the chest cavity through the esophageal hiatus complicated by strangulation , necrosis , abscess formation , and communication between the gastric lumen and the left lung . a 26yearold female patient previously healthy with bmi of 33 kg / m ( 96 kg\1.7 m ) status postlaparoscopic gastric plication 3 weeks prior to presentation transferred to our institution for management of highgrade fever . at presentation , patient reports highgrade fever reaching 40 starting 1 week ago associated with mild abdominal pain , productive cough , and greenish sputum . complete blood count with differential shows leukocytosis wbc 17,000 and left shift neutrophils 83% , with elevated crp of 40 . consequently , antibiotics were started with no clinical or radiological improvements after 48 h. chest ct scan was performed showing a left lower lobe consolidation ( fig . 1 ) and a large left subphrenic abscess ( fig . hence , patient underwent ctguided drainage of the abdominal abscess , whereby 1500 cc of purulent material was evacuated and sent for culture and a 14french catheter was left in the cavity . at this time , a gastric leak was suspected and the patient was kept npo , started on tpn and broadspectrum antibiotics . patient improved drastically postdrainage and a control ct scan was performed with significant decrease in the size of the abscess and decrease in the consolidation in the left lower lobe , but a leak from the stomach could not be ruled out . so the patient underwent an esophagogastroduodenoscopy and was found to have a fistulous tract between the fundus and the abscess ; in addition , there was a large communication between the fundus and the left lung . after the diagnosis of grade iv fistula was made , patient was scheduled for surgical management . ct scan , abdomen view , showing the large left subphrenic abscess collection . during the surgery ( figs 3 and 4 ) , the patient was found to have hiatal herniation of the plicated gastric fundus into the chest with strangulation and necrosis of the gastric wall which was widely opened into the chest ( fig . the exciting cavity was drained and the herniated stomach pouch was pulled out . then reversal of plication was made ( fig . 7 ) , subtotal gastrectomy carried out , and handsewn gastrojejunal anastomosis carried out ( fig . 8) . a jejunojejunal anastomosis was carried out as well and three drains were inserted . intraoperative view of the fistulous tract ( thin arrow ) , between the stomach ( long thick arrow ) and the left lung through the diaphragm ( short thick arrow ) . bariatric surgery is the most promising option for morbid obese patients with an average loss of twothirds of excess weight within 1.52 years . the surgical procedures widely used are malabsorptive , restrictive , or a combination of both . however , the above mentioned are expensive procedures and can be associated with serious complications . hence , gastric plication is an attractive option intended to provide the benefits of the previously known bariatric procedures with respect to weight loss and resolution of comorbidities , while reducing the incidence of complications and cost . however , gastric plication is not a complicationfree procedure with multiple reported serious complications including leaks , acute gastric perforation , and acute gastric obstruction . to our knowledge , this is the first published case of hiatal herniation of the plicated gastric fundus with strangulation , necrosis , abscess formation , and communication with the left lung . this complication is added to the above reported serious complications of greater curvature gastric plication . it may be attributed to the presence of unrepaired hiatal defect , overtightening of the sutures at the level of the fundus which is considered a relatively watershed area . from here furthermore , standardization of the technique with the aim of decreasing these threatened complications should be opted . the recent widespread use of bariatric surgery has been attributed to the high success rate of weight loss and improvement of comorbidities . multiple challenges have inspired the search for an ideal surgery 5 , 6 and explain the dynamic nature and evolution of the field of bariatric surgery . in brief , gastric perforation , gastric obstruction , gastric necrosis , gastric herniation , and gastric leaks dampen the success of greater curvature gastric plication . es : did the literature review and wrote the article ; antoine el asmar : organized the figures and legends and wrote the article ; faf : did the data collection and obtained the patient 's consent ; zer : performed the operation and reviewed the written article .

key clinical messagegastric plication is not a complicationfree procedure . herein , we present the first known case of gastric plication complicated by herniation of the gastric fundus into the chest cavity through the esophageal hiatus complicated by strangulation , necrosis , abscess formation , and communication between the gastric lumen and the left lung .

pharmacological monitoring of clozapine is extensive as compared to any other psychiatric medication due to its side - effects . most fatal side - effect of clozapine is agranulocytosis , but the prevalence of this complication is around 0.91% . sometimes fatal complication such as hypertension , pericarditis , tachyarrhythmia , and st wave changes mimicking myocardial infarction have also been reported . many of the adverse effects are dose dependent , are associated with speed of titration and tend to be more common at the beginning of therapy . we report a case of a 45-year - old male who developed clozapine induced supraventricular tachycardia ( svt ) during dose titration , which was successfully treated with verapamil . k , a 45-year - old male with no significant past or family history presented with 8 years continuous illness characterized by delusions of persecution , reference , third person auditory hallucinations , and severe socio - occupational dysfunction . there was history of a suicidal attempt 4 years ago in response to distress caused by the auditory hallucinations . on clinical evaluation , he fulfilled diagnostic criterion for paranoid schizophrenia ( international classification of disease-10 ) . he had failed adequate trials of antipsychotics trifluoperazine and risperidone and a course of nine modified electroconvulsive therapies . in view of the treatment resistance , baseline investigations prior to initiation of clozapine inclusive of complete hemogram , fasting blood glucose , lipid profile , liver and renal functions , electrocardiogram ( ecg ) , and electroencephalogram were within normal limits . there was no history of comorbid medical disorders except bronchial asthma without any recent exacerbation . clozapine was initiated at 25 mg with daily increase in dose by 25 mg until a dose of 100 mg with daily monitoring for adverse events . as he was tolerating clozapine well the dose was increased thereafter by 50 mg daily and a dose of 250 mg was reached on the 7 day . at this dose , he developed sudden chills , rigors , fever , and tachycardia on the 8 day of initiation of clozapine . ecg was suggestive of svt with a heart rate of 207 beats / min and echocardiography was normal . verapamil was preferred to beta blockers in view of comorbid bronchial asthma and he was started on 120 mg / day . clozapine was withheld ; however , he had relapse of psychotic symptoms , which necessitated re - initiation of clozapine . patient is on regular follow - up and is in remission on a combination of clozapine and verapamil . patients may develop svt or sinus tachycardia when on clozapine due to its vagolytic property . persistent tachycardia can cause cardiomyopathy or it could be a feature of an underlying myocarditis . cardiac side - effects with clozapine have been described to be associated with speed of dose titration . in a study by ronaldson et al . ( 2012 ) , doses higher than 250 mg in the first 9 days was associated with higher risk of myocarditis . in our case , the patient was tolerating clozapine well until dose of 250 mg was reached on the 7 day . hence , rapid dose titration could be an important factor associated with cardiovascular adverse events with clozapine . drugs of choice in treating svt include adenosine , calcium channel blockers like verapamil and beta blockers . verapamil was preferred to beta blockers in this case due to the presence of comorbid asthma . an earlier report has also described successful treatment of clozapine related persistent sinus tachycardia with verapamil . verapamil may also have an augmenting role in the treatment of schizophrenia , especially when prominent negative symptoms and affective disturbances are present . this case highlights the importance of slow titration of clozapine to prevent cardiovascular adverse effects and potential role of verapamil in treating clozapine - induced svt and its possible augmenting effect on clozapine .

clozapine is known to be an effective antipsychotic for schizophrenia . cardiovascular complications associated with initiation of clozapine include tachycardia , postural hypotension , and myocarditis . factors associated with development of cardiovascular adverse events are not clearly known , and dose titration has been described to be one among the associated risk factors . we report a case of a 45-year - old man with treatment resistant schizophrenia who developed supraventricular tachycardia during initiation of clozapine and discuss the role of verapamil in its successful management .

gall bladder ( gb ) perforation is a rare visceral complication of percutaneous nephrolithotomy ( pnl ) that carries a high mortality . we report a case of biliary peritonitis due to gb perforation that occurred after an otherwise uneventful pnl . a 19-year - old male patient underwent pnl for a 1.5 1.5 cm right renal lower pole stone . stone - guided bull 's eye puncture with fluoroscopy unit in 0 degree and 30 degree was performed with an 18 gauge needle . after the c arm showed the needle near the desired calyx in 0 degree , it was rotated to 30 degree toward the surgeon and access to the calyx was sought by aligning the needle with it . this step required minor adjustments and resulted in multiple passes ( about six ) of the puncture needle . the stone was removed in toto without use of lithotripsy and a 26 fr nephrostomy tube ( pcn ) was applied . the patient recovered well after the operation and was asymptomatic for the next 2 days except for mild abdominal pain . his nephrostomy output was clear and was left in situ for 2 days according to the institutional protocol . on the evening of the second post - operative day , the patient developed abdominal distension and pain along with hemodynamic instability ( bp = 90/60 ) , tachycardia and decreased urine output . x - ray abdomen did not reveal any free air in the abdomen or air fluid levels . x - ray chest was normal and ultrasound ( usg ) abdomen revealed free fluid in the abdomen . an usg - guided pelvic drain was placed that extruded 1.5 l of golden yellow bilous aspirate . exploratory laparotomy was performed on the third post - operative day , about 56 h after the procedure . three small perforations were noted in the body of the gb on the posterior surface . a small perforation was noted in the caudate lobe of the liver . the whole gut was carefully examined along with mobilization of the right colon and kocherisation of the duodenum , but no other perforation was identified . isolated gb perforation is a rare complication of pnl with few cases reported in the literature . cases carry a high mortality due to delay in diagnosis and the irritant nature of the bile . described a case of gb perforation that was diagnosed 48 h after the procedure and treated with laparoscopic procedure and cholecystectomy . described two cases where , in the first case , the patient underwent exploratory laparotomy for biliary peritonitis with cholecystectomy and insertion of a t - tube into the bile duct 48 h after standard pnl . the patient underwent exploratory laparotomy and cholecystectomy 12 h after the procedure for biliary peritonitis . turner et al . have reported the only case in the literature where the diagnosis was made intraoperatively by opacification of the gb by a radiocontrast agent . described the first case of duodenal injury with biliary peritonitis caused by choledochal necrosis and bile leakage following pcnl . this is also the only case reported in the literature with a fatal outcome , with the cause designated as septic shock with acute respiratory distress syndrome . gb perforation should be kept in mind during right - sided pnl in lean and thin patients . the distance between calyces of the right kidney and the gb can be as little as 2 cm . a combination of fluoroscopy and ultrasound should be used for access . in our case , the patient was thin and the initial access was directly stone guided , which may have contributed to the injury . although the skin was punctured at a single point and the needle was placed at the desired calyx , thereafter the 18 g needle required adjustments with the c arm in 30 degree before free flow of urine was aspirated from the puncture needle . this step required multiple passes ( about six ) back and forth of the needle . looking at the size and number of the gb perforations , we assume that this is the step at which the injury occurred . surgeons tend to be more adventurous with a thin needle rather than with the thick dilators . we believe that even microscopic injuries to the gb are significant , and this has also been reported in the literature . credence to our theory comes from observations from cholecystectomy , where sometimes a tense gb needs to be aspirated before removal . absence of free air under the diaphragm also occurs in the absence of concomitant bowel injury . most cases in the literature have reported an average delay of 48 h to diagnosis , matching our own time period of 56 h. all cases reported in the literature have required open or laparoscopic cholecystectomy . urologists performing pnl must keep the possibility of biliary peritonitis in mind , especially when a thin patient develops unexplained peritonitis after a right - sided procedure . laparotomy or laparoscopy is the most definite way to diagnose this condition as there is an absence of early clinical signs . it must be remembered that the condition is a life - threatening complication if there is delay or failure to diagnose .

a 19-year - old male patient underwent right percutaneous nephrolithotomy ( pnl ) for right renal 1.5 1.5 cm lower pole stone . the procedure was completed uneventfully with complete stone clearance . the patient developed peritonitis and shock 48 h after the procedure . exploratory laparotomy revealed a large amount of bile in the abdomen along with three small perforations in the gall bladder ( gb ) and one perforation in the caudate lobe of the liver . retrograde cholecystectomy was performed but the patient did not recover and expired post - operatively . this case exemplifies the high mortality of gb perforation after pnl and the lack of early clinical signs .

the art and science of discontinuing patients from invasive mechanical ventilation continues to attract attention . the discontinuation process consists of two components : weaning ( assessing the need for ventilatory support ) and extubation ( assessing the need for an airway ) . investigators have increasingly focused on the latter component , where 520% of extubations may fail and require reintubation . delayed extubation is associated with increased length of stay , increased risk for ventilator - associated pneumonia , and increased mortality in brain - injured patients . conversely , reintubation ( extubation failure ) after planned extubation is associated with adverse outcomes , including increased hospital mortality , prolonged hospital stay , higher costs , and greater need for tracheotomy and transfer to postacute care [ 2 - 4 ] . although the adverse effects of reintubation could reflect the severity of underlying illness or could result from complications during reintubation , this has not been demonstrated with multivariate analysis [ 2 - 4 ] . rather , delayed timely reinstitution of ventilatory support may allow for deterioration and new organ failure , ultimately contributing to increased mortality and increased costs . in response to this observation , investigators have examined whether postextubation application of noninvasive ventilation ( niv ) can improve outcome . unfortunately , niv did not improve outcome for established postextubation respiratory failure and was actually associated with increased intensive care unit ( icu ) mortality when used in a large cohort with early signs of extubation failure ( only 10% of whom had chronic obstructive pulmonary disease ) . hence the relevance of the study by seymour and colleagues , who extend previous work by finding that extubation failure ( in a 16-bed medical surgical icu ) also exacts a devastating toll in the community setting . using a retrospective methodology , these investigators noted that both postextubation icu length of stay and hospital length of stay was significantly longer in patients requiring reintubation ( 9 days and 11 days longer , respectively ) . both icu mortality and hospital mortality were also higher for reintubated patients , although the latter did not achieve statistical significance . using estimates from direct and indirect charges , seymour and colleagues found that total hospital costs increased by an average of nearly $ 34,000 for reintubated patients . although the results of seymour and colleagues ' study are enticing , several issues with the study design will need to be addressed when future investigators examine this issue . a classic case control methodology should ideally be employed , matching controls for sex , age , case type ( e.g. surgical versus medical ) , severity of illness ( or organ failure score ) , etiology of respiratory failure , and duration of mechanical ventilation prior to extubation . in addition , several groups have noted that patients reintubated for airway problems or upper airway obstruction and those patients reintubated more rapidly have a better prognosis than other reintubated patients . with so many potential factors impacting outcome for reintubated patients , multivariate analyses to determine the independent effect of extubation failure are mandatory . how should the results of this study and other studies conducted in tertiary care academic centers affect how we care for ventilated patients ? given the poor outcome of patients failing extubation and the inconsistent benefit for niv to prevent reintubation , clinicians should be more vigilant in identifying who is at high risk for extubation failure . predictors developed to predict weaning outcome have not faired well in accurately predicting extubation outcome . this is not unexpected as extubation failure often occurs for reasons other than an imbalance between work of breathing and the load on the respiratory system , the typical reason for weaning failure . patients often fail extubation because of upper airway obstruction , inadequate cough , excess respiratory secretions , abnormal mental status , or a combination of more than one of these factors . the quantitative cuff leak test ( the difference between inspired and expired tidal volumes during assist - control ventilation with the endotracheal tube cuff deflated ) can identify a cohort at increased risk for postextubation stridor [ 12 - 14 ] . objective , quantitative assessments of cough strength and secretion volume can similarly predict postextubation failure . indeed , decreased peak expiratory flow rates using a calibrated flow meter ( < 60 l / min ) and increased sputum volume ( > 2.5 ml / hour in the 23 hours prior to extubation ) were associated with relative risks for reintubation of 4.8 and 3 , respectively . the same investigators noted a relative risk of extubation failure of 4.3 in patients unable to complete four simple neurological tasks ( open eyes , follow with eyes , grasp hand , stick out tongue ) . combining the three risk factors of decreased peak cough flow , increased sputum volume , and abnormal neurological assessment had a synergistic effect . only 3% of patients without risk factors required reintubation , compared with 100% of patients with all three risk factors . based on these studies , one can recommend delaying extubation if the risk factor ( e.g. excess secretions , abnormal mental status ) can be substantially corrected in 13 days . intuitively , little is gained by waiting for extubation if risk factors are irreversible or would take more than a few days to correct . in the latter instance , the benefits of waiting are offset by the risks of significantly prolonging invasive ventilation . whether the latter group should be extubated despite the elevated risk for reintubation or alternatively be considered for tracheotomy is unclear . a preliminary report suggests that immediate application of niv in such a high - risk cohort may be effective in improving outcome . in conclusion , the study of seymour and colleagues further supports the notion that extubation failure is an outcome to be avoided , wherever it occurs .

extubation failure is an outcome of increasing importance but nearly all studies have been conducted in academic settings . the article by seymour and colleagues demonstrates that extubation failure is an outcome to be avoided in the community hospital setting as well . patients failing extubation experience longer lengths of stay , experience higher intensive care unit mortality , and incur greater hospital costs . investigators have identified tools for predicting extubated patients at highest risk for reintubation . the predictors focus on detecting upper airway obstruction , inadequate cough , excess respiratory secretions , and abnormal mental status . systematic application of these predictors has the potential to improve outcome .

they can occur anywhere on the skin and often appear as firm and well - demarcated dermal nodules . malignant degenerations within epidermal cysts are very rare [ 1 , 2 , 3 , 4 , 5 ] . case reports exist which emphasise the connection between basal cell carcinoma and epidermal cysts as both may arise from the infundibular portion of hair follicles [ 2 , 3 ] . here , we report the case of a basal cell carcinoma arising from an epidermal cyst . a man in his 50s presented to our department with a long history of a cystic lesion on the left shoulder which had rapidly grown in size over the previous 34 months . on physical examination , there was a firm , movable , well - demarcated , voluminous dermal nodule . on the basis of these clinical findings a working diagnosis of epidermal cyst was favoured , and the lesion was subsequently enucleated under local anaesthetic due to its progressive increase in size . macroscopically the cyst , which was 35 mm in diameter , was lined by a thick wall and contained a whitish lobulated nodule measuring 25 mm in its largest diameter ( fig . 1 ) . histology revealed a cystic basal cell carcinoma arising from the lining of an epidermal cyst ( fig . 2 ) . immunochemistry showed lack of expression of berep4 in the cyst 's squamous epithelium but strong positivity on the nodular portion ( fig . malignant tumours arising from epidermal cysts are rare [ 1 , 2 , 3 , 4 , 5 ] . the incidence of tumours originating from epidermal cysts is estimated at around 1% in the literature , with about 70% of them being squamous cell carcinomas and only about 10% of them being basal cell carcinomas [ 3 , 5 ] . the possible common origin from the infundibular portion of the hair follicle may explain the connection between basal cell carcinoma and epidermal cyst [ 2 , 3 ] . described a 55-year - old man with a cystic lesion on the back , which had been present for 20 years and had increased in size during the last year . a diagnosis of a basal cell carcinoma arising in an epidermal cyst was made after histological examination . ikeda and ono reported the case of a 78-year - old man who presented with small papules on the upper eyelid present for 50 years . one cyst had grown rapidly and had been partially ulcerated for the last few years . both cases reported a lesion which had existed for many years but showed recent rapid growth , with histological examination favouring a diagnosis of malignant transformation . in addition , delacrtaz reported the case of a basal cell carcinoma arising from an epidermoid cyst which had been present for several years in a 65-year - old woman . similarly in our case , due to the rapid change in size , the otherwise benign - looking lesion was excised and the histopathology report showed basal cell carcinoma arising from an epidermal cyst . given the lack of specific clinical parameters , a basal cell carcinoma arising from an epidermal cyst may not be recognised , and histological examination of these lesions plays an important role in arriving at a correct diagnosis and , consequently , appropriate management . policy restrictions implemented over the past few years in order to cut national health services costs , for so - called benign skin lesions and the revision to the management of clinically harmless cysts , with their referral to specialists and surgical excision having been discouraged , made the treatment of such cases a challenge for both general practitioners and dermatologists . this case , however , demonstrates that a history of progressive growth should prompt proper surgical excision and histopathological assessment even when a cyst might appear clinically benign .

malignant degeneration within epidermal cysts is very rare . however , these lesions may not be recognised clinically , and histological examination plays an important role in arriving at a correct diagnosis . hence , we believe that benign - looking cystic lesions with a history of progressive growth should be surgically excised and submitted for histopathological assessment .

more than 200 million people are annually infected with malaria world - wide . in comparison , congenital malaria ( cm ) occurs very infrequently . since then , only about 300 cases have been reported in world literature so far . a 16-day - old male child was admitted with complains of refusal to feed and poor activity . the baby was delivered at the gestational age of 32 - 34 weeks , in the same hospital by cesarean section . activity , pulse , grimace , appearance , respiration score at 1 min and 5 min was 7/10 . he had been admitted on 1 day of life for low birth weight ( 1,500 g ) and poor activity . rooting and sucking the baby was treated with intravenous antibiotics and fluids for probable sepsis and was discharged after 4 days of admission on repeated requests of parents . the baby came in the out - patient department on 10 day of life for follow - up . the baby was still on spoon feeding and there was no weight gain ( weight = 1,480 g ) . in order to find the cause of failure to gain weight in the baby , admission of the baby hence , sepsis screen was performed on the out - patient basis and it came out to be negative . on present admission , except for mild tachycardia , vital signs were stable . on abdominal examination , hepatosplenomegaly was present . on 2 day of admission , the direct fraction of serum bilirubin ( t = 9.6 mg / dl , d = 4.6 mg / dl , i d = 5.0 mg / dl ) was elevated . sepsis screen ( total leukocyte count = 8500/mm , platelet count = 96300/mm , c - reactive protein = negative , band cells = 5% ) was again negative . the peripheral blood smear examination showed the presence of plasmodium vivax . a provisional diagnosis of cm was made . the mother then gave a history of fever with chills at third trimester of pregnancy , for which she was treated with some drugs . the baby was treated with oral chloroquine at the standard cumulative dose of 10 mg / kg given in divided doses over 3 days . after completion of the course of chloroquine , the baby showed marked improvement in activity . after 1 month of discharge , the baby had significant weight gain ( weight = 2,700 g ) , pallor subsided ( hemoglobin% ( hb% ) = 17.6 g / dl ) , spleen was not palpable and the baby was active and playful and was on a full breast feeds . cm increases the risk of neonatal mortality by increasing the risk of low birth weight , pre - mature labor , intrauterine growth retardation and still birth . fetal exposure to maternal blood containing infected red blood cells ( rbcs ) may be occur inutero or intrapartum . though , the infection is present from birth , the usual age of appearance of classic features is on the 10 - 20 day of life . the late appearance of symptoms is because of the protective maternal immunoglobulin g ( igg ) antibody transmitted to the baby and also due to low parasitemia in the early days of life . in the neonate as mature schizont ruptures , several merozoites are released , which infect other rbcs and this cycle continues ; thus increasing parasitemia gradually with days of life . the increased burden on spleen to clear the infected rbc leads to splenomegaly , jaundice and anemia ; the classic manifestations of cm . before this period , neonates of cm may manifest with non - specific features as refusal to feed and poor activity , like the presentation in the first two visits of our case . the review of previously reported cases of cm in preterm babies shows that cm may present at an earlier age in preterm babies . this can be due to the fact that the transmission of maternal protective igg antibody occurs very insignificantly in preterm babies . however in the present case , the neonate was preterm and low birth weight and presented without fever . review of the earlier reported cases of cm in preterm infants also shows the same trend . this can be explained by the well - known fact that the preterm and low birth weight babies are more prone to hypothermia rather than fever in conditions of infections . the absence of splenomegaly and normal peripheral blood smear examination in initial two visits in our patient may be due to low parasitemia in initial days of life . serological tests of higher sensitivity are needed for the early diagnosis of malaria especially , in stage of low parasitemia . the present case highlights that cm may present without fever in preterm and low birth weight babies . cm should be included in the differential diagnosis of such neonates who present with a constellation of symptoms of splenomegaly , jaundice and anemia even in the absence of fever . the present case also shows that cm may present with non - specific symptoms of lethargy and refusal to feed in initial few days of life .

congenital malaria ( cm ) is a rare disease with only about 300 cases reported so far . in general , it presents with fever along with other common features such as jaundice , anemia and hepatosplenomegaly . we report a case of cm who presented atypically without fever along with other typical features .

the present research work was undertaken to design low - cost modified release ( 24 h ) tablets of metoprolol succinate using hpmc k15 m and eudragit ( rlpo and rspo ) as a matrixing agents . the reason of using combinations of such polymers was to overcome the disadvantages of individual matrix forming agents . tablets were made by using metoprolol ( 100 mg each tablet ) , hpmc ( release retardant hydrophilic polymer ) , eudragit and lactose , by wet granulation process with pvp k30 ( in isopropyl alcohol ) . compression was done on a 10 station tablet machine ( rimek mini press india ) . the effects of polymer on drug release were studied in ph 1.2 buffer using usp type ii apparatus at 50 rpm . drug release and drug content was analyzed spectrophotometrically at 272 nm ( uv spectrophotometer , jasco ) with validated uv method . all the batches were evaluated for weight variation , hardness , friability , assay and found within acceptable limits of pharmacopoeia . in - vitro drug release characterized with dissolution testing in electro lab usp apparatus with 1.2 ph buffers . it showed that drug release was very retarded in f-1 due to high proportion of eudragit and hpmc polymers . formulation f-2 release was slower that f-4 because of low permeability of rspo than rlpo . equal proportion ( 1:1 ) of rspo and rlpo made an optimum permeability for drug release from matrix . the data obtained from in - vitro dissolution studies were fitted in different models viz . it can be concluded formulation with desired drug release achieved with combination of eudragit rlpo and rspo in ratio of 1:1 . the addition of gel forming polymer ( hpmc ) were essential to achieve stable and persistent gel formed by hydration of hpmc polymer . the results of present investigation shows the prepared metoprolol tables were found to have good controlled release properties with controlled non - fickian diffusion .

metoprolol succinate is a selective beta - adrenergic receptor blocker useful in treatment of hypertension , angina and heart failure . the purpose of the present work was to design and evaluate controlled release matrix type tablet of metoprolo succinate using hpmc k15 m and eudragit ( rlpo and rspo ) as a matrix forming agents . effect of various polymer alone and combinations were studied in ph 1.2 buffer using usp type ii paddle at 50 rpm . hpmc was used to form firm gel with eudragit polymer . formulation with equal proportion ( 1:1 ) of eudragit rspo and rlpo showed optimum drug release t50=7 hrs and t100=16 hrs indicate optimum permeability for drug release from matrix . the drug release mechanism was predominantly found to be non - fickian diffusion controlled .

totally implantable central venous access devices for administration of chemotherapeutic agents ( chemoport ) are commonly used in cancer patients with an indication for chemotherapy . percutaneous implantation of a chemoport via the subclavian vein is associated with several kinds of potential complications , including pneumothorax , malposition , infection , bleeding , arrhythmias and thrombosis , both during placement and later in long - term maintenance.1 ) transection and embolization of a chemoport , so called " pinch - off " syndrome ( pos ) , is a rare complication and the reported incidence is approximately 1.6 percent ( 26/1644 ) , with a range of 0.1 to 2.1 percent.2 ) we present a case in which a chemoport embolized into the inferior vena cava ( ivc ) and was successfully retrieved by a percutaneous approach using a goose neck snare . a 66-year - old man presented with descending colon cancer ( t3n1 m0 , stage iiia ) in 2007 . the lower anterior resection of colon and adjuvant chemotherapy was performed for this patient , and he was doing well . non - symptomatic metastatic nodule was discovered in follow up abdominal computed tomography on 2 years after the surgery . he underwent segmentectomy of the liver and an implantable central venous access device , the chemoport ( celsite st 201 , 8.5 fr , b. braun medical inc , melsungen , hesse , germany ) , was placed in the right subclavian area , for administration of chemotherapeutic agent . the post - insertion chest x - ray ( cxr ) confirmed good placement of the chemoport ( fig . six - days after implantation of the chemoport , he complained of chest discomfort and swelling of right infraclavicular area . a cxr showed that the distal portion of the chemoport had been fractured and embolized into the ivc ( hinke grade 3 ) ( fig . he was transferred to the cardiac catheterization room for percutaneous retrieval of embolized part of chemoport . puncture of the femoral vein was followed by insertion of a 7 fr sized venous sheath . the fractured distal segment of the chemoport was subsequently caught and moved into the femoral vein using a goose neck snare ( vascular retrieval forceps/3 fr/120 cm , cook inc , bloomington , in , usa ) ( fig . venous access site was compressed manually after the removal of venous sheath . after the confirmation of hemostasis on venous puncture site , catheter transection with subsequent embolization is a rare complication after the central venous device implantation.3)4 ) particularly , it can happen when a central venous catheter is compressed vigorously and repeatedly between the clavicle and the first rib in the case of insertion with subclavian approach . this effect can provoke tearing of catheter associated with the scissoring effect related with movement of shoulder.5 ) in 1984 , aitken and minton6 ) first described the " pinch - off sign " ( compression of the catheter as it crosses between the clavicle and the first rib ) on cxr with a case of catheter fracture and embolization . in order to avoid such fractures , they recommended insertion of the catheter more laterally to the mid - clavicular line , where the angle between the clavicle and the first rib is wider.6 ) in 1990 , hinke et al.7 ) developed a radiographic scale of catheter distortion : grade 0 , no compression , and distortion ; grade 1 , abrupt change in course without luminal narrowing , grade 2 , some degree of luminal narrowing , grade 3 , complete catheter fracture . most patients with pos are asymptomatic , and therefore it often goes unrecognized.8 - 11 ) the possible accompanying symptoms include infraclavicular pain or swelling with flushing or infusion due to extravasation of fluid.9 - 11 ) asymptomatic patients with pos can be neglected for a long time with a subsequent need for costly surgical treatment.12 ) therefore , clinicians should be aware of clinical clues of pos , such as the intermittent positional nature of the occlusion relieved by rolling of the shoulder or raising the arm on the ipsilateral side.9 - 11 ) difficult to aspirate blood and resistance to flushing or infusion are clinical symptoms consistent with pos.9 - 11 ) clinical suspicion of pos should be confirmed by obtaining a cxr.7)10 ) in our case , the fracture site of the catheter was just below the body of the port and might not be suitable for pos in view of the infraclavicular compression . we could confirm the symptoms of fracture and embolization of the catheter by obtaining a cxr early . early detection and intervention might provide the opportunity for prevention of further complications and costly surgical techniques , such as thoracotomy for removal of the catheter . as reported in the literature , the transected and embolized catheter should be removed as soon as possible using a less invasive technique.7)9)11 ) percutaneous removal of the catheter with local anesthesia is generally regarded as a safe and successful procedure.9)10)13 ) if the migrated catheter adheres to the myocardium , an open thoracotomy would be required for removal.13 ) in conclusion , this case suggests that early detection of pos based on the clinical signs and radiologic findings could provide an opportunity for safe removal of the catheter and prevention of subsequent complications .

the central access device is commonly used as a route of chemotherapuetic agents in patients with malignant diseases for its convenient and safety for insertion . this report describes a case of 66-year - old man with colon cancer who suffered a rare complication in which a chemoport embolized into the inferior vena cava and it was successfully retrieved by a percutaneous approach using a goose neck snare .

we reviewed the records of all patients who received hat treatment in the period january 1 , 2001december 31 , 2003 , in the 23 treatment centers operating in north equator province . we included only those case - patients who had received complete treatment with melarsoprol , obtained from sanofi aventis ( paris , france ) under the world health organization donation program with 1 of the following regimens : 3 series of 3 injections ( 3.4 mg / kg ) at 7-day intervals for patients with a cerebrospinal fluid ( csf ) leukocyte count > 20 leukocytes / mm , or 2 series of 3 injections ( 3.4 mg / kg ) at 7-day intervals for patients with csf leukocyte counts of 520 leukocytes / mm . patients were asked to return for a routine follow - up visit to the hat treatment center at 6 , 12 , 18 , and 24 months after treatment or any time they felt unwell between visits . age , sex , disease stage , and results of parasitologic tests of the patients who experienced a relapse were recorded during the chart review . hat relapse was defined as follows : trypanosomes found in body fluids at any follow - up assessment or a csf leukocyte count > 20/mm and twice as high as the count at the previous follow - up visit . this case definition for relapse is used by the national program and in clinical trials ( 6 ) . patients who did not show up for suggested follow - up visits were not visited at home . the relapse rate was calculated as the number of patients with hat who experienced a relapse , divided by all patients who received full melarsoprol treatment during the study period . the study included 4,925 patients with second - stage parasitologically confirmed hat ; all were treatment - nave for hat , and none had been referred by another center . table 1 shows the relapse rate by geographic area for the years 2001 , 2002 , and 2003 . the patients from the central part of the province showed the highest relapse rates , and the trend increased over the 3 years ( for trend 22.3 , p<0.001 ) . table 2 shows characteristics of the patients with a relapse of hat after melarsoprol treatment . this proportion dropped to 73% after 2 years , according to the annual reports for 20012005 . only 4.8% of patients with first - stage illness experienced a relapse ; direct evidence of the parasite was found in 27% of these case - patients . these data show that high failure rates with melarsoprol are no longer limited to kasai province in drc . the hat focus of the equateur nord province does not border that in the kasai province , and given the limited contact between both provinces , resistant strains likely did not spread from kasai to equateur nord province . the reported failure rate is certainly underestimated because some of the patients who did not return for follow - up visits probably died at home or sought treatment elsewhere . we can not exclude the possibility that some retreated patients had been reinfected . however , the trend in observed incidence rates in equateur nord province had been declining since 2004 , and , regardless , the incidence was too low to contribute substantially to the observed 19.5% failure rate . the program used only basic parasitologic confirmation tests and none of the more sensitive concentration techniques , such as capillary tube centrifugation , quantitative buffy coat test , or the miniature anion - exchange column for trypanosomiasis during the study period , which explains the low proportion of relapses that were parasitologically confirmed . melarsoprol was used on a massive and unprecedented scale in equateur nord province from 1996 through 2005 , when 38,945 new patients received treatment with melarsoprol ( annual reports of national program 2000 and 2005 ) , so drug pressure ( i.e. , the use of a certain antimicrobioal agent potentially selecting out resistant strains ) was certainly present in the region . similarly high failure rates with melarsoprol in the kasai province led the national control program to introduce eflornithine as a first - line treatment there in 2006 . the cause of these high relapse rates remains unclear because until now melarsoprol resistance could not be demonstrated in parasites in vitro or in animal models ( 5 ) . the program used a shorter melarsoprol treatment regimen than that used by other countries , where 3 series of 4 injections are used . this difference is unlikely to be an explanation for the high relapse rates found , however , as in other provinces of drc , relapse rates with the same regimen remained considerably lower ( e.g. , a 1.4% reported relapse rate for bandundu province , according to the 2006 annual report of the national control program ) . given this high failure rate , a switch to the safer eflornithine regimen is the most obvious solution . however , this drug is more complex to administer : patients receiving it require intravenous fluids and a high standard of nursing care . eflornithine offers the additional advantage of lesser toxicity , which might enhance the acceptability of hat treatment . a cost - effectiveness analysis showed that eflornithine is the more cost - effective option whenever relapse rates with melarsoprol treatment exceed 15% ( 7 ) . legitimate concerns have been raised regarding the use of this drug in monotherapy as first - line treatment because there are no alternatives if resistance to it emerges . a clinical trial on the use of the combination dfmo ( alpha - difluoromethylornithine)nifurtimox is in progress ( 8) . public - private partnerships such as the drugs for neglected diseases initiative and others are currently investing in development of such drugs , but a new drug will not likely be available within the next decade .

a retrospective chart review of 4,925 human african trypanosomiasis patients treated with melarsoprol in 20012003 in equateur nord province of the democratic republic of congo showed a treatment failure rate of 19.5% . this rate increased over the 3 years . relapse rates were highest in the central part of the province .

the main objective of root canal treatment is thorough mechanical and chemical cleansing of the entire pulp space followed by complete obturation with an inert filling material . therefore , it is imperative that aberrant anatomy is identified prior to , and during the root canal treatment of such teeth . in 1974 , vertucci and william described the presence of an independent middle mesial canal in a mandibular first molar . since then unusual canal anatomy associated with mandibular first molar has been reported in several clinical studies / case reports . the present case report describes root canal treatment in a mandibular first molar with three separate root canal orifices and a single exiting foramen . a 20-year old female patient was referred to our department of conservative dentistry and endodontics with the chief complaint of pain in the lower right back tooth since the past 3 days . clinical examination revealed a deep disto - occlusal carious lesion in relation to right mandibular first molar ( tooth # 46 ) . the preoperative radiograph demonstrated a disto - occlusal radiolucency approaching the pulp space and widening of periodontal ligament space in relation to the mesial and distal root apices [ figure 1a ] . a diagnosis of necrotic pulp with symptomatic apical periodontitis was established and endodontic therapy was scheduled . ( a ) preoperative radiograph of 46 , ( b ) intraoral photograph showing three distal canal orifices in access cavity preparation , ( c ) working length radiograph , ( d ) postobturation radiograph , ( e ) postobturation radiograph with 30 degree mesial angulation following local anaesthesia , an endodontic access cavity was prepared under rubber dam isolation on tooth # 46 . examination of pulp chamber floor revealed five distinct root canal orifices : two were detected mesially ( mesiobuccal and mesiolingual ) ; and , three distally ( distobuccal , middle distal and distolingual ) [ figure 1b ] . cleaning and shaping of canals was done , and the canals were dried with absorbent points . the obturation was done by cold lateral compaction of gutta - percha [ figure 1d , e ] . the majority of mandibular first molars have two roots , one mesial and one distal , and their usual root canal distribution is two canals in the mesial root and one or two canals in the distal root . the major variant of root canal system of mandibular first molar is the presence of a middle mesial canal with 1 - 15 % incidence . incidence of three canals in distal root of mandibular first molar in an indian population is 1.7% ; 0.2% in senegalese population ; 1.7% in turkish population ; 0.7% in burmese population ; 1.6% in thai population ; and , in sudanese population 3% incidence has been reported . this case demonstrates a rare anatomical configuration and supports previous reports of the existence of such configuration in mandibular first molars . detailed review of case reports with three canals in the distal root / roots is summarized in table 1 . in this case report , distal root has three distinct root canal orifices with single apical termination , that could be described as type xviii canal configuration according to sert and bayirli supplemental canal configurations of root canal morphology . type xviii canal pattern in distal root of mandibular first molar is previously reported in only one case . diagnostic measures are important aids in location of root canal orifices including multiple pretreatment radiographs , examination of pulp chamber floor with a sharp explorer , troughing grooves with ultrasonic tips , staining of chamber floor with 1% methylene blue dye , performing sodium hypochlorite champagne bubble test , visualizing canal bleeding points , and use of dental operating microscope and magnification loupes . review of the case reports with the finding of three or more canals in distal root / roots of mandibular first molar usually , a prudent inspection of the pulp chamber floor by proper visualization allows the clinician to search for additional canals . proper and thorough instrumentation is one of the key factors in the success of endodontic therapy ; therefore , the clinician should be aware of the incidence of these extra canals in the mandibular first molar .

with the increasing number of reports of aberrant root canal morphology , the clinician needs to be aware of the variable anatomy . various case reports have been published with the finding of middle mesial canal in mandibular first molar , however finding of middle distal canal in distal root of mandibular first molar is rare . this case report describes root canal treatment of two rooted mandibular first molar with five root canals ( three in distal and two in mesial root ) , and sert and bayirli type xviii canal configuration in distal root .

hysterectomy is the second most frequent major surgical procedure among reproductive age women with approximately 600,000 hysterectomies performed annually in the united states . it is currently undisputed that cystoscopy is required after each hysterectomy to confirm the integrity of the urinary tract before leaving the operating room . we are reporting a case of asymptomatic bladder cancer discovered incidentally during a posthysterectomy cystoscopy . a 42 year old patient , gravida 0 , with a known fibroid uterus and history of menometrorrhagia is admitted for definitive surgical treatment . her endometrial biopsy shows mild endometrial hyperplasia and her pap smear is within normal limits . so , laparoscopic hysterectomy is performed with uterine morcellation and as routinely done at the end of the operation cystoscopy is performed . this reveals an exophytic bladder tumor above the ureteral orifice on the right side ( figure 1a ( fig . biopsies are taken with three passes of a cup biopsy forceps and sent for pathology . the bleeding site is fulgurated with point cautery using the 20/20 cautery setting which gives good hemostasis with no evidence of bladder injury ( figure 1b ( fig . papillary transitional cell carcinoma , histologic grade i with no evidence of invasion . the specimen labeled uterus and cervix because the bladder is the final storage cistern for excreted toxins , there are many risk factors for bladder cancer including smoking , occupational exposures , drinking water with arsenic contamination , chemo- and radiotherapy and chronic cystitis . the american cancer society estimates that 68,810 new cases of bladder cancer will be diagnosed in the united states during 2008 of which 14,100 people will die of the disease . the chance of a woman having this cancer is about 1 in 85 . for men , fortunately , most people with bladder cancer will not die of the disease . upon diagnosis , most patients have their cancer confined to the bladder ( 74% ) . in 19% of the cases , females , however , are approximately twice as likely as males to die from the disease because of delay in diagnosis . a conscientious gynecologist should not be timid about biopsying bladder abnormalities detected at the time of postoperative cystoscopy . superficial mucosal biopsies of papillary lesions will not bleed significantly and can yield important diagnostic information . it is easier to treat bladder cancer if it is caught early . at this point , there is insufficient evidence that a decrease in mortality from bladder cancer occurs with hematuria or urinary cytology testing . this case illustrates the additional merit of performing posthysterectomy cystoscopy as a screening test for bladder cancer .

it is currently undisputed that cystoscopy is required after each hysterectomy to confirm the integrity of the urinary tract before leaving the operating room . sometimes , secondary findings are detected on cystoscopy like interstitial cystitis and exophytic tumors . we are reporting a case of asymptomatic bladder cancer discovered incidentally during a posthysterectomy cystoscopy . the chance of a woman having this cancer is about 1 in 85 . this demonstrates the additional merit of performing cystoscopy after hysterectomy as a screening test for bladder cancer .

cerebro - vascular diseases are one of the top 10 causes of mortality and morbidity in children . current figures suggest the incidence of 25/100,000 children / year for childhood stroke and at least 300 children in the united kingdom are diagnosed with stroke per year . cerebral sino - venous thrombosis ( csvt ) is a rare but serious cause of stroke in children . various risk factors have been identified in the literature including dehydration , sepsis , inflammatory diseases , and prothrombotic factors . iron deficiency anemia ( ida ) is a common pediatric problem affecting up to 25% of all the children worldwide . in an american survey 9% of children 1 - 2 years of age , 3% of children 3 - -5 years of age , and 2% of children 6 - 11 years of age were found to be iron deficient . a young nine - month - old boy of asian origin presented to our hospital with 1 day history of mild temperature , vomiting , and coryzal symptoms . he was born out of nonconsanguineous marriage and is the only child of his parents . he had a normal birth and development , and was up to date with his immunizations . there was no family history of any serious neurological conditions or strokes . on initial examination he was noted to be very pale and had a systolic murmur over the precordium . g / l , platelets 866 , white cell count 14 , mean corpuscular volume ( mcv ) 48 , mean corpuscular hemoglobin ( mch ) 11 , reticulocyte count 22 , and total iron of 7 g / l . after 7 days of hospitalization , he suddenly became drowsy and encephalopathic with gcs of 9/15 . mr venogram ( mrv ) confirmed extensive thrombosis of internal cerebral vein , vein of galen , straight sinus , sigmoid sinus , and basal vein of rosenthal [ figure 1 ] . magnetic resonance imaging and mr venogram done after the acute illness demonstrating bilateral thalamic infarction with hemorrhagic transformation and extensive venous sinus thrombosis he was started on low molecular weight heparin ( lmwh ) . ida has been linked with various neurological complications like motor developmental delay , behavioural problems , breath holding spells , stroke , pseudotumor cerebri and cranial nerve palsies . ida has also been associated with csvt as described in some case reports and case series in the pediatric literature . described six children aged between 6 and 18 months , who developed stroke with anemia . all children had preceding mild viral infection of either the upper respiratory or gastrointestinal tract . in a case control study by maguire et al . , anemia was significantly more common in children with stroke than in controls ( 53% vs. 9% ) . previously healthy children who developed vaso - occlusive stroke are 10 times more likely to have ida than healthy children , who do not develop stroke . iron deficiency can increase the number of platelets in blood , which is linked with a hypercoagulable state . it has been found that microcytosis decreases the cell deformability and increase the viscosity , causing abnormal flow patterns . under conditions of stress or infections , the metabolic demand at the tissue level rises which can create anemic hypoxia and can predispose to venous thrombosis . no other predisposing factors for csvt were present like sepsis , trauma , autoimmune diseases or prothrombotic disorders . management of csvt involves anticoagulation therapy ( act ) and symptomatic measures such as hydration , antimicrobials , control of seizures with anticonvulsants and management of raised intracranial pressure . unfractionated heparin or low molecular weight heparin ( lmwh ) is recommended in the absence of any major hemorrhage in older children , except in neonates . repeat venous imaging is recommended after 3 months to evaluate for recanalization and resolution of clot . if venous sinuses are partially recanalized , treatment should be continued for at least 6 months . thrombolysis , thrombectomy or surgical decompression has only been used in isolated cases in seriously ill patients or in those with worsening thrombosis despite adequate anticoagulation . in the study by kenet the predictors of recurrent thromboses included persistent occlusion on follow - up venous imaging , heterozygosity for the g20210a mutation in factor ii and the lack of anticoagulant therapy . children with severe ida should be actively treated and monitored , especially during minor infections because of the risk for developing csvt .

iron deficiency anemia is a common pediatric problem affecting up to 25% children worldwide . it has been linked with cerebral venous sinus thrombosis in the literature . we describe a 9-month - old child who had severe iron deficiency anemia and developed acute venous sinus thrombosis associated with minor infection . treatment with anticoagulation was partially successful with persistent thrombosis after 3 months . we reviewed the current literature highlighting the association of anemia as a risk factor for development of stroke in children .

if so , will the patient and/or parents be amenable to a surgical treatment plan ? as graber states in his text , many diagnostic factors must be analyzed , a differential diagnosis must be made and in light of your clinical experience as well as that of others , the indication and the contraindications of therapeutic modifiability must be weighed . in today 's often complex treatment plans , other physicians and dentists are integrated into the planning and treatment process . the contemporary orthodontist must not only keep up with current technical trends in orthodontic treatment but also successfully communicate , negotiate , and navigate the patient to a successful result . often the patient 's primary reason for seeking treatment is to improve his or her dental and /or facial esthetics . today 's orthodontist has many treatment options to choose from in reaching his or her goals . virtually all these treatment options are designed to reach the same general orthodontic goal : class i occlusion . however , each treatment choice almost always has an effect on the face and facial esthetic . this is very true in orthodontic treatment and may be even more dramatic in the area of combined orthodontics and orthognathic surgical cases . adult patients with dentofacial skeletal deformities like a class iii malocclusion require careful treatment planning , an integrated approach , and patient cooperation . in almost all soft - tissue relationships of the face , the position of the underlying hard tissue is a primary determinant of overlying soft - tissue morphology . this is true for the lips , teeth , chin and bony chin projection , and malar prominence . growth of the face is an enormously complex function of skeletal , dental and soft - tissue growth , with genetic and environmental factors both playing significant roles in the final facial form . facial esthetics has been of great interest to orthodontists in the year since angle , hellman , case and farkas opinions of what constitutes an attractive face have come from many sources and have been more than adequately covered in the orthodontic literature.[512 ] contemporary orthodontists are familiar with the principles of designing treatment to improve the profile rather than affecting it adversely . although class ii dentofacial deformities are more common , the need for treatment and improvement in terms of facial profile is generally greater in class iii patients . the purpose of this article is to illustrate such a case and to show the positive effect that certain treatment decisions have on the profile . a 26-year - old male patient presented with the chief complaint of unaesthetic facial and dental appearance [ figures 1a1c ] . to allow adequate surgical movement , 14 were extracted and the maxillary incisors were retracted . no extractions were performed in the mandibular arch because there was minimal crowding , no retraction was necessary , and a class ii molar relationship at the end of the treatment was considered acceptable . the mandibular incisors were aligned and the archforms were coordinated [ figures 2a and 2b ] . ( a - b ) prior surgery photographs surgery included a bsso set back of about 7.5 mm bilaterally which was as determined by the prediction tracing [ figures 3a and 3b ] . rigid internal fixation with screws and plates was used to stabilize the osteotomy site , and splint fixation was done during the surgery to maintain the result [ figures 4a4c ] . the patient was followed up closely after the procedure and orthodontic treatment was resumed 6 weeks after the surgery . ( a - b ) surgical treatment objective ( sto ) ( a - c ) splint fixation and postsurgical photographs six months later , the fixed appliances were removed [ figures 5a and 5b ] , and a retention program was initiated . ricketts superimposition of pre- and post - treatment cephalometric tracings confirmed the success of treatment [ figures 6a6d ] . ( a - b ) post - treatment photographs ( a - d ) rickett 's superimposition ( a - f ) post - retention photographs surgical - orthodontic treatment is sometimes the only option for achieving an acceptable occlusion and a good esthetic result in a patient with a class iii dentofacial deformity , as illustrated in this case report with [ figure 8 ] showing the improvement in the profile of the patient . correction of a class iii dentofacial deformity requires a multi - disciplinary team approach to ensure a satisfactory outcome .

this case report describes the surgical - orthodontic treatment of a 26-year - old post - pubertal male patient with a class iii dentofacial deformity . in the pre - surgical orthodontic phase of treatment , a reverse overjet of 5.5 mm was created and arch compatibility was obtained . a mandibualr set back with bsso was performed during surgery to restore ideal overjet , overbite , occlusion and optimal esthetics . after 1 year of treatment , the results remained stable .

in 2013 , specimens were collected from a shiitake cultivation farm , located beside high mountains in geochang - gun , gyeongnam province , korea . slime mold fruiting bodies developed on the top and side surfaces of the oak logs , a year after being cut . the bark of infected oak logs came off easily , exposing the sapwood beneath ( fig . 1a , 1b , and 1c ) . fruiting bodies formed close , profuse , large colonies and mature sporangia appeared brown , cylindrical , 10 to 15 mm tall with dark reddish - brown spore - masses ( fig . 1d ) . after removing the spores , the sporangium appeared bright brown ( fig . the sporophore morphology , surface structures of sporangia , columella , capillitium , peridium , spores , stalk , and hypothallus of the slime mold samples were assessed through stereomicroscopy and light microscopy . the stalk appeared black , shiny , and slender , measuring 1.0~4.0 0.1 mm to 0.2 mm . primary branches extended from junctions within the net and at distant intervals from the columella , simple at first , then suddenly branching vigorously to form a smooth surface net with rounded or angular mesh forms measuring 20~70 m in width ( fig . the columella was black , reaching almost to the top of the sporotheca , tapered , rigid , and flexuous towards the tip ( fig . 2c ) . spores were lilac - brown , 7~9 m in diameter , almost smooth with fine , pale warts ( fig . for in vitro culture , moist chambers consisting of a sealed sterilized plastic box with three sheets of kim 's towel at the bottom . spore masses and fruiting bodies were transferred to the plastic box and incubated at room temperature ( 25~28 ) . 3b ) . based on morphological characteristics , the pathogenic slime mold causing decay of the oak bark was identified as stemonitis splendens rostaf , as reported by nieves - rivera and stephenson .

severe bark decay disease was observed on oak logs at a shiitake cultivation farm in geochang - gun , gyeongnam province . the symptoms observed were fruiting bodies that had developed on the top and side surface of oak logs . as a result , the bark came off easily exposing the sapwood . slime mold specimens collected from oak logs showed developing fruiting bodies comprising of stalks , hypothallus , capillitium , and columella , and the causal agent of bark decay disease was identified as stemonitis splendens on the basis of morphological characteristics . to our knowledge , this is the first report of stemonitis splendens causing bark decay of oak logs used for shiitake mushroom cultivation in korea .

pleomorphic lipoma ( pl ) is a rare variant of lipoma on a continuum with spindle lipoma . microscopically , these tumours are composed of mature fat cells mixed with bland spindle cells , hyperchromatic round cells , and multinucleated giant cells . the vast majority of tumours are located in the subcutaneous tissue of the posterior neck and upper back . to best of our knowledge , this is the third cases reported in international literature . a final diagnosis may be difficult because of the prevalence of spindle and multinucleated pleomorphic cells and the presence of abundant myxoid stroma . we add a new illustrative case to the 2 cases of pl of tongue reported in literature . a 44-year - old woman presented with a slow - growing , painless nodule of the tongue with difficulty in deglutition . clinical examination revealed a soft , sub - mucosal nodule , measuring approximately 3 cm in maximum diameter , covered by normal mucosa . a surgical excision was performed . histological examination showed mature adipocytes , diffusely infiltrating striated muscle fibres , [ figure 1 ] and abundant mucoid stroma [ figure 2 ] . in this myxoid background were present bland - appearing spindle cells and multinucleated giant cells with radially arranged nuclei in a the spindle and giant cells were strongly positive for cd34 [ figure 4 ] and negative for s100 . a fluorescence in situ hybridization ( fish ) was performed on formalin - fixed , paraffin - embedded tissue sections using mdm2 ( 12q15 ) dual - colour probe ( vysis , downers grove , il , usa ) . the post - operative course was uneventful ; after 1 year , the patient was free of disease although the tumour was present at the margins of the excised specimen and is currently on follow - up . the mass was poor circumscribed and lipomatous in appearance with mature adipocytes , diffusely infiltrating striated muscle fibers ( h and e , 10 ) mature adipose tissue was admixed with abundant mucoid stroma ( h and e , 20 ) mucoid areas showed bland - appearing spindle cells and multinucleated giant cells with radially arranged nuclei in a floret - like pattern ( h and e , 20 ) the spindle and giant cells were strongly positive for cd34 ( immunoperoxydase , 40 ) lipomas are the most common mesenchymal tumours of soft tissue but are uncommon in the oral and maxillofacial region . classic lipoma is the most frequent type in these sites , but other variants have been described including some cases of atypical lipomatous tumour ( alt)/well - differentiated liposarcoma ( wdl ) . pl is a distinctive variant of lipoma originally described by enzinger , characterized by replacement of mature fat by bundle of spindle cells , hyperchromatic round cells and giant cells with floret - like nuclei admixed with dense collagen fibres or within a myxoid stroma . exceptionally , pl have been described in the tongue ; to best of our knowledge , only two case have been reported in literature . the different proportion of fat cells , spindle cells , collagen fibres , and mucoid substance confers to pl a variable macroscopic and microscopic appearance that can hamper the diagnosis . neurofibroma , ancient schwannoma , myxoma , and nodular fasciitis are the lesions that most frequently showed cellular features that overlap with pl . the most difficult differential diagnosis is with alt / well - differentiated liposarcoma ( wdl ) , and with pleomorphic liposarcoma . the presence of infiltrative margins , the identification of bizarre multinucleated giant cells with hyperchromatic nuclei , and some lipoblast - like cells may suggest a diagnosis of malignancy . moreover , the floret - like cells of pl are not pathognomonic but may be present also in liposarcomas . unlike the latter , the former lacks of true lipoblasts , cellular pleomorphism , marked vascularisation , mitotic activity , and show an intense immunoreactivity for cd34 . in difficult cases , the combination of immunohistochemistry and ( fish ) that shows the amplification of mdm2 and cdk4 genes may play a role in differential diagnosis with benign adipose tumours . despite the worrisome morphological features , pl is benign , rarely recur , and a possible malignant transformation is not described in literature . in conclusion , pl is a benign lesion that rarely can arise in unusual site as the tongue and is cured by complete local excision . the cytological features and the immunoreactivity for cd34 may suggest a pl addressing a proper surgical procedure .

we herein report a rare case of pleomorphic lipoma of the tongue with a review of world literature . a 44-year - old woman presented with a nodule of the tongue that had been present for over three years . clinical examination revealed a yellowish sub - mucosal lesion , measuring 3 cm in maximum diameter , protruding from lingual surface . a first biopsy showed a lipomatous tumour composed of mature adipocytes intermingled with myxoid areas composed of spindle uniform in size and shape and multinucleated floret - like giant cells . spindle and giant cells were positive for cd34 . a diagnosis of pleomorphic lipoma was made . in view of the benign nature of this mass , it was de - bulked rather than completely excised in order to preserve swallowing function .

electroanatomic maps of the urinary bladder were developed using a noncontact mapping system ( ensite ) , which consisted of a roving catheter , a noncontact multielectrode array ( mea ) 64-electrode basket , and a custom designed amplifier system , with custom designed software , connected to a silicon graphics workstation . the reference electrode was located 16 cm distal to the basket . in cardiology application , a geometric model of the heart the current sensed by the proximal and distal ring electrodes mounted on the mea catheter created a location specific voltage distribution . the local medical ethics committee commisie mensgebonden onderzoek approved the study under number 46832.091.13/metc 2013/279 . three women aged 34 , 56 , and 82 years with lower urinary tract symptoms were included in the study . the first patient was a 34-year - old woman with oab symptoms ( urge incontinence ) ; her urodynamic study revealed detrusor overactivity ( do ) . the second patient was a 53-year - old woman with chronic neurogenic nonobstructive urinary retention . the bladder was drained using a 14-fr catheter , through which 200 ml of nacl 0.9% was injected into the bladder . the roving catheter was replaced by an urodynamic pressure catheter together with an mea catheter . the electrovesicography ( evg ) and the vesical pressure recordings were started simultaneously . during the measurement , evg data were sampled at a frequency of 1.2 khz ; the recorded signals were unipolar , with a bandpass filter between 0.1 and 300 hz . the measurements were performed using the ensite system , simultaneously with pressure flow study of the bladder using urodynamics systems ( medical measurement systems b.v . , the electrical signals obtained from the ensite system and the pressure signals obtained from the urodynamic system were manually synchronized . an envelope of a segment of the evg data was created using the absolute values of the mean of all channels recordings . the correlation coefficient for the correlation between the envelope of the evg data and the pressure signal of the bladder was calculated . the p - values were calculated by using two - tailed t - test with a significance level of 0.05 . data segments with detrusor pressure activity ( do and/or voiding act ) were selected ; the related evg and detrusor pressure ( pdet ) recording are shown in fig . scatter plots were made of the delay with the highest correlation coefficient , showing a positive correlation between the pdet and the envelope , and negative correlation between abdominal pressure ( pabd ) and the envelope ( fig . to our knowledge , the current study is the first attempt to measure the electrical activity within the urinary bladder in humans . some previous studies reported signals measurements : shafik et al . reported bladder signals of 1.6 mv , while hashitani et al . reported bladder signals of 72 mv . this might be explained by the fact that the measured signals were estimated by the ensite software , which was originally developed to measure electric activity of the heart , which has a different geometry from the urinary bladder . another possibility to explain these low amplitudes could be the low conductivity of the saline fluid used to fill the bladder . the maximal distance for the ensite system to measure the electrical activity in the heart is 5 cm . 1 , the catheter is not located in the middle of the bladder , but rather lies against the bladder wall . this deviation from the central position of the mea catheter could lead to recording of one side only , the side closer to the catheter bladder activity . low bladder volumes might lead to direct contact between the mea catheter and the bladder wall , which might result in motion artifacts . therefore , we tried to maintain a maximal distance of 3.6 cm between the catheter tip and the bladder wall , which corresponds to a volume of about 200 ml . technical artifacts might be enormous for an accurate interpretation , especially in different bladder volumes and thicknesses . the tip of the electrode might be monitored with a camera using the video urodynamic study . ideally , the correlation coefficients of one segment should be significant for the detrusor pressure and insignificant for the abdominal pressure . however , the aim of this study was to test the possibility of developing the electroanatomical mapping for the bladder . in the next phase of the study , we will try to examine the electroanatomical features of the urinary bladders in healthy and disease status . electroanatomical mapping of the bladder might reveal crucial information about bladder pathophysiology for new management strategies for oab . for instance , electroanatomical mapping might indicate specific locations for the onabotulinum toxin a injections , thereby increasing the effectiveness of treatment and decreasing the costs . electroanatomical mapping of the bladder might be useful to differentiate the underlying pathologies in patients with bladder underactivity . minimal electrical activity could be observed , and significant weak to moderate correlation coefficients were found for the correlation between detrusor and abdominal pressures , and evg . the electrical propagation activity over the bladder wall could not be detected using the current method .

a noncontact mapping system ( ensite ) was used for electroanatomical mapping of the bladder simultaneously with pressure flow study in three women with lower urinary tract symptoms . we selected the periods of obvious detrusor activity . data were processed to remove baseline drift , and an envelope of electrovesicography ( evg ) data was created . the correlation coefficient for the correlation between between the evg envelope and the detrusor pressure ( pdet ) was calculated . bladder geometry was successfully created in all 3 patients . simultaneous recording of evg and pressure flow data was successful in 1 patient . scatter plots were made of the highest correlation coefficient , showing a positive correlation between the pdet and the envelope , and negative correlation between abdominal pressure ( pabd ) and the envelope . minimal electrical activity could be observed . significant weak to moderate correlation coefficients were found for the correlations between pdet and evg and between pabd and evg .

in this issue of critical care the japanese research group headed by ishihara highlight the issues involved in measuring blood glucose . their approach does not involve attempting to reduce mortality by controlling the glucose level ; rather , they use its response to a glucose bolus as an index of physiological parameters such as plasma volume and cardiac output . their work is admirable , and more effort should be given to simplifying the measurement of parameters that are useful in intensive care . we should not overlook the potential utility of glucose measurement , as pioneered by ishihara over the past decade . ishihara and coworkers introduced the concept of the initial distribution volume of glucose ( idvg ) , which is determined by measuring the arterial blood glucose level just before and repeatedly for about 10 min after a bolus infusion of 5 g glucose is administered . the data are analyzed by computer according to a one - compartment kinetic model , in which the concentration time profile is represented as a function of glucose clearance and the volume of distribution of administered glucose . it is crucial that measurements are taken from an arterial line because glucose is rapidly distributed over 65% of the total extracellular fluid volume as soon as the blood passes through the capillary bed . when measured in this manner the glucose concentration extrapolated to time zero is diluted in proportion to cardiac output . the glucose clearance then becomes a hybrid of the distribution of exogenous glucose between plasma and the interstitial fluid and the glucose uptake into cells . this approach was first reported in 1993 , and ishihara and coworkers concluded that only two samples are needed to estimate idvg : one before the bolus infusion and another 3 min later . such a simplification is justified because variations in glucose clearance and endogenous glucose production are of little importance over short time increments , at least when it is applied in a fairly coherent group of patients . in subsequent studies , however , sampling was usually extended to 7 min . idvg correlates reasonably well with plasma volume in bled dogs and with the incidence of hypovolaemic hypotension after surgery for oesophageal cancer , although these findings may merely reflect the effect of hypovolaemia on cardiac output . in later studies , ishihara and coworkers suggested that idvg is a measure of the ' central ' extracellular fluid volume as well as of cardiac preload . their views became more complex when indocyanine green was introduced as a direct measure of plasma volume . a deviation in the ratio of indocyanine green to idvg is said to indicate capillary leakage of proteins after cardiac surgery , because this marker binds to proteins . as for glucose clearance , however , < 10 min is a very short period for ongoing capillary leakage to make a difference . furthermore , any such leakage would cancel out if a concentration time curve of dye is extrapolated back to time zero . alternative explanations should not be overlooked because control methods designed to measure capillary leak ( such as use of radioactive albumin ) were not applied , and a similar increase in the indocyanine / idvg ratio also occurs early after induction of intravenous anaesthesia and after administration of histamine . all of these ideas about the physiological meaning of idvg may be difficult to differentiate for the intensivist . although idvg perhaps most directly reflects a fraction of the extracellular fluid volume , several of ishihara and coworkers ' later studies actually strongly support their first interpretation , namely that idvg indicates cardiac output . this correlation between idvg and cardiac output is logical and renders idvg highly useful because it both predicts a key parameter in body physiology and can be measured quickly and with little effort and cost . unfortunately , this view is somewhat countered by the fact that idvg is said to be undisturbed by vasoactive drugs , although most of these agents actually change cardiac output . what the limits are and the errors that may be hidden in the determination of idvg are the most recent issues . idvg is apparently accurate if it is repeated after 30 min in clinical patients , although the study presented in this issue holds that blood glucose remains elevated for another 30 min , which is also the case in healthy individuals ( fig . ishihara and coworkers , in addition to repeating their previous finding that a 3-min postinfusion sample is sufficient to predict idvg , also compare calculations of idvg based on plasma glucose and blood glucose . the difference is quite small and , logically , should be accounted for by displacement of glucose from the parts of the red blood cells that consist of haemoglobin . blood difference in idvg and the haematocrit , but i believe that haemoglobin would be a more reasonable comparitor because haemoglobin reflects differences in the water content of blood . nevertheless , the authors conclude that measurements can be based on both plasma and blood samples , although these are not interchangeable . it appears that the idvg will be ready for limited implementation once it has been tested by additional independent groups . the method is safe and easy to apply , but intensivists must reach a consensus about its place in the clinic and what it really shows . i foresee that idvg may serve as a screening test to separate patients with a hyperkinetic circulation from those with a hypokinetic one . relative stability of the volume of distribution of glucose when 5 g glucose is given by intravenous infusion over 10 min on three occasions immediately following each other in one healthy volunteer . ishihara and coworkers infuse glucose even faster and use the arterial plasma glucose level measured between 3 and 7 min to calculate the volume of distribution .

the initial distribution volume of glucose ( idvg ) can be calculated from the arterial plasma glucose level between 3 and 7 min after a bolus intravenous infusion of 5 g glucose . ishihara and colleagues have investigated the value of idvg over the past decade . although idvg is simple and cheap to measure , there have been several very different proposals regarding what it should be used for . the most interesting and logical correlate is that between idvg and cardiac output . a recent study showed that it does not matter much whether the calculation of idvg is based on blood or plasma samples .

in 1997 , the short stature homeobox containing gene ( shox ) was cloned from the pseudoautosomal region of the short arm of the x and the y chromosome ( par1 ) ( 1 ) . subsequent studies have shown that shox haploinsufficiency leads to short stature , turner skeletal features , and leri - weill dyschondrosteosis ( lwd ) characterized by mesomelic limb shortening and madelung deformity ( 2,3,4 ) . here , we report a boy with short stature , turner skeletal feature , and a ring y chromosome missing shox . the boy was the first child born to non - consanguineous parents after an uncomplicated term pregnancy . his birth length was 46.3 cm ( 1.7 sd ) , and birth weight 2.9 kg ( 0.6 sd ) . subsequently , his clinical course was uneventful , although his height remained just below 2.0 sd . the paternal height was 169.4 cm , and the maternal height 161.0 cm . at age 11 physical examination showed a prepubertal boy ( testis size , 2 ml ; pubic hair , tanner stage 1 ) with proportionate short stature ( 127.3 cm , 2.3 sd ) and mild cubitus valgus ( fig . b , radiological findings indicating bowing of the radius and dorsal dislocation of the distal ulna . ) . bone age was 10 yr . endocrine studies for short stature were normal , as were cerebral mri scans . chromosomal analysis showed a 46,x , r(y)(p11.3q11.2 ) karyotype in all the 20 lymphocytes examined ( fig . 2 g - banding karyotype showing the ring y - chromosome ( box ) . ) , and fluorescence in situ hybridization ( fish ) analysis with a shox probe ( yp11.3 ) ( mbc , tokyo , japan ) and an xq / yq telomere probe demonstrated loss of shox from the ring y chromosome ( fig . 3fig . 3 fish analysis of this patient showing the presence of a single copy of the shox gene ( green signal ) on the x chromosome . ) . fish was also performed with an sry probe , confirming the presence of sry . a , photographic appearance showing cubitus valgus . b , radiological findings indicating bowing of the radius and dorsal dislocation of the distal ulna . fish analysis of this patient showing the presence of a single copy of the shox gene ( green signal ) on the x chromosome . shox haploinsufficiency resulting from a ring y chromosome was identified in a boy with short stature , cubitus valgus , and mild turner skeletal features ( 2,3,4 ) . the results are consistent with the association of shox haploinsufficiency with short stature and turner skeletal features . in addition , the mild skeletal manifestation in this prepubertal boy is compatible with the previous notion that skeletal maturing effects of gonadal estrogens induce the growth failure and skeletal anomalies in patients with shox haploinsufficiency ( 4 ) . indeed , severe phenotype in shox haploinsufficiency has usually been observed in pubertal to adult females with normal ovarian function ( 4 , 5 ) . in this study , it is notable that shox haploinsufficiency was found in a prepubertal boy . chromosome analysis is usually performed on girls with short stature because of the possibility of turner syndrome , and shox analysis is frequently carried out on pubertal to adult females because of obvious skeletal manifestations . by contrast , such analyses remain rare for prepubertal boys primarily due to male sex development and mild skeletal phenotype . we recommend such analyses for boys with short stature and turner - like skeletal features . identification of shox haploinsufficiency will permit application of gnrh analog ( 6 ) therapy and appropriate genetic counseling .

we report on an 11-yr - old boy with short stature and turner skeletal features . chromosome analysis revealed a 46,x , r(y)(p11.3q11.2 ) karyotype , and fish analysis showed loss of the short stature homeobox containing gene ( shox ) from the ring y chromosome . the results are consistent with the association of shox haploinsufficiency with short stature and turner skeletal features , and suggest the importance of shox analysis in boys with turner - like skeletal phenotype .

situs inversus totalis ( sit ) is a rare congenital malformation characterized by transposition of organs to the opposite side of the body in the mirror image of normal . it occurs in 1:5,000 to 1:10,000 of hospital admissions , and although most patients are asymptomatic , it can be associated with a number of other conditions such as cardiac anomalies and kartagener 's syndrome [ 1 , 3 ] . the aim of this report is to describe the case of symptomatic cholelithiasis managed by three - port laparoscopic cholecystectomy in a woman from brazilian amazonia with sit . a 43-year - old woman , born and resident in brazilian amazonia , presented with a 15-day history of dolorous syndrome localized at the left hypochondrium and epigastrium with no other concomitant digestive problems . on physical examination , she was afebrile , without jaundice , and abdominal examination was unremarkable . during clinical assessment , abdominal ultrasonography showed situs inversus and hyperechogenic images in the gallbladder lumen , compatible with multiple free stones . was identified , diagnosis of sit and cholelithiasis was made and the dolorous syndrome was attributed to it . based on this diagnosis , the patient underwent three - port laparoscopic cholecystectomy by a left - hand surgeon . however , the surgical team and the laparoscopic devices were located as a mirror image configuration from the one used in orthotopic patients . the operating surgeon and the video monitor assistant were positioned on the patient 's right side and the tv monitor was placed on the upper left side of the patient . three ports were used : a 10-mm trocar was inserted infraumbilically through which the zero viewing endoscope was introduced . another 10-mm trocar was inserted 3 cm below the xiphisternum at midline ; and finally , a 5-mm trocar at the left hypochondrium hemiclavicular line 5 cm below the costal margin . the infraumbilical port was used to create the pneumoperitoneum ( 12 mm hg ) with carbon dioxide ( co2 ) . 2 ) . the operating surgeon held the dissecting instruments with his left hand through the 10-mm trocar while holding the gallbladder at the infundibulum with a grasper through the 5-mm trocar , moving the infundibulum right and left , back and forth to display the calot triangle . the cystic duct was then isolated , clipped and divided followed by the cystic artery . the gallbladder was dissected from the liver bed and subsequently extracted through the infraumbilical port . the patient had an uneventful recovery and was discharged home on the first postoperative day . since campos and sipes described the first case of laparoscopic cholecystectomy in a patient with situs inversus , this uncommon malformation has been challenging and amazing many surgeons . due to the contralateral disposition of the viscera , the diagnosis and surgical approach of these patients may be more difficult than that of orthotopic patients . according to previous reports , however , the procedure often requires more time to rearrange the equipment in the operating room and extra care to recognize the mirror image anatomy . the anatomical variations and , mainly , the contralateral disposition of the biliary tree demand an accurate dissection and exposition of the biliary structures to avoid iatrogenic lesions . there is widespread acceptance that four - port technique is the standard procedure of traditional laparoscopic cholecystectomy . however , technical improvements have permitted the execution of less invasive procedures , using only three or even two ports to perform laparoscopic cholecystectomy . these modifications actually reduced postoperative pain , analgesia requirement , length of hospital stay and costs [ 7 , 8 ] . no other reports in the international literature were found describing the three - port technique in patients with sit , though . in our case , only three ports were necessary to perform a safe dissection and to obtain a good exposure of the gallbladder and the biliary tree . the dissection of the biliary tree can be carried out with either the right or the left hand , however for right - handed surgeons using the unskilled and nondominant left hand , the manipulation may be cumbersome and not precise . in the present case , the left - handed surgeon performed the dissection of the calot triangle by holding the dissecting instruments with the left hand through the 10-mm trocar and a grasper with the right hand to maneuver the gallbladder . the patient had a normal follow - up and , 5 months after surgery , remains asymptomatic . in conclusion , this case confirms that three - port laparoscopaic cholecystectomy is a safe and feasible surgical approach even in patients with sit presenting symptomatic cholelithiasis , despite the reverse anatomical relationships . however , to overcome technical difficulties and avoid iatrogenic lesions , the procedure must be carried out by an experienced laparoscopic surgeon , especially if the surgeon is left - handed , used to the three - port technique in orthotopic patients .

situs inversus totalis ( sit ) is an uncommon anomaly characterized by transposition of organs to the opposite side of the body in a mirror image of normal . we report on an adult woman , born and resident in brazilian amazonia , presenting acute pain located at the left hypochondrium and epigastrium . during clinical and radiological evaluation , the patient was found to have sit and multiple stones cholelithiasis . laparoscopic cholecystectomy was safely performed with the three - port technique in a reverse fashion . in conclusion , this case confirms that three - port laparoscopic cholecystectomy is a safe and feasible surgical approach to treat cholelithiasis even in rare and challenging conditions like sit .

central vein catheterization has commonly been used for volume resuscitation , emergency venous access , chemotherapy , parenteral nutrition , hemodialysis , and central venous pressure monitoring . the percutaneous approach includes access via the internal jugular vein , femoral vein , or subclavian vein . during a case of right subclavian venous catheterization using the landmark method , we experienced extravasation , breakage , and entrapment of a guidewire within the thorax that was subsequently removed using video - assisted thoracoscopic surgery ( vats ) . we report this case for educational purposes because this procedure is common but must be performed carefully . a 79-year - old female patient diagnosed with ascending colon cancer was admitted to the division of colon and rectal surgery of our institution for a scheduled operation on july 23 , 2012 . at admission , the patient 's calculated acute physiology and chronic health evaluation ii score was 10 with a predicted death rate of 11.3% . central venous catheterization was performed for preoperative , intraoperative , and postoperative volume resuscitation and nutritional therapy . a senior surgical resident used the landmark method to perform catheterization of the right subclavian vein . the spectrum central venous catheter set ( length , 20 cm ; size , 7.0 f ; william a. cook australia pty . ltd . , brisbane , australia ) the right subclavian vein was successfully punctured using the seldinger technique , and the guidewire was then inserted . slight resistance was detected during the guidewire insertion process , but the resident proceeded with it . when guidewire advancement was not possible , its removal was attempted . however , by this point , it could be neither advanced nor removed because of resistance . chest radiography was immediately performed to determine the position of the guidewire , and the results indicated guidewire looping and entrapment within the upper right clavicle ( fig . chest computed tomography scans revealed that the broken guidewire was outside the vein and had not induced hemothorax , pneumothorax , or hematoma of the soft tissues ( fig . after we had explained this to the patient , under local anesthesia , we tried to remove the broken guidewire through infraclavicular skin incision but we could not find the guidewire . the patient was transferred to the operating room for the scheduled operation and underwent vats of the right thorax . the surgical manifestation was metallic foreign body impaction in the upper chest wall that was successfully removed ( fig . volume resuscitation was conducted through the internal jugular vein during the operation , while nutritional support was delivered via peripheral venous access . the use of subclavian venous access has decreased in recent years because of its associated potentially life - threatening complications such as hemothorax , pneumothorax , and mediastinal hematoma . however , it has the advantages of increased patient comfort and convenience in the postoperative care period . especially considering its convenience of consistent landmarks despite being a blind procedure in emergent settings , it is frequently performed when rapid venous access is required , such as during cardiopulmonary resuscitation . a recent study reported that the use of bedside real - time ultrasound for subclavian vein catheterization was effective . however , more studies have demonstrated that the ultrasound technique is better than the landmark method in the internal jugular vein , and its effectiveness in the subclavian vein is both controversial and known to be technically difficult [ 3 - 5 ] . when ultrasound is not possible or a patient is in a surgically emergent setting , rapid venous access via the subclavian fig . wang and sweeney reported a case of guidewire entrapment during left subclavian venous catheterization in which they were able to remove the entrapped catheter using gentle traction . that report argued that a guidewire should not be inserted further if resistance is detected during insertion or removal , and that j - tip guidewires should be used to reduce the risk of vascular perforation . despite these lessons of wang and sweeney , complications involving guidewire knotting and entrapment onan et al . recently reported a case of a knotted and entrapped guidewire that was removed using an infraclavicular incision under local anesthesia . in our case , because the patient was already scheduled for an operation that required general anesthesia , the entrapped guidewire can be removed using vats . there has been a recent decrease in the use of the subclavian venous catheterization method . however , use of this procedure is inevitable sometimes in emergency conditions requiring rapid venous access or when other insertion sites are unavailable because of previous insertions or catheter - related infections . therefore , surgeons and physicians must be well familiarized with and educated on the standard landmark method . as our experience demonstrates , resistance encountered during guidewire insertion indicates possible knotting , looping , or entrapment ; in such cases , the guidewire should not be forcibly inserted or removed . in addition , when experts are not available , the use of ultrasound - guided internal jugular vein access rather than the subclavian vein approach can help reduce the risk of complications . in conclusion , mastery of the basic principles of this technique is important , and such procedures should be gently performed using accurate landmark assessment with the patient in trendelenburg position long enough to allow for sufficient venous retention .

subclavian venous catheterization was once widely used for volume resuscitation , emergency venous access , chemotherapy , parenteral nutrition , and hemodialysis . however , its use has drastically reduced recently because of life - threatening complications such as hemothorax , pneumothorax . in this case , a patient admitted for a scheduled operation underwent right subclavian venous catheterization for preoperative , intraoperative , and postoperative volume resuscitation and parenteral nutrition . the procedure was performed by an experienced senior resident . despite detecting slight resistance during the guidewire insertion , the resident continued the procedure to the point of being unable to advance or remove it , then attempted to forcefully remove the guidewire , but it broke and became entrapped within the thorax . we tried to remove the guidewire through infraclavicular skin incision but failed . so video - assisted thoracoscopic surgery was used to remove the broken guidewire . this incident demonstrates the risks of subclavian venous catheterization and the importance of using a proper and gentle technique .

the phalanx of the affected unstable finger is fused with the adjacent normal phalanx using a bone graft . a 35 years old male patient presented with a lump on the dorsum of the right hand of 8 months duration . after the second recurrence , he was offered amputation , through the wrist by the first surgeon and an onco surgeon as well . the suggestion was for ray amputation . on presentation , there was swelling on the dorsum of the hand [ figure 1 ] . x - ray showed a thin shadow of subchondral bony rim of the third metacarpal head [ figure 2 ] . clinical photograph dorsl aspect of hand at presentation showing swelling , dilated veins along 3 ray metacarpal x - ray of hand anteroposterior and oblique views at presentation showing involvement of whole of 3 metacarpal the tumor consisting of soft tissue between the adjacent second and fourth metacarpal was excised . this exposed the base of the proximal phalanx of the affected middle finger [ figure 3 ] . a corticocancellous bone graft was interposed between the remaining unstable proximal phalanx and the adjacent proximal phalanx of the ring finger [ figure 4 ] . the wires in the second metacarpal were for added stability only [ figures 5 and 6 ] . graft placement shown by star postoperative x - ray of same patient showing external fixator holding the affected digit in place together with the ring finger . bone graft is marked with an arrow and seen across the base of the proximal phalanges of ring and long finger postoperative photograph dorsum of hand showing three kirschner wires across proximal and middle phalanx . external fixators spanning across to the second metacarpal to prevent loosening the proximal half of the proximal phalanges is normally within the skin of the web spaces [ figure 4 ] . flexion at the metacarpophalangeal joint of the connecting rod of the spanning fixator prevented stiffness at the joint [ figure 6 ] . x - ray in the year 2012 [ figure 7a ] and in october 2014 [ figure 7b d ] , which was 7 years after surgery , showed graft maturation , integration without absorption . the accompanying tables 1 and 2 show the rom , grip strength , and pinch strength . he can play cricket , drive car , can do personal care and office work painlessly . flexion and extension of the proximal phalanges of long and ring fingers at metacarpophalangeal ( mp ) joints occur together . similarly , there is rom of 3090 of the affected long finger at the mp joint . abduction and adduction of the long and ring fingers occur together but do not affect his activities . wider graft would have kept the digits wider apart and may have been more beneficial . there was also inability of the index to actively extend fully , though fully correctable passively . x - ray anteroposterior and oblique views of hand showing ( a ) good graft consolidation ( in 2012 ) ( b ) the absence of graft absorption ( in october 2014 ) ( c and d ) . two views in an attempt to abduct and adduct the digits showing graft holding the two phalanges clinical photograph at 7 years followup showing ( a ) patient performing active extension ( b ) patient performing active flexion ( c ) at rest , the long and ring finger rest in slight radial deviation ( d ) end on view with active extension of digits ( e ) end on view with patient actively flexing the digits ( f ) active extension of the digit the range of motion is documented the grip strength and pinch strength several methods of reconstruction of the loss of metacarpal head have been described1234567 including ray amputation.89 the patient may accept amputation , only if informed about significant morbidity . this , however , may not be accepted very easily . in the current case , the patient continued seeking opinions , even outside the country in spite of being offered ray amputation . this is a situation which exemplifies that no patient would agree for an amputation if salvage is available . there may be donor site morbidity when metatarsal from the foot is used for reconstruction of the head of the metacarpal . there is no implant used which may have a long term fallout like a foreign body reaction or rejection . being in a healthy milieu of well - vascularized tissue , the graft gets well integrated . the technique has the potential for use in traumatic loss of metacarpal head as well . fixator can be replaced with a small low profile plate as long as length and rotation is kept corrected .

a finger rendered unstable due to loss of metacarpal head can be stabilized by creating a synostosis at the base of the proximal phalanx of the affected finger with the adjacent normal finger . a cortico cancellous graft bridges the two adjacent proximal phalanges at their bases which are temporarily stabilized with an external fixator . the procedure can be done for , recurrence of giant cell tumor of metacarpal and for traumatic metacarpal loss . the procedure and long term follow up of one patient is presented who had giant cell tumor . this option should be considered before offering ray amputation . there is no micro vascular surgery involved , nor is there any donor site morbidity . the graft heals well without any absorption . the affected finger shows excellent function in the long term followup .

schwannomas are benign tumors that originate from nerve sheaths composed exclusively of schwann cells8910 ) . a major - nerve , intramuscular schwannoma is an extremely rare condition9 ) . due to low frequency of this tumor type and lack of specific instrumental signs and symptoms , we present a rare case of intramuscular schwannoma originating from the dorsal ramus nerve in a 62-year - old woman . a 62-year - old woman patient was admitted to the hospital because of a palpable back mass on her left side . the mass was identified eight years prior , and grew slowly , until pain developed upon touch five years prior . the mass was observed in the left erector spinae muscles ( in the l2 - 4 region ) by magnetic resonance imaging ( mri ) . t2- and t1-weighted images showed heterogeneous high signal intensity , and intermediate to low signal intensity , respectively ( fig . 1 ) . the preoperative diagnostic evaluation suggested the growth was metastasis , sarcoma , or a peripheral nerve sheath tumor . the lesion was thought to originate on the cranial side , and was completely removed , including the origin . when the mas was cut , the surface of the mass was mottled , whitish pale - yellow , and myxoid with hemorrhagic foci ( fig . microscopically , the tumor was composed of compact spindle cell regions ( antoni - a ) , with a nuclear , palisading and whirling cell pattern , and loosely arranged areas of lower cell density ( antoni - b ) , along with ectatic , irregularly - shaped hyalinized vessels ( fig . the most common types of benign soft tissue tumor are lipoma and related variants ( 16% ) , and other types include fibrous histiocytoma ( 13% ) , nodular fasciitis ( 11% ) , hemangioma ( 8% ) , and schwannoma ( 5%)5 ) . approximately 25 and 45% of schwannoma cases occur in the head and neck areas , respectively12 ) . the symptom frequencies reported among patients with benign schwannoma are 5 - 52% for tenderness , 20% for radicular pain , 60 - 96% for the tinel sign , and 7.6 - 82% for motor weakness6 ) . intramuscular schwannomas are highly uncommon ; however , reports have been documented for such tumors originating from the psoas and coracobrachialis muscles , with palpable masses that presented with either no symptoms or lower extremities numbness , but no characteristic symptomatic features12489 ) . schwannomas typically originate from a small nerve branch within the muscle , and symptoms vary depending on the site of origin6913 ) . because intramuscular schwannomas originate from motor branch nerves , neurological symptoms , including pain , motor weakness , paresthesia , are rare69 ) . in our case , there was no radicular pain or motor weak ness ; however slight tenderness was reported . in our patient the erector spinae muscles are dominated by the lumbar dorsal ramus nerve , which branches to form the spinae nerve . the dorsal ramus nerve runs dorsocaudally in the transverse domain , and generally separates into the medial , intermediate , and lateral branches3 ) . schwannomas are typically well encapsulated and solid with membranes composed of a thin fibrous capsule pressing on perineural tissue12 ) . however , if a schwannoma is large , it appears heterogeneous in radiological exams , indicating hemorrhage and tissue necrosis1 ) . in the present study the histological hallmark of a schwannoma is varying proportions of two distinctive tissues : fascicular type ( antoni - a ) and reticular type ( antoni - b)911 ) . antoni - a is highly cellular , with compact , spindle - shaped cells17911 ) . immunohistochemically , schwannomas typically show diffuse , strongly s-100 protein expression11 ) . in the present case , we cautiously removed the encapsulated mass and excised the origin , which appeared to be the dorsal ramus nerve . our tissue biopsy confirmed the presence of a very rare intramuscular benign schwannoma , with typical features . to our knowledge , this is the first report of a dorsal ramus nerve schwannoma within the erector spinae muscles . when a patient has palpable , deep or intrinsic back muscle tissue mass , a radiological examination , such as a computed tomography ( ct ) or mri should be considered . in the ct or mri , a distinct pattern in the surrounding wall of the mass is suggestive of schwannoma , which we confirmed by needle biopsy . if histological findings suggested the presence of antoni - a or -b and the s-100 protein is strongly expressed , a diagnosis of dorsal ramus schwannoma should be considered .

we present a rare case of intramuscular schwannoma originating from the dorsal ramus nerve in a 62-year - old woman . the mass grew slowly , with pain developing upon touch five years prior . no neurological deficit was detected . the mass was observed in the erector spinae muscles in magnetic resonance imaging ( mri ) , and surgical excision was performed . the mass was well encapsulated with clear margin . the lesion appeared to originate from the cranial side . we completely removed the mass including the origin . histopathology confirmed a schwannoma diagnosis . this is the first report , to our knowledge , of a dorsal ramus - nerve schwannoma within the erector spinae muscles .

we report a case of advanced mucinous adenocarcinoma of the prostate involving almost the entire bladder , who had failed treatment with hormonal and radiotherapy . he proceeded to have radical pelvic exenteration surgery that resulted in long - term cure . a 59 year old man presented in 1995 with haematuria and bladder outlet obstructive symptoms . clinical examination revealed a large benign prostate greater than 100 grams and a psa of 28ng / ml . a year later , he re - presented with clot retention . due to the size of the prostate gland and the fact that it was thought to be benign , histology showed mucinous cystadenocarcinoma of the prostate with extracellular mucin involving more than 50% of the specimen which was also psa positive . mri scan showed an enormous multicystic tumour arising from the prostate gland infiltrating the posterior wall of the bladder and also involving the rectum ( figure 1 ) . mri scan showing an enormous multicystic tumour arising from the prostate gland infiltrating the posterior wall of the bladder and also involving the rectum the patient was offered pelvic exenteration but elected to have radical radiotherapy . after radical radiotherapy , psa levels fell to 35ng / ml but post - radiotherapy ct scan showed no response to treatment and no distant metastasis . meanwhile , he continued to have haematuria and a debulking transurethral resection of the prostate was needed to control the haematuria . during the procedure , three years after his first presentation , the patient became cachetic and he finally agreed to have pelvic exenteration after counselling . histology revealed mucinous adenocarcinoma of prostate invading the whole thickness of the bladder only leaving a small area at the dome un - involved and also invading the rectal wall . fourteen years later his psa has remained undetectable and there was still no evidence of recurrence on surveillance ct scans . mucinous adenocarcinoma of the prostate is a rare morphological variant of prostatic adenocarcinoma , accounting for an incidence of about 0.2 - 0.4% ( 1,2 ) . this diagnosis is established on tumours with more than 25% of the gland containing extracellular mucin ( 3 ) . , it can be difficult to diagnose mucinous adenocarcinoma using transrectal needle biopsies since the biopsy samples may not be entirely representative . microscopically it displays features of single round and cribriform glands floating within mucinous lakes , staining positive for psa and prostate - specific acid phosphatase and staining negative for cdx2 ( marker for intestinal tumours ) . very rarely , it can be associated with intracellular mucin positive signet - ring cells ( 4 ) . our case displayed the usual features of mucinous adenocarcinoma without any evidence of signet - ring cells . the first interesting finding in our case is the infiltration of bladder with prostatic tumour sparing only a small area at dome . due to its rarity and lack of studies with high volume of cases , the natural history and prognosis remains controversial . traditionally , it was believed to be associated with an aggressive behaviour and poorer prognosis , but a subsequent case series distinguished that it was the associated signet - ring cell component that resulted a very poor prognosis ( 5 ) . in contrast , a match - paired comparison of 14 patients with mucinous adenocarcinoma who underwent radical prostatectomy suggested a favourable prognosis ( 2 ) . another study also demonstrated that mucinous adenocarcinoma of the prostate treated by radical prostatectomy is not more aggressive than non - mucinous adenocarcinoma ( 4 ) , although long - term data was not available . our case supports a long - term favourable outcome after radical surgical treatment . in spite of failure of response to initial therapies and the locally advanced stage of the disease , the patient remained reccurence free 14 years after first presentation and 11 years after surgery . in the context of this rare variant of prostatic carcinoma , we have highlighted a successful curative outcome from radical surgery , despite failed initial hormonal and radiotherapy treatment even in a locally advance disease . the favourable outcome of radical surgery suggests that radical surgery should be considered , especially in cases with failed initial treatments .

the management of mucinous prostatic adenocarcinoma include hormonal treatment , radiotherapy and radical prostatectomy with variable long - term outcome . we report a 59 year old man with advanced mucinous prostatic adenocarcinoma involving almost the entire bladder and had failed treatment with hormonal and radiotherapy , but subsequently underwent radical pelvic exenteration surgery that resulted in long - term cure . he remains alive , his psa remains undetectable and his surveillance ct scans did not show any evidence of recurrence after 11 years post - surgery . the favourable outcome of radical surgery suggests that radical surgery should be considered , especially in cases with failed initial treatments .

laparoscopic adjustable gastric banding ( lagb ) is a restrictive bariatric technique used in the management of morbid obesity , defined as a body mass index ( bmi ) of more than 45 kg / m . today , it is a popular choice in managing morbid obesity surgically due to its lower complication rates and technical simplicity and safety , when compared to other bariatric surgical procedures.(1 ) lagb was proven to result in a more significant reduction in weight ; in addition to significantly improving obesity - related co - morbidities such as type-2 diabetes mellitus , hypertension , and dyslipidemia ( 2 ) . its proven role in preventing obesity - related obstetric complications add to its favourability(3 ) . regarding the causes of mortality in lagb , pulmonary embolism yields the highest mortality rates in the early post - operative period ( 4 ) . on literature review , only two cases of mortality in the early post - operative period were due to stomach necrosis as a complication of lagb(5 ) . to our knowledge , this is the first reported case of stomach torsion in pregnancy as a complication of lagb . we present a 25-year - old primigravida in her 29 weeks of gestation , with a two - week history of persistent vomiting associated with upper abdominal pain . past surgical history included a previous laparoscopic cholecystectomy and lagb in 2007 , which was deflated once the pregnancy was discovered . on physical examination , abdominal examination was unremarkable apart from a palpable uterus , which conformed to the gestational age . blood results showed a reduced serum albumin at 32g / dl , with normal full blood count , urea and electrolytes , and liver function . ultra sound - abdomen and oesophogastroduodenoscopy ( ogd ) x - ray studies and computed tomography ( ct ) were contraindications due to pregnancy . initially , we commenced conservative management with antiemetic , antispasmodic , analgesia , and proton pump inhibitor . we sought advice from the bariatric surgery team who agreed with our conservative management and close observation . the patient 's oral intake was deteriorating , therefore feeding via nasogastric tube ( ngt ) was commenced in order to maintain the patient 's nutritional status ; and was later replaced with peripheral total parenteral nutrition ( tpn ) due to the patient 's intolerance to the ngt . the patient 's condition failed to improve after being managed conservatively for two weeks , and her nutritional status continued to deteriorate . this eventually led to the development of fatty liver , manifested as a raised alanine aminotransferase ( alt ) of 591 and fatty liver changes on abdominal ultrasound . the fetus was also affected adversely as evident by an intra uterine growth restriction ( iugr ) shown on obstetric growth ultra sound scan . in response to this deterioration , a multidisciplinary decision was made to proceed to an elective caesarean section at 32 weeks , three weeks after admission . outcome of the caesarean section was a male , weighing 1875 g , who was admitted to the neonatology unit due to prematurity . during the post - partum period , the liver function , namely alt , was noted to improve to normal levels . a barium swallow study , performed on the fifth day post - operation was reported , initially by a senior radiologist , as not showing evidence of mechanical obstruction . however , due to the patient 's continued deterioration , we suspected mechanical obstruction after reviewing the barium swallow , so we sought a second opinion from the radiology department , who confirmed this ( figure 1 ) . therefore , a decision to proceed with an urgent laparotomy that was performed that afternoon . barium swallow showing signs of mechanical obstruction with no contrast seen beyond the fundus of the stomach . the arrow demonstrates the gastric band , which was found behind the stomach acting as an axis for gastric torsion intra - operatively , the gastric band was found in adhesion posterior to the stomach , and was removed . the stomach , which was found torted at 180 degrees , remained viable and was therefore not resected . the patient continued to improve and was shortly discharged . on her four months outpatient follow - up , the patient was well , asymptomatic and gained one stone in weight . in the case of our patient , we believe that the vomiting in addition to the vertical growth of the uterus led to a gradual rotation of the stomach antero - ventrally . the fact that the gastric band was fixed ( secondary to adhesions ) to its surrounding structures including the posterior aspect of the stomach , suggests that the gastric band acted as an axis or pivot onto which the stomach rotated in the manner described previously , eventually resulting in torsion of the stomach . the delay in reaching the diagnosis in this case equated to a delay in commencing definitive treatment , and as a result , the patient developed fatty liver and fetal intrauterine growth restriction . this is due to the fact that it was challenging to treat our patient , as her symptoms were indeed non - specific and quite common in pregnancy . in addition , we had a limited number of imaging studies available for use during pregnancy . this case also highlights the difficulty in managing the complications of lagb in small district general hospitals , as the staffs are not exposed regularly to the complications of lagb .

laparoscopic adjustable gastric banding ( lagb ) was done for the first time in belgium in 1993 . gastric torsion after band slippage is extremely rare . literature review of gastric banding and complications in pregnancy did not reveal any case of gastric torsion . hence , we report this rare case of gastric torsion in a pregnant lady following gastric banding .

upright position of the upper molars during retraction of anterior teeth in maximum anchorage cases is very critical in orthodontics . in day to day clinical practice retraction force is usually applied from the power arm attached between maxillary lateral incisor and canine to the gingival hook of maxillary molar tube [ figure 1 ] . as the force is applied below the center of resistance ( cr ) of maxillary molars , they tend to tip mesially during the space closure and uprighting of molars is often required during the finishing stage . thus to overcome these problems , the force on molars should be applied at their cr , which is at the trifurcation areas . recently , in a case report vibhute designed molar stabilizing power arm made up of rectangular stainless steel wire to be engaged in the miniscrew implant head slot and in the auxillary molar tube for optimizing anterior en mass retraction . here in this clinical tip , we have presented a method to prepare a removable power arm that can be attached to the headgear tube of molar tube during the retraction of anterior teeth . use of conventional retraction force from the power arm attached between maxillary lateral incisor and canine to the gingival hook of maxillary molar tube take an approximately 3.5 cm of 21 gauge hard stainless steel wire.then make a c shaped hook at its one end and then give 90 bend approximately 6 - 8 mm below the neck of c shaped hook [ figure 2].then do the stress relieving heat treatment and now the power arm is ready for use . c shaped hook at its one end and then give 90 bend approximately 6 - 8 mm below the neck of then do the stress relieving heat treatment and now the power arm is ready for use . first insert the horizontal arm of the power arm in the round tube of the headgear tube from distal aspect [ figure 3a ] and then keeping the vertical arm upright , place a 90 bend to horizontal arm at the mesial end of headgear tube [ figure 3b ] so that the mesial and distal arms are parallel to each other and care should be taken that the height of the mesial vertical arm of the power arm is slightly above the gingival hook of the molar tube.then ligate the mesial vertical arm of the power arm with the gingival hook of the molar tube by ligature wire [ figure 3c].now force can be applied from the power arm to the intermaxillary hook for the retraction of anterior teeth [ figure 3d ] . first insert the horizontal arm of the power arm in the round tube of the headgear tube from distal aspect [ figure 3a ] and then keeping the vertical arm upright , place a 90 bend to horizontal arm at the mesial end of headgear tube [ figure 3b ] so that the mesial and distal arms are parallel to each other and care should be taken that the height of the mesial vertical arm of the power arm is slightly above the gingival hook of the molar tube . then ligate the mesial vertical arm of the power arm with the gingival hook of the molar tube by ligature wire [ figure 3c ] . now force can be applied from the power arm to the intermaxillary hook for the retraction of anterior teeth [ figure 3d ] . insertion of horizontal arm of the power arm in the round tube ( headgear tube ) from distal aspect a 90 bend in the horizontal arm at the mesial end of headgear tube . note both mesial and distal arms of the power arms are parallel to each other and the level of mesial vertical arm is above the level of gingival hook of the molar tube ligation of the mesial vertical arm of the power arm to the gingival hook of the molar tube application of retraction force from the intermaxillary hook to the power arm . note the line of force is along or near to the center of resistance of molar easy to fabricate and use in busy clinical practiceheight of power arm can be adjusted depending on the requirement in individual cases . for example distal movement of the molar crown ( uprighting ) can be done by keeping the height of power arm above the cr of molars during retraction of anterior teethno special armamentarium is required for its fabricationcan be prepared and stocked . easy to fabricate and use in busy clinical practice height of power arm can be adjusted depending on the requirement in individual cases . for example distal movement of the molar crown ( uprighting ) can be done by keeping the height of power arm above the cr of molars during retraction of anterior teeth no special armamentarium is required for its fabrication can be prepared and stocked . can cause irritation in the sulcus when either the sulcus depth is less or the height of power arm is very high . the fabrication and clinical use of this power arm in maxillary first molars during the retraction of anterior teeth is very promising in routine orthodontic practice .

attachment of force elements from the gingival hook of maxillary molar tubes during the retraction of the anterior teeth is very common in orthodontic practice . as the line of force passes below the center of resistance ( cr ) of molar , it results its mesial tipping and also anchorage loss . to overcome this problem , the line of force should pass along the cr of molar . this article highlights a method to overcome this problem by attaching a removable power arm to the headgear tube of molar tube during the retraction of the anterior teeth .

the purpose of this study was to find out the supplemental value of topiramate , after miniplate fixation of infraorbital nerve results from compression of the nerve due to entrapments , as it leaves the infra orbital foramen . the surgical management of infra orbital nerve injury requires decompression of nerve by reduction of zygomatic complex fracture and sometimes mobilization of nerve , surrounding soft - tissue and help in early recovery of sensory function . smith - swintosky claimed that topiramate help in nerve regrowth and enhanced the recovery of facial nerve function after injury when administered orally at therapeutically relevant doses , and significantly increased neurite outgrowth in cell cultures derived from fetal rat cortical and hippocampal tissues . sakavicious reported a 64.4% incidence of infra orbital nerve injury of zygomatic - complex fracture . schilli reported that in 95% cases of zygomatic complex fractures , the fracture lines involve the infra orbital foramen and may cause some degree of sensory disturbances . the main pharmacological action of this compound has been identified and responsible for its anticonvulsant action as it reduces the duration and frequency of action potentials within spontaneous epileptiform bursts of neuronal firing it has neuroprotective activity reported in rodent models of cerebral ischemia brain injury , stroke , epilepsy , etc . , it can be prescribed in dosages 50 - 400 mg daily in divided dosages . dosages can be increased by 25 - 50 mg / day each subsequent week as tolerated . peak plasma concentration can be achieved in 2 h following a single 400 mg oral dose . symptoms of nerve injury may be varied from paresthesia , numbness at the site of the nose , upper lip . several methods of sensory testing have been applied , i.e. , gross mapping of altered areas of sensation . the conventional mechanical tests including two - point discrimination light - touch pinprick and sharp - blunt discrimination . few studies have suggested that the treatment of isolated zygomatic complex fracture with open reduction and mini plate fixation , yields better recovery of sensory function . undisplaced zygomatic complex fracture can be treated conservative method successfully generally open reduction and miniplate fixation gives better results than transosseous wiring or conservative methods . gabapentin single or combination , topiramate and carbmezepine have also been used in post traumatic neuropathic pain . various studies have been reported about the beneficial effects of this antiepileptic drug in post - traumatic nerve injury without affecting the final size of the traumatic lesion . two cases were slected in this study , who were reported after 2 - 3 weeks of injury . chief complaints of the patients were altered sensation in the distribution of infraorbital nerve . on clinical examination step deformity and tenderness was present at the infra orbital margin and frontozygomatic region . infra orbital nerve paresthesia was tested with two - point discrimination test and cotton wick test . on percussion conventional x - rays ( occipetomental and submento vertex view of the skull were advised to rule out the involvement / entrapment of infra orbital nerve . the surgical decompression of the nerve was achieved by fracture reduction and single miniplate fixation was done at fronto zygomatic region . the initial dose of topiramate was 25 mg / day administrated for the 1 week at night and the dosages had to be increased to 50 mg / day in the 2 week . postoperatively patients were assessed clinically and radio logically , the patients were recalled after 7 days to check up and suture removal . dose were increased to 50 mg twice daily and further dose titration advised as to increase by 25 mg twice daily and minimum dose was maintained . a minimum of 6 months follow - up was chosen in both the patients . , the patients were responding well with complete functional recovery and remission of symptoms . antiepileptic drug like topiramate was supplemented post miniplate fixation in infra orbital nerve injury cases for early nerve recovery as reported in the literature . . reported , study of the 30 subjects in highly significant beneficial effect on nerve function , champy , et al . , stated that reduction and fixation are important factors in the recovery from sensory disturbances of the nerve . above mentioned studies of the miniplate fixation at fronto zygomatic region patients were supplemented with topiramate 25 mg to 50 mg twice daily , which helped in early recovery of sensory nerve function . drug supplementation showed early improvement in nerve function as reported , but takes the longer period for complete recovery . this may be explained on the basis that a surgical exploration / reduction of fracture fragments prevents further damage to the nerve and drug therapy helps in nerve regeneration as reported by many studies . from our study , we recommend an open reduction with miniplate fixation at fronto zygomatic region supplemented with topiramate in therapeutic dosages provided early recovery of sensory function of infra orbital nerve .

this study was done to find out the role of topiramate therapy in infraorbital nerve paresthesia after miniplate fixation in zygomatic complxex fractures . a total 2 cases of unilateral zygomatic complex fracture , 2 - 3 weeks old with infra orbital nerve paresthesia were slected . open reduction and plating was done in frontozygomaticregion . antiepileptic drug tab topiramate was given in therapeutic doses and dose was increased slowly until functional recovery was noticed .

in the previous issue of critical care , sekhon and colleagues conducted a single - center retrospective cohort study to determine whether hemoglobin concentration was associated with outcomes among 273 critically ill adults with severe traumatic brain injury ( tbi ) . after adjusting for age , glasgow coma scale scores , external ventricular drain insertion , and allogeneic red blood cell ( rbc ) transfusion , the authors report that the estimated odds of in - hospital mortality among patients with a mean 7-day hemoglobin concentration < 90 g / l was 3.1 ( 95% confidence interval , 1.5 to 6.3 ) times the estimated odds of in - hospital mortality among those with a mean 7-day hemoglobin concentration 90 g / l . the etiology of icu anemia is multifactorial and includes the negative effects of the systemic inflammatory response on hematopoiesis , frequent phlebotomy , and hemodilution from intravenous fluid resuscitation . among icu patients with tbi , the prevalence of reduced hemoglobin concentration ranges from 22 to 69% , depending on the presence or absence of extracranial hemorrhage and the timing of hemoglobin measurements . although a hemoglobin transfusion threshold > 70 g / l was adopted for icu patients following publication of the transfusion requirements in critical care trial , this target may be poorly tolerated by those with severe tbi . anemia - induced compensatory mechanisms result in cerebral arteriolar dilatation and increased brain blood flow , which could be detrimental for those with cerebral edema or intracranial hypertension . moreover , as brain tissue oxygen tension is dependent on systemic hemoglobin , reduced hemoglobin concentrations among those with tbi could decrease cerebral oxygen delivery and contribute to brain hypoxia . although the findings of the study by sekhon and colleagues provide support for the above physiologic concerns regarding reduced hemoglobin concentrations following brain injury , the adverse relationship between anemia and clinical outcomes is an inconsistent finding among available clinical studies [ 1,5 - 16 ] . of the one randomized controlled trial and the now 14 available cohort studies of which we are aware ( two of which were based on post - hoc analyses of similar datasets derived from randomized controlled trials ) [ 1,5 - 9,11 - 18 ] , eight reported an association between anemia and an increased risk of poor neurological outcomes or mortality , while the remaining seven observed no such association . moreover , in a recent systematic review of comparative studies , insufficient evidence was found to support a difference in outcomes between higher and lower hemoglobin levels among mostly tbi patients . possible explanations for the inconsistency in results across studies include differences in tbi severity among study patients and inadequate consideration of the effects of anemia during critical time periods . although a set hemoglobin threshold may exist under which harm may occur among those with tbi , adverse outcomes may be more likely to occur during times of low cerebral blood flow , brain hypoxia , and/or ineffective autoregulation . some support for this argument was afforded by the findings of a recent retrospective cohort study , which reported that although anemia alone did not appear to be detrimental among patients with severe tbi , the simultaneous combination of anemia and brain hypoxia was linked with an increased risk of unfavorable outcomes . another significant limitation of the existing literature on this topic has been the absence of a defined disease - exposure relationship among patients with tbi . although it is plausible that development of reduced hemoglobin concentrations may be most important during the first 7 days following severe tbi , the use of the mean as a summary measure of exposure has the potential to result in exposure misclassification . moreover , as the effects of anemia on outcomes following tbi are likely to be small , and a tremendous amount of brain hypoxia due to anemia would probably be needed to increase mortality , a sensitive measure of neurological performance or outcome is probably a more important outcome variable . possibly the most important limitation of the available literature relating anemia to outcomes among those with tbi , however , is the inadequate consideration of the effects of rbc transfusion . although rbc transfusion often results in a small incremental increase in brain tissue oxygen tension in this patient population , transfused blood has important differences from the patients ' own blood and does not always improve cerebral metabolism . moreover , at least five retrospective cohort studies have reported that rbc transfusion increases the risk of death or worsened neurological outcome among those with tbi . admittedly , however , these observations could have been related to selection bias and an unbalanced distribution of outcome determinants between treatment groups . moreover , as anemia and rbc transfusion are probably highly correlated , those studies that used interaction terms for anemia and rbc transfusion in their regression models probably introduced multicollinearity , and therefore their estimated coefficients and odds ratios may be invalid . in summary , although preclinical experiments suggest several potential adverse effects of anemia among patients with tbi , the results of the available clinical studies are conflicting , and it remains unclear whether rbc transfusion may further increase risk of adverse outcomes . however , because anemia is common among adults with severe tbi , and a recent survey reported that clinical equipoise may exist among specialists as to when to transfuse allogeneic rbcs , randomized controlled trials of liberal versus restricted transfusion thresholds are required among adults with severe tbi . these trials will probably require use of multimodal monitoring to understand whether improved outcomes are only witnessed among those with simultaneous signs of brain hypoxia or cerebral ischemia .

in the previous issue of critical care , sekhon and colleagues report that mean 7-day hemoglobin concentration < 90 g / l was associated with increased mortality among patients with severe traumatic brain injury ( tbi ) . the adverse relationship between reduced hemoglobin concentrations and outcomes among those with tbi has been an inconsistent finding across available studies . however , as anemia is common among adults with severe tbi , and clinical equipoise may exist between specialists as to when to transfuse allogeneic red blood cells , randomized controlled trials of liberal versus restricted transfusion thresholds are indicated .

a 60-year - old woman presented with an abnormality detected by screening mammography . upon physical examination , we noted a non - tender nodule with a relatively circumscribed margin in the upper outer quadrant of the left breast . the mammograms revealed a 1.5 cm , ill - defined , high - density mass in the left outer breast ( fig . us showed an irregular shaped , ill - defined homogeneous hypoechoic mass with an echogenic halo ( fig . color doppler study showed moderate vascularity in the peripheral halo portion of the lesion ( fig . 1d ) . we classified the mass as breast imaging reporting and data system ( bi - rads ) category 4c ( moderate suspicion for malignancy - estimated probability for malignancy ranging from 50% to 95% ) . next , we performed us - guided automated gun biopsy using a 14-gauge needle and histological examination of the biopsy specimens revealed the presence of an inflammatory pseudotumor . further , excisional biopsy confirmed this diagnosis . upon gross pathology , we did observe an ill - defined pinkish - white mass without necrosis or hemorrhage ( fig . microscopically , we noted irregularly oriented intersecting fascicles of spindle cells at low magnification with hematoxylin and eosin staining . mixed inflammatory cells such as lymphocytes , histiocytes , and plasma cells were infiltrated between the spindle cells . at high magnification , the proliferating spindle cells had bland - looking nuclei and the nucleoli were inconspicuous . we did observe mitoses ( up to 3 of 10 per high - power field ) , however , no atypical mitoses were found ( fig . following an immunohistochemical assay , we found the spindle cells to be reactive for anti - sma ( smooth muscle actin ) and demonstrated myofibroblastic differentiation ( fig . we also found the tumor cells to be negative for a reaction for pan - ck ( pancytokeratin ) , which resulted in the exclusion of the possibility of metaplastic carcinoma . we also found the tumor cells to be negative for a reaction to anaplastic lymphoma kinase ( alk ) ( figure not shown ) . during a two - year follow up period , we did not find any evidence for tumor recurrence at the left breast , as demonstrated by mammographic and us images . inflammatory pseudotumors of the breast are extremely rare ; a literature search yielded only fifteen cases in the english - language literature ( 1 - 10 ) . in all 15 cases , in addition , we found that all the lesions were surgically excised ; however , the three patients showed recurrence after surgery , with two of the three patients having bilateral recurrence ( 2 - 4 ) . the pathogenesis of inflammatory myofibroblastic tumors is controversial ; although , the etiology of this entity remains unclear and is considered by some investigators to have an aberrant reactive or inflammatory response to local cytokines in nature ( 5 , 10 , 11 ) . however , cases with vascular invasion , local recurrence , and even metastasis have been reported ( 5 , 10 - 12 ) . furthermore , the cytogenetic analysis of one case of an inflammatory pseudotumor of the breast showed that the disease was due to clonal proliferation , thus supporting the hypothesis that an inflammatory pseudotumor of the breast is a true neoplasm ( 7 ) as opposed to an exuberant tissue response to inflammation . alk , expressed due to a chromosomal translocation involving 2p23 has recently been demonstrated in some cases of an inflammatory pseudotumor ( 13 , 14 ) . radiologically , our case appeared as an ill - defined mass on mammographic and us examination , which is consistent with cases described by haj et al . however , for most of the previously reported cases , a well - defined border was depicted on mammograms ( 5 ) . there was also one case with a rare imaging finding , where us demonstrated the presence of a focal area of irregularly marginated acoustic shadowing without a mass configuration ( 15 ) . it should be emphasized that the imaging findings of our case were suspicious for malignancy . first , the mass was seen in this case with an ill - defined margin on mammograms and us and the overlying skin was minimally retracted as determined on physical examination , which was also described by haj et al . additionally , we depicted the vascularity in the peripheral halo portion of the lesion on color doppler study . because the mass was located within a fat layer , fat necrosis could be included in the differential diagnosis . in conclusion , we have presented a case of an inflammatory pseudotumor of the breast , which was initially misdiagnosed as being malignant due to the ill - defined border of the lesion on mammograms and us . we should consider surgical excision and a close follow - up due to its tendency to enlarge locally and to recur after excision .

inflammatory pseudotumor , also known as inflammatory myofibroblastic tumor and plasma cell granuloma , is an uncommon low - grade lesion composed of spindle cells admixed with mature plasma cells and other inflammatory cells , such as histiocytes , lymphocytes , and eosinophils . here , we describe the mammographic and ultrasonographic findings of a case of an inflammatory pseudotumor of the breast in a 60-year - old woman . with the suspicion of malignancy , core needle biopsy and surgical excision confirmed the mass as being an inflammatory pseudotumor of the breast .

their knowledge and attitude toward prevention of dental caries were assessed based on demands about their role in promoting oral health , assessment of dental caries during routine well - child care , and curriculum in pediatric postgraduation to upgrade oral health . the collected data were tabulated , and percent frequency distributions for responses to every question were assessed and presented in table 1 . dental disease is one of the most vulnerable chronic disease affecting children throughout the world . preventive dentistry is yet to be in common practice as that are seldom cared about by the parents and because of the lack of knowledge about with the medical professionals as well . pediatricians and family physicians are renowned for effects on the oral health of children because of their early health visits . none of the participants reported that pediatricians are responsible for infant oral health presumes that pediatricians are not examining the oral cavity as a part of routine . early recognition of dental caries and prophylactic measures against dental problems prevents from infection , dietary problems , missed school days , and poor quality of life as too . feeding patterns such as bottle feeding beyond 1 year , children allowed to bed with nursing bottle are responsible for an increase in the exposure of primary dentition to fermentable carbohydrates . this increase favors both an early colonization by oral mutans streptococci and due to increase in the number of these microorganisms in the dental plaque and saliva , which increases the risk of developing caries . a pediatrician should know the need of treatment and preservation of milk teeth for a healthy permanent dentition , which matches with our findings where pediatricians agreed that milk teeth are important . about 70% of the pediatricians were discussed with the parents about baby bottle tooth decay . if teeth are infected or lost too early due to baby bottle tooth decay , the child may develop speech problems , poor eating habits , and crooked teeth . in our study , only a very few of them ( 7% ) have done the nutritional counseling . according to american academy of pediatric dentistry , the child should come for the visit within 6 months of the eruption of the first teeth . nutritional counseling is a cooperative mode of interaction between patients and health - care providers aimed at insisting patients in adopting healthy dietary behaviors . graph 1 shows that all of them agreed for the establishment of dental home along with medical home , in our study reported the essentiality in providing improved quality of dental health . almost all of them felt that the need for dental educational program and to publish the dental articles in medical journals to promote the familiarity with oral health issues for prevention of dental caries . however , there are certain barriers to the involvement of pediatricians in this process , some of which include insufficient time during appointments and lack of discussion between health professionals in the field of dentistry and medicine . opinion of the pediatricians about conducting dental education program , publishing dental articles in medical journals , dental with medical home together from this study , we conclude that there is a lack of awareness about prevention of dental caries among pediatricians in kanchipuram district . to overcome these following principles group practice of pediatricians and dentists is vital , including preventive dentistry topics in the medical curriculum . advocating dentists as part of well - child care and establishing dental home along with medical home publishing pediatric journals concerning about the oral health to improve the knowledge is also essential in promoting a good oral health hygiene .

background : pediatricians and other health - care providers could play an invaluable role in ensuring the maintenance of optimal preventive as well as curative dental health in children . this study was aimed at assessing the pediatrician 's perspective on basic oral health care in children in kanchipuram district.materials and methods : a questionnaire survey was carried out among pediatricians which covered various aspects of knowledge , attitude , and role of pediatricians in preventive dental care . the collected data were tabulated , and percent frequency distributions for responses to every question were assessed.results:none of the participants reported that pediatricians are responsible for infant oral health presumes that pediatricians are not examining the oral cavity as a part of routine . all of the pediatricians gave nutritional counseling to the parents but only 7% of them of caries . all the pediatricians liked the concept of an association between lack of knowledge among pediatricians and pediatric dentist and establishment of a dental home along with a medical home.conclusion:from the present study , we conclude that there is a lack of awareness about prevention of dental caries among pediatricians in kanchipuram district . to overcome this , advocating dentists as part of well - child care and establishing dental home along with medical home . publishing pediatric journals concerning about the oral health to improve the knowledge is also essential in promoting good oral health hygiene .

the patient was a 51-year - old man with a 1-month history of lower back pain . at the onset , the pain radiated to the right buttock with a tingling sensation down his right lower limb posteriorly to his ankle . he did not report any difficulty with bowel , bladder , or sexual function . on physical examination , a straight leg - raising test of the right leg was positive at 60 degrees . the deep tendon reflexes were 2 + on the both knees and ankles . a magnetic resonance imaging ( mri ) scan demonstrated a mass at the level of the l4 - 5 interspace and , compression of the thecal sac and the nerve root on the right side ( fig . 1 ) ; it was not possible to determine whether the lesion was completely extradural or partially intradural . owing to the signal characteristics , a synovial cyst arising from the medial aspect of the facet joint was suspected to adhere to the entire length of the nerve root sleeve . a 22-gauge 3.5-inch spinal needle was advanced under fluoroscopic guidance into the right l5/s1 zygapophysial joint . by injecting the right l5/s1 zygapophysial joint with contrast , a right synovial cyst was introduced into the cyst directly with a right paramedian , interlaminar approach under fluoroscopic guidance ( fig . serosanguinous fluid 1.0 ml was aspirated , and triamcinolone acetate 10 mg was injected into the cyst . the patient felt an immediate relief of symptoms after the aspiration , and had no signs or symptoms of recurrence at the follow - up 6 months later . no demonstrable lesion was found in the 6 months follow - up mri ( fig . lumbar z - joint synovial cysts usually originate from the z - joint capsule . the cyst can be lined with synovium and contain serous , gelatinous , or hemorrhagic fluid . the development of z - joint synovial cysts is linked to degenerative spondylosis , segmental instability and perhaps trauma . at least 1% of all lumbar radicular pain may be the result of z - joint synovial cysts . z - joint synovial cysts are frequently associated with a narrowed spinal canal caused by stenosis , so z - joint synovial cysts easily become symptomatic . accurate diagnosis of z - joint synovial cyst results in a number of therapeutic implications . facet joint injection with steroid and long - acting anesthetic can provide temporary or prolonged pain relief which may be of value in patients unfit for surgery . indirect aspiration via the facet joint can be effective , and direct aspiration under fluoroscopic guidance has been successful . surgery , to relieve sciatica caused by a z - joint synovial cyst is effective in a high proportion of patients . minimally invasive techniques for the treatment of lumbar synovial cyst seem to eliminate many of the risks of traditional surgical techniques . in this case , direct needle aspiration of the cyst was performed , and this less invasive procedure may be employed as an alternative to surgery . since the cyst may spontaneously decompress , conservative treatment can be beneficial . z - joint synovial cysts are treated with an interlaminar or intra - articular approach . however , in using the intra - articular approach , aspiration of cyst fluid is often difficult because of the relative ball - valve effect , which occurs as negative pressure is applied . described a technique used to rupture the cyst by injecting the joint or inferior joint recess with as much as 3 ml of betamethasone and bupivacaine , followed by 1 - 5 ml injection of normal saline . rupture of the cyst was accomplished in 50% of cases , with pain relief in 9 out of 12 patients . jacob et al . introduced a 20-gauge spinal needle into the cyst and aspirated 1.0 ml of fluid under ct guidance . the patient was asymptomatic within 3 days , and remained pain free at the 18-month follow - up . koenigsberg positioned a 22-gauge spinal needle into the cyst and fluid was aspirated under ct guidance with no contrast solution used . the patient had immediate partial pain relief , followed by complete relief on the third day following the procedure . lim et al . passed a 22-gauge needle into a cyst under ct guidance , and injected 20 mg of triamcinolone and 1 ml of bupivacaine . the patient reported immediate complete relief of pain , and remained pain - free for 9 months after the treatment . after multiple interventions to aspirate and drain the cyst through the z - joint , gishen and miller used ct guidance to aspirate the cyst through the lamina with a bone biopsy needle . long - term resolution of symptoms occurred and mri taken after a year showed no recurrence . complete regression of the cyst seems to occur only with complete rupture . in our patient , cyst puncture was performed with live fluoroscopy , to ensure the position of the needle within the contrast - filled cyst . the patient derived complete resolution of his right limb radicular pain after puncture of a z - joint synovial cyst and remained pain - free at the 6 month follow - up .

a 51-year - old man with a 1-month history of lower back pain and radiating pain visited to our pain clinic . a magnetic resonance imaging ( mri ) scan demonstrated a cyst like mass at the level of the l4 - 5 interspace and compression of the thecal sac and the nerve root on the right side . we performed percutaneous needle aspiration of the lumbar zygapophyseal joint synovial cyst under fluoroscopic guidance . the patient felt an immediate relief of symptoms after the aspiration , and had no signs or symptoms of recurrence at the follow - up 6 months later . no demonstrable lesion was found in the 6 months follow - up mri .

the uk national bowel cancer screening program invites men and women aged between 60 74 years old to be routinely screened every 2 years ( 1 ) . this is based on the finding that population screening using biennial faecal occult blood testing has demonstrated a 16% reduction in mortality from colorectal cancer ( 2 ) . a uk pilot study has successfully demonstrated this as a feasible and reliable method of screening ( 3 ) . screening endoscopists are required to pass an endoscopy driving test before being allowed to screen and have their screening data rigorously evaluated . a 90% caecal intubation rate , verified by visualisation of the ileocaecal valve and appendix orifice , or intubation of the terminal ileum of these , terminal ileal intubation with ileoscopy has the additional benefit of determining whether the source of bleeding is the distal ileum . we present a case where terminal ileal intubation carried out during a screening colonoscopy led to the identification and treatment of a pathology that if missed , could have a significantly worsened prognosis . a 74 year old man was referred to our endoscopy unit after a positive faecal occult blood test . he had no preceeding symptoms or history that would place him at increased risk of colorectal cancer . at colonoscopy , excellent views were obtained to the ileocaecal valve ( icv ) and appendix orifice , confirming identification of the caecum . with no colonic pathology seen , the endoscopist proceeded to intubate the icv , as part of his routine practice . a 3 cm ileal polyp was identified 5 cm proximal to the valve ( figure 1 ) and biopsies were taken . endoscopic view of the carcinoid tumour in the distal ileum histology demonstrated features of a classical neuroendocrine carcinoid tumour infiltrating the muscularis mucosa . abdominal ct scan , black arrow highlighting the carcinoid tumour in the distal ileum ct scanning demonstrated the lesion intususscepting into the terminal ileum . ( figure 2 ) resected specimen , black arrow demonstrating the carcinoid tumour in the opened distal ileum the patient underwent a laparoscopic right hemicolectomy one month after diagnosis . twelve out of fifteen lymph nodes resected were involved with further evidence of extranodal spread . carcinoids are neuroendocrine tumours derived from enterochromaffin cells most commonly found in the gastrointestinal tract ( 65% of cases ) with an annual incidence of approximately two per 100,000 cases . around 22% of cases present with distant metastases and in half these cases no primary tumour can be found ( 4 ) . despite evidence for improving colonic diagnoses , completion of colonoscopy by passing through the icv this is due to the perceived difficulty of intubating the valve as well as the anticipated increase in procedure time . with practice , ileoscopy has been shown to be achievable in at least 85% of routine colonoscopies . in skilled hands , it adds on average just additional 3 minutes to the procedure and contributes significantly to quality assurance and diagnostic yield ( 5 ) .

the uk national bowel cancer screening programme invites men and women aged between 60 74 years old to be routinely screened every 2 years . a 90% caecal intubation rate or intubation of the terminal ileum is considered to be the best practice means of identifying completeness . this case report describes how terminal ileal intubation carried out during a routine screening colonoscopy led to the identification and treatment of a carcinoid tumour . despite evidence for improving colonic diagnoses , completion of colonoscopy by passing through the ileocaecal valve is not performed routinely due to the perceived difficulty of the manoeuvre . with practice , ileoscopy has been shown to be achievable in at least 85% of routine colonoscopies and contributes significantly to quality assurance and to the diagnostic yield .

mowat - wilson syndrome ( mws ) ( mim#235730 ) is characterized by a typical facies , severe mental retardation , epilepsy , and variable congenital malformations , including hirschsprung 's disease ( hscr ) , genitourinary abnormalities , congenital heart disease , and agenesis of the corpus callosum . mws is caused by de novo heterozygous mutations or deletions in the zinc finger homeobox 1b gene ( zfhx1b ) located in the 2q22 region . zfhx1b encodes the smad - interacting protein-1 ( smadip1 or sip1 ) , a transcriptional corepressor involved in the transforming growth factor - beta signaling pathway . over 100 mutations have been described in patients with typical features of mws ; these have essentially been truncating mutations ( nonsense or frameshift ) or large deletions of the zfhx1b gene , suggesting a haploinsufficiency mechanism . we present the clinical data and the molecular analysis of a 2-year - old moroccan boy with mowat - wilson syndrome who was born to consanguineous parents . the patient was the first boy born to healthy consanguineous parents , both 29 years old , with no relevant familial history . the pregnancy and delivery were normal and the child was born at term , with normal weight , length , and head circumference . he had normal passing of meconium in the first 24 h of life , and no history of chronic constipation was reported . in the neonatal period , he developed seizures . he could hold his head up at 10 months , sit by himself at 24 months , and was not yet walking . at 2 years of age he presented with striking dysmorphic features : square - shaped face with a prominent but narrow triangular chin , plagiocephaly , thick eyebrows , sunken eyes , hypertelorism , broad nasal bridge , saddle nose , prominent columella , open mouth , and large uplifted ear lobes [ figure 1 ] . facial phenotype of the patient mri scan of the brain revealed agenesis of the corpus callosum and cerebral hypotrophy . electroencephalogram ( eeg ) , echocardiography , and genitourinary ultrasound examinations were normal . since the patient presented with typical dysmorphic features , severe developmental delay , epilepsy , and agenesis of the corpus callosum we suspected a mws , and molecular analysis of the zfhx1b gene this analysis led to the identification of a novel heterozygous nonsense mutation , c.1165a > t ( p.lys389x ) in exon 8 of the zfhx1b gene . at the time of diagnosis , the mother of the patient was 8 months pregnant . mowat - wilson syndrome , first clinically delineated by mowat et al . in 1998 , is a rare mental retardation - multiple congenital anomalies syndrome associated with typical facial dysmorphism , including hypertelorism , medially flared and broad eyebrows , enophthalmia , prominent columella , pointed chin , and uplifted earlobes , which typically prompts the clinician to consider the diagnosis . patients can present a variety of other anomalies , such as short stature ( 50% ) ; microcephaly ( 84% ) ; hscr ( 50% ) ; chronic constipation ( 25% ) ; malformations of the brain , particularly agenesis of the corpus callosum ( 60% ) ; seizures ( 75% ) , with no predilection for any particular seizure type ; congenital heart defects ( 75% ) ; and urogenital anomalies , particularly hypospadias ( 55% ) . in our patient , suspicion of mws was based essentially on the dysmorphic features associated with severe mental retardation and seizures . absence of microcephaly , hscr , congenital heart defect , and hypospadias did not preclude the diagnosis . several differential diagnoses of mws can be evoked . in patients with mental retardation ( mr ) , microcephaly , and hscr , born to consanguineous parents , the goldberg - shprintzen syndrome ( goshs ) , a rare autosomal recessive disorder , can be suspected if associated with specific dysmorphia . severe mr , seizures , ataxia , microcephaly , a prominent jaw , and a happy behaviour phenotype are also features of angelman syndrome . finally , pitt - hopkins syndrome can be considered in patients with mr , characteristic facial gestalt , and episodes of hyperventilation . in mws , the zfhx1b gene mutations are most often truncating ( nonsense , frameshift , or deletions ) and no obvious genotype - phenotype correlation has been identified so far . in a few cases , few recurrent mutations ( 6/100 ) have been identified . as this disorder is sporadic , with the mutations occurring de novo as the genetic counseling of mws is reassuring , it is important to evoke this diagnosis , particularly in consanguineous families . in our case ,

mowat - wilson syndrome is a mental retardation - multiple congenital anomaly syndrome characterized by a typical facies , developmental delay , epilepsy , and variable congenital malformations , including hirschsprung disease , urogenital anomalies , congenital heart disease , and agenesis of the corpus callosum . this disorder is sporadic and is caused by heterozygous mutations or deletions of the zfhx1b gene located in the 2q22 region . we report here the first moroccan patient , born to consanguineous parents , with mowat - wilson syndrome , due to a de novo , unreported mutation of the zfhx1b gene .

a 17-year - old male was referred to our hospital for evaluation of a painless swelling on the right cheek , which had been identified 3 or 4 months earlier . the extraoral examination showed swelling on the right cheek causing some facial asymmetry ( fig . 1 ) . the intraoral examination revealed a slight swelling on the right mandiblular ramus region , extending to the right retromolar area ( fig . the panoramic radiographic examination showed the presence of a multilocular radiolucency with partially ill - defined border between the right mandibular condyle and the distal root of the right mandibular third molar . since the radiolucency was not associated with the crown of the impacted third molar and seemed to involve the mandibular foramen , the first radiologic impression involved neural origin tumor along with more aggressive lesions such as desmoplastic fibroma , juvenile aggressive fibromatosis , or fibrosarcoma ( fig . ct examination showed an expansile solid ovoid slightly enhancing mass involving the right mandibular condyle and ramus , measuring around 3.53.2 cm giving the impression of an ameloblastoma ( figs . 4 - 6 ) . microscopic examination revealed a non - encapsulated tumor consisting of bland fibroblast cells with wavy cytoplasm . a few strands and nests of odontogenic epithelium were observed ( figs . 7 and 8) . based on the clinical , radiographic , and histopathologic findings , the definitive diagnosis was codf . according to covani et al,8 the codf was believed to originate from mesenchymal odontogenic tissue such as dental papilla , periodontal ligament , or dental follicle . considering the histogenesis of the lesion in the who classification,9 it has been suggested that the epithelium - poor type of codf is derived from the dental follicle , whereas the epithelium - rich type arises from the periodontal ligament . the peak incidence of codfs have been observed in the second decade of life and shows a female predilection.10 this lesion was originally thought to occur almost exclusively in the mandible , and was mostly found in the posterior mandible.11 clinically , codf manifests as a painless swelling and has a slow growth that results in cortical expansion.10,11 clinical symptoms such as pain and paresthesia are uncommon.12 radiologically , most cases of codfs are radiolucent , unilocular , and with well - defined borders similar to other radiolucent lesions such as traumatic bone cyst , ameloblastoma , odontogenic cysts , and central giant cell granulomas.13 araki et al14 reported that the diagnosis of codf by radiographic findings was extremely difficult , especially when the lesion was associated with a crown of the unerupted tooth that might resemble a dentigerous cyst . since the present case showed a multilocular radiolucent lesion involving ramus and even condylar process with partially ill - defined borders , the differential diagnosis involved a wide range of pathosis from benign lesions such as ameoloblastic fibroma , odontogenic myxoma to more aggressive lesions such as desmoplastic fibroma , juvenile aggressive fibromatosis or fibrosarcoma . the codf case reported by daniels10 was somewhat bigger in size , however it resembled a dentigerous cyst . handers et al3 reported that there were only two mandibular lesions among the 19 codf cases , and one of the mandibular lesions with a large multilocular radiolucency involving most of the ramus was similar to this case except for the fact that the margin was scalloped and showed well - defined buccal cortical expansion suggesting benign nature of the lesion . kaffe and buchner13 stated that the majority of codfs were unilocular radiolucent lesions with well - defined border , however they might also appear as multilocular lesions and might exhibit a mixed radiolucent - radiopaque appearance with poorly defined or diffused borders in rare cases . the great variability in radiologic appearance of the codfs means that it should be considered in the differential diagnosis of all radiolucencies found in the jaws .

central odontogenic fibroma is a rare odontogenic neoplasm that originates from odontogenic ectomesenchyme . here , a case of central odontogenic fibroma in a 17-year - old male is reported . since the present case showed a multilocular radiolucency with partially ill - defined border between the right mandibular condyle and the distal root of the right mandibular third molar , differential diagnosis involved a wide range of pathosis from benign lesions like ameoloblastic fibroma and odontogenic myxoma to more aggressive lesions such as desmoplastic fibroma , juvenile aggressive fibromatosis , or fibrosarcoma .

as part of its mission to support researchers in the production and sharing of knowledge in a rapidly changing publishing industry the university library system , university of pittsburgh ( uls ) has partnered with the rehabilitation engineering and research center ( rerc ) on telerehabilitation to produce the international journal of telerehabilitation ( ijt ) . in its role as publisher , the uls seeks to transform the traditional subscription - based model of scholarly communication , promote the principle of open access to scholarly research , and incentivize scholars worldwide to join in this commitment . this novel interdisciplinary collaboration engages librarians , information technologists , publishing professionals , practitioners , researchers , policy experts , and engineers . established in 2008 , the ijt is one of the first scholarly journals to publish peer - reviewed research specifically focused on telerehabilitation and includes original research , case studies , technical reviews , and policy papers . the ijt is published biannually and has thus far produced six issues and a pre - publication issue . articles are vetted through a rigorous peer - review process for quality and then offered free of charge to the world through open access immediately upon publication . no author fees are charged by the journal , further reducing the barriers to publish . the ijt provides an accessible version of all published articles formatted to work well with text - to - speech software . for non - textual content , the accessible version includes language that conveys a detailed description of the information contained within the graph , table , or image . the open journal systems ( ojs ) software enables the flow of scholarly content from initial author submissions through online publication and indexing . the platform provides a set of reading tools to extend the use of scholarly content through rss feeds and postings to facebook , twitter , and other social media so that potential readers can discover journal articles via blogs , databases , search engines , and library collections . the ijt is registered with several major indexing and abstracting services , such as the directory of open access journals , a collection of free full - text quality - controlled scientific and scholarly journals ; ulrich s , the global source for periodicals ; ebsco discovery services , one of the world s premiere abstracting and indexing services for scholarly content ; and the open archives registry ; and others . data about the ijt s readership was generated on april 2 , 2012 at 3:21 p.m. using affinium netinsight 7.3 ( copyright 19962008 unica corporation ) for web activity between march 1 , 2011february 29 , 2012 , including : user domains ; visitor hits ; total page views ; most frequent referrers ; robot / spider summary ; and temporal and browser summaries . as depicted in table 1 , the ijt was viewed 44,843 times between march 1 , 2011february 29 , 2012 , with 202,290 total visits . readers from over 40 countries accessed ijt during this period , with the top ten being : united states , russian federation , ukraine , united kingdom , latvia , germany , italy , australia , poland , and france . the collaboration is also fostering the development of an interactive web - based product dedicated to disseminating information about telerehabilitation . planned also are content additions to high volume , open source dissemination vehicles such as wikipedia . this model collaboration exemplifies a best - practice interdisciplinary partnership that could be replicated by institutions worldwide to achieve broader dissemination of peer - reviewed scholarly research results through open access .

this publisher s report describes the collaboration between a university library system s scholarly communication and publishing office and a federally funded research team , the rehabilitation engineering research center ( rerc ) on telerehabilitation . this novel interdisciplinary collaboration engages librarians , information technologists , publishing professionals , clinicians , policy experts , and engineers and has produced a new open access journal , international journal of telerehabilitation , and a developing , interactive web - based product dedicated to disseminating information about telerehabilitation . readership statistics are presented for march 1 , 2011 - february 29 , 2012 .

distant metastases in laryngeal carcinoma are rare and when present , most commonly involve the lung . we report a rare case of laryngeal carcinoma presenting with metastases to all five distal phalanges of left hand with simultaneous metastasis to multiple sites after 2 years of receiving radical chemo - radiation to the head and neck region with complete local control . a 55-year - old man was diagnosed as a case of carcinoma supraglottic larynx ( stage t4n1m0 ) in august 2007 . histopathology of primary site was squamous cell carcinoma , and fine needle aspiration cytology ( fnac ) of neck node was also squamous cell carcinoma . the patient was planned for radical chemo - radiation after complete clinical and investigative workup . he received external beam radiotherapy ( ebrt ) using 6 mv photon to a total dose of 66 gy in 33 fractions over six and half weeks ( from 07 - 08 - 2007 to 22 - 08 - 2007 ) with concurrent cisplatin chemotherapy at 3 weeks interval . at 1 month after completion of treatment , patient was free from disease both clinically and on direct laryngoscopic examination and kept on regular follow up . patient presented after 2 years with complaints of swelling on tip of all fingers and nail bed of left hand [ figure 1 ] , multiple subcutaneous nodule in upper and lower limb , and loss of appetite with significant weight loss . an fnac from tip of fingers and subcutaneous swelling was suggestive of metastatic carcinoma [ figure 2 ] . contrast - enhanced computed tomography ( cect ) of chest , abdomen , and pelvis , revealed metastasis in bilateral lungs and liver [ figure 3a b ] . local examination of neck and direct laryngoscopic examination was suggestive of no evidence of disease ( ned)/essentially normal . in view of his very poor general condition and widespread dissemination of disease , the patient was offered palliative treatment only and he died within 2 months at home . metastatic swelling of all five distal phalanx of left hand photomicrograph showing cluster of malignant cells with extensive necrosis and apoptosis in background ( hematoxylin and eosin stain , original 400 ) ( a ) multiple bilateral lungs metastases , ( b ) multiple liver metastases the incidence of distant metastases in squamous cell carcinoma of head and neck ( scchn ) approaches 20%25% . the most common sites of metastases are lung ( 70%75% ) , liver ( 17%38% ) , and bone ( 23%44%).[24 ] skin metastases has been reported to occur in 1%2% of patients with scchn and account for fewer than 10% of all distant metastases . other malignancies associated with skin metastases include carcinoma of bronchus , breast , colon , and kidney . cancers arising in the oral cavity are the commonest head and neck cancers metastasizing to skin . review of the surgical literature revealed only seven previously reported cases of cutaneous metastases from squamous cell carcinoma of the larynx . the site of skin metastases include neck , chest , scalp , face , lips , axilla , areola , back , arms , and digits , with the most common being the neck and chest . it is evident on literature search that multiple metastases from a laryngeal carcinoma involving all five distal phalanges , bilateral lung , liver and multiple subcutaneous nodule in upper and lower extremities , as described above is not reported till date . the skin metastases may evolve through three possible mechanisms , direct spread , local spread , and distant spread . local spread can be ascribed to spread through dermal lymphatics with resultant implantation in the skin . this route of hematogenous spread could be either through pulmonary circulation or bypassing pulmonary circulation via azygous and vertebral venous plexus . in the indexed case , the acrometastasis is most likely due to spread by hematogenous route via pulmonary circulation as the patient has multiple bilateral lung , liver , multiple subcutaneous nodules along with cutaneous phalangeal metastasis . cutaneous metastases from laryngeal carcinoma may present as non - tender firm nodules , as sclerodermoid lesions or may mimic an inflammatory process . the diagnosis should be confirmed by cytology or histopathological examination of the lesions and in this case it was confirmed with a positive cytology report . treatment is essentially aimed at providing symptomatic relief and improving the quality of life . in solitary acral metastases , the patient presented with disseminated disease with involvement of all five distal phalanges , so further treatment offered was essentially palliative as numerous metastases developed rapidly at different sites and because of poor general condition . the indexed case , at initial presentation in 2007 , had localized disease to supraglottic region with ipsilateral neck node involvement . despite a disease - free interval of 2 years this case underscores the importance of considering metastases in the differential diagnosis of a new swelling appearing in a patient previously treated for head and neck cancer .

subcutaneous metastasis from carcinoma larynx is a rare presentation and to the phalynx is the rarest . we herein describe a case report of carcinoma supraglottic larynx , which is involving all five distal phalanges of left hand with simultaneous metastases to lung and liver . acrometastasis is an unusual presentation , which might mimic an infectious or inflammatory pathology . the brief report highlights the importance of clinical awareness of metastatic dissemination to unusual sites in the face of increasing cancer survivorship .

epithelioid hemangioendothelioma is a rare vascular neoplasm , considered to have clinical behavior intermediate between a benign hemangioma and malignant angiosarcoma . , these tumors often arise from a medium - to - large - caliber vein , most commonly in the extremities . symptoms of these tumors vary depending on location , and can present with extremity swelling , pain , cough or dyspnea . complete surgical excision of these tumors is advocated given their potential for malignant degeneration and metastasis . a 17-year - old male presented with complaints of left - arm swelling and occasional pain . imaging obtained of the chest and neck revealed a large anterior mediastinal mass involving the major venous structures of the left chest ( fig . 1 ) . computed tomography ( ct)-guided needle biopsy was performed , with inconclusive results , and this was followed by a left video - assisted thoracoscopic surgery ( vats ) procedure yielding enough tissue for formal diagnosis of an epithelioid hemangioendothelioma . after extensive multidisciplinary consultation and preoperative planning , the patient was taken to the operating room for a median sternotomy , thymectomy and en - bloc excision of the tumor and vessels ( fig . 2 ) . vascular reconstruction of the left brachiocephalic and left subclavian vein was performed with an 8 mm ringed polytetrafluoroethylene graft , with an additional end - to - side anastomosis of the left internal jugular vein to the graft . the patient tolerated the initial procedure well , was extubated on postoperative day 1 and advanced to an oral diet . after several days , large - volume milky drainage from the chest tube was evaluated and presence of a chyle leak confirmed . the patient returned to the operating room on postoperative day 6 for a right vats with ligation of the thoracic duct . final tumor measurements were 7.5 5.5 3.5 cm , and final pathology confirmed an epithelioid hemangioendothelioma with no mitoses , < 5% necrosis and a final pathologic staging of pt2b . figure 1:computed tomography demonstrating a mass in the left chest involving the brachiocephalic vein . figure 2:intraoperative photography demonstrating the epithelioid hemangioendothelioma encasing the left brachiocephalic vein , left internal jugular vein , and left subclavian vein . intraoperative photography demonstrating the epithelioid hemangioendothelioma encasing the left brachiocephalic vein , left internal jugular vein , and left subclavian vein . malignant degeneration and metastases are reported to occur in 25% of patients , with death occurring in up to 15% of patients . despite the indolent clinical course , the potential for tumor advancement mandates complete surgical excision . the vascular involvement necessitates meticulous preoperative planning and multidisciplinary approach for aggressive resection and concomitant reconstruction of involved vessels . in this case , the surgical team included cardiothoracic surgeons , vascular surgeons and a pediatric surgeon .

epithelioid hemangioendotheliomas are rare vascular tumors , often arising from medium to large veins in the extremities . symptoms of these tumors vary depending upon location . rarely , tumors may arise in chest and involve large vessels in the mediastinum . we present a case of a 17-year - old male presenting with compressive symptoms of the left upper extremity who was found to have a large epithelioid hemangioendothelioma encasing the left brachiocephalic vein .

in the previous issue of critical care , hamzaoui and colleagues present an observational study on the haemodynamic effects of norepinephrine in septic patients with life - threatening hypotension . within 6 hours of admission to the intensive care unit , a threshold mean arterial pressure ( map ) 65 mmhg was selected to commence an infusion of norepinephrine , regardless of the degree of prior volume resuscitation . measurements of cardiac index and derived indices of preload ( end - diastolic global volume index ) and stroke volume variation were made at baseline and following augmentation of map with norepinephrine . the patients were further categorised according to baseline left ventricular ejection fraction and whether they were able to achieve the target map . the investigators found that norepinephrine significantly increased map to a median value of 75 mmhg , which was associated with significant increases in cardiac output and indices of stroke volume and preload . this effect was consistent independent of baseline left ventricular ejection fraction - apart from those patients with left ventricular ejection fraction < 45% , who attained map > 75 mmhg . the authors concluded that the early administration of norepinephrine directed at achieving a target systemic perfusion pressure was achievable through parallel increases in cardiac output and preload . although hamzaoui and colleagues ' study is observational and single - centred in a relatively small population of septic patients using derived indices from pulse contour analysis to quantify changes in preload and contractility , the results are consistent with physiological models that define the protean haemodynamic effects of endogenous catecholamines , specifically norepinephrine , under homeostatic and pathological conditions . norepinephrine exhibits sympathetic activity over an expanding population of adrenoreceptors on the circulation ( 1a and 1b , 2a , 2b and 2c , 1 , 2 and 3 ) , acting centrally on the myocardium , on the arterial ( conduit ) circulation and on the venous ( capacitance ) circulation . haemodynamic function at any point in time represents the balance between the two circulations , so that changes in one are represented by compensatory changes in the other . under pathological conditions such as septic shock , qualitative and quantitative changes in cardiac function and vascular responsiveness result in unpredictable cardiovascular responses between and within individuals , initially as a compensated high output or vasodilated state to a decompensated low output or vasoplegic state . teleologically , this represents exhaustion of endogenous neurohumoral responses induced by pathological processes or an overwhelmed host response . in this context , the use of exogenous infusions of catecholamines , such as norepinephrine or epinephrine , should be seen as neurohormonal augmentation therapy to defend decompensating haemodynamic function rather than as a rescue therapy to treat shock . this understanding is somewhat at variance to traditional clinical practice , supported by current guidelines that recommend haemodynamic resuscitation follows a step - wise approach - initial fluid loading , followed by the use of an inotrope to improve cardiac output , followed by a vasopressor to squeeze the circulation to augment the perfusion pressure . three recently published randomised controlled trials comparing the effects of catecholamines in severe sepsis have demonstrated equivalence in haemodynamic responses without adverse effects on organ function or mortality [ 8 - 10 ] . of the three catecholamines studied , norepinephrine was associated with the lowest incidence of drug - specific side effects compared with epinephrine ( hyperlactataemia and hyperglycaemia ) and dopamine ( arrhythmias ) . on the basis of these studies and a recent commentary furthermore , these trials represent a perceptible change in clinical practice to preferentially use catecholamines early in resuscitation to defend map as the principal haemodynamic endpoint , although it is acknowledged that there is little evidence or agreement on an optimal perfusion pressure in septic shock . the justification for selecting map is based on pragmatic reasons - map is easy and accurate to measure - as well as it being an aggregate index of organ perfusion pressure . however , as there is little direct relationship between perfusion pressure and venous return , which remains difficult to measure under clinical conditions , clinicians rely on the assumption that parallel changes in the arterial and venous circulations will occur . the use of norepinephrine as a neurohormonal augmentation therapy by hamzaoui and colleagues demonstrated inotropic and vasopressor responses in a heterogeneous population of patients with severe sepsis using current monitoring techniques . these data are consistent with established biological and basic science evidence , and provide additional strength to the argument for viewing norepinephrine as a neurohormone rather than as a vasopressor and to recommend its early use as the first - line agent for life - threatening hypotension .

septic shock causes unpredictable cardiovascular responses through adrenoreceptor - mediated changes in cardiac function and vascular responsiveness . the use of norepinephrine should be regarded as neurohormonal augmentation therapy to defend decompensating haemodynamic function rather than as a rescue therapy to treat shock . recent trials represent a perceptible change in clinical practice to preferentially use norepinephrine early in resuscitation to defend the mean arterial pressure and to use norepinephrine as a neurohormone rather than as a vasopressor .

vitreoretinal surgeons often face a condition in which particulate material has deposited on the retinal surface , mostly during vitrectomy for vitreous hemorrhage or during diabetic vitrectomy . another similar condition may occur with triamcinolone - assisted vitrectomy when particles deposit over the retinal surface . the classic and useful instrument to handle this condition has been the back - flush needle . this is a simple extrusion flute complemented by a soft reservoir , which can be pressed by the surgeon s finger to push fluid into the eye . when the needle is held at a suitable distance from the retina , this action produces a flush of fluid that causes the deposited materials to be washed away from the retinal surface . with smaller gauge vitrectomy instruments however , the fluid current produced by the back - flush needle is weaker than that obtained by 20-gauge vitrectomy , and sometimes removal of deposited material from the retinal surface takes considerable time . moreover , the pushing action over the reservoir causes some untoward motion of the needle tip , necessitating holding of the needle in the mid - vitreous cavity to avoid touching the retina and causing trauma . to solve this problem , some surgeons use the suction action of the vitrectomy probe to produce fluid currents in the vitreous cavity but this method may not be very effective and does not always work in the intended way . another solution is to use the soft tip needle very close to the retinal surface . this technique poses the danger of contact between the instrument and delicate retinal tissue . with modern vitrectomy machines , the reflux mode of the instrument followed by suction but these options and their successful use may not be simple and readily available with older vitrectomy machines . i employ a simple method to remove particles from the retinal surface with the aid of a 5 ml syringe attached through a connector tubing to a 23-gauge soft tip needle ( figure 1 ) . the surgeon holds the tip of the needle in the mid vitreous cavity , and the operation assistant slowly injects balanced salt solution into the eye . in this way , turbulent flow is produced in the vitreous cavity that washes the particulate matter from the retinal surface . then active suction via the same instrument by the operation assistant or using the vitrectomy probe by the surgeon in a very slow and controlled manner can extrude the particles from the eye . with the technique described herein , the primary objective is creating turbulent flow in the vitreous cavity without directing the fluid current toward the retinal surface . firstly one should avoid creating fluid currents toward retinal breaks , otherwise retinal detachment may develop . it is advised not to use this technique when a retinal break exists . i have used this technique in many of my operations , and have found it helpful when i use older vitrectomy machines without the capability of fluid reflux .

removal of particulate materials from the retinal surface is somewhat difficult during small gauge vitrectomy . simple injection of balanced salt solution into the vitreous cavity in a controlled manner using a connector tubing between the syringe and needle can produce enough turbulence to float the deposited material and remove it .

congenital syphilis is a potentially serious pathology affecting newborns of infected mothers . in the third - world countries , 3 - 15% of the women are infected with syphilis in their reproductive age . as per the world health organization ( who ) , in india , 65.4% women attending antenatal care were tested for syphilis at the first visit and 0.3% were seropositive for syphilis . young females without adequate antenatal care have 95% chance of transferring the infection to their fetus transplacentally . the who estimates that every year , maternal syphilis is responsible for 25% abortions or still birth and 25% of newborn are low birth weight or have serious infections . besides abortions , still births , and perinatal deaths , live born babies may have early congenital syphilis ( before two years of age ) and late congenital syphilis ( after two years ) . stigmata - including scars and deformities which are the consequences of early or late congenital syphilis . despite the fact that congenital syphilis can be prevented by detection and treatment of infected expectant mothers this case is presented in order to emphasize that congenital syphilis still exists and global antenatal screening is mandatory to prevent this serious , yet largely preventable disease . a three month old female child weighing 2 kg normally delivered at term presented with lesions all over the body with oro - genital erosions since 1 month . on examination , there were severe desquamating erythematous papulosquamous lesions over face , upper extremities , trunk , buttocks and legs . multiple superficial erosions were present on palm , soles , genitals , buttocks and natal cleft [ figures 13 ] . she had high arched palate without perforation which enables her to suck properly [ figure 4 ] . x - ray of skull and long bones showed no abnormality . ophthalmic examination including fundoscopy was normal . papulosquamous lesions with oral involvement erosive lesion over genitals erosive lesions over natal cleft high arched palate with oral erosions on history , it was found that the baby was delivered at home and the mother had not taken any antenatal visits . mother had a history of lesion over the genital area twice in the past i.e. , two years and six month prior to the birth of the patient for which she has taken some treatment from local doctor . the records of the above - mentioned condition or any treatment taken were not available . she is second gravida with h / o of single second trimester abortion during last pregnancy . father of the baby did not have any history of any sexually transmitted diseases ( stds ) but had an h / o unprotected premarital exposure . venereal disease research laboratory ( vdrl ) with dilution of patient was 1:512 while that of parents were 1:64 . presumptive diagnosis of congenital syphilis was made based on four fold raise in patient titre . in single dose and patient was treated successfully with 1.5 lakh u / day i.m . the case definition of congenital syphilis as per centers for disease control ( cdc ) , usa , includes newborns with clinical evidence of active syphilis , as well as those who do not present any signs and are born to the mothers with untreated or inadequately treated syphilis . congenital syphilis is a multisystem infection caused by treponema pallidum and transmitted to the fetus via the placenta . the risks of vertical transmission and fetal diseases are directly related to the stage of maternal syphilis during pregnancy . it is estimated that in women with syphilis of a few years duration , about half of the pregnancies will be affected , with one half of the affected pregnancies ending in stillbirth ( including miscarriages ) , and the other half in perinatal death or serious neonatal infection ( congenital syphilis ) . early congenital syphilis usually manifest as characteristic skin lesions , such as vesiculobullous or a macular copper - colour rash on the palms and soles and papular lesions around the nose and mouth and in the diaper area , as well as petechial lesions . other features include rhinitis , bone abnormalities , chorioretinitis , lymphadenopathy , hepatosplenomegaly , and nephrotic syndrome . late congenital syphilis , which presents after two years of age , may have a variety of skeletal and dental defects , interstitial keratitis , and eighth nerve deafness ( hutchinson 's triad ) . due to limited resources a presumptive diagnosis of congenital syphilis is frequently the basis for treatment of newborn and the presumption of transmission is raised by the positive serology of the mother with inadequate antenatal care . treatment is based upon a maternal positive nonspecific treponemal test at pregnancy or delivery in combination or not with clinical symptoms of newborn . however , confirmation of syphilis requires demonstration of syphilis spirochete in the tissues or body fluids by detection of anti - treponemal igm antibodies or by dna or rna amplification , which could not be done in this case . even one case of congenital syphilis is a sentinel public health event , since timely diagnosis and treatment of syphilis infected pregnant woman should prevent transmission almost entirely . the report urges greater vigilance and screening for syphilis among pregnant women and newborns , and contributes to the evidence that syphilis is still prevalent among women . physicians , especially gynecologists , obstetricians and pediatricians , have to be vigilant in order to allow for early diagnosis and appropriate treatment of congenital syphilis .

congenital syphilis is a potentially serious pathology affecting newborns of infected mothers . even one case of congenital syphilis is a sentinel public health event , since timely diagnosis and treatment of syphilis infected pregnant woman should prevent transmission almost entirely . here , we are reporting a case of early symptomatic congenital syphilis presented with severe desquamating papulosquamous lesions over multiple body parts along with erosive lesions around oral cavity and nostrils .

implantable cardioverter defibrillators ( icds ) are a proven therapy for secondary and primary prevention of sudden cardiac death.1,2 because of their effectiveness , the number of patients having these devices is increasing by the day.3 so , it is important for the primary care physicians , cardiologists , and the patients alike to be aware of the common problems that can be encountered . electromagnetic interference ( emi ) we are reporting a case of aicd firing due to emi resulting from leakage of electric current in the pool . this is a case of a 76-year - old male with past medical history of gout , diabetes mellitus , coronary artery disease , and ischemic cardiomyopathy with ejection fraction of 30% . the atrial lead was 5594 capsure sp novus , made by medtronic and implanted in july 2006 while right ventricle / superior vena cava ( rv / svc ) lead was 6947 sprint quattro secure , made by medtronic and implanted in march 2009 . on his current presentation , he came to see his cardiologist after being shocked by his icd three times . he denied any chest pain , palpitations , headache , lightheadedness , or dizziness before being shocked . as soon as he felt shocks , he came out of the pool and did not get any further shocks after coming out of water . the patient was taking subcutaneous insulin , aspirin , clopidogrel , metoprolol , candesartan , simvastatin , furosemide , famotidine , allopurinol , and colchicine at home . the patient was allergic to penicillin and social history was significant for smoking half a pack of cigarettes per day for 40 years . the physical examination was normal . from the icd interrogation done in his cardiologist s office , the device was programmed to detect ventricular fibrillation ( vf ) at > 188 bpm and ventricular tachycardia ( vt ) between 162188 bpm . pacing lead impedance was 272 ohms and defibrillator lead impedance was 39 ohms for rv and 52 ohms for svc . stored intra - cardiac electrograms recorded during this event showed high frequency undulating noise consistent with 60 hz alternating current ( fig . the pool was examined by a certified electrician who found a small leak into the pool from a lamp . emi , also called radio frequency interference ( rfi ) when in high frequency or radio frequency , is a disturbance that affects an electrical circuit due to either electromagnetic induction or electromagnetic radiation emitted from an external source . the disturbance may interrupt , obstruct , or otherwise degrade or limit the effective performance of the circuit . for the normal functioning of an icd , appropriate detection of myocardial action potentials is needed . emi resulting in icd malfunction is a well - known phenomenon.4 source of emi may be a normally functioning device including electronic article surveillance systems , hand - held radiofrequency remote controls , slot machines , abdominal muscle stimulators , etc . emi may also be due to leakage of alternating electrical current from different devices such as a washing machine , refrigerator , swimming pool , and shower , among many others . if the radiofrequency signal is strong enough , it can be detected by the icd . the detection of these signals depend on various factors including the strength of signal , distance of the device from the source of emi , path of the current through the body , and the size of receiver.5 icds have built - in algorithms for detection of ventricular dysrhythmias . it is difficult for these algorithms to differentiate emi from true ventricular arrhythmia ; thus emi may be detected and interpreted by an icd as a shockable rhythm leading to inappropriate shock delivery . inappropriate shock delivery from icd in an awake patient is not only painful and frightening but also pro - arrhythmic.6 currently , there are few cases reported in the literature where emi resulted in an inappropriate icd shock ( table 1 ) . our case , along with the other cases reported , illustrate some potential environmental hazards in patients with an icd . these patients typically deny any symptoms such as dizziness , lightheadedness , or syncope before the shock delivery . interrogation of icd reveals high frequency background noise ( resulting from emi ) superimposed on patient s baseline rhythm . management of such inappropriate shock includes educating the patients about potential sources of emi and their avoidance ( table 2 ) . at the same time , efforts should be made to improve the icds , which includes better shielding of the devices and improving the software algorithms in order for emis to be differentiated from real cardiac dysrhythmias .

as the number of patients having implantable cardioverter defibrillator ( icd ) devices is increasing , it is important for the physicians and patients to be aware of situations and conditions that can result in interference with normal functioning of these devices . there are multiple cases of malfunction of icds reported in literature and it may be of great significance to have an overview of these incidents for appropriate recognition and future prevention . here we are reviewing the available literature as well as reporting an interesting case of electromagnetic interference ( emi ) resulting from leak of current in pool water causing firing of icd .

main causes of bowel obstructions are postoperative adhesions , second leading causes are malignant tumors or strictures of the small bowel , followed by hernias . intussusception , volvulus , crohn 's disease , and gallstones ( gallstone ileus ) account for only a small percentage of cases . since the iliac crest has become an often used site for autogenous bone graft , one of the rare complications is a graft site hernia . a 53-year - old man was admitted for the elective resection of a pseudarthrosis and reconstruction of the left femur with iliac crest bone from the right side . the patient also suffered from liver cirrhosis child b and thrombosis of the portal vein due to infection with hepatitis c and alcohol abuse . a hepatocellular carcinoma was diagnosed in a liver biopsy performed during hospitalisation . at the right iliac crest bone harvest point , two fragments of artificial bone , which had been inserted for stabilisation , subsequently dislocated . because of the patient 's limited health , there was no immediate removal of the dislocated fragments . in the course of further hospitalisation , the patient complained of increasing abdominal pain and showed signs of bowel obstruction . a lump on the right iliac crest could be palpated , and bowel movement was auscultated . a ct of the abdomen confirmed an obstruction of the small bowel caused by the herniation of the ileum into the the bone defect in the right iliac crest ( figure 1 ) . during laparoscopy , the small bowel had herniated directly below the cecal pole through the peritoneum ( figures 2 , and 3 ) . due to collateral circulation in the peritoneum and cecum caused by portal hypertension , an intraperitoneal onlay - mesh repair could not be performed . after the trocars were removed , the wound at the right iliac crest was reopened . then , a dynamesh of 12 13 cm was fixed with single sutures . after returning to a normal diet and an uneventful recovery , hernia symptoms range from a palpable lump in the groin or abdomen , pain , and tenderness , to nausea and vomiting when obstruction occurs . in most cases , since the iliac crest has become a common donor site for autogenous bone graft , numbers of postsurgical inferior lumbar hernias are rising . the incidence varies between 59% as shown in previous reports [ 3 , 4 ] . other reported complications are nerve and ureteral injury , arterial injury , fracture , pelvic instability , herniation , ileus , and hematoma . due to the increased morbidity and mortality associated with these defects , it can be accomplished through laparoscopic , retroperitoneal or transabdominal approach . the first laparoscopic repair of lumbar hernia was described in 1996 by burick and parascandola . other techniques include soft tissue transfers to bridge the gap of the abdominal wall defect ( transversalis fascia , abdominal musculature , and tensor fascia lata ) or the bosworth repair ( the anterior superior iliac spine is moved inferiorly and posteriorly , so muscles and fascia cover the defect ) . a new corkscrew anchor system has been described by patten et al . to place sutures in the postharvest iliac crest remnant . as described , we repaired the extraperitoneal hernia after iliac crest bone harvest with an onlay mesh . if symptoms of bowel obstruction occur after an iliac bone crest harvest , it is important to think of a hernia . while removing the iliac bone crest , verification of an intact peritoneum is important . a laparoscopic repair should be performed if possible , as it has proved to be safe for the repair of hernias through the inferior lumbar triangle [ 9 , 10 ] .

the iliac crest has become an often used site for autogenous bone graft , because of the easy access it affords . one of the less common complications that can occur after removal is a graft - site hernia . it was first reported in 1945 ( see the work by oldfield , 1945 ) . we report a case of iliac crest bone hernia in a 53-year - old male who was admitted for elective resection of a pseudarthrosis and reconstruction of the left femur with iliac crest bone from the right side . one and a half months after initial surgery , the patient presented with increasing abdominal pain and signs of bowel obstruction . a ct scan of the abdominal cavity showed an obstruction of the small bowel caused by the bone defect of the right iliac crest . a laparoscopy showed a herniation of the small bowel . due to collateral vessels of the peritoneum caused by portal hypertension , an ipom ( intraperitoneal onlay - mesh ) occlusion could not be performed . we performed a conventional ventral hernia repair with an onlay mesh . the recovery was uneventful .

profuse nasal bleeding due to craniofacial trauma important are commonly associated with fractures of the facial bones and skull base1 . several of these control techniques are described epistaxis , and the posterior tapenade with a foley associated with anterior packing one of the most used , both by the relative ease of the procedure as the wide availability of materials2 . we report a case of using foley catheter to control bleeding nose after polytrauma outcome with a severe and unusual . 50 year - old - man crashed presenting high loss of consciousness , deformity of the face and profuse nosebleeds . pa kept you lowered level of consciousness during the service showing score 6 scale glasgow . the measures were supportive , stabilizing the airway by endotracheal intubation , volume resuscitation , and stabilization of the cervical spine , posterior nasal tampanomanto with foley catheter in the left nostril and bilateral anterior gauze , which is effective . performed plain radiographs of the cervical spine and face which was evidenced in facial bone fractures . performed computed tomography , facial bones and cervical spine which showed multiple fractures in the bones of the face and skull base as well as fracture of the odontoid process of the 2nd vertebra . also evidenced intracerebral migration of foley catheter with path to the posterior portion of the right parietal lobe through the ethmoid fracture . ( figure 1 ) axial ct scan of the skull showing through penetration of the ethmoid bone fracture path and intra cerebral foley catheter . patient underwent craniotomy after 48 hours of trauma for drainage of subdural hematoma , viewing the withdrawal of the probe and control bleeding in his path . showed clinical improvement and neurological stimuli when responding to reduced sedation . due to nasal drainage of cerebrospinal fluid with high flow underwent endoscopic sinus surgery on the 10th day of hospitalization for closing cerebrospinal fluid fistula high output in the ethmoid sinus , the migration path of the probe the patient developed mild neurologic improvement , keeping vigil with important cognitive and left hemiplegic . released from the intensive care unit on the 39th day of hospitalization being held in ward with tracheotomy and device pressure continuous positive airway pressure ( cpap ) pending clinical stabilization after 3 episodes of pneumonia , for realization of fracture fixation on process odontoid . severe cranial trauma with changes in facial architecture , require special attention , by signposting high impact injuries and also by the common association with skull base fractures3 . the management of severe epistaxis associated with these fractures requires care possible weakness of this nasal wall . the techniques of posterior tapenade with foley catheter associated with anterior packing are widely discussed and generally do not differ greatly in the literature , but the actual mechanism of action is not consensus . the main theses are that compression in the rear walls of the nasal cavity cause occlusion of bleeding vessels of the balloon would only serve as a platform to support effectively the above buffer containing bleeding or a combination of these mechanisms2 . the allocation of the foley catheter in these situations becomes critical because during the procedure does not need to have a portion thereof inserted into the nasal cavity , thus causing errors in positioning . in this case the insertion should be done under direct vision / indirect probe , where the floor of the nasal cavity , and confirmation of the presence of the same in the oropharynx before inflating the balloon are essential as is the use of larger diameter catheter possible4 . just as in the allocation of other probes to confirm the position with imaging test imposes greater security and the lateral skull radiograph usually enough to confirm this . in the medical literature there described 3 cases of intracranial migration of foley catheter during packing later , all related to profuse epistaxis after severe craniofacial trauma and restricted to anterior and middle tank3 4 5 . in our report but the probe maintained a straight path being positioned in the left parietal lobe . other reports of nasogastric tube after penetrating trauma , surgery on the skull base and also not related to trauma are described , demonstrating the anatomy of the region of weakness6 7 8 . this is a rare but possible complication in the treatment of severe nose bleeds associated with fracture of the skull base . this brief report highlights the risks related to the method and suggests some care to prevent complications , the main one being to verify the presence of the balloon probe oropharynx before the final positioning of the probe .

summary introduction : severe epistaxis is common in patients with head trauma , especially when associated with multiple fractures of the face and skull base . several methods of controlling bleeding that can be imposed . the anterior nasal tapenade associated with posterior foley catheter is one of the most widespread , and the universal availability of necessary materials or their apparent ease of execution . methods : case report on control of severe epistaxis after severe tbi , with posterior nasal packing by foley catheter and control tomography showing multiple fractures of the skull base and penetration of the probe into the brain parenchyma . conclusion : this is a rare but possible complication in the treatment of severe nose bleeds associated with fracture of the skull base . this brief report highlights risks related to the method and suggests some care to prevent complications related through a brief literature review .

modular total hip arthroplasty system are now widely used , as these components increase the flexibility during primary and revision total hip arthoplasty . but this modularity itself associated with some risk of intraoperative and postoperative complications . we report a case of late disassembly of a primary total arthroplasty in a 42 years old patient five years after the replacement surgery where the femoral head remained in the acetabular socket . femoral head should be solidly impacted onto the stem and confirm that it has been assembled correctly before reduction . modular total hip arthroplasty system now widely employed , that offer the advantage of increase flexibility in components selection during the surgery , but it introduce the risk of intraoperative errors in matching and disassembly of the components postoperatively1 2 . we report a unusually late separation of a modular femoral head from the neck of a primary total hip arthroplasry . a 42 years old man , who had osteoarthritis of right hip ( fig 1 ) , had an uncemented total hip replacement done through posterolateral approach . a porus coated , metal backed acetabular component with metal liner and a taper - locked modular femoral head with hydroxyapatite coated femoral stem were used . initial results was excellent , the patient had no pain and could walk without supportive aids . the patient was regularly followed up to about five years and all the x - rays of those period were normal and had no abnormalities ( fig . preoperative x - ray , showing osteoarthritis of hip joint . showing radiographs at various intervals , a- immediate postoperative , bone month post surgery and c - one year post surgery radiograph of hip joints at three years after surgery . five years after postoperatively , while the patient was rising from a chair , the patient experience a sudden click and followed by complete functional disability and impossibility to bear the weight . standard radiograph showed disassembly of femoral neck and head while the head of prosthesis remained inside the acetabular socket . all the femoral and acetabular components visible in the x - ray are normal in appearance . there are no fracture lines in any components or complete fracture of any components or any other extra , abnormal sized or shaped metal piece visible in the x - ray ( fig . open reduction was performed , same head was assembled onto the neck and the head was reduced into the acetabular socket . there was no evidence of visible corrosion of the interface between modular head and neck of femoral components . intra - operative images are not available as that were not taken during the surgical procedure . the modular femoral head disassembled from the stem and remained in the acetabular socket postoperative period was uneventful and a quick functional recovery was achived . modularity in total hip arthroplasty has been benefit in term of allowing inventory reduction , while provide surgeon versatility intraoperatively and thus allowing optimal joint reconstruction 3 , but it also introduce the risk of failure at the interfaces . modular femoral head may disassemble during close reduction of a dislocated prosthesis or during normal activity 1 such as in case report of current study . we suspect that the mechanism of this disassembly of femoral head was the sealed air that pushes back the stem neck and unlocks the taper lock . it is also possible that the head was not impacted adequately onto the stem intraoperatively . as a result of this experience , certain recommendation can be made to prevent this type of complication . the taper should be neatly clean and completely dry before the implantation of femoral head onto it . it is advised to use second blow as it may disengage the head if it was not placed centrically onto the taper , otherwise this second blow solidly lock the taper lock mechanism in a centrally placed head . always confirm that , the head has been assembled correctly by applying manual distraction forces to femoral head . disassembly of modular total hip arthroplasty system after surgery is rare , but it can occur in any case . therefore , whenever using such type of arthroplasty system , all the precautionary measures should be taken during surgery which are necessary to prevent such type of complication .

introduction : modular total hip arthroplasty system are now widely used , as these components increase the flexibility during primary and revision total hip arthoplasty . but this modularity itself associated with some risk of intraoperative and postoperative complications.case report : we report a case of late disassembly of a primary total arthroplasty in a 42 years old patient five years after the replacement surgery where the femoral head remained in the acetabular socket.conclusion:femoral head should be solidly impacted onto the stem and confirm that it has been assembled correctly before reduction .

immunization is one of the most cost - effective public health interventions and is largely responsible for the reduction of under-5 mortality rate . vaccine preventable diseases have declined markedly worldwide since the introduction of the routine immunization program in 1978 , which was later upgraded in 1985 as the universal immunization program ( uip ) . cutaneous side effects include local reactions like erythema , induration with or without tenderness , subcutaneous nodules , and hypertrichosis at the site of injection . rarely erythema multiforme has also been reported . we hereby report a rare case of focal hypertrichosis in an infant following routine immunization with the pentavalent vaccine . a 4-month - old healthy male infant presented with focal areas of increased hair growth over bilateral thighs . the child was born out of a nonconsanguineous marriage , full - term normal vaginal delivery . gurin ( bcg ) vaccination at birth and combination vaccine at 6 weeks and 10 weeks of age which included diphtheria , pertussis and tetanus toxoid , hepatitis b , and hemophilus influenza type b ( dtpw - hepb - hib ) . mother gave a history of localized swelling at the site of injection which was later followed by increased hair growth at the injection site bilaterally after about 2 weeks of injection . there was no history of local trauma , topical applications , or any other oral or injectable drug administered to the child . on examination , there were focal areas of hypertrichosis ( pigmented hair ) about 3 cm 2 cm localized over a bilateral anterolateral aspect of thighs [ figures 1 and 2 ] . localized area of pigmented hair over anterolateral aspect of left thigh at the site of vaccination localized area of pigmented hair over anterolateral aspect of right thigh in an infant hypertrichosis is characterized by excessive hair growth that is abnormal for the age , sex , or race of an individual , or for a particular area of the body . it can be congenital or acquired , generalized , or localized . acquired localized hypertrichosis ( alh ) has been described as a separate entity with various underlying factors . it has been reported to result from tattoos , sclerotherapy , and subsiding psoriasis , respectively . it can present in an irregular pattern on the legs in chronic venous insufficiency , around the edges of a burn , at the site of insect bites , and after radical inguinal lymphadenectomy . contact eczema , pretibial myxedema , arthritis , occupational , or self - inflicted trauma have also been associated with this phenomenon . rarely , alh has been observed after vaccination including measles and bcg vaccination . the exact mechanism underlying this phenomenon is unknown , but it has been suggested that prolonged exposure to antigen results in the production of various cytokines by the immune system . these cytokines can also affect nonimmune system cells such as those in the hair follicles and promote localized hair growth . pentavalent vaccine given for routine immunization in children contains adjuvant like aluminium salts ( aluminium hydroxide and aluminium phosphate ) . persistent tender or itchy subcutaneous nodules and granulomas have been previously reported with these agents . the classic histopathological appearance of these injection site reactions consists of a nodular inflammatory infiltrate with lymphoid follicles within the deep dermis and subcutaneous tissue with large collections of macrophages and eosinophilic infiltrate . finely granular refractile material can be found within macrophages , and the diagnosis can be confirmed by electron probe microanalysis . the development of focal hypertrichosis following pentavalent vaccine has not been described previously in indian literature . though it is a benign side effect , the authors here want to throw some light on this rare and less known side effect of pentavalent vaccine , which is routinely given to infants as per the uip . further research might help in revealing the exact mechanism for localized hypertrichosis at the injection site following pentavalent vaccine .

hypertrichosis is characterized by increased hair growth independent of androgen excess . there are various causes of acquired localized hypertrichosis including chronic irritation and inflammation . localised hypertrichosis following pentavalent vaccine has not been described previously in indian literature . we hereby report a case of a 4-month - old healthy infant presenting with focal circumscribed areas of hypertrichosis over anterolateral aspect of bilateral thighs at the site of vaccination .

critical care is evolving beyond a focus on short - term survival to include interventions aimed at reducing survivors longer term complications . in this context , denehy and colleagues conducted a novel randomized controlled trial evaluating a rehabilitation intervention starting in the icu and continuing through the outpatient setting , with longitudinal evaluations at icu and hospital discharge , and 3 , 6 and 12 month follow - up . this new study adds to existing prospective controlled trials [ 2 - 4 ] that have evaluated the effect of icu - based rehabilitation on patient outcomes . denehy and colleagues evaluated 150 patients , with an icu stay 5 days , recruited from a single 20-bed medical - surgical icu in australia . usual care physical rehabilitation versus a rehabilitation intervention , prescribed based on physiological principles and standardized physical testing , which commenced in the icu and continued in the ward and outpatient settings . the primary outcome was the 6 minute walk test ( 6mwt ) at 12 month follow - up , with secondary outcomes including physical function and quality of life measures at icu and hospital discharge , and 3 , 6 and 12 months follow - up . of the patients enrolled , 92% required intubation and mechanical ventilation , with 55% ventilated at recruitment ( icu day 5 ) . there were no major adverse events and no significant differences in primary or secondary outcomes at 3 , 6 and 12 months . the 6mwt was significantly lower in the intervention versus control group at icu discharge , which may have been due to a higher acuity of illness in the intervention group . post hoc analysis revealed that improvement in the 6mwt from icu discharge to 12 months was significantly greater in the intervention versus control group ( mean change 292 m versus 219 m ; difference 73 m ( 95% confidence interval 9 to 136 ) ) . to understand the trial results and their generalizability , it is important to examine how rehabilitation was provided in each group and the differences in rehabilitation between the two randomized groups . first , the physiological - based approach to rehabilitation prescription may help enhance reproducibility of the intervention and consistently exercise patients at a higher level . second , given survivors frequent long - lasting neuromuscular and functional impairments [ 5 - 8 ] , an intervention spanning the icu and outpatient settings may be of value . however , notably with this latter point , denehy and colleagues reported a low rate of participants completing outpatient rehabilitation sessions , with only 41% having at least 70% attendance . in terms of understanding usual care , on ten occasions during the trial there was prospective measurement of rehabilitation interventions delivered to icu patients who were not enrolled in the trial . this sampling of usual care revealed that 52% of patients were mobilized in the icu , including some mechanically ventilated patients sitting out of bed or marching in place . this description of usual care represents substantially greater rehabilitation than delivered in two prior randomized trials ( table 1 ) . for instance , in schweickert and colleagues , usual care patients received a median of 0 ( interquartile range 0 to 0 ) hours per day of physical and occupational therapy while mechanically ventilated . moreover , the intensity of usual care rehabilitation in the denehy and colleagues trial also may have been greater than in other australian icus , based on a one - day , bi - national point prevalence study that demonstrated no mechanically ventilated patients were mobilized out of bed . comparison of in - icu rehabilitation for intervention and usual care groups in prospective trials data are reported as median ( inter - quartile range ) . based on prospective measurement of pt interventions delivered to patients who were mechanically ventilated for > 48 hours at the study site icu and were not enrolled in the trial . mv mechanically ventilated , ot occupational therapy , prom passive range of movement , pt physical therapy . potentially because of a smaller difference in the dose of rehabilitation between the intervention and control groups in the denehy and colleagues trial compared to prior prospective controlled trials ( table 1 ) , this new study did not demonstrate a benefit of the novel rehabilitation intervention . however , an important issue highlighted by this trial is the need for standardized measurement and reporting of usual care rehabilitation in clinical trials . such standardization would allow a better understanding of the difference in rehabilitation intensity between the trial s randomized groups , and between the trial and prior studies . moreover , such standardization would allow readers to evaluate the generalizability of the trial s findings to their own icus , based on their local rehabilitation practice patterns . to achieve this goal and help advance rehabilitation research , investigators must discuss this issue and achieve consensus . a post hoc analysis demonstrated that patients in the intervention versus control group had a greater improvement in their 6mwt from icu discharge to 12 month follow - up . this difference may be important if it reflects a changed trajectory of recovery and translates into survivors reaching clinically meaningful outcomes sooner ( for example , earlier return to work ) . , this trial provides a novel longitudinal evaluation of physical rehabilitation delivered across the continuum of patient recovery , highlighting the importance of understanding we conclude that critically ill patients in both australia and the us ( and likely many other countries ) may benefit from the exceptional usual care received in the investigators study site icu in melbourne , australia . ap receives support from the national institutes of health ( grant number t32hl007534 - 31 ) .

denehy and colleagues conducted a novel randomized controlled trial evaluating a rehabilitation intervention starting in the icu and continuing through the outpatient setting , with 1 year longitudinal follow - up . while the intervention did not demonstrate improved patient outcomes , this study illustrates important issues regarding usual care control groups in clinical trials .

fixed drug eruptions ( fdes ) is an entity that is frequently encountered by all physicians . they are clinically distinct with characteristic recurrences at the same sites on re - exposure to offending drug . recent studies from india suggest that fixed drug eruptions ( fdes ) account for 2043% of all cutaneous adverse drug reaction ( cadr ) patterns . exact pathogenesis remains obscure but intraepidermal cd8 t cells that persist at the previous injury site mediate and are directly implicated in the epidermal injury causing localized cutaneous changes . fde has multiple variants , including generalized , linear , bullous , urticarial , pigmenting , nonpigmenting , wandering , eczematous , psoriasiform , erythema dyschromicum perstans like , vulvitis and oral fde . a 42-year - old man presented to our dermatology clinic with painful blistering eruption affecting the acral sites and lips . the day before , he had taken paracetamol , ciprofloxacin , and metronidazole from local pharmacy for tooth ache . within 3 h of ingestion of the drugs a few hours later he developed bullae over these sites and erosions on the lips . his medical records revealed a similar episode 10 months back , which developed a day after taking paracetamol over the same sites . he had received ciprofloxacin for urinary tract infection as an inpatient in 2006 without any adverse reaction . cutaneous examination revealed multiple bullae , a few with prominent hemorrhagic component were noted on the dorsa of hands with erythema near the thenar eminence [ figure 1 ] . on histopathological examination , the epidermis revealed foci of basal cell vacuolation , lymphocytic exocytosis , and many necrotic keratinocytes at and above the basal layer . there was also an intraepidermal to subepidermal bulla displaying marked hemorrhage and many neutrophils , a few eosinophils and lymphocytes within its lumen . there was superficial dermal edema and moderate perivascular infiltrates of lymphocytes , histiocytes , neutrophils , and eosinophils . laboratory investigations revealed total white blood cell count 13,200/cu mm with absolute eosinophil count of 160/cu mm . the patient was treated with topical steroid - antibacterial preparation for 1 week . on follow - up , he was counseled to avoid paracetamol in future and to carry a drug alert card . ( a - c ) multiple bullae , a few with prominent hemorrhagic component , were noted on the dorsa of hands ( d ) erosions and crusting on the lips ( a ) intraepidermal to subepidermal hemorrhagic blister with adjacent epidermis showing occasional necrotic keratinocytes ( 200 ) . ( b ) epidermis with necrotic keratinocytes , basal cell vacuolation , and lichenoid infiltrate seen in the superficial dermis ( 40 ) paracetamol is a commonly used nonsteroidal anti - inflammatory drug with a reliable safety profile . systemic manifestations have also been described in patients with fde , though they are very rare . in our patient , the temporal correlation with the drug , history of a similar episode and the quick improvement led us to a diagnosis of bullous fde due to paracetamol . applying naranjo 's algorithm , a causality score of 8 was obtained and was categorized as probable reaction to paracetamol [ table 1 ] . naranjo adverse drug reaction probability scale in appropriate clinical settings , other differentials to bullous fde include blistering disorders , bullous lupus erythematosus , linear iga bullous dermatosis and bullous pemphigoid . fdes may exhibit anatomical preferences to genitalia , lips , and sacrum . in some patients fde could be a result of cross - sensitivity if the drugs are closely related , however it does not follow an all or none reaction . a repeat exposure at times may not result in fde owing to refractoriness , and it could vary from weeks to months . oral rechallenge is the most reliable technique of identifying the causal agent but can be potentially disastrous . a positive patch test over the previously affected area is a relatively safe method . lymphocyte transformation tests useful in many types of drug eruptions yield poor results in cases of fde . clinicians should have a high index of suspicion and should be vigilant of the possible adverse reactions to drugs with robust safety profiles . identification of the offending drug becomes even more challenging in scenarios when the patient is on multiple drug therapy . we report this case to draw attention to a rare side effect of paracetamol , one of the most common over the counter drug . clinicians should have a high index of suspicion and should be vigilant of the possible adverse reactions to drugs with robust safety profiles . identification of the offending drug becomes even more challenging in scenarios when the patient is on multiple drug therapy . we report this case to draw attention to a rare side effect of paracetamol , one of the most common over the counter drug . clinicians should have a high index of suspicion and should be vigilant of the possible adverse reactions to drugs with robust safety profiles . identification of the offending drug becomes even more challenging in scenarios when the patient is on multiple drug therapy . we report this case to draw attention to a rare side effect of paracetamol , one of the most common over the counter drug .

we report a case of a 42-year - old male who presented with second episode of bullous eruptions after ingestion of paracetamol . there were no systemic complaints . the temporal correlation with the drug , history of a similar episode and the quick improvement led us to a diagnosis of bullous fixed drug due to paracetamol . applying naranjo 's algorithm , a causality score of 8 was obtained and was categorized as probable reaction to paracetamol . clinicians should be vigilant of the possible adverse reactions to drugs with robust safety profiles . drug alert cards could play an important role in preventing recurrences .

diaporthe helianthi munt .- cvet , anamorph phomopsis helianthi , is one of the causal agent of stem canker of sunflower ( helianthus annuus ) . the fungus belongs to division ascomycota , subdivision pezizomycotina , class sordariomycetes , order diaporthales , family diaporthaceae . disease develops on leaves by causing brown necrotic lesions at the edge of the leaf blade and then spreads through the veins to the petiole . the leaf dries and remains attached to the stem . from the junction of the leaf the pathogen gradually infects the stem causing diffuse necrosis . the main loss is the shriveling of capitula and lodging of stem , which breaks at different levels . this isolate belongs to a group of highly virulent isolates characterized by the presence of a gene fragment having homologies with aspergillus terreus lovastatin nonaketide polyketide synthase gene ( lovb ) . the genome of d. helianthi strain 7/96 was sequenced using illumina mate - paired sequencing technology by bgi hong kong co ( bgi - hongkong co. , limited , 16 dai fu street , tai po iindustrial estate , tai po , new territories , hong kong ) . mate - paired reads of 90 bp ( 1.80 gbp ; average coverage 38.80 ) were assembled using velvet v 1.2.10 . the genome of d. helianthi consists of 13,383 sequence scaffolds with a total assembly length 46.50 mbp ( n50 = 6347 and n90 = 1502 ) , 51.10% gc - content , and a maximum scaffold size of 54,299 bp . the completeness of the assembly was assessed using busco v12 , which estimated the genome sequence to be 98.26% complete . analysis with signalp 4.1 revealed that 1433 predicted proteins ( 9.92% of the proteome ) contain a secretion signal peptide . among those 45 are species - specific as they do not have any sequence similarity to proteins in public databases , based on blast searches ( e - value threshold of 1e-5 ) . such features are characteristic of fungal effectors , which are proteins that have key roles in restricting the host defense . a first comparative analysis within diaporthales and model organisms with publically available genomes [ fusarium , neurospora , colletotrichum , magnaporthe ] evidenced that d. helianthi 7/96 genome contains a remarkable number ( at least 40 ) of putative polyketide synthases ( pkss ) . analysis of pks gene family in strain 7/96 could be an intriguing starting point to unravel d. helianthi sunflower interactions . this whole - genome shotgun project has been deposited in genbank under the accession n : mavt00000000 ( bioproject prjna327798 ) . this whole - genome shotgun project has been deposited in genbank under the accession n : mavt00000000 ( bioproject prjna327798 ) . this work was supported by a dedicated grant from the italian ministry of economy and finance to the national research council for the project innovazione e sviluppo del mezzogiorno - conoscenze integrate per sostenibilit ed innovazione del made in italy agroalimentare - legge n. 191/2009 .

diaporthe helianthi is a fungus pathogenic to sunflower . virulent strains of this fungus cause stem canker with important yield losses and reduction of oil content . here we present the first draft whole - genome sequence of the highly virulent isolate d. helianthi strain 7/96 , thus providing a useful platform for future research on stem canker of sunflower and fungal genomics . the genome sequence of the d. helianthi isolate 7/96 was deposited at ddbj / ena / genbank under the accession number mavt00000000 ( bioproject prjna327798 ) .

cervical aplasia is a mullerian anomaly , in which patients lack a uterine cervix and the lower uterine segment narrows to terminate in a peritoneal sleeve at a point well above the normal communication with the vaginal apex . we report a case of cervical aplasia , associated with a functioning uterine corpus and an absent vagina . reporting the case of an 18-year - old unmarried girl , who presented to us with history of primary amenorrhea and cyclical lower abdominal pain . on examination , bimanual rectal examination was normal . her hormonal profile and all the other routine blood tests were normal . examination under anesthesia confirmed absent vagina . on inserting the laparoscope , a big endometriotic cyst in left ovary was visualized . a year later , she again presented to us with pain abdomen and another endometriotic cyst in the left ovary . she was taken up for a re - look laparoscopy in an attempt to create a passage - way for menstruation . we had good experience in this as we had successfully created such a menstrual passage - way in the past in two of our patients with fragmented cervix . the tentative plan for this was to establish the lower limit of uterus and upper limit of neovagina and henceforth , suture them together . a longitudinal incision was given over fundus of the uterus with harmonic scalpel and a suction cannula was passed through this incision till the lower limit of uterus . however , utero - vaginal anastomosis could not be performed , because the intervening distance in this patient was so much that mobilization of the uterus was not technically possible and the procedure had to be abandoned . later , this patient got married and presented to us again after 5 years of initial treatment with left lower abdominal pain . she reported satisfactory coital function and her husband had two issues from his previous marriage . sonographic evaluation showed another endometriotic cyst ( 11 cm 8 cm ) in left ovary . the case was discussed with the patient and her family and prognosis regarding reproductive potential was explained . they decided in favor of hysterectomy and the patient was taken up for laparoscopy again . on inserting the laparoscope , a pelvic mass was visualized which was formed by a jumble of dilated left tube , left ovarian cyst with left ovary , and loops of small bowel which were all matted together [ figures 1 and 2 ] . a hysterectomy was planned so round ligament and infundibulopelvic were cut with harmonic on the left side . carefully , upper limit of bladder was determined with the help of a bougie inside the bladder . uterine arteries could not be seen on either side even after a conscious attempt and dissection and the uterus seemed to be deriving its entire blood supply from the ovarian and tubal vessels . uterus with left tube and ovary were separated from the underlying loose peritoneal fold [ figure 3 ] with the help of harmonic which completed the hysterectomy then the uterus was morcellated and removed [ figures 4 and 5 ] . cystoscopy was done after the procedure which revealed an ectopic position of left ureteric opening . dense adhesion of omentum covering the entire uterus , left tube and ovary totally jumbled mass of dilated left tube and ovarian cyst loose fold of peritoneum replacing the cervix final picture after hysterectomy with left salpingo - oopherectomy congenital cervical anomalies are classified as type ib in the american fertility society classification of mullerian anomalies . they can further be classified into complete agenesis and dysgenesis where , congenital agenesis of the cervix is a rare condition . hence , thorough pre - operative work - up including an intravenous urograph is mandatory . diagnosis is suspected on the basis of history , clinical examination , and ultrasonography and can be confirmed by means of magnetic resonance imaging . differentiation from a high vaginal septum can be made as there is no vaginal dilatation with the accumulation of blood due to an absent passage - way . conservative laparoscopic surgery consisting of uterovaginal anastomosis has also been described and recommended as first line treatment by some authors . in our own experience , conservative management is a better treatment option in cases of cervical fragmentation and dysgenesis . our purpose of reporting , this case is to highlight the need to individualize treatment in all such patients of cervical anomalies . while , we also recommend uterovaginal anastomosis as the first line of management , both surgeon and the patient should be prepared for hysterectomy , especially , in extreme cases like this . this will save repeated morbid procedures as well as financial and psychological burdens as correct decisions help provide timely management to the patient .

we report a case of cervical agenesis or lack of uterine cervix . it is a rare mullerian anomaly and occurs in 1 in 80,000 - 100,000 births . the patient presented to us with primary amenorrhea and cyclical left lower abdominal pain . she was diagnosed to have cervical agenesis associated with vaginal agenesis and left endometriotic cyst . neovagina was created laparoscopically . utero - vaginal anastomosis was tried but it was not technically feasible . subsequently , laparoscopic hysterectomy was done due to recurrent endometriotic cyst formation .

needle tract implantation is a rare but well - documented complication following percutaneous diagnostic and therapeutic approaches such as biopsy , percutaneous ethanol injection ( pei ) , microwave coagulation therapy , and radiofrequency ablation for hepatocellular carcinoma ( hcc ) . the skin , subcutaneous tissue , muscle , peritoneum , and liver parenchyma have been reported as sites of implantation , but implantation into the intrahepatic bile duct ( ihbd ) has not been described previously . the patient was a 74-year - old man who had undergone transcatheter arterial embolization for hepatitis c virus - related hcc ( couinaud 's segment iii / iv ) in april 2003 and pei for recurrence at the same site in february 2006 ( fig . the patient was found to have dilation of the ihbd by computed tomography ( ct ) in october 2008 . contrast - enhanced ct showed a thrombosis occupying the left hepatic duct to the lateral branches with peripheral bile duct dilation ( fig . however , there was no tumor in the liver parenchyma , including the region treated by pei . magnetic resonance cholangiopancreatography revealed a defect of the left hepatic duct caused by the thrombosis with dilation of the peripheral lateral branches ( fig . serum concentrations of carcinoembryonic antigen and carcinohydrate antigen 19 - 9 were within the respective reference ranges , but the serum concentration of alpha - fetoprotein was elevated ( 21 mg / ml ; normal < 6.8 mg / ml ) . based on these findings , we performed a left hepatic lobectomy under a preoperative diagnosis of hcc with bile duct invasion . the cut surface of the resected specimen showed a yellowish tumor thrombosis occupying the region between the left hepatic duct and lateral branches ( fig . histologic examination showed that the thrombosis in the ihbd was hcc . since part of the hcc in the region treated with pei was adjacent to the tumor thrombosis in the ihbd in diagnostic imagings , we diagnosed hcc implantation into the ihbd due to pei . the postoperative course was uneventful and the patient is doing well without recurrence 8 months after the operation . the frequency of needle tract implantation after pei has been reported to be approximately 1% . during percutaneous interventional procedures , viable cancer cells that adhere to the needle can be disseminated along the needle tract during removal . in addition , blood or fluid refluxing back along the tract may carry cancer cells into the peritoneal cavity or to the surface of the skin . however , some reports suggest that tumor cells disseminate within the liver rather than along the route of puncture , and that needle puncture of a tumor through the portal vein may facilitate migration of tumor cells from a high - pressure tumor arterial region to the low - pressure portal vein , leading to rapid intrahepatic dissemination . in our case , the needle used for pei might have created a pathway along its track between the tumor artery ( high pressure ) and the ihbd ( low pressure ) . intervals of 5 to 46 months between pei and development of needle tract implantation have been reported , whereas intrahepatic dissemination occurring 1 month after pei or radiofrequency ablation has been described . in our case , the interval after pei was 32 months , which suggests that growth of the ihbd implantation may have been similar to that in needle tract implantation ( route of puncture ) . hcc with bile duct invasion has a high risk of intrahepatic recurrence within a few months after surgery . tumor implantation into the ihbd may have different characteristics to hcc with bile duct invasion , but we are carefully observing our patient for possible recurrence .

a 74-year - old man who had undergone transcatheter arterial embolization for hepatitis c virus - related hepatocellular carcinoma ( couinaud 's segment iii / iv ) in april 2003 and percutaneous ethanol injection for recurrence at the same site in february 2006 was found to have dilation of the intrahepatic bile duct by computed tomography in october 2008 . contrast - enhanced computed tomography and magnetic resonance cholangiopancreatography showed a thrombosis occupying the left hepatic duct to the lateral branches with peripheral bile duct dilation . serum concentration of alpha - fetoprotein was elevated . we performed a left hepatectomy under a preoperative diagnosis of hepatocellular carcinoma with bile duct invasion . the cut surface of the resected specimen showed a tumor thrombosis occupying the region between the left hepatic duct and lateral branches , but no tumor in the liver parenchyma . histologic examination showed that the thrombosis in the intrahepatic bile duct was hepatocellular carcinoma . since part of the hepatocellular carcinoma in the region treated with percutaneous ethanol injection was adjacent to the tumor thrombosis in the intrahepatic bile duct in diagnostic imaging , we diagnosed implantation into the intrahepatic bile duct due to percutaneous ethanol injection . the postoperative course was uneventful and the patient is doing well without recurrence 8 months after the operation .

there was no family history of similar complaints or history of sudden death in family . there was no obvious dysmorphic features except small proximal phalanges of little fingers of both hands , giving an impression of fifth finger clinodactyly ( fig . 1 ) . the child 's height was normal as per his age and mid - parental height . differential diagnosis of catecholaminergic polymorphic ventricular tachycardia and anderson - tawil syndrome ( ats ) were entertained . exercise testing , carried out after prolonged exercise , showed initial increase in compound muscle action potential ( cmap ) amplitude with a progressive drop and slow recovery . in view of genetic heterogeneity for bidirectional vt , genomic dna was subjected to exome sequencing by next generation sequencing ( ngs ) technique . genes responsible for catecholaminergic polymorphic ventricular tachycardia ( cpvt ) and anderson - tawil syndrome were analysed for sequence variations . the patient was found to harbour a known , pathogenic , heterozygous variant p.arg218trp caused by a substitution ( c.652c > t ) in exon 2 of the kcnj2 gene . none of them was found to harbour this variation , suggesting that the variation is denovo in the affected child . apart from digitalis toxicity , other etiologies include myocarditis , myocardial infarction , metastatic cardiac tumour , herbal aconite poisoning and cardiac channelopathies i.e. catecholaminergic polymorphic vt ( cpvt ) and anderson - tawil syndrome ( ats ) . absence of drug or herbal medicine intake , structurally normal heart with normal bi - ventricular function pointed towards channelopathy in our patient . in ats , unlike cpvt , ventricular arrhythmias are associated with extra cardiac manifestations like episodic flaccid muscle weakness and dysmorphic features . characteristic dysmorphologies include low - set ears , hypertelorism , small mandible , clinodactyly and syndactyly . our patient did not have any of the described dysmorphic features except fifth finger clinodactyly . in 60% patients ( also called type 1 ats ) pathogenic mutation in kcnj2 gene is evident . reduced ik1 resulting from kcnj2 mutations alters late cardiac repolarization and leads to both distinctive t - u wave morphology and an increased propensity to ventricular arrhythmias . in a series by haruna et al . , 30% patients presented with classical triad of symptoms and 70% patients presented with any two of three symptoms . characteristic t - u wave pattern is present in 90% of type 1 ats and this pattern has 84% sensitivity and 97% specificity in diagnosing ats . ventricular tachyarrhythmia has been observed in about 65% patients , bidirectional vt being most common followed by polymorphic vt , monomorphic vt and rarely vf . cardiac conduction abnormalities and dilated cardiomyopathy has also been reported . in absence of flaccid muscle paralysis , long exercise protocol may reveal an immediate post -exercise increment followed by an abnormal decrement in the compound motor action potential after prolong exercise , as in our patient . differentiation of ats from cpvt is crucial because later situation is much more fatal than former and sudden cardiac death is rare in ats . although ats can be differentiated from cpvt by classical extra - cardiac features , there is a probability of phenotypic expression of cardiac derived symptomatology only , as in our case . however a nonfatal course , prominent u wave with prolongs qu interval and subclinical neuro - electrophysiological finding pointed towards ats . at least 50% patients diagnosed with ats have an affected parent . up to 50% of cases present sporadically without family history and these cases are due to denovo mutation , as in our case . the mutation also carries high degree of variable phenotypic expression and incomplete penetrance , with as much as 20% mutation positive carriers being asymptomatic . despite high arrhythmia burden , patients with kcnj2 mutation ( ats i ) have low rate of syncope and cardiac arrest . no single pharmacological agent has been found to be effective in preventing arrhythmia load . while few patients showed improvement with calcium channel blockers or amiodarone , same drugs are ineffective in other cases or even exacerbate torsades de pointes . although beta - blockers and sodium channel blockers ( mexiletine , propafenone , and flecainide ) have been described ineffective , a good response was seen in our patients with combination of beta - blocker and flecainide . pacing in combination with nicorandil has been described to be effective in some cases . apart from reducing the arrhythmia load by pharmacotherapy , implantable cardioverter - defibrillator ( icd ) is indicated to prevent sudden cardiac death ( scd ) . although presence of ats itself is considered a class iib indication for icd placement , history of cardiac arrest due to ventricular fibrillation or vt should be regarded as a class i indication for icd placement in ats . until further data regarding risk stratification becomes available , icd therapy should be reserved for ats patients with a history of cardiac arrest , syncope , or sustained rapid and/or symptomatic vt . to conclude we report a case of bdvt of rare etiology and diagnosis of ats should be considered in presence of bdvt with structurally normal heart , even in absence of classical diagnostic criteria .

bidirectional ventricular tachycardia ( bdvt ) is a rare form of ventricular arrhythmia , characterized by changing qrs axis of 180 degrees . digitalis toxicity is considered as commonest cause of bdvt ; other causes include aconite toxicity , myocarditis , myocardial infarction , metastatic cardiac tumour and cardiac channelopathies . we describe a case of bdvt in a patient with anderson - tawil syndrome .

a 57-year healthy avid mountain climber came with 20 days history of sudden onset painless diminution of vision in the left eye . best corrected visual acuity ( bcva ) was 20/20 in the right eye and 20/50 in the left eye . 1 and 2 ] revealed multiple flame shaped superficial hemorrhages located in all the four quadrants up to the mid periphery . in addition , the left eye also had a dark blotchy intra retinal hemorrhage at the fovea measuring approximately 0.5 dd . od color fundus montage at presentation showing multiple superficial hemorrhages os colour fundus montage at presentation showing multiple scattered superficial hemorrhages and a blotchy hemorrhage at fovea the patient underwent a complete hemogram , basic coagulation profile and peripheral blood smear , which revealed no abnormality . he underwent a general physical check up and imaging to rule out cardiac or neurological abnormalities , which turned out to be normal . follow up , a near total resolution of hemorrhages with bcva 20/20 , n6 in both eyes was noted , which confirmed our diagnosis . od colour fundus montage at two weeks follow up showing relative reduction in the hemorrhages os color fundus montage at two weeks follow up showing relative reduction in the hemorrhages od color fundus montage at one month follow up showing near total resolution of hemorrhages os color fundus montage at one month follow up with near total resolution of hemorrhages and a dilated stq vein high - altitude retinal hemorrhages ( harh ) were first described more than four decades ago by singh , et al . autoregulation in response to hypoxia , increase in venous pressure secondary to raised intra cranial pressure and variations in hematocrit levels have been described . hypoxia , due to deficient oxygen at a high altitude , induces various compensatory mechanism in the retinal vasculature , which leads to retinal hemorrhages . choroidal circulation does not exhibit autoregulation ; hence , the occurrence of hemorrhages is more in the superficial retina than at a deeper level . this is a usually a self - limiting condition which does not require any active intervention .

high altitude retinopathy is a condition often seen among mountain climbers or among persons who reach high altitudes rapidly . in this report , we describe a case of a 57 year old healthy gentleman who presented with diminution of vision in both the eyes associated with retinal hemorrhages and the spontaneous resolution of the same .

total and segmental colonic transit time ( ctt ) can be assessed noninvasively using radio - opaque markers . , can also be used to differentiate between patterns of delayed colonic transit and to evaluate the response to treatment . several methods have been published , differing in the number of markers ingested , in the number of days markers are ingested and in the number and intervals of abdominal x - rays [ 4 , 7 ] . in this method , the patient swallows one capsule containing 10 radio - opaque markers at the same hour for six consecutive days . on the seventh day , a plain abdominal x - ray is obtained at the same hour as the capsules were swallowed . interpretation is based on the identification of markers in three regions as defined by bony landmarks and gaseous outlines [ 1 , 4 ] . by counting the markers in the right , left and rectosigmoid regions , total and segmental ctts can be calculated according to the formula : ctt ( in hours ) = sum of markers 2.4 . a 16-year - old girl with a long history of urinary tract infections and functional constipation presented with deterioration of her defecation problems following influenza h1n1 . abdominal pain and painful defecation intensified , and the frequency of bowel movements decreased from once every day to twice a week , despite up to 80 g per day of polyethylene glycol 4000 . on physical examination multiple masses could be palpated bilaterally in the abdomen which is consistent with faecal retention . because of the refractory nature of her constipation , a ctt was performed as described above . total ctt was 124.8 h ( 52 markers ; upper limit of normal 62 h ) , segmental transit times being 33.6 , 16.8 and 74.4 h , respectively ( fig . 1plain abdominal x - ray during ctt study before bowel cleansing with klean - prep plain abdominal x - ray during ctt study before bowel cleansing with klean - prep the girl was admitted for bowel cleansing with 4 l of polyethylene glycol because her symptoms persisted while only clear liquids were seen passing , this treatment was repeated twice in the next week . back on high doses of oral polyethylene glycol ( 80 g per day ) , the girl continued to complain of abdominal pain combined with a low frequency of bowel movements . although on physical examination the bilateral masses could not be felt anymore , palpation of the abdomen was repeatedly extremely painful . two months after the first study , therefore , the marker study was repeated . now 42 markers were found retained , most of them in the right hemicolon , translating into a ctt of 110.8 h , segmental transit times being 72 ( right ) , 0 ( left ) and 28.8 ( rectosigmoid ) h ( fig . 2 ) . because this suggested the presence of a caecal fecaloma , we decided to perform colonoscopy , aiming at disimpaction of the faecal mass , preceded by standard bowel preparation with 4 l of klean - prep. to our surprise the entire colon was empty , while dozens of radio - opaque markers were found clustered in small groups into sticky mucus to all quadrants of the right hemicolon wall ( fig . no further endoscopic abnormalities were encountered , in particular no signs of mucosal disease at the site the markers were found . therefore , no biopsies were taken during the endoscopy . the abdominal pain subsided over the next few days , and oral laxative medication could eventually be lowered to 10 g of polyethylene glycol per day . 3radio - opaque markers sticking together to the caecum wall as seen during colonoscopy plain abdominal x - ray during ctt study 2 months after bowel cleansing radio - opaque markers sticking together to the caecum wall as seen during colonoscopy it can aid in the differentiation of defecation disorders such as functional constipation and functional non - retentive faecal soiling . it can also be used when history seems to be unreliable , for example in patients with eating disorders . studies in adults and children show a strong positive correlation between the severity of symptoms of constipation and ctt , a transit time of over 100 h in children being associated with a poorer outcome of chronic constipation after 1 year . a study in 25 constipated adults reported unchanged ctt with marker accumulation shifted to the distal colon , while in another study in 10 adults , bowel cleansing resulted in significant shortening of ctt , but with unchanged distribution of radio - opaque markers . this case report shows that markers do not always mix appropriately with faeces and therefore sometimes may not adequately reflect ctt . apparently , in an empty colon , the markers can be caught in mucus and stick to the colonic wall for a longer period , even when it is followed by the normal passage of faeces . looking back to the x - rays , the typical pattern of clustering of the markers should probably have been interpretated as a sign of entrapment . in conclusion , while ctt assessment using radio - opaque markers can be applied successfully in the investigation of defecation disorders , the results can not be accepted blindly . especially the clustering of many markers within narrow margins might point at entrapment of markers against the colonic wall .

we report a misleading outcome of colonic transit time ( ctt ) assessment in an adolescent girl with functional constipation . we found prolonged total and right segmental ctt despite high doses of oral polyethylene glycol 4000 and repeated treatment with polyethylene glycol electrolyte solution ( klean - prep ) by nasogastric tube . a colonoscopy aiming at disimpaction of a possible faecal mass revealed an empty colon with dozens of radio - opaque markers adhered to the colonic wall . this report shows that the result of a ctt can not be accepted blindly . especially the clustering of many markers within narrow margins might point at entrapment of markers in mucus against the colonic wall .

in 1958 , cantrell et al . ( 1 ) described a syndrome which consists of the following : 1 ) a midline , supraumbilical abdominal wall defect ; 2 ) a defect of the lower sternum ; 3 ) a deficiency of the anterior diaphragm ; 4 ) a defect in the diaphragmatic pericardium ; 5 ) congenital intracardiac defects . several authors have described similar cases , and it is currently classified as an anterior body wall midline developmental anomaly ( 2 ) . the estimated prevalence varies from one in 65,000 to 200,000 births ( 2 , 3 ) . in this case report , we describe successful vaginal delivery of a pregnant woman who had been diagnosed with this syndrome in childhood . a 23-yr - old nulliparous , primigravid woman was referred to our maternal - fetal medicine unit at 18 weeks ' gestation . she had been previously seen at our institution in the pediatric clinic as a child of 6 yr , when she presented with two umbilici and an epigastric pulsatile mass present since birth . at that time , she complained of intermittent abdominal pain in the area between the two umbilici . on physical examination , the superior umbilicus was found to be a dimple in the epigastrium connected to the actual umbilicus inferiorly by a fibrous band . a 13 cm pulsatile chest plain radiograph showed situs solitus and slightly decreased pulmonary vascularity and abdominal plain radiograph was unremarkable . cardiac catheterization , angiography , and echocardiography were performed and the pulsatile mass was found to be a substernal apical diverticulum of the heart beneath the weakened abdominal wall . periodic follow - up studies over the next 6 yr , including chest radiography , ekg , and echocardiography showed no remarkable changes . at age 23 yr , she presented to our institution at 18 weeks ' gestation and was examined by echocardiography . the echocardiogram revealed left ventricular ejection fraction of 63% , suspected mild right ventricular outflow tract compression without a pressure gradient , and insignificant mild narrowing of left pulmonary artery origin . during prenatal evaluation , the patient did not complain of any significant symptoms except for a pulsatile sensation in the epigastrium and mild intermittent dyspnea . there were no abnormal obstetric findings , including antenatal routine laboratory results , midtrimester maternal serum screening test , and vaginal examination . on fetal ultrasonogram , an epigastric dimple and the umbilicus were connected by a fibrous band , and the substernal cardiac diverticular beating beneath the abdominal wall was similar as previously described ( fig . induction of labor with vaginal dinoprostone insertion and intravenous oxytocin was performed . during the intrapartum period , the 1-min and 5-min apgar score was 9 and 9 and there was no gross anomaly noted including the umbilical cord and umbilicus . postpartum uterine contraction was adequate , and she was discharged with the healthy baby without any significant hemorrhage or abdominal pain . previous case reports have described various conditions associated with cantrell 's pentalogy , but as far as we are aware , this is the first reported case of successful vaginal delivery of a pregnant woman diagnosed with this condition . all five anomalies must be present for diagnosis of cantrell 's pentalogy to be made , but the severity may be quite variable , ranging from subtle to lethal . prognosis depends on the severity of the cardiac and associated anomalies . in affected patients with complex heart anomalies who undergo surgery during the first days of life possible causes of death include cardiac rupture , tamponade , endocarditis , embolism , arrhythmia , and heart failure ( 3 , 4 ) . the etiology of cantrell 's pentalogy is unknown , but it has been postulated that a defect in the common mesodermal origin accounts for the association of the five anomalies . most of the reported cases are sporadic , but x - linked inheritance has been suggested in some families , and mutations in genes located on the x chromosome have been suspected ( 5 , 6 ) . it is possible that some intestinal loops pass the umbilical ring and herniate into the cord during embryonic development , and a defect in normal internalization of the physiological umbilical hernia results in a persistent herniation and abundant umbilical skin ( 7 ) . in fact , the care of pregnant woman with cantrell 's pentalogy has not been previously described . with close antenatal follow - up and intrapartum monitoring we observed the patient closely for any symptoms and signs of dyspnea , abnormal abdominal pain , or tachycardia . this case report demonstrates that vaginal delivery may be an option for women with cantrell 's pentalogy .

cantrell 's pentalogy is a rare condition that consists of defects involving the abdominal wall , lower sternum , anterior diaphragm , pericardium , and heart . in the literature to date , pregnant women with cantrell 's pentalogy have not been discussed . we performed successful vaginal delivery of a 23-yr - old nulliparous , primigravid woman who had been diagnosed with this condition . diagnosis was based on cardiac catheterization , angiography , and echocardiogram , and abdominopelvic ct . vaginal delivery may be an option for women with cantrell 's pentalogy and may be attempted with caution .

a 71-year - old woman with hypertension and parkinson 's disease suddenly developed blurred vision and exotropia of the left eye . she also had adduction paresis of the left eye , abducting nystagmus of the right eye , left exotropia in the primary position , a skew deviation with the right hypotropia , an excyclotorsion of the right eye and an incyclotorsion of the left eye , upbeat nystagmus , intermittent right exotropia on downward gaze , and deficiency of convergence of the left eye ( fig 1-a , 1-b ) . diffusion - weighted brain mri performed 18 hours after the symptom onset showed an acute infarction in the left upper paramedian pontine tegmentum adjacent to the fourth ventricle in the area of mlf . the follow - up mri , performed 8 days later , revealed a tiny discrete lesion at the same area ( fig 1-c ) . this lesion showed high signal intensity on t2-weighted and fluid attenuated inversion recovery ( flair ) mri , and low signal intensity on apparent diffusion coefficient ( adc ) map . cerebral magnetic resonance angiography ( mra ) results were normal . over the next 30 days , this is the first report of wemino combined with contraversive otr due to a tiny lesion in the ipsilateral upper paramedian pontine tegmentum in the area of the mlf . wemino has rarely been reported.2,3 of the four patients with wemino reported by johnston and sharpe,2 only one had the responsible lesion confined to the pontine tegmentum in the area of the mlf , which was verified by neuropathologic examination . iketa and okamato also reported a patient who had an infarct identified by mri in the area of the mlf.3 however , these patients had neither skew deviation nor otr . otr is common in patients with mlf involvement.1 otr is contraversive in patients with pontomesencephalic brainstem lesions involving the rostral mlf or the interstitial nucleus of cajal , while it is ipsiversive in patients with medullary lesions.4 therefore , contraversive otr , observed in our patient , seems to be related to the lesion of the left pontine mlf rostral to the decussation.5 these findings should be differentiated from non - paralytic pontine exotropia , which is a syndrome of ino with contralateral exotropia . contralateral exotropia in this condition is known to be due to secondary deviation induced by over - excitation of contralateral paramedian pontine reticular formation under fixation with the paretic eye.6 although the mechanism of wemino remains unclear , the findings of our patient suggest that wemino is related to the mlf lesion .

wall - eyed monocular internuclear ophthalmoplegia ( wemino ) with contraversive ocular tilt reaction has not been previously reported . a 71-year - old woman suddenly developed blurred vision . examination revealed left internuclear ophthalmoplegia , left exotropia , right hypotropia , and rightward head tilt . magnetic resonance imaging showed a tiny infarction at the area of the left medial longitudinal fasciculus in the upper pons . wemino with contraversive ocular tilt reaction may be caused by a paramedian pontine tegmental infarction that selectively involves the medial longitudinal fasciculus .

plaque radiotherapy is one of the most commonly used methods in the treatment of choroidal and ciliary body melanoma.1,2 plaque radiotherapy has also been used in the treatment of retinoblastoma3 and choroidal hemangioma.4 one of the difficulties encountered in plaque radiotherapy pertains to removal of the plaque . after the plaque has stayed on the eye for an average period of 37 days depending on the radioisotope being used and the radioactivity of the plaque , there may be radiation - induced changes in the conjunctiva and tenon s capsule.5 these tissues usually become edematous and there may even be a marked inflammatory reaction around the plaque . the identification of the plaque and anchoring sutures at the time of plaque removal may become a serious problem , especially when the plaque is placed posterior to the equator . in this paper , we propose an alternative method of plaque placement whereby imbricated sutures are used to facilitate in the removal of the plaque . after conjunctival peritomy , dissection of the tenon s fascia , and isolation of the rectus muscles , the dummy plaque is brought into the field . after the dummy plaque is removed , 5/0 nylon sutures are placed through the eyelet marks on the sclera . the radioactive plaque is then brought in position on the globe and 5/0 nylon sutures are passed through the previously noted eyelets on the plaque . at this point , 1/0 silk suture or 2/0 mersilene is imbricated with the 5/0 nylon suture ( figure 1a ) when the nylon suture is tied and cut ( figure 1b ) . the 1/0 silk or 2/0 mersilene is also tied about 1 cm above the sclera ( figure 1c ) and cut ( figure 1d ) . the conjunctiva is brought anteriorly over the plaque and imbricated silk sutures and closed with 7/0 interrupted vicryl sutures . plaque removal procedures are usually done under monitored care local anesthesia . at the time of plaque removal the imbricated silk or mersilene sutures are easily found under the conjunctiva and followed back to the plaque ( figure 1e ) . the imbricated silk / mersilene suture and the nylon suture are then cut together at the level of the plaque eyelet and removed . iodine-125 coms ( collaborative ocular melanoma study ) plaques were used in this study but the technique can easily be modified for all plaque types as well . the time spent for suturing the plaque on the sclera using imbricated sutures was recorded . recording of the time was started with the bringing of the plaque on the sclera and stopped at the completion of the last suture securing the plaque to the sclera . time recording was stopped with removal of the plaque from the sclera out of the surgical field . all surgical procedures were done in the presence of the senior author , jsp , in the operation room . this technique was used in approximately 140 plaque radiotherapy procedures performed over the past four years . plaque insertion times ranged from 9.1 minutes to 14 minutes ( mean : 10.8 minutes ) and plaque removal times ranged from 2.8 to 3.3 minutes ( mean : 3.0 minutes ) . the widely used surgical technique for plaque placement involves using 5/0 nylon suture to secure the plaque to the sclera . however , it does not address the problem of cutting the suture that is firmly attached to the plaque and sclera . the imbricated suture technique besides allowing localization of the radioactive plaque readily also provides a surface that separates the 5/0 nylon from the surface of the eyelet platform , making suture cutting easier and safer at plaque removal . every new technique takes a bit of learning curve time but in the end this technique is not much longer at initial plaque placement but markedly diminishes removal time . the radiation exposure times recorded in our study showed that the surgeon was subject to less than 10.8 minutes of radiation exposure time during plaque insertion which shows that the addition of the extra sutures does not add time to the placement while the removal exposure times were only about three minutes . though there is little in the literature about plaque placement and removal times , these removal exposure times appear quite low .

this paper describes a new technique to suture the radioactive plaque to sclera . the radioactive plaque is conventionally sutured to the sclera using 5/0 nylon sutures . the imbricated suture technique involves using a 1/0 silk or 2/0 mersilene suture imbricated with the 5/0 nylon suture when the nylon suture is tied and cut . the imbricated suture technique allows easy identification of the plaque at removal and provides a surface that separates the 5/0 nylon from the surface of the eyelet platform , making suture cutting easier and safer . the radiation exposure times ranged from 9.1 minutes to 14 minutes ( mean : 10.8 minutes ) during plaque insertion and from 2.8 to 3.3 minutes ( mean : 3.0 minutes ) during plaque removal with the imbricated suture technique . this technique may decrease radiation exposure time and may prevent inadvertent scleral damage .

his medical history revealed hospitalization for heart failure as well as treatment for arterial hypertension and permanent atrial fibrillation . diagnosis was by transesophageal echocardiography showing a linear structure dividing the left atrium in two chambers ( figure 1 ) . pulmonary veins drained into the postero - superior chamber and the mitral valve and the left atrial appendage were located in the antero - inferior chamber . consequently , the diagnosis of cor triatriatum sinistrum class a according to the lam classification was made . furthermore , the diagnosis of a calcified bicuspid aortic valve with moderate stenosis was established corresponding to a sievers type classification of 1 , l / r meaning one raphe between a fused left and right coronary cusp . a classical combination of a sinus of valsalva and ascending aortic dilatation was seen during ct angiography ( figure 2 & 3 ) . heart failure therapy was optimized , symptoms improved and he is currently seen on a regular basis in our outpatient clinic . the combination with bicuspid aortic valve disease is even rarer , as is late presentation in life as in our patient , and a mere single digit report in the literature was available . the median age in a recently published series of the mayo clinic was 19 years . obviously , functional obstruction of the membrane is moderate and , therefore , physiologically compensated . by the onset of atrial fibrillation , it might have been that symptoms occurred . however , this was not connected to a congenital defect , but due to the onset of atrial fibrillation per se . regarding diagnostics , transthoracic and transesophageal echocardiography have obviously become the treatment modalities of first choice to establish the correct diagnosis . furthermore , the rare association with a bicuspid aortic valve was made . in our patient , additional ct angiography further revealed ectasia of the sinus of valsalva as well as the ascending aorta . these are most likely the very aspects making this case report unique , as we were not able to identify a single case report where a clear categorization of lam classification and loeffler groups , as sievers classification of bicuspidity , was established . furthermore , this patient is one of the few who seems to do well with modification of heart failure therapy as well as rate control of atrial fibrillation . summarizing , the combination of cor triatriatum sinistrum and bicuspid aortic valve disease is a rare variation of nature . furthermore , membranes with a larger effective orifice area might be treated conservatively in distinct clinical situations .

we presented a 73-year - old patient with a history of hospitalizations for heart failure as well as treatment for arterial hypertension and permanent atrial fibrillation and who was found to have cor triatriatum sinistrum in combination with bicuspid aortic valve . patient refused surgical correction , but his condition improved on conservative therapy for heart failure and atrial fibrillation .

the paper in the previous issue by du and colleagues describing critical care in china illustrates the increasing recognition and provision of critical care that follows economic development . given that the two countries with the most rapid economic development , china and india , are also the two most populous countries in the world , this translates into a huge potential demand for critical care . there are , however , a number of hurdles that need to be overcome in order to develop high quality intensive care , and the sheer size of the problem is mind - boggling : there are close to 2.9 million hospital beds in china . current nursing provision in china is low , with a nurse : bed ratio of 1.37 - 2.02:1 . this compares unfavourably with western europe , where 65% of icus surveyed in 1996 reported higher ratios . the authors highlight the fact that , while knowledge of state of the art advances is relatively easily acquired from conferences , basic knowledge and skills are inadequately taught . patients are patients whatever their nationality and , as such , we have a responsibility to help improve care beyond the confines of our own icus . first we have to understand the problem by seeking more data on critical care outside developed countries . papers such as that by du and colleagues are a useful starting point and should be encouraged by journal editors . a worldwide registry of icus could provide even more useful and detailed data and a collaborative project to develop such a registry is currently underway . this requires a change in attitude to intellectual property and sharing of resources . why teach a handful of trainees in your unit when you could teach hundreds across the world why do we hand over copyright of book chapters to publishers with commercial interests when we could reach far more people by posting the chapters on the internet ? open access journals are a step in the right direction but , for developing countries , the emphasis may be in the wrong place . research articles in critical care , for example , are free but review articles , which are probably of greater use to those requiring basic training , attract a fee . third , we can try to make our teaching in developing countries more context specific . for example , there is little point in teaching about the latest ventilation modes if a basic understanding of ventilation is lacking . however , all our efforts will be in vain if those who we train do not stay in their own countries . migration , while addressing the systematic shortfall of staff in developed countries , is one of the underlying causes for the shortfall of healthcare workers in developing countries . the united states , for example , currently trains 30% too few doctors to meet its own needs and 25% of doctors in canada , new zealand , usa and uk were trained abroad . we should tell our politicians that this is not acceptable . finally , du and colleagues article illustrates the huge inequality that exists in many developing countries . in china as the daily hospital cost for a patient with severe sepsis is us$502 and the mean annual income in rural areas is only us$697 , it is obvious that critical care is out of the reach of the majority . as acute care specialists we can contri bute to education in acute care as well as intensive care . initiatives such as the global healthcare workforce alliance are currently working to minimize the deficiency of 4.3 million healthcare workers in developing countries . with a high proportion of deaths in these countries resulting from acute illness or injury , acute care

the rapid economic growth in parts of the developing world is being accompanied by an expansion of critical care . hurdles to expansion include lack of critical care training for healthcare workers . this is coupled with a need for a huge number of healthcare workers due to the high populations of countries such as china and india . intensivists in the developed world can and should help .

while the consequences of oxygen deprivation are well known , we also know that excessive oxygenation creates new problems because hyperoxia exacerbates lung injury . so like many things in life , ' too much ' is not the solution to ' not enough ' . assessments of tissue oxygenation have taught us that ' normoxia ' differs among organs , and that tissue oxygenation can decrease when the environment or activity levels change . for example , lung alveolar cells normally reside under 14% o2 , while oxygenation in intestinal epithelium can be less than 2% . severe exercise decreases myocardial oxygenation from 4% to less than 1% o2 , while high altitude induces systemic hypoxemia . during embryonic development , systemic oxygenation in the fetus while severe hypoxia can threaten survival at any stage of life , it is interesting that our cells often experience significant hypoxia without sustaining injury . moreover , we have learned that both cells and organisms quickly acclimate to lower oxygen environments . this is evidenced by altitude - acclimated climbers near the summit of mt everest who were alert with arterial po2 less than 25 mmhg ! so why is hypoxia tolerated well in some circumstances but not in others ? in this issue of critical care , dr martin and colleagues consider the effects of hypoxia on physiology , and they review mechanisms allowing cells and organisms to tolerate oxygen deprivation without sustaining injury . one mechanism involves the up - regulation of protective genes by hypoxia - inducible factor ( hif ) transcription factors . the cadre of genes controlled by hif varies among cell types , but generally includes the expression of glycolytic enzymes , glucose transporters , vascular growth factors , and genes regulating vascular tone and systemic oxygen transport . hif also contributes to the down - regulation of mitochondrial respiration , which lessens tissue need for oxygen . loss of hif is lethal during embryonic development , largely because hypoxia acts as a morphogen controlling migration and differentiation of cells in the embryo and placenta . other systems engaged by hypoxia include amp - dependent protein kinase ( ampk ) , which responds to increases in cellular [ amp ] and is also activated by hypoxia . interestingly , o2 acts as a signal in triggering the activation of both hif and ampk during hypoxia by releasing low levels of reactive oxygen species ( ros ) from the electron transport chain . these ros migrate to the inter - membrane space where they can escape to the cytosol and trigger the activation of hif and ampk . thus , o2 acts in a paradoxical manner as a signaling molecule activating protective mechanisms during hypoxia . martin and colleagues raise the provocative concept of ' permissive hypoxia ' in critical illness . to be sure , the degree to which hypoxemia should be corrected a reduction in cellular energy demand during hypoxia , a form of adaptive hibernation , could lessen the consequences of oxygen deprivation . but before we reach for the fio2 control on the ventilator , we should consider other arguments . first , organ failure is essentially a situation where cells fail to perform their normal tissue function . in heart failure , cardiomyocytes are alive yet they fail to contract normally . in hypoxic tissues , adaptive responses might foster survival , but the consequences for organ function can be catastrophic . for example , in hypoxic lungs ros signals activate ampk , which triggers internalization of the epithelial na , k - atpase , an enzyme essential for alveolar edema reabsorption . hence , responses triggered by hypoxia may not optimize tissue repair and survival in the critically ill . microvascular heterogeneity in the patient can create local hypoxic areas within excessively perfused regions . at the tissue level perfusion a parallel situation occurs in solid tumors , where local cellular anoxia occurs despite high blood flows and excessive ( albeit abnormally structured ) capillary density . hypoxia triggers protective responses , but not all of these are adaptive at the tissue level . a better understanding of the heterogeneity of microvascular oxygen supply in the critically ill patient would help us begin to understand the situation before we turn down the oxygen . ampk : amp - dependent protein kinase ; hif : hypoxia - inducible factor ; ros : reactive oxygen species .

human cells require o2 for their energy supply , and critical illness can threaten the efficient delivery of o2 in accordance with tissue metabolic needs . in the accompanying article , martin and colleagues point out that hypoxia is a normal and well - tolerated stress during embryonic development . a better understanding of how fetal cells survive these conditions and how adult cells adapt to high altitude exposure may provide insight into how these mechanisms might be engaged in the treatment of hypoxemic patients . they suggest that ' permissive hypoxia ' represents a therapeutic possibility . but before we turn down the inspired o2 levels we should consider the broader effects of hypoxia on tissue repair in critical illness .

carbamazepine is an iminostilbene derivative and chemically related to the tricyclic antidepressants , mainly used as an antiepileptic drug in partial and tonic - clonic seizures , also used in trigeminal neuralgia and bipolar affective disorder . in clinical trials the total incidence of reported adverse reaction to carbamazepine is 4.5 per million at defined daily doses , corresponding to 2.7 per million at prescribed daily doses . among the adverse reactions of carbamazepine , most often reported are skin reactions ( 48% ) , hematological ( 14% ) , hepatic disorder ( 10% ) . carbamazepine - associated adverse reaction are wide ranging from mild drowsiness , vertigo , ataxia , diplopia , skin rashes to severe convulsion , coma , hematological toxicity ( aplastic anemia , agranulocytosis ) , hypersensitivity reaction ( dermatitis , splenomegaly ) , hepatic ( most commonly a transient elevation of hepatic transaminases ) or pancreatic abnormality . here we present a case of erythematous skin rashes with hepato - splenomegaly caused by carbamazepine . a 12-year - old male child presented to emergency room with rashes all over body , mainly on limbs . he had a history of neurocysticercosis 1 month ago , for which he received albendazole for 5 days . he has been receiving carbamazepine 400 mg tablet once daily since last 27 days prophylacticaly to prevent seizures . physical examination revealed erythematous skin rashes and hepato - splenomegaly . the patient was hospitalized and after excluding other causes of rashes with hepato - splenomegaly , we concluded that carbamazepine was the cause for this reaction . to exclude other common causes of hepato - splenomegaly , tests for the presence of malaria parasite and complete blood count with peripheral blood film examination were done , but no abnormalities were found . there was no fever , eosinophilia and other systemic symptoms , therefore ruling out the diagnosis of dress . the rashes were red , elevated , of different sizes and associated with itching [ figure 1 ] . the patient improved and sgot , sgpt levels returned to normal following which the patient was discharged . at the end of 2 weeks of follow - up physical examination , liver and spleen size were normal . the most common idiosyncratic reaction is an erythematous skin rash ; other responses such as hepatic dysfunction and splenomegaly are unusual . a causality assessment of this adr using the naranjo criteria revealed that an adverse drug reaction due to carbamazepine was possible ( overall score-4 ) . starting doses of carbamazepine are usually the lowest value for children 4 - 8 mg / kg / day ; subsequent increases should be made only after achieving a steady state with the previous dose ( after an interval of five or more half lives ) . the key determinants of efficacy and safety of this drug are the seizure frequency and presence of side effects . monitoring of serum carbamazepine level can be very useful for establishing the initial dose schedule . there is no simple relationship between the dose of carbamazepine and concentration of the drug in plasma . therapeutic concentration are reported to be 6 - 12 g / dl , although considerable variations occur . to conclude , we recommend that monitoring is essential for any unusual adverse event occurring during carbamazepine therapy . in case any adverse reaction of carbamazepine occurs , we should monitor plasma drug concentration and withdraw and replace the drug , if necessary .

carbamazepine is an antiepileptic drug . in clinical trials the total incidence of reported adverse reaction to this drug is 4.5 per million at defined daily doses , corresponding to 2.7 per million at prescribed daily doses . among the adverse reactions of carbamazepine , most often reported are skin reactions ( 48% ) , hematological ( 14% ) , hepatic disorder ( 10% ) . herein , we present a case with erythematous skin rashes and hepato - splenomegaly .

this project began as part of a larger study concerned with a suspected nipah virus outbreak in the region . active surveillance of bats was performed in 3 districts of bangladesh : meherpur and naogaon during march 2003 and rajbari during february and march 2004 ( figure 1 ) . bats were anesthetized by a 0.05- to 0.1-mg intramuscular injection of ketamine hydrochloride . injured bats and those that had clinical signs and symptoms were euthanized under sedation by exsanguination . brains of all euthanized bats were removed at necropsy and placed into individual sterile containers . all specimens were held in temporary storage at 18c ( after collection ) and later placed at 80c . bat brains collected in 2003 ( n = 212 , table ) were tested by the direct fluorescent - antibody test ( dfat ) ( 10 ) , by using both monoclonal ( centocor inc . , malvern , pa , usa ) and polyclonal ( chemicon international , temecula , ca , usa ) fluorescein isothiocyanate labeled anti rabies virus antibodies , and were subsequently processed for isolation by the mouse inoculation test ( mit ) ( 11 ) . if death occurred during the mit , mouse brains were subjected to the dfat , and a second intracerebral passage was conducted with 5% brain suspensions , using 0.22-m filters ( millipore corp . , bedford , ma , usa ) . bat brains collected in 2004 ( n = 151 , table ) were subjected to the dfat only . * the presence of virus - neutralizing antibodies was determined by an adaptation of the rapid fluorescent focus inhibition test ( rffit ) , as described ( 7 ) . because of volume limitations and the cytotoxicity of some specimens , 207 serum samples were available for testing at a starting dilution of 1:20 , and 81 samples at a starting dilution of 1:50 ( table ) . four different lyssaviruses were used in an initial in vitro screening : aravan , khujand , irkut , and ablv . when a positive result was obtained , testing on the sample was repeated , and comparative assays undertaken for additional lyssaviruses : eblv-1 , eblv-2 , duvv , and rabv ( e.g. , routine rabies challenge virus standard , cvs-11 ) . the dose of each virus used for the rffit was 50 infectious units per 100 l . the duration of the test was 20 hours for ablv and cvs-11 and 40 hours for other challenge viruses . no evidence of lyssavirus antigen was detected in any bat brain by dfat , and no neurotropic viruses were isolated by mouse inoculation . if a limited number of deaths occurred during the initial mit ( 1 or 2 mice of 5 infected ) , those effects were not reproduced during the subpassage by filtration , which suggests that bacterial contamination of the field samples caused the death of mice during the initial mit . one serum sample repeatedly demonstrated neutralizing activity against khujand virus , at a titer of 54 . this sample was obtained from a young female giant indian flying fox ( pteropus giganteus ) ( figure 2 ) captured in the meherpur district in 2003 . two other serum samples obtained from the same species ( 1 male and 1 female ) in rajbari district in 2004 , neutralized aravan and khujand viruses at titers of 1416 . for these latter samples , neutralization was detected at dilutions of 1:20 and 1:25 but not detected at a dilution of 1:50 . the titers of all serum specimens were < 10 ( i.e. , no neutralization occurred in the dilution of 1:20 ) against other lyssaviruses . antigenic cross - reactivity has been reported among aravan , khujand , and other members of the lyssavirus genus ( 12 ) . therefore , detectable antibody may cross - react with other related lyssaviruses , as well as with viruses yet to be discovered . based upon this preliminary survey , thus , it is not surprising that all brain samples collected were negative for detection of lyssavirus antigen . because different lyssaviruses and bat species are found in asia , and therefore different virus - host interactions would be expected in the region , extrapolating antibody - positive / virus - positive ratios , as have been estimated from american ( 13,14 ) or european ( 15 ) bat populations , would be difficult . further surveillance for asian bat lyssaviruses should be conducted . public health authorities need to be aware of the potential for bats to transmit lyssaviruses , and public education of this potential should be enhanced . frugivorous bats forage in fruit plantations in many regions of the old world tropics , including bangladesh . absence of current information on human rabies after bat exposure may be a result of inadequate education , incomplete surveillance , and lack of characterization of viruses from rabies cases ( 6 ) .

lyssavirus surveillance in bats was performed in bangladesh during 2003 and 2004 . no virus isolates were obtained . three serum samples ( all from pteropus giganteus , n = 127 ) of 288 total serum samples , obtained from bats in 9 different taxa , neutralized lyssaviruses aravan and khujand . the infection occurs in bats in bangladesh , but virus prevalence appears low .

in the 7-year period 20012007 , 14 ( 1.8% ) of 768 foodborne outbreaks were associated with foods that were distributed internationally ( appendix table ) . in total , these outbreaks affected at least 542 persons in australia , 4.4% ( 542/12,423 ) of all those affected by foodborne disease outbreaks during the period . the number of persons affected in other countries as a result of these events was unknown . given the nature of foodborne disease , more outbreaks that we were unable to identify were likely associated with internationally distributed foods . several point - source outbreaks were related to each other by a common food source , even though the foods were often branded differently and supplied by different companies . the outbreaks of suspected norovirus infection ( outbreaks 4 , 6 , and 9 ) were associated with individually quick frozen ( iqf ) oysters all harvested from the same region in japan ; this association was later confirmed after a national investigation into 3 related outbreaks ( outbreaks 7 , 8 , and 10 ) ( 9 ) . these outbreaks occurred over a 3-year period and resulted in australia s imposing restrictions on importation of iqf oysters from this growing area . no outbreaks was considered to be of serious public health impact because of their small size and moderate severity . in 4 ( 29% ) of 14 outbreaks , the event was considered however , agents considered novel in australia were common causes of disease in the country exporting the food ( 10 ) . in 5 ( 36% ) of the 14 outbreaks , food had been distributed to other countries , resulting in multinational food recalls ; 4 more events had the potential to spread to other countries . we identified the implicated food for 2 outbreaks ( outbreaks 1 and 14 ) because other countries rapidly published reports in eurosurveillance weekly . we alerted other countries to the implicated food for 3 other common - source outbreaks ( outbreaks 3 and 5 , by using rapid reports in the same publication and outbreak 2 through promed mail ) ( 1114 ) . during these investigations , we attempted to identify other countries that had also received contaminated food . before the inception of infosan , we relied on diplomatic communications with the exporting country , which were often unsuccessful . in a recent incident in which persons became infected with toxigenic vibrio cholerae after eating raw whitebait ( outbreak 13 ) , infosan emergency made inquiries of the exporting country and confirmed that fish had not been exported to other countries and that no outbreak was observed locally ( 15 ) . during a multicountry outbreak of drug - resistant shigellosis ( outbreak 14 ) , infosan emergency focal point at who gained the exporting country s cooperation to trace back the produce to the facility concerned and informed other countries receiving the same batch of produce ( 11 ) ( appendix table ) . although ihr ( 2005 ) only came into force in june 2007 , we consider that there would have been a basis for reporting 6 ( 43% ) of 14 imported food outbreaks , with 3 of these being part of the same iqf oyster contamination event . although national ihr focal points may decide not to notify or report an outbreak under ihr ( 2005 ) , it is vital that they publish rapid reports involving imported and exported foods , given the potential of these foods to spread disease internationally , and consult with who through infosan emergency . in this report , we considered only those events that resulted in human illness , but it is important for national ihr focal points to consult with the infosan emergency contact point for their country and to consider notifying and/or reporting events in which food is contaminated in the absence of human illness . serious , unusual , or unexpected events associated with domestic food may also trigger the criteria , even when foods are not exported . note that under article 9.2 of ihr ( 2005 ) , public health risks associated with importation of contaminated goods may be reported to who independent of the event s meeting the annex ii criteria . this stipulation would allow reporting when available information is insufficient to make an adequate assessment under annex ii . the role of who and other agencies in these events of potential international importance will undoubtedly continue to evolve . outbreaks of illness that implicated internationally distributed foods and assessment of questions on the ihr ( 2005 ) decision instrument , australia , 2001 - 2007 *

every year , australia identifies 23 outbreaks associated with imported foods . to examine national authorities obligations under the international health regulations ( 2005 ) , we reviewed outbreaks in 20012007 that implicated internationally distributed foods . under these regulations , 6 ( 43% ) of 14 outbreaks would have required notification to the world health organization .

tamoxifen citrate ( tc ) was received as gratis sample from sun pharma pvt . ltd . all lipids compritol 888 ( glyceryl dibehenate ) , precirol ato 5 ( glyceryl disterate ) , gelucire 50/13 pellets ( stearoyl macrogol-32 glycerides ) , galeol pellets ( glyceryl monosterate ) were kindly gifted by gattefosse pvt . surfactants like lipoid s 75 - 3 , lipoid s pc-3 , phospholipon 80 h and phospholipon 90 was kindly gifted by lipoid ag , germany . tc loaded solid lipid nanoparticles were prepared by high shear homogenization followed by ultra sonication . lipid phase containing tc and the aqueous phase were heated to 70c , separately . the aqueous phase was poured into the lipid phase , with the stirring speed of 28,000 rpm for 10 minutes with heating using programmable digital homogenizer - pdh ( omni , usa ) . dispersion was ultrasonicated for 10 minutes to reduce the particle size and to avoid agglomeration of particles in the dispersion . quantity of tc was kept 0.1% . while drug : lipid ratio was kept 1:10 in the whole dispersion . particle size ( ps ) , particle size distribution - polydispersity index ( pdi ) and zeta potential of various batches were evaluated by zetasizer nano zs 90 ( malvern instruments ltd . ) . effect of type of lipid and concentration of surfactants are elaborated in tables 1 to 3 . cmpt.1 ( compritol 888 and 1% of tween 80 ) was found to be stable after 30 days according to ps and pdi analysis . effect of types of lipid and concentration of tween 80 on formulation effect of types of lipid and concentration of pluronic f-68 on formulation effect of types of lipid and concentration of pva on formulation tc loaded sln prepared by high shear homogenization followed by ultra sonication by using compritol 888 and tween 80 ( 1% ) showed good particle size , particle size distribution

tamoxifen citrate ( tc ) is an estrogen receptor antagonist and drug of choice for hormone sensitive breast cancer . solid lipid nanoparticles loaded with tc were prepared by high shear homogenization followed by ultrasonication . the aim of the present work is to study the effect of four different solid lipids and three surfactants on formulation and stability of sln . they were characterized for particle size , polydispersity index and zeta potential by zetasizer nano . sln prepared by solid lipid compritol 888 ( glyceryldibehenate ) and tween 80 ( 1% ) showed desired particle size of 206.9 nm , pdi of 0.046 and zeta potential of 9.32 mv .

anomalous mitral arcade or hammock valve is a rare congenital anomaly of the mitral tensor apparatus , which consists in a fibrous continuity between mitral leaflets and enlarged papillary muscles , without interposition of chordae tendineae or with an underdeveloped chordal apparatus . this condition causes a restrictive movement of the leaflets that interferes with the achievement of an optimal position for valvular closure during ventricular systole . this malformation is characterized by progressive worsening of valvular defect , which could be regurgitation , stenosis or both . we report the case of a 15-year - old female with mitral regurgitation diagnosed in infancy , in therapy with diuretics , vasodilators , and digoxin and in regular clinical and echocardiographic follow - up . the patient reported , in the last year , progressive exertional dyspnea , fatigue , and palpitations ( new york heart association class iii ) with echocardiographic evidence of initial left ventricular dysfunction and severe mitral insufficiency ( vena contracta 0.6 cm , effective regurgitant orifice 0.37 cm , rigurgitant volume 57 ml ) . the color doppler flow of the mitral valve revealed an eccentric jet ( headed to the posterolateral wall of the left atrium ) due to a dysplastic valve with thickened leaflets , especially the anterior one [ figure 1 and video 12 ] , hypertrophy and partial fusion of the papillary muscles and the chordae , which appeared shortened . the mitral annulus was dilated ( 37 mm 39 mm ) and so was the left ventricle , without regional dysfunction but with a global systolic function mildly reduced ( left ventricular ejection fraction 50 - 52% ) and a severe left atrial enlargement ( volume index 50 ml / m ) . these findings , confirmed with the transesophageal approach , were consistent with the ones described in anomalous mitral arcade . the three - dimensional acquisition in this patient had not added information due to the extremely thickened tissue and the disruption of the entity papillary muscles - chordae - leaflets . hammock valve with hypertrophic and fibrotic papillary muscles and hypoplastic chordae in diastolic and systolic phase the patient was referred to cardiac surgery for mitral valve repair . during surgery , the anterior papillary muscle was hypertrophic , fibrotic , cranially deployed and directly connected to the anterior leaflet segment a1 ( place of incomplete cleft ) and posterior leaflet segment p1 , with total aplasia of chordae tendineae . the repair consisted of anterior and posterior papillary muscle splitting with two longitudinal lesions , removal of two secondary hypoplastic posterior paracommissural chordae and cleft closure of a1-a2 segments . an echocardiographic study was performed on postoperative day 3 and showed good surgical result , with normal mitral leaflets coaptation , a mild residual mitral regurgitation , and a mean transvalvular gradient of 4 mmhg . the patient was discharged on postoperative day 6 with warfarin and bisoprolol therapy . at the follow - up evaluation 3 months later the patient reported improvement of the exercise capacity without complaining fatigue or dyspnea in everyday activity ; warfarin was withdrawn . in 1967 , layman and edwards described for the 1 time anomalous mitral arcade as a mechanism of congenital mitral insufficiency . the english word hammock was used firstly by carpentier in 1976 to describe the typical aspect of the anomalous valve seen from the atrial side during cardiac surgery . peculiar aspects of this valve are : the presence of a dimensionally adequate orifice , thickened and shortened chordae , direct link between papillary muscles and anterior leaflet and a reduced space between the anomalous chordae . this malformation may be the result of an arrest in the development of the mitral valve before attenuation and lengthening of the collagenized chordae tendineae . clinical course could be variable and it is related to the severity of mitral stenosis / insufficiency . most cases described are about pediatric patients , there are only few cases described in adult ; usually these patients underwent mitral valve replacement with a mechanical prosthesis , only in one case the patient became asymptomatic with angiotensin - converting enzyme inhibitor and diuretics and was scheduled for follow - up . an accurate evaluation of mitral valve apparatus with transthoracic echocardiography is of paramount importance to suspect anomalous mitral arcade and it is also useful to determine the best timing for intervention and the more appropriate reparative technique . sometimes this anomaly could be confused with rheumatic mitral disease on transthoracic echocardiography and the high spatial resolution of computed tomography combined with multiplanar four - dimensional images can reveal anatomic and functional details of the mitral apparatus suggesting the correct diagnoses . in our case , a careful echocardiographic evaluation of the mitral valvular and subvalvular apparatus was fundamental to diagnose anomalous mitral arcade ; the patient underwent successful valve repair , which is more technically challenging than valve replacement .

anomalous mitral arcade is a rare congenital anomaly affecting the mitral tensor apparatus . this condition causes a restrictive movement of the leaflets and interferes with the normal closure of the valve during ventricular systole . we report a case of a 15-year - old female with this condition and initial left ventricular dysfunction , who successfully underwent mitral valve repair . this reparative technique is more technically challenging then valve replacement and only few cases are described in literature .

a 53-year - old lady , of nigerian ethnicity , presented to our hospital acutely with constant epigastric pain and colicky left upper quadrant pain . venous blood tests revealed an amylase of 1388 iu / l , normal liver function tests and normal inflammatory markers . ultrasound scanning demonstrated a single large calculus within the gallbladder , with no evidence of cholecystitis . as per our particular local protocol , a decision was taken to proceed to an emergency cholecystectomy during the same admission , using a laparoscopic approach . the patient was positioned in lloyd - davies , with the right - handed operating surgeon standing between the legs for optimum comfort . the assistant stood on the patient 's right and the laparoscopic stack was placed on the patient 's left side . a veress needle technique was used for insufflation , as the patient was morbidly obese ( body mass index of 41 ) . the primary operator used a 5 mm supra - umbilical port and a 5 mm left sub - costal port to accommodate a retractor and diathermy hook , respectively . the assistant used a 5 mm sub - xiphisternal port to accommodate a retractor and a 10 mm left mid - clavicular line port to operate the camera ( fig . calot 's triangle was clearly identified , with two branches of the cystic artery found . both of these were clipped , as well as the cystic duct ( fig . the gallbladder was removed in a bag after diathermy extraction off the liver bed , through the 10 mm port . figure 1:port placement ( 5,5,5,10 ) for laparoscopic cholecystectomy : ( a ) normal anatomy and ( b ) situs inversus . port placement ( 5,5,5,10 ) for laparoscopic cholecystectomy : ( a ) normal anatomy and ( b ) situs inversus . situs inversus totalis is a congenital condition involving complete transposition of the organs from their anatomically normal positions to the opposite side of the body . dextrocardia was first recognized by marco severino in 1643 , and then , more than 100 years later , matthew baillie , a british physician and pathologist , first described situs inversus totalis . the first case report of laparoscopic cholecystectomy in total situs inversus was published in 1991 by campos and sipes , who advocated a mirror - image setup for a patient in a supine position . since then , over 80 other reports have been published discussing the safety of a laparoscopic approach to cholecystectomy in cases of situs inversus totalis . a number of approaches , including the use of a left - handed surgeon or single - incision laparoscopy , have been advocated to avoid the need for a right - handed surgeon to cross hands , with the patient placed in the supine position [ 24 ] . the use of the lloyd - davies position , however , as we describe here , allows much more ergonomic flexibility without the need for personnel or equipment the operating facility may not have . in general , the lloyd - davies position may be preferred for laparoscopic cholecystectomy as it allows the operating surgeon to stand between the patient 's legs and therefore involves less twisting to the upper back and more space for operating without encountering the assistant . the advantages of it are accentuated in the situation of situs inversus , as the potential for uncomfortable movements is increased for a right - handed surgeon . a 5 mm 30 laparoscope is optimal , as it allows for movement of the laparoscope to any of the ports as the gallbladder is mobilized and the ideal viewing position changes ( fig . it should be noted that the use of a left - handed surgeon does not negate risk , as they will still be performing an unfamiliar procedure with an associated learning curve . vascular anomalies of the celiac trunk and liver are thought to be more common in patients with situs inversus and we noted an additional cystic artery branch in our dissection . awareness of the increased potential for vascular anomalies , combined with meticulous dissection , is therefore essential . laparoscopic cholecystectomy can be safely carried out in patients with situs inversus totalis by a number of different methods . the techniques we describe here allow comfortable , rapid removal of the gallbladder no matter the handedness of the surgeon or resources of the operating facility .

abstractwe present the case of a 53-year - old lady with acute gallstone pancreatitis and situs inversus totalis , who underwent emergency laparoscopic cholecystectomy . we describe our operative approach for this challenging anatomy and discuss the advantages our particular technique confers with reference to the current literature .